EMBASSY OF EUCLID
For profit - Corporation
75 Beds
EMBASSY HEALTHCARE
Data: November 2025
Trust Grade
50/100
#455 of 913 in OH
Photo by Heritage Healthcare of Euclid
Photo by Heritage Healthcare of Euclid
Photo by Heritage Healthcare of Euclid
1 / 5 photos
Last Inspection: June 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Embassy of Euclid has a Trust Grade of C, which means it is average and falls in the middle of the pack among nursing homes. It ranks #455 out of 913 facilities in Ohio, placing it in the top half, and #41 out of 92 in Cuyahoga County, indicating that only a few local options are better. Unfortunately, the facility is worsening, with issues increasing from 5 in 2023 to 19 in 2024. Staffing is a concern, with a rating of 2 out of 5 stars and a 69% turnover rate, significantly higher than the state average of 49%, suggesting instability among caregivers. While there have been no fines, which is a positive aspect, specific incidents such as a failure to prevent pressure ulcers for a resident and a lack of water testing for Legionella indicate serious compliance issues. Overall, while the facility has some strengths, such as no fines and being in the top half of state rankings, it also has significant areas needing improvement.
- Trust Score
- C
- In Ohio
- #455/913
- Safety Record
- Moderate
- Inspections
- Getting Worse
- Staff Stability ⚠ Watch
- 69% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most Ohio facilities.
- Skilled Nurses ○ Average
- Each resident gets 33 minutes of Registered Nurse (RN) attention daily — about average for Ohio. RNs are the most trained staff who monitor for health changes.
- Violations ⚠ Watch
- 52 deficiencies on record. Higher than average. Multiple issues found across inspections.
50/100
Top 49%
Needs review
5 → 19 violations
★★★☆☆
3.0
Overall Rating
★★☆☆☆
2.0
Staff Levels
★★★★★
5.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2023: 5 issues
2024: 19 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: 69%
23pts above Ohio avg (46%)
Frequent staff changes - ask about care continuity
Chain: EMBASSY HEALTHCARE
Part of a multi-facility chain
Ask about local staffing decisions and management
Staff turnover is elevated (69%)
21 points above Ohio average of 48%
The Ugly 52 deficiencies on record
1 actual harm
Dec 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
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 observation, interview, record review and review of the facility policy the facility failed to ensure Resident #29 rece...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and review of the facility policy the facility failed to ensure Resident #29 received timely incontinence care and was free from skin breakdown. This affected one resident (Resident #29) out of three residents reviewed for incontinence care. The facility census was 66.
Findings include:
Review of Resident #29's medical record revealed and admission date of 12/18/20 and diagnoses included cerebral infarction due to unspecified occlusion or stenosis of unspecified cerebral artery, major depressive disorder, and unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety.
Review of Resident #29's Annual Minimum Data Set (MDS) assessment dated [DATE] revealed A Brief Interview for Mental Status was not completed due to resident was rarely or never understood. Resident #29 was dependent for toileting, bathing, and personal hygiene. Resident #29 was frequently incontinent of urine and always incontinent of bowel.
Review of Resident #29's care plan revised on 09/11/24 included Resident #29 had a history of CVA (cerebrovascular accident) with functional impairment. Resident #29 was dependent on staff for activities of daily living (ADL) and exhibits with incontinence. Resident #29's ADL needs would be met through the next review. Interventions included Resident #29 was a total assist with activities of daily living; Resident #29 was a two person assist with a mechanical lift. Resident #29 had bladder and bowel incontinence. Resident #29 would be comfortable, clean, dry and free from skin breakdown through the next review. Interventions included to monitor peri-area and rectal area for redness, irritation, and skin excoriation, breakdown; provide peri-care after each incontinent episode.
Review of Resident #29's medical record revealed the resident did not have skin break down as of 12/10/24.
Observations on 12/10/24 from 8:30 A.M. revealed Resident #29 was sitting in a padded wheelchair by a table in the common area.
Observation on 12/10/24 at 9:21 A.M. revealed Resident #29 was sitting in a padded wheelchair by the same table in the common area. Resident #29's head was laying on the table.
Observation on 12/10/24 at 11:16 A.M. revealed Resident #29 was sitting in a padded wheelchair by the same table in the common area and an aide was placing a garment to protect her clothes from food spills around her neck and across her chest.
Observation on 12/10/24 at 12:43 P.M. of Resident #29 revealed Resident #29 was sitting in the wheelchair by the same table in the common area and Certified Nursing Assistant (CNA) #400 pushed Resident #29's wheelchair from the table to the nurses station and stated she was getting ready to assist Resident #29 to bed, but she needed a mechanical lift and was waiting for a second aide to help her.
Observation on 12/10/24 at 1:12 P.M. revealed Registered Nurse (RN) #401 assisted CNA #400 to use a mechanical lift to place Resident #29 into her bed and have incontinence care provided. RN #401 stated he was not assigned to care for Resident #29 but was helping CNA #400 because the other aide was at lunch. CNA #400 proceeded to remove Resident #29's incontinence brief and a large amount of yellow urine and a large amount of feces were observed on the brief. CNA #400 began cleaning Resident #29's perineal area using a wash cloth and warm basin of water. CNA #400 wiped down with the wash cloth then back up and when the wash cloth wiped up feces could be seen on the wash cloth. CNA #400 folded the washcloth with the feces on it and kept wiping the perineal area multiple times down and then back up and each time she wiped upward a moderate amount of feces could be seen on the wash cloth. After cleaning Resident #29's perineal area CNA #400 turned Resident #29 on her right side and cleaned her rectal area. A nickel size discolored pink area could be seen in the crease of the right thigh and buttock and in the center of the discolored pink area was a small open area with a reddish-pink wound bed. CNA #400 stated the area was not open and rubbed her finger over the area, but when she rubbed her finger over the open area Resident #29 cried out in pain. CNA #400 and RN #401 confirmed Resident #29 had a small open area in the right crease of her buttock and thigh. After confirming Resident #29's open area CNA #400 took a towel and wet one side of it with water from the basin and used it to wipe Resident #29's buttocks and dry them with the end of towel not placed in water. CNA #400 and RN #401 placed a clean incontinence brief on Resident #29 and CNA #400 stated she would tell the nurse assigned to Resident #29 about the open area, have it evaluated and get treatment orders. CNA #400 stated Resident #29's incontinence brief was dry when she put her in the wheelchair before breakfast and this was the first time Resident #29 received incontinence care since she was placed in her wheelchair. CNA #400 indicated Resident #29 usually stayed in the common area until after lunch because there were activities and there was more stimulation in the common area than in her room.
Interview on 02/10/24 at 3:46 P.M. of the Director of Nursing (DON) confirmed CNA #400 did not provide incontinence care correctly.
Review of Resident #29's progress notes dated 12/10/24 at 5:34 P.M. included the nurse was notified by staff that Resident #29 had a small area to the right buttocks, the wound team was made aware, MASD (moisture associated skin damage) was present and new orders were received. Resident #29's son and physician were aware. The interdisciplinary team met, reviewed report, updated Resident #29's care plan, and treatment implemented.
Review of Resident #29's physician orders dated 12/10/24 at 5:47 P.M. revealed cleanse right and left buttocks with soap and water, pat dry, apply Triad paste and leave open to air every shift and as needed for treatment.
Review of the facility policy titled Perineal Care undated included it was the practice of the 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. If the perineum was grossly soiled, turn resident on side, remove any fecal material with toilet paper, then remove and discard. Cleanse buttocks and anus, front to back, vagina to anus in females using a separate wash cloth or wipes. Thoroughly dry. Re-position the resident in the supine position, change gloves if soiled and continue with perineal care. For females 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). Repeat on opposite side using separate section of the washcloth or a new disposable wipe. Clean urethral meatus and vaginal orifice using clean portion of the washcloth or new disposable wipe with each stroke. Pat dry with towel. Always note any skin changes such as rash, red pr pink areas or any discolorations to skin. Report to nurse when applicable.
This deficiency represents non-compliance investigated under Master Complaint Number OH00160445 and Complaint Number OH00159858.
Jun 2024
13 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
Based on observation, staff interview, and medical record review, the facility failed to treat residents with dignity while feeding. This affected one resident (#48) of three residents who were provid...
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Based on observation, staff interview, and medical record review, the facility failed to treat residents with dignity while feeding. This affected one resident (#48) of three residents who were provided assistance with feeding. The facility census was 65.
Findings Include:
Review of the medical record for Resident #48 revealed an admission date of 12/18/20. Diagnoses included cerebral infarction, seizures, dementia, and dysphasia.
Review of the quarterly Minimum Data Set (MDS) assessment, dated 06/17/24, revealed Resident #48 had severely impaired cognition.
Review of Resident #48's physician orders for June 2024 revealed an order for feeding assist with all meals on 01/24/24 and the resident was ordered a dysphasia puree texture diet on 04/22/24.
Observation on 06/25/24 at 12:29 P.M. revealed Resident #48 in was in a Broda chair (a chair designed to tilt and recline for comfort and mobility) with a plate of puree food on the table.
Observation and interview on 06/25/24 at 12:41 P.M. revealed State Tested Nurse Aide (STNA) #909 was standing beside Resident #48 while feeding her. STNA #909 confirmed she was standing and stated she knew she should sit to feed residents.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0569
(Tag F0569)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of resident funds accounts, and staff interview, the facility failed to make final disper...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of resident funds accounts, and staff interview, the facility failed to make final dispersal of resident funds within 30 days of a resident's death. This affected one (#219) of one residents reviewed for final dispersal of resident funds. The facility census was 65.
Findings Include:
Review of Resident #219's medical record revealed the resident was admitted to the facility on [DATE] and expired on [DATE].
Review of Resident #219's resident funds account revealed a check dated [DATE] for $90.56 was sent to the Attorney General and a check dated [DATE] for $1,768.00 was sent to to cover the balance due on the resident's account.
Interview on [DATE] at 2:25 P.M. with the Administrator verified Resident #219's personal funds were not disbursed within 30 days after the resident's death as required. The Administrator stated they were aware there was a problem getting the checks out within the 30 day timeframe.
CONCERN
(D)
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 medical record review, review of self-reported incidents, staff interview, and review of a facility policy, the facilit...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of self-reported incidents, staff interview, and review of a facility policy, the facility failed to report an allegation of abuse, neglect, or injury of unknown origin to the State Survey Agency as required. This affected one (#67) of two residents reviewed for abuse. The facility census was 65.
Findings Included:
Review of the medical record revealed Resident #67 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD), congestive heart failure, high blood pressure, and nicotine dependence. Resident #67 discharged from the facility against medical advice (AMA) on 04/17/24.
Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #67 was cognitively intact and required one person physical assistance for completing activities of daily living.
Review of a progress note dated 04/16/24 at 8:00 A.M. revealed Resident #67 was observed in room during tray pass for breakfast and it was observed that Resident #67's nose and lips were swollen surrounded with small amount of dry blood. Resident #67 was asked what happened and the resident stated that a lighter was lit in his room and it blew up in his face at about 2:00 A.M. or 3:00 A.M. Resident #67 indicated he was not a snitch and refused to give staff any information
Review of self-reported incidents (SRIs) submitted to the Ohio Department of Health's Enhanced Information Dissemination Collection System (EIDC) (database used for facilities to report required instances of abuse, neglect, injuries of unknown origin, and misappropriation) revealed no report was filed related to Resident #67's claim on 04/16/24 that an unknown person lit a lighter in his room and caused injuries to his face.
Interview with Administrator on 06/26/24 at 10:00 A.M. verified the facility did not file a report with the State Survey Agency for Resident #67's allegations on 04/16/24 as required.
Review of the policy titled, Abuse, Neglect, Exploitation, & Misappropriation of Resident Property, dated 10/01/20, revealed all incidents and allegations of abuse, neglect, and exploitation, mistreatment of a resident, or misappropriation of resident property, and all injuries of unknown source must be reported immediately to the Administrator or designee. If the event that caused the allegation involves an allegation of abuse or serious bodily injury, it should be reported to the Ohio Department of Health immediately, but not no later than two (2) hours after the allegation is made.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
MDS Data Transmission
(Tag F0640)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to electronically transmit encoded, accurate, and comple...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to electronically transmit encoded, accurate, and complete Minimum Data Set (MDS) assessment data to the Centers for Medicare and Medicaid (CMS) system within 14 days of completing the assessment. This affected one (#2) of three residents reviewed for discharge. The facility census was 65.
Findings:
Review of the medical record for Resident #2 revealed a discharge MDS assessment dated [DATE] had been completed but not transmitted as of 06/24/24. Resident #2 was discharged from the facility after he failed to return from an authorized leave of absence (LOA) on 01/01/24.
During interview on 06/26/24 at 1:15 P.M., the Director of Nursing (DON), Licensed Practical Nurse (LPN) #905, and Social Worker #922 confirmed Resident #2 left on an authorized leave of absence and did not return.
Follow up interview on 06/26/24 at 1:40 P.M., the DON confirmed Resident #2's discharge MDS assessment had not been transmitted until 06/26/24.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0645
(Tag F0645)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure a Preadmission Screening and Resident Review (...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure a Preadmission Screening and Resident Review (PASARR) Level I screen was completed after a resident remained in the facility longer than 30 days as required. This affected one (#13) of two residents reviewed for PASARR. The facility census was 65.
Findings Include:
Review of the medical record revealed Resident #13 was admitted to the facility on [DATE] with diagnoses that included schizophrenia, chronic obstructive pulmonary disease, and high blood pressure.
Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #13 was cognitively intact and required minimum assistance for completing his activities of daily living.
Review of the medical record revealed a PASARR was completed for Resident #13's stay in the facility on 04/09/24.
Social Worker (SW) #922 verified Resident #13's PASARR was not completed timely as required in an interview on 06/26/24 at 1:30 P.M.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to timely act upon pharmacist recommendations to address...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to timely act upon pharmacist recommendations to address any medication irregularities in the medical record. This affect one (#40) of five residents reviewed for unnecessary medications. The facility census was 65.
Findings Include:
Review of the medical record revealed Resident #40 was admitted to the facility on [DATE] with diagnoses that included visual hallucinations, repeated falls, and bipolar disorder.
Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #40 was moderately cognitively impaired and required the assistance of one staff person for completing her activities of daily living.
Review of a pharmacist recommendation dated 03/04/24 revealed Resident #40 had a physician's order dated 03/16/23 for the medication carvedilol (medication used to treat high blood pressure) with instructions to give 6.25 milligrams (mg) by mouth two times a day for hypertension (high blood pressure) and hold for systolic blood pressure (SBP) below 100 millimeters of mercury (mmhg) and/or a heart rate below 60 beats per minute. The pharmacist noted nursing was no longer taking and documenting blood pressure and pulse prior to administration as required. The pharmacist further documented for Resident #40's physician to updated the order entry in the facility's medical record system to force nursing to document the blood pressure and pulse with each dose, and also educate nursing staff that any order with a parameter attached to it required the parameter to be checked, and the dose to be held, when the parameter(s) fall outside of the stated range.
Review of Resident #40's medication administration record (MAR) for March 2024 revealed blood pressure monitoring was added and completed, but no pulse monitoring was completed as recommended by the pharmacist.
Review of the pharmacist recommendation dated 04/01/24 revealed the pharmacist noted further that pulse monitoring was continuing not to take place related to Resident #40's physician order for carvedilol.
The Director of Nursing verified the facility did not respond to the pharmacist's notification in a timely manner of a lack of obtaining Resident #40's pulse prior to administering carvedilol in an interview on 06/27/24 at 9:30 A.M.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0757
(Tag F0757)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and review of a facility policy, the facility failed to adequate monitoring was...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and review of a facility policy, the facility failed to adequate monitoring was completed as ordered prior to the administration of a medication. This affected one (#40) of five residents reviewed for unnecessary medications. The facility census was 65.
Findings Include:
Review of the medical record revealed Resident #40 was admitted to the facility on [DATE] with diagnoses that included visual hallucinations, repeated falls, and bipolar disorder.
Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #40 was moderately cognitively impaired and required the assistance of one staff person for completing her activities of daily living.
Review of a physician order dated 03/16/23 revealed Resident #40 was ordered carvedilol (medication used to treat high blood pressure) with instructions to give 6.25 milligrams (mg) by mouth two times a day for hypertension (high blood pressure) and hold for systolic blood pressure (SBP) below 100 millimeters of mercury (mmhg) and/or a heart rate below 60 beats per minute.
Review of Resident #40's medication administration records from September, October, November, and December 2023, and January and February 2024 revealed no documented blood pressures or pulse measurements were taken as ordered prior to giving the medication.
Review of a pharmacist recommendation dated 03/04/24 revealed the pharmacist noted nursing was no longer taking and documenting blood pressure and pulse prior to administration as required. The pharmacist further documented for Resident #40's physician to updated the order entry in the facility's medical record system to force nursing to document the blood pressure and pulse with each dose, and also educate nursing staff that any order with a parameter attached to it required the parameter to be checked, and the dose to be held, when the parameter(s) fall outside of the stated range.
Interview with the Director of Nursing on 06/27/24 at 9:30 A.M. verified the nursing staff did not obtain Resident #40's blood pressure or pulse prior to administering carvedilol as ordered in September 2023 through February 2024.
Review of the policy titled, Administering Medications, dated 04/01/19, revealed medications are administered in accordance with prescriber orders, including any required time frame.
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 ensure insulin was dated when opened, was store...
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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 ensure insulin was dated when opened, was stored in the container for the resident it was ordered for, and was disposed of once expired. This affected five (#13, #15, #26, #33, and #40) of thirteen residents who receive insulin. The census was 65.
Findings include:
1. Observation on [DATE] at 3:14 P.M. revealed a used injector pen of Humalog insulin for Resident #33 was stored in a medication cart. The pen was open and in use with no date written when use began. Interview during the observation with Licensed Practical Nurse (LPN) #905 stated all insulin pens should be dated when initially opened and verified Resident #33's insulin injector pen was not dated.
2. Observation on [DATE] at 3:23 P.M. revealed a used injector pen of Lispro insulin for Resident #13 and Resident #15 were stored in a medication cart. The pens were open and in use with no date written when use began. Further observation of the medication cart revealed an open vial of Lispro insulin for Resident #26 that was dated [DATE], and an opened vial of Humalog insulin for Resident #40 that was stored in a box labeled for Resident #15.
Interview during the observation of the medication cart on [DATE] at 3:23 P.M., Assistant Director of Nurse (ADON) #930 stated all insulin pens should be dated when initially opened and insulin generally expires 28 days after opening and should be removed from the medication cart. ADON #930 verified Resident #13 and Resident #15's insulin was not dated, verfiied Resident #26's Lispro insulin was past expiration, and verified Resident #40's vial of Humalog insulin was stored in a box labeled for Resident #15.
Review of the facility policy titled, Insulin Storage and Dispensing Information, dated 2021, revealed Lispro and Humalog insulin is good for 28 days.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observation, staff interview, and policy review, the facility failed to store food in a safe and sanitary manner. This affected six (#3, #10, #44, #48, and #172) of 31 residents residing on t...
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Based on observation, staff interview, and policy review, the facility failed to store food in a safe and sanitary manner. This affected six (#3, #10, #44, #48, and #172) of 31 residents residing on the 300 and 400 units. The census was 65.
Findings include:
Observation on 06/24/24 at 3:14 P.M. revealed four containers of applesauce that were not dated and a container of pudding dated 06/20/24 were sitting in the top drawer of the medication cart. The containers were warm to the touch. Another container of applesauce dated 06/20/24 was currently provided to residents who had difficulty swallowing medications.
Interview on 06/24/24 at 3:20 P.M. with Licensed Practical Nurse (LPN) #905 stated the containers of applesauce and pudding were in the medication cart when she arrived, so she used them. LPN #905 removed all containers from the cart and stated the containers should have been dated.
The facility identified six (#3, #10, #44, #48, and #172) residents who utilized applesauce or pudding with medication administration on the 300 and 400 units.
Review of the facility policy titled, Dating for Food Storage, dated 2021, revealed staff were to date foods that were time and temperature controlled (applesauce and pudding) when made and document the use by date as well. The foods should also be kept for designated days and be stored at 41 degrees Fahrenheit or lower.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected most or all residents
Based on record review, staff interview, and review of the Centers for Disease Control and Prevention (CDC) guidance for water management, the facility failed to provide evidence of water testing cond...
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Based on record review, staff interview, and review of the Centers for Disease Control and Prevention (CDC) guidance for water management, the facility failed to provide evidence of water testing conducted to monitor and prevent the growth of Legionella (a bacteria that causes Legionnaire's disease) in the building water system. This had the potential to affect all 65 residents in the facility. The census was 65.
Findings Include:
During the entrance conference, the facility was asked to provide a copy of the Legionella water management program and evidence of water testing being conducted. The facility provided the policy titled, Legionella Water Management Program, revised September 2022; however, the facility had no evidence to support that regular testing for Legionella was being done in the building.
Interview on 06/27/24 at 12:50 P.M. with the Administrator verified the facility had no documented evidence of water testing related to Legionella prevention.
During a follow up interview on 06/27/24 at 1:00 P.M., Maintenance Director (MD) #915 indicated the facility did conduct water testing from different water sources in the facility and send the samples out; however, the results do not return for two to three weeks. MD #915 stated the facility had been unable to locate the previous maintenance director's records and were unable to provide evidence of routine water testing.
Review of the CDC document titled, Overview of Water Management Programs, dated 03/15/24, revealed water management programs require regular monitoring of key areas for potentially hazardous conditions.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0921)
Could have caused harm · This affected most or all residents
Based on observation, staff interview, review of a State Fire Marshal report, and policy review, the facility failed to maintain a safe, clean, sanitary, and well maintained environment and equipment....
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Based on observation, staff interview, review of a State Fire Marshal report, and policy review, the facility failed to maintain a safe, clean, sanitary, and well maintained environment and equipment. This had the potential to affect all 65 residents residing in the facility. The facility census was 65.
Findings Include:
1. An environmental tour was conducted on 06/26/24 between 9:30 A.M. and 9:45 A.M. with Maintenance Director (MD) #915. Observation of the carpeting throughout the facility was significant discolored and stained. The ceiling in the 400 hall dining room area was completely ripped off and plastic sheeting was covering the ceiling to prevent debris from falling. One of the walls of the dinning room was completely taken down to the wooden studs. Observation of the 300 and 400 Hall tub room had drilled out holes in the shower room that were directly in front of the room. The holes exposed rusted pipes and numerous cob webs. Observation of the ceiling light about the 100 and 200 Hall nurses' station did not have a cover. The 100 and 200 Hall tub room had a noted brown substance on the floor that was not easily removed and various other debris on the floor including an open ketchup packet. Further observation of the 100 and 200 Hall tub room revealed numerous other towels that were discolored and wet were thrown about in the room. Observation of the laundry area revealed multiple ceiling tiles completely off the ceiling along with other water damaged areas exposing the piping above the ceiling. Lights covers observed throughout the facility contained numerous dead insects inside the light covers.
Further observation during the tour on 06/24/24 between 9:30 A.M. and 9:45 A.M. revealed the tube feeding pole used by Resident #4 had significant amount of dried and caked on residual tube feeding supplement at the bottom of the pole. The stand up closet next to Resident #48's bed had the back panel half off and exposing multiple nails. The room occupied by Resident #6 and Resident #21 had a large hole in the bathroom door and a significant area of stained black and brown substances on the bathroom floor. Resident #58's bathroom also had black and brown substances on the bathroom floor. The privacy curtains in the rooms occupied by Resident #11, Resident #20, Resident #25, Resident #30, and Resident #211 were stained with various unknown substances. The base board behind Resident #37 and Resident #45's beds was hanging off the wall exposing the drywall.
Interview with MD #915 during the tour stated the facility had a major flood related to pipes breaking in January 2024 causing the ceiling to collapse. MD #915 further explained that repairs were just approved on 06/20/24 and work was expected to begin on sometime in July 2024. MD #915 verified all the environmental concerns at the time of discovery during the tour.
Review of the State Fire Marshal report from 06/20/24 revealed (regarding the 300 hall dinning room area) the area had a water leak earlier this year and needs to be repaired as soon as possible (ASAP). There is a shock risk because there are many open junction boxes with exposed wires. The missing drywall also will allow smoke and flame spread if they would have a fire.
2. Observation on 06/24/24 at 8:35 A.M. revealed Resident #12's electric wheelchair was in the hallway and the wheelchair had food debris and dust covering the arm rests, seat, and footrest.
Interview on 06/24/24 at 8:47 A.M., with the Director of Nursing (DON) verified the observation of Resident #12's wheelchair and directed staff to clean the wheelchair.
3. Observation on 06/25/24 at 3:52 P.M. revealed Resident #56's wheelchair was missing the right armrest and the vinyl on the left armrest was cracked exposing the padding underneath.
Interview on 06/25/24 at 3:55 P.M., with the DON verified the observations and directed staff to replace the wheelchair.
Review of the facility policy titled, Cleaning and Disinfection of Resident-Care Equipment, dated 2024, revealed direct staff were responsible for cleaning single-resident equipment when visibly soiled.
MINOR
(C)
Minor Issue - procedural, no safety impact
Deficiency F0575
(Tag F0575)
Minor procedural issue · This affected most or all residents
Based on observation and staff interview, the facility failed to ensure all required postings were on displaying in the facility in a manner that was accessible and understandable. This had the potent...
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Based on observation and staff interview, the facility failed to ensure all required postings were on displaying in the facility in a manner that was accessible and understandable. This had the potential to affect all 65 residents residing in the facility. The facility census was 65.
Findings Include:
Observation of the facility on 06/26/24 between 2:45 P.M. and 3:00 P.M. revealed no evidence of posted contact information for the State Survey Agency and other pertinent agencies and advocacy groups, including the State licensure office, adult protective services, the Office of the State Long-Term Care Ombudsman program, the protection and advocacy network, home and community based service programs, and the Medicaid Fraud Control Unit, were accessible to residents and resident representatives.
The Administrator verified that such required information was not posted in an interview on 06/26/24 at 3:10 P.M.
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 daily nursing staffing information was up-to-date and posted in a prominent place readily accessible to residents and visitors. ...
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Based on observation and staff interview, the facility failed to ensure daily nursing staffing information was up-to-date and posted in a prominent place readily accessible to residents and visitors. This had the potential to affect all 65 residents residing in the facility. The facility census was 65.
Findings Include:
Observation of the posted nursing staff information on 06/24/24 at 8:45 A.M. revealed the posted nursing staff information was located on a bulletin board inside a staffing information area near the front desk that was not visible to residents and visitors. Further observation revealed the posted nursing staffing information was dated 06/14/24.
Receptionist #955 verified the posted nursing staffing information was not current and not visible to residents or visitors in the facility during an interview on 06/24/24 at approximately 8:45 A.M.
Apr 2024
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
Pressure Ulcer Prevention
(Tag F0686)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of the facility policy the facility failed to ensure individualized c...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of the facility policy the facility failed to ensure individualized care planned interventions were developed and followed to prevent Resident #17 from developing pressure ulcers, and failed to ensure the pressure ulcers were timely identified, properly treated, and interventions were initiated to promote healing.
Actual Harm occurred on 01/06/24 when Resident #17 who was cognitively impaired, at risk for pressure ulcer development, and required assistance with bed mobility, developed new, in-house acquired bilateral heel pressure ulcers that were first assessed to be unstageable (a type of bed sore that occurred due to prolonged pressure on a specific area of the skin, resulting in the lack of blood flow and oxygen to the tissue. It is a full thickness tissue loss where the depth of the wound or bed sore was completely obscured by eschar in the wound bed) without proper prevention, treatment, and interventions implemented. This affected one resident (Resident #17) out of three residents reviewed for pressure ulcers. The facility census was 67.
Findings include:
Review of Resident #17's medical record revealed an admission date of 03/15/23 and diagnoses included epilepsy, unspecified, intractable, with status epilepticus, edema, and type two diabetes mellitus.
Review of Resident #17's care plan dated 10/18/23 included Resident #17 was at risk for potential for alteration in skin integrity related to decreased mobility. Resident #17 would not develop any skin breakdown through the comprehensive review target date of 01/25/24. Interventions included pressure reducing cushion to the chair, pressure reducing mattress to the bed and evaluate Resident #17's specific risk factors. There were no interventions related to turning and repositioning or off loading heels from the mattress. There were no additional care plans or interventions related to Resident #17's bilateral pressure ulcers until 03/04/24 which was two months after pressure ulcers were identified.
Review of Resident #17's Braden Scale dated 12/16/23 revealed Resident #17 was at moderate risk for developing a pressure ulcer, injury.
Review of Resident #17's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #17 did not have a pressure ulcer, injury.
Review of Resident #17's Weekly Skin Evaluation dated 01/01/24 included Resident #17's skin was intact and dry. Resident #17 had bilateral lower extremity pitting edema and diuretics were continued.
Review of Resident #17's Annual Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #17 had severe cognitive impairment. Resident #17 required partial to moderate assistance to roll from lying on back to left and right side, and return to lying on back on the bed, to move from lying on the back to sitting on the side of the bed and with no back support. Resident #17 required substantial to maximal assistance for toileting and personal hygiene. Resident #17 had a pressure ulcer, but the stage was not documented.
Review of Resident #17's progress notes dated 01/06/24 at 5:31 P.M. revealed on 01/05/24 at 11:00 P.M. Resident #17 had an open area on the back of his right ankle and heel, area soft and mushy. Resident #17 had an area to the left heel which was soft but unopened. Areas cleansed with normal saline and silver alginate was applied. Medihoney was applied to the right ankle and heel. ABD pad applied to both areas and wrapped with Kerlix.
Review of Resident #17's physician orders dated 01/05/24 through 01/08/24 did not reveal orders to cleanse the right ankle and heel open areas with normal saline and apply silver alginate or to apply medihoney to the right ankle and heel. There were no orders to apply an ABD (abdominal) pad and wrap with Kerlix for both heels.
Review of Resident #17's physician orders dated 01/06/24 revealed orders for heel protectors while in bed, every shift Resident #17 to have heel protectors while in bed.
Review of Resident #17's physician orders from 01/06/24 through 04/09/24 did not reveal orders for turning and repositioning.
Review of Resident #17's progress notes from 01/06/24 through 04/09/24 did not reveal evidence Resident #17 was turned and repositioned.
Review of Resident #17's aide charting from 01/06/24 through 04/09/24 did not reveal a task for turning and repositioning Resident #17.
Review of Resident #17's Weekly Pressure Report Only dated 01/08/24 included Resident #17 had pressure ulcers of the right and left heel, and the pressure ulcers were first observed on 01/06/24. Resident #17 had a right heel unstageable pressure injury and measurements were length 7.9 cm, width 8.7 cm and depth was UTD (unable to determine). Resident #17 had an unstageable left heel pressure ulcer and measurements were length 5.6 cm, width 4.9 cm and depth UTD.
Review of Resident #17's Wound Care notes dated 01/08/24 included Resident #17 presented with heel wounds. Resident #17 was a long term care resident of the facility and was confused, weak, poorly mobile and quite frail appearing. Wound Care Physician (WCP) #260 wrote he was asked to evaluate Resident #17's heels and the right heel had an unstageable pressure ulcer and measurements were length 7.9 centimeters (cm), width 8.7 cm and depth UTD (unable to determine) cm. The wound base was composed of 90 percent granulation tissue and 10 percent eschar. The entire base of the heel is open tissue with pink granulation tissue, and there were a few small patches of eschar. The wound was draining serous fluid. Prevalon boots at all times to relieve pressure. This was the initial evaluation of Resident #17's right heel and treatment was pack wound with alginate, cover with ABD (abdominal pad), pad and wrap with Kerlix. Change and apply treatment daily and prn (as needed). Please consider Prevalon boots. Further review of the notes included the second wound was an unstageable pressure injury located on the left heel. Half of the wound was thick, dry well adhered eschar and half black non-blanching tissue. The area was dry and not draining. Start skin prep to mature the eschar and measurements were length 5.6 cm, width 4.9 cm and depth UTD cm. The wound base was composed of 50 percent DTPI (deep tissue pressure injury) tissue. This was the initial evaluation of Resident #17's left heel wound and treatment was apply skin prep, cover with ABD pad and wrap with Kerlix daily and prn. Additional orders were Prevalon boots (heel protection boots which lift the heel to help prevent the development of heel pressure injuries).
Review of Resident #17's care plan dated 03/04/24 included Resident #17 had actual skin integrity related to an unstageable wound of the left heel and a stage three pressure ulcer of the right heel. Resident #17's skin injury would be healed by the review date of 04/18/24. Interventions included to educate resident, family, caregivers of causative factors and measures to prevent skin injury, and pressure relieving device in bed. There was no evidence of interventions related to Prevalon boots, off loading heels from the mattress or a turning and repositioning schedule.
Review of Resident #17's Braden Scale dated 03/16/24 revealed Resident #17 was at moderate risk to develop a pressure ulcer or injury.
Review of Resident #17's Wound Care notes dated 04/09/24 included Resident #17's right heel wound was a stage three pressure ulcer (Full-thickness loss of skin, in which subcutaneous fat may be visible in the ulcer and granulation tissue and rolled wound edges are often present. Slough and/or eschar may be visible but do not obscure the depth of tissue loss). and measurements were length 4.2 cm, width 3.4 cm and depth was 0.2 cm with intact skin bridge present. The wound base was 100 percent granulation tissue with moderate serous drainage. Wound status was slightly larger but remained clear. Continue to wear protective boots. Treatment was cleanse wound with normal saline, pat dry, cover with ABD pad and wrap with Kerlix. Skin prep heel, pack deepest part of the wound bed with moistened collagen. Change and apply treatment daily and prn. Continue to wear protective boots. Further review revealed Resident #17's left heel wound was an unstageable pressure ulcer and measurements were length 1.1 cm, width 2.2 cm and UTD cm. Wound base was 100 percent slough with moderate serous drainage. Sharp, excisional debridement was performed using a scalpel and forceps. The tissue was debrided down to the muscle and eschar was removed. Post debridement measurements were length 1.1 cm, width 2.2 cm and depth UTD cm. Area debrided was three square cm. Treatment orders were cleanse left heel wound with normal saline, pat dry, apply Santyl ointment followed by calcium alginate to wound bed. Cover with ABD pad and wrap with Kerlix, Change and apply treatment daily and prn. Recommendations included pressure reduction mattress per facility protocol, offload heels per facility protocol, reposition per facility protocol. The plan of care was discussed with nursing staff and resident.
Review of Resident #17's physician orders dated 04/09/24 revealed orders for Santyl ointment 250 Unit/Gram, apply to left heel topically every night shift for wound care. There was no evidence calcium alginate was ordered to be applied to the left heel after Santyl ointment was applied.
Review of Resident #17's Treatment Administration Record (TAR) dated 04/09/24 revealed Santyl Ointment 250 Unit/Gram, apply to left heel topically every night shift for wound care. Registered Nurse #252 signed the TAR on 04/09/24 that she applied Santyl Ointment to the left heel, but there was no evidence calcium alginate was applied to Resident #17's left heel after the Santyl ointment was applied. Further review of the TAR dated 04/10/24 at 1:02 A.M. revealed Registered Nurse (RN) #252 documented she applied Santyl Ointment topically to both feet.
Observation on 04/09/24 at 4:10 P.M. of Resident #17 revealed he was lying on his back in bed, had slid down in the bed, both feet were pressed firmly against the footboard, and his heels were resting directly on the mattress. Both Resident #17's right and left ankles and heels had dressings noted, and the dressings were not dated. Resident #17 did not have Prevalon boots on and was not lying on a low air loss mattress.
Interview on 04/09/24 at 4:10 P.M. of Resident #17 revealed he was pleasantly confused and unable to answer questions.
Observation on 04/09/24 at 4:12 P.M. of Resident #17 with Wound Nurse/Licensed Practical Nurse (WN/LPN) #235 revealed Resident #17 was lying on his back in bed, had slid down in the bed, both feet were pressed firmly against the footboard, and his heels were resting directly on the mattress. Both Resident #17's right and left ankles and heels had dressings, and the dressings were not dated. Resident #17 was not wearing Prevalon boots and was not lying on a low air loss mattress. WN/LPN #235 confirmed Resident #17 did not have Prevalon boots on, the dressings were not dated, his feet were pressed up against the footboard and his heels were directly on the mattress. WN/LPN #235 confirmed Resident #17 was not lying on a low air loss mattress, but his current mattress was a pressure reduction mattress with a perimeter mattress. WN/LPN #235 stated Resident #17 was very tall and staff had to keep moving him up in his bed.
Observation on 04/10/24 at 8:00 A.M. of Resident #17 with Licensed Practical Nurse (LPN) #204 revealed Resident #17 was lying in bed on his back, had slid down in the bed, his left foot was pressed firmly against the footboard, his right leg was bent and both heels were resting directly on the mattress. Resident #17 was not wearing Prevalon boots. Observation revealed Resident #17's Prevalon boots were lying on the floor next to the wall in his room. LPN #204 confirmed Resident #17 was not wearing Prevalon boots, his heels were not offloaded to reduce pressure on his heels, and LPN #204 left the room to find an aide to help move Resident #17 up in the bed. LPN #204 returned to the room with State Tested Nursing Assistant (STNA) #212 and moved Resident #17 up in the bed. LPN #204 stated Resident #17 slid down in the bed frequently, his feet pressed against the footboard, and it could be because he was tall and the bed was not long enough for him. LPN #204 indicated the facility could order a longer bed for Resident #17. Neither LPN #204 or STNA #212 put Resident #17's Prevalon boots on him to offload his heels from the mattress.
Interview on 04/10/24 at 8:00 A.M. with STNA #212 revealed she was not assigned to care for Resident #17 today, and right now there was no aide assigned to care for Resident #17 because STNA #232 had not arrived to work and Resident #17 was in STNA #232's assignment. STNA #212 stated all the aides were watching over STNA #232's residents until she arrived. STNA #212 stated she had not repositioned Resident #17 or provided care for him today. STNA #212 stated she was not usually assigned to care for Resident #17 and did not know anything about his bilateral heel wounds.
Observation on 04/10/24 at 9:15 A.M. of Resident #17 revealed STNA #223 was feeding Resident #17 and LPN #204 was completing dressing changes of his heels. Observation of LPN #204 revealed she was changing Resident #17's right heel dressing. LPN #202 stated she cleansed Resident #17's right heel with normal saline, patted it dry, and applied skin prep before the surveyor entered the room. LPN #204 held Resident #17's right heel up and with the surveyor observed Resident #17's right heel wound. The wound was about one and half inches by one inch, was reddish-pink in color, small amount of clear drainage and a skin bridge was intact. Further observation revealed Resident #17's right heel had a very dark, blackened area to his right heel about the size of a quarter, and the blackened area was close to the wound LPN #204 was completing a dressing change on. LPN #204 confirmed the dark, black area on Resident #17's right heel. Observation revealed LPN #17 provided a clean barrier under Resident #17's right heel, donned clean gloves, applied collagen, an ABD pad, then wrapped the heel with Kerlix. LPN #204 stated she had already completed Resident #17's left heel dressing, the tissue was soft, a small amount of reddish-brown drainage was noted, and she cleansed the left heel wound with normal saline, applied Santyl ointment, followed by an ABD pad and then wrapped the heel with Kerlix. LPN #204 stated she did not apply alginate to the wound. When asked about Resident #17 not having Prevalon boots on to offload his heels from the bed, LPN #204 stated she was just getting ready to put them on and walked over to the Prevalon boots lying against the wall and put them on Resident #17's heels.
Interview on 04/10/24 at 9:15 A.M. with STNA #223 revealed she was only feeding Resident #17 to help out, did not have him in her assignment, and had not provided care or repositioning for him. STNA #223 stated she did not know Resident #17 and was not usually assigned to work on the nursing unit he resided on.
Interview on 04/10/24 at 9:48 A.M. with STNA #233 revealed there was no permanent STNA assigned to take care of residents residing on the nursing unit Resident #17 resided on. STNA #233 stated she did not routinely take care of Resident #17 and could not name any aide who would know him and would be able to talk about his bilateral heel sores. STNA #233 stated she never looked at Resident #27's heels when she cared for him, but she did know he had sores on them.
Interview on 04/10/24 at 10:52 A.M. with WN/LPN #235 revealed she was made aware Resident #17 was not wearing his Prevalon boots while he was in bed and his heels were not offloaded off the mattress. WN #235 stated she would need to educate the staff about the importance of Resident #17 wearing Prevalon boots.
Interview on 04/10/24 at 12:22 P.M. with Certified Wound Nurse Practioner (CWNP) #261 revealed she did not see a quarter sized, very dark and blackened area on Resident #17's right heel close to his existing wound when she saw him on 04/09/24. CWNP #261 stated if she had seen it she would have documented the observation and ordered a treatment if needed. CWNP #261 stated she would have skin prep applied to the area and would evaluate the area on her next visit to the facility. CWNP #261 stated a pressure injury could happen very quickly, and could happen in one day or even in an hour.
Interview on 04/10/24 at 12:45 P.M. with WN/LPN #235 revealed Resident #17's right and left heel pressure ulcers were found on 01/06/24, it was a weekend, she was not working, but the nurse who found the pressure ulcers notified her via a text message on her phone. WN/LPN #235 was not aware Resident #17 had a blackened area on his right heel close to his existing pressure ulcer, and she would look at it on 04/11/24 when his dressing change was completed. WN/LPN #235 did not want to take the dressing off on 04/10/24 to observe the area because he just had his dressing changed and she did not want to put him at risk by doing a second dressing change.
Interview on 04/10/24 at 1:07 P.M. with STNA #212 revealed she had Resident #17 in her assignment because STNA #232 took a different assignment when she arrived. STNA #212 stated she took care of Resident #17 since around 9:30 A.M. STNA #212 stated she assisted Resident #17 to his chair in his room because his son came to visit and asked her to help Resident #17 get out of bed and into his chair. STNA #212 stated she got another aide to help her assist Resident #17 to his chair. STNA #212 stated Resident #17 was lying on his back in bed and she had not repositioned him from 7:00 A.M. until about 10:30 A.M. when she transferred him to his chair. STNA #212 stated Resident #17 did not typically refuse care or repositioning.
Interview on 04/10/24 at 1:13 P.M. with WN/LPN #235 and the Director of Nursing (DON) revealed the physician orders placed on 04/09/24 in Resident #17's electronic record for his left heel were not correct and when WN/LPN #235 placed the orders she forgot to put Santyl ointment followed by calcium alginate, ABD pad and Kerlix. WN/LPN #235 stated because she did not place the orders correctly the TAR was also wrong and on 04/10/24 LPN #204 did not apply calcium alginate after the Santyl was applied and before placing the ABD pad and wrapping with Kerlix. The DON stated the documentation on the TAR of Santyl to Resident #17's both feet was probably a mistake.
Interview on 04/10/24 at 2:35 P.M. with the DON revealed she could explain why there were no orders for treatments to Resident #17's right and left heel wounds in his electronic record on 01/05/24. The DON stated the facility was transitioning from one electronic system to another in early January and Resident #17's orders were placed on a paper TAR and did not get transcribed into his electronic record. The DON indicated she would try to find Resident #17's paper TAR which was in the medical records area in the basement of the facility, left the room to find it and arrived a short time later with Resident #17's paper TAR dated 01/05/24 with orders for treatments to the right and left heel wounds.
Interview on 04/11/24 at 1:05 P.M. with Minimum Data Set (MDS) Nurse #234 revealed the Annual MDS assessment dated [DATE] had a mistake which she corrected. MDS #234 stated Resident #17 did not have a pressure ulcer on that assessment and the question if Resident #17 had a pressure ulcer should have been marked no.
Review of the facility policy titled Pressure Injury Prevention and Management reviewed 08/22/22 included the facility was committed to the prevention of avoidable pressure injuries, unless clinically unavoidable, and to provide treatment and services to heal the pressure ulcer, injury, prevent infection and the development of additional pressure ulcers, injuries. Licensed nurses would conduct a Braden Scale pressure injury risk assessment whenever the resident's condition changed significantly. Evidence-based interventions for prevention would be implemented for all residents who were assessed at risk or who had a pressure injury present. Interventions included to redistribute pressure such as repositioning, protecting and, or offloading heels etcetera, provide appropriate, pressure-redistributing, support surfaces. Interventions on a resident's plan of care would be modified as needed. Considerations for modifications included new onset or recurrent pressure injury development.
Review of the policy titled Specialty Mattresses revised 07/2018 included specialty mattresses were not typically used for extremities that could be elevated or would benefit from the use of pressure reduction devices such as pillows, pressure reduction boots. Use of low-air-loss mattresses was reserved for residents with stage three and stage four pressure ulcers.
This deficiency represents non-compliance investigated under Complaint Number OH00151992.
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 observation, interview, record review and review of the facility policy, the facility failed to ensure Resident's #1, #...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and review of the facility policy, the facility failed to ensure Resident's #1, #24 and #55 received proper, timely incontinence care. This affected three resident's (Resident's #1, #24 and #55) out of four resident's reviewed for incontinence care.
Findings include:
1. Review of Resident #55's medical record revealed an admission date of 02/04/22 and diagnoses included cerebral infarction, pseudobulbar affect, and type two diabetes mellitus with ketoacidosis without coma.
Review of Resident #55's Annual Minimum Data Set (MDS) 3.0 assessment revealed Resident #55's Brief Inteview for Mental Status was not assessed. Resident #55 was always incontinent of urine and bowel. Resident #55 was dependent for all ADL's (Activity of Daily Living) including toileting and personal hygiene.
Review of Resident #55's care plan revised 05/18/22 included Resident #55 experienced bowel incontinence. Resident #55's toileting needs would be met by staff, with interventions aimed at the prevention of infection and, or skin impairment. Interventions included inspect for skin breakdown and intervene when needed, and provide incontinence care every two hours and as needed, apply house moisture barrier cream as needed.
Observation on 04/08/24 at 5:35 A.M. of State Tested Nursing Assistant (STNA) #251 preparing to provide incontinence care for Resident #55 revealed STNA #251 prepared a basin of warm soapy water, gathered supplies including two incontinence briefs and proceeded to provide incontinence care for Resident #55. STNA #251 removed Resident #55's incontinence brief, and when the incontinence brief was removed it was revealed Resident #55 was wearing two incontinence briefs. STNA #251 confirmed Resident #55 was wearing two incontinence briefs and said Resident #55 was a heavy wetter. Both incontinence briefs were soaked with urine, and further observation revealed the folded sheet under Resident #55 used as a draw sheet was extremely wet with urine. Observation revealed Resident #55's fitted sheet covering his mattress was dirty and had dried unidentified material stuck to it. STNA #251 confirmed the sheet had dried material on it, scraped some of the dried material with his fingers and brushed it on the floor. STNA #251 continued with Resident #55's incontinence care, picked up one of the two clean incontinence briefs, tore the tabs off and placed the brief inside the second brief. STNA #251 stated he had to use two incontinence briefs for Resident #55 because he was a heavy wetter, and he made a liner by ripping the tabs off one of the incontinence briefs. STNA #251 put the incontinence brief with the makeshift liner on Resident #55, finished with the incontinence care and left Resident #55's room.
Interview on 04/08/24 at 10:00 A.M. with the Director of Nursing (DON) revealed it was not acceptable to have two incontinence briefs on residents and she would start educating the staff right away.
Review of the facility policy titled Perineal Care undated included it was the practice of the 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.
2. Review of Resident #1's medical record revealed an admission date of 12/28/21 and diagnoses included pruritus, dementia and unspecified psychosis not due to a substance or known physiological condition.
Review of Resident #1's Quarterly MDS 3.0 assessment dated [DATE] revealed Resident #1 had severe cognitive impairment. Resident #1 was always incontinent of urine and bowel. Resident #1 was dependent on staff for toileting hygiene and bathing.
Review of Resident #1's care plan revised 08/31/21 included Resident #1 had episodes of bladder and bowel incontinence related to impaired mobility and diagnoses. Resident #1 would be at a reduced risk for complications from incontinence through the next review. Resident #1 would be comfortable, clean, dry and free from skin breakdown through the next review. Interventions included to assist Resident #1 with toileting needs, provide peri care after each incontinence episode, apply house barrier cream after incontinence care.
Review of Resident #1's aide charting in the electronic medical record revealed on 04/08/24 at 1:25 A.M. Resident #1 was incontinent of urine and care was provided. There was no further evidence on 04/08/24 from 1:25 A.M. through 7:00 A.M. that Resident #1 was incontinent of urine and care was provided. Further review revealed there was no evidence on 04/08/24 from 12:00 A.M. through 6:59 A.M. that Resident #1 was incontinent of bowel and incontinence care was provided.
Observation on 04/08/24 at 6:17 A.M. of Resident #1 revealed Resident #1 was in the bathroom sitting in her wheelchair next to the sink, the water was running, and a very unpleasant strong odor of feces and urine was noted in the room. STNA #201 was standing next to Resident #1 assisting her to wash her hands and clean her nails. STNA #201 stated Resident #1 had feces under her fingernails and she was helping her clean her hands and fingernails. Further observation revealed Resident #1's bed did not have any sheets on it, a very large wet spot covered the bare mattress, and dirty feces covered sheets were on the floor under Resident #1's bed along with a dirty incontinence brief with feces covering the inside and outside of the brief in multiple areas. STNA #201 confirmed the feces covered incontinence brief and sheets were under Resident #1's bed and on the floor, she left them on the floor because when she entered the room Resident #1 was already in the bathroom and she needed to assist her before tending to the bed, incontinence brief and sheets on the floor.
Further observation revealed two additional incontinence briefs covered in urine and feces were in the trash can in the room. STNA #201 stated those incontinence briefs were from earlier, and she had not taken them out of the room yet. STNA #201 stated the large wet spot on the mattress was urine and she needed to clean the area before putting sheets back on the bed. STNA #201 stated Resident #1 often took her incontinence briefs off and sometimes they were found in the bed and sometimes on the floor. STNA #201 was vague when she was asked about the last time she provided incontinence care for Resident #1.
Review of the facility policy titled Perineal Care undated included it was the practice of the 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.
3. Review of Resident #24's medical record revealed an admission date of 06/07/23 and diagnoses included chronic obstructive pulmonary disease, aphasia (a language disorder caused by damage in a specific area of the brain that controls language expression and comprehension), cerebral infarction, and major depressive disorder.
Review of Resident #24's Quarterly MDS 3.0 assessment dated [DATE] revealed Resident #24 was cognitively intact. Resident #24 was always incontinent of urine and bowel. Resident #24 was dependent on staff for toileting hygiene and bathing and required substantial to maximal assistance for personal hygiene.
Review of Resident #24's care plan revised 02/06/24 included Resident #24 had episodes of bladder and bowel incontinence related to impaired mobility, physical limitations and diagnoses. Resident #24 would be at reduced risk for complications from incontinence through the next review. Interventions included to assist Resident #24 with toileting needs, provide disposable incontinence products.
Observation on 04/08/24 at 6:30 A.M. of STNA #251 revealed he was preparing for incontinence care of Resident #24. STNA #251 gathered two clean incontinence briefs, towels, prepared a basin of warm soapy water, and proceeded to provide Resident #24's incontinence care. Observation of Resident #24 revealed STNA #251 removed two incontinence briefs, and they were both saturated with urine and a large bowel movement. STNA #251 stated he had to put two incontinence briefs on Resident #24 so her briefs did not leak. STNA #251 stated Resident #24 liked a bigger incontinence brief, and he used a larger incontinence brief, then ripped the tabs off a second incontinence brief to make a liner. Resident #24 stated the incontinence briefs pinched her and that was why she asked for a larger brief. Further observation revealed Resident #24's draw sheet and fitted sheet were soaked with urine, and a large dried urine ring could be seen around the wet urine on the sheets. Resident #24 stated the last time she was changed was before she went to sleep. When asked if she put her call light on to be changed Resident #24 stated she did not think about putting her call light on to be changed and it was uncomfortable to lay in urine. STNA #251 confirmed the sheets were soaked and there was a dried urine ring around the wet urine. STNA #251 stated there were only three aides working last night, he had a split assignment which made it difficult to give the residents he was assigned to the care they needed. STNA #251 finished the incontinence care, dipping clean towels into the soapy water each time he needed a new towel, using the same gloves each time and put two clean incontinence briefs on Resident #24, one of which had the tabs ripped off to make a liner. STNA #251 did not remove his soiled gloves used for incontinence care and after Resident #24's incontinence care was complete, using the same soapy water he used for incontinence care he dipped a clean towel in the water and proceeded to clean Resident #24's face with the towel dipped in the water. STNA #251 confirmed he did not change his gloves and stated but I used a clean towel each time. When explained to him he did not change his gloves, and his gloves were soiled from the incontinence care STNA #251 stated I see what you are getting at and he would keep that in mind when he provided resident incontinnce care.
Review of the facility policy titled Perineal Care undated included it was the practice of the 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.
This deficiency represents non-compliance investigated under Complaint Number OH00151992.
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 F0744
(Tag F0744)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and review of the facility policy, the facility failed to ensure Resident #45 had...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and review of the facility policy, the facility failed to ensure Resident #45 had an individualized care plan with appropriate interventions in place to manage symptoms of dementia to prevent wandering in other residents rooms. This affected one resident (Resident #45) out of three resident reviewed for dementia care. The facility census was 67.
Findings include:
Review of Resident #45's medical record revealed an admission date of 08/22/23 and diagnoses included dementia, major depressive disorder, and morbid obesity.
Review of Resident #45's Quarterly MDS 3.0 assessment dated [DATE] revealed Resident #45 had severe cognitive impairment. Resident #45 used a manual wheelchair. Resident #45 was independent for bed mobility, the ability to transfer from a bed to a wheelchair, and the ability to come to a standing position from sitting in a wheelchair or the side of the bed.
Review of Resident #45's care plan revised 01/24/24 included Resident #45 had impaired cognitive process for daily decision making. Resident #45 was at risk for further decline in cognitive status. Resident #45 would not exhibit further decline in cognitive status and Resident #45's needs would be met daily through the next review on 04/16/24. Interventions included to reorient and redirect as needed. Further review did not reveal a care plan for monitoring Resident #45 to ensure he did not go in resident rooms and upset residents when he tried to take their belongings.
Review of Resident #45's progress notes from 10/08/23 through 03/30/24 revealed many notes stating Resident #45 required continuous supervision and redirection because Resident #45 roamed around the facility and entered other resident rooms unannounced and went through their belongings. Resident #45 was sometimes agitated, aggressive and combative with staff when they attempted to redirect him.
Review of Resident #10, Resident, #45, Resident #53 medical records, and facility Self Reported Incidents revealed the following incidents related to Resident #45's wandering behavior:
a. Review of Resident #10's medical record revealed an admission date of 09/01/20 and diagnoses included peripheral vascular disease, nontraumatic intracranial hemorrhage, and dementia.
Review of Resident #10's Quarterly MDS 3.0 assessment dated [DATE] revealed Resident #10 was cognitively intact. Resident #10 had impaired cognitive function related to dementia. Resident #10 would cope with his cognitive impairment evidenced by having no episodes of anxiety or frustrations through the next review. Interventions included to reassure Resident #10 of safety and redirect as needed.
Review of the facility Self Reported Incident Form (SRI) tracking number 244499 dated 02/23/24 included Resident #45 wandered into Resident #10's room and began going through his belongings. Both residents had a diagnosis of dementia. Resident #45 was verbally aggressive and saying he wanted to fight with Resident #10. Housekeeper #262 redirected Resident #45 out of Resident #10's room and before she could intervene Resident #45 reentered Resident #10's room and Resident #10 hit Resident #45 on the head with his cane to get him out of the room. Resident's #10 and #45 were immediately separated. Resident #45 had a small nickel size bump on his head and neither resident had a significant injury. Resident #10 and #45 were referred to psych services for evaluation. Resident's #10 and #45 were monitored and there was no further incident.
b. Review of Resident #53's medical record revealed an admission date of 12/29/23 and diagnoses included epilepsy, major depressive disorder, factitious disorder imposed on self and schizoaffective disorder, bipolar type.
Review of Resident #53's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #53 was cognitively intact. Resident #53 was independent with ADL's (Activity of Daily Living) and required setup or clean-up assistance with bathing.
Review of Resident #53's care plan dated 03/07/24 included Resident #53 had the potential to make false allegations. Resident #53 would be educated on how false allegations can affect other people. Interventions were to help Resident #53 make positive decisions. Resident #53 refused Psych services despite education and encouragement from staff. Staff would encourage Resident #53 to talk with Psych services. Interventions included to keep Resident #53 safe during episode of behavior, and attempt to redirect. There was no care plan or evidence Resident #53 had self-inflicted injuries.
Review of Resident #53's progress notes dated 03/26/24 at 5:25 P.M. revealed Resident #53 saw Resident #45 reaching for his belongings located in his drawer and snatched the item out of Resident #45's hand causing him to hit his hand on the dresser. Resident's #45 and #53 were separated. Resident #53 had pain from hitting his hand on the dresser, his physician was notified and an x-ray of his right hand was ordered.
Review of Resident #53's progress notes dated 03/26/24 at 11:21 P.M. revealed the portable x-ray company was called for Resident #53's right hand x-ray results and the results were pending.
Review of Resident #45's medical record revealed Resident #45 was moved to a different room on 03/27/24 and not on 03/26/24 the date of incident.
Review of Resident #45's progress notes dated 03/28/24 at 1:11 P.M. revealed Resident #45 was moved from room [ROOM NUMBER] to 107A. Family aware. There were no notes regarding the reason Resident #45 was moved and no notes about Resident #45 entering Resident #53's room and going through his belongings.
Review of Resident #53's progress notes dated 03/28/24 at 7:56 P.M. included Resident #53 returned from the local hospital with a cast on his right hand due to a closed displaced fracture of the neck of the fourth metacarpal bone of his right hand. Resident #53's physician aware.
Review of Resident #53's hospital After Visit Summary dated 03/28/24 revealed Resident #53 was seen for a hand injury. Resident #53's diagnosis was hand injury, right, initial encounter, right hand pain, closed displaced fracture of the neck of the fourth metacarpal bone of the left (right) hand.
Review of Resident #45's progress notes dated 03/29/24 at 7:02 P.M. included Resident #45 was in another unidentified resident's room which he destroyed, throwing items all over the room, and also throwing items including a candle and flower pot at the resident whose room he destroyed. The resident then struck Resident #45 and Resident #45 was escorted out of the room by staff. Resident #45 grabbed a metal fork and held in a threatening way towards staff. Resident #45 refused to allow a head to toe assessment. Resident #45's physician made aware, family was unable to be contacted. Resident #45 to be sent out for behaviors via 911 and EMS (Emergency Medical Services).
Review of Resident #45's progress notes dated 03/30/24 at 2:18 P.M. revealed Resident #45 was admitted to the hospital for dementia with behavioral disturbances.
Review of Resident #53's progress notes dated 04/03/24 at 5:38 P.M. written by Resident #53's physician included Resident #53 was seen on rounds following a recent ER (Emergency Room) visit which revealed a fracture to the metacarpal on Resident #53's right hand. Resident #53 was involved in an altercation with another resident, resulting in swelling of the hand. An x-ray was ordered and did not reveal any fractures. Two days later Resident #53 left following an appointment and went to the ER. Asked Resident #53 numerous different ways if Resident #53 had any other injury following the altercation and initial x-ray that might have resulted in an injury. Resident #53 denied another injury and stated I've used that x-ray company before, they are no good, they do not know what they are doing, there was a fracture and they missed it. Resident #53's physician showed Resident #53 the portable x-ray pictures taken at the facility which showed no fracture and Resident #53 stated they must not have turned it the right way or something. Resident #53's physician wrote given Resident #53's history he was suspicious there might have been subsequent trauma (possible self-inflicted) that Resident #53 was not forthcoming with. Resident #53 reported having a lawyer. Resident #53 was currently in an ulnar gutter splint.
Interview on 04/08/24 at 10:20 A.M. with Licensed Practical Nurse (LPN) #206 revealed she was working on 03/26/24, the day Resident #45 entered Resident #53's room uninvited. LPN #206 stated she heard a noise in Resident #53's room, Resident #53 was screaming and yelling because Resident #45 was trying to steal his belongings. Resident #53 told her he hit the money out of Resident #45's hand and his hand hit the dresser. LPN #206 stated she notified Resident #53's physician, the Director of Nursing (DON), and removed Resident #45 from Resident #53's room and transferred Resident #45 immediately to another room, right after the altercation happened. LPN #206 stated Resident #45 had dementia, was really confused and could be redirected. LPN #206 indicated she never saw the money in Resident #53's drawer. LPN #206 stated Resident #53's physician ordered an x-ray of his right hand, and the x-ray was negative for a fracture. LPN #206 stated Resident #53 did not tell her Resident #45 pushed his wheelchair into him, causing him to fall forward and hit his hand while he was trying to hit the money out of Resident #45's hand. LPN #206 stated she was told Resident #53 had a fracture and had a cast on his arm and hand.
Observation on 04/08/24 at 10:54 A.M. of Resident #53 revealed he was lying in bed and had a cast on his right arm and hand. Resident #53 stated Resident #45 came into his room about four to five times uninvited and sometimes he would get violent. Resident #53 stated he told the nurses about it but nothing was done and Resident #45 continued to enter his room uninvited. Resident #53 indicated on 03/26/24 Resident #45 again came into his room uninvited, started going through his dresser, and had Resident #53's money in his hand. Resident #53 stated he tried to grab his money out of Resident #45's had, Resident #45 was getting violent and pushed against him with his wheelchair causing Resident #53 to fall forward and hit his right hand on the dresser. Resident #53 stated his hand swelled up, the facility took an X-ray and told him the X-ray did not show he had a fracture. Resident #53 stated two days after this happened he went to the hospital ER, had his hand evaluated and the hospital x-rays showed he had a fracture of his right hand. Resident #53 stated Resident #45 came into his room uninvited two more times after they had the situation with his money. Resident #53 indicated they finally moved Resident #45 across the facility to another room which was not close to his. Resident #53 stated he was in worst shape now than when he was admitted .
Interview on 04/09/24 at 8:18 A.M. with State Tested Nursing Assistant (STNA) #212 revealed Resident #53 told her he knew his hand was broken, and he was going to sue the physician who said it was not broken. STNA #212 stated Resident #53 was extremely upset Resident #45 came into his room uninvited and tried to steal his belongings. STNA #212 stated Resident #45 wandered in and out of all the residents rooms and became aggressive if staff or other residents tried to stop him from going through their belongings. STNA #212 indicated Resident #45 used his wheelchair as a weapon when he was agitated and combative, and had pushed his wheelchair into her when he was upset. STNA #212 stated she had seen Resident #45 push his wheelchair into other staff and residents when he was upset. STNA #212 stated Resident #45 was very strong and was in the hospital now.
Interview on 04/09/24 at 8:53 A.M. with the Administrator and the Director of Nursing (DON) revealed Resident #53 said a resident with dementia (Resident #45) came into his room and took things out of his drawers and when Resident #53 was attempting to get his belongings back he hit his arm on the nightstand and said he was in a lot of pain. The Administrator stated Resident #53's physician ordered an x-ray and the x-ray was negative for a fracture, and he did not know how Resident #53 fractured his hand. The DON stated Resident #53 told her the facility x-ray was wrong and that was why he went to the hospital ER for an x-ray. The Administrator stated Resident #53 went on an unsupervised LOA (leave of absence) and he did not know what happened, but he thought Resident #53 went to the hospital ER and when he returned to the facility Resident #53 had a cast on his arm and said he had a fracture of his hand. The Administrator and DON stated they did not remember Resident #53 saying Resident #45 pushed his wheelchair against him causing him to fall forward. The Administrator stated last week Resident #53 came to him, said he did not want to cause trouble, but he just wanted compensation for the work he would be missing. Resident #53 said he would call off the state if we compensated him. The Administrator indicated he knew Resident #53 from other nursing homes and Resident #53 always had problems. The Administrator and DON stated Resident #53 told them he fractured his hand at the facility because he hit it on his dresser, but they thought it was possible he self-inflicted the fracture because his goal was to receive money.
Interview on 04/10/24 at 10:53 A.M. with the Administrator and Physician #263 revealed Resident #53 told him Resident #45 was in his room uninvited in his wheelchair looking through his belongings and allegedly had Resident #53's money in his hands. Resident #53 reached for his money, ended up on the ground and the injury to his hand happened when Resident #45 was leaving the room he ran over his hand with the wheelchair. Physician #263 stated there were other concerns with Resident #53, but following the episode an x-ray of Resident #53's hand was ordered and did not show a fracture. Two days later Resident #53 went to the ER, and the x-rays at the ER showed he had a fracture. Physician #263 stated he looked at the x-rays taken at the facility and did not see a fracture, and he asked Resident #53 several ways if there was another incident following the incident with Resident #45 when he hit his hand. Resident #53 denied another incident occurred. Physician #263 stated he had a suspicion either something else happened or the injury was self-inflicted and resulted in a fracture. Physician #263 stated he reviewed the hospital notes and there was nothing that led him to believe the injury was self-inflicted except that the location of the fracture is where things tend to break when folks improperly punch something. Physician #263 stated he was not sure the fracture was consistent with Resident #53's hand hitting a dresser and his general demeanor was suspicious.
Interview on 04/11/24 at 2:11 P.M. with Resident #53 via a phone call revealed Resident #45 was back in the facility and had already been in a resident room next door to Resident #53 causing problems. Resident #53 stated he heard yelling and screaming and then Resident #45 was removed from the room and redirected to another part of the facility. Resident #53 stated he was going to have to sleep with one eye open until he was discharged from the facility.
Review of the facility policy titled Dementia Care undated included it was the policy of the facility to provide the appropriate treatment and services to every resident who displayed signs of, or was diagnosed with dementia, to meet his or her highest practicable physical, mental and psychosocial well-being. Care plan interventions would be related to each resident's individual symptomology and rate of dementia (or related disease) progression with the end result being noted improvement or maintained of the expected stable rate of decline associated with dementia and dementia-like illnesses. Care and services would be person-centered and reflect each resident's individual goals while maximizing the resident's dignity, autonomy, privacy, socialization, independence, choice and safety. If needed, the environment would be modified to accommodate individual resident care needs.
This deficiency represents non-compliance investigated under Master Complaint Number OH00152659 and Complaint Number OH00151992.
Mar 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
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 observation, interview, and record review, the facility failed to ensure physician orders were in place for care or tre...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure physician orders were in place for care or treatment of a peripherally inserted central catheter (PICC) line. This affected one (Resident #11) of one facility-identified residents with a PICC line. The facility census was 65.
Findings include:
Review of medical record for Resident #11 revealed an admission date of 02/20/24 with diagnoses including congestive heart failure, epilepsy, cerebral infarction, and mixed hyperlipidemia.
Review of progress note for Resident #11 dated 02/20/24 revealed the resident was admitted to facility with a PICC line to left arm used to administer medication to treat endocarditis.
Review of physician's orders for Resident #11 revealed an order dated 02/21/24 for 100 milliliters (ml) daily of ceftriaxone sodium intravenously for 28 days. Review of the physician's orders revealed there were no orders for care and treatment of the of the PICC line site.
Review of the plan of care for Resident #11 initiated 02/20/24 revealed it did not include interventions regarding care and treatment of the resident's PICC line.
Observation on 03/04/24 at 10:20 A.M. revealed Resident #11 had an intact, transparent dressing to the PICC line on the left upper arm which was not dated.
Interview on 03/04/24 at 10:25 A.M. with Resident #11 confirmed the PICC line dressing was changed at hospital and had not been changed since his admission to the facility.
Interview on 03/04/24 at 11:09 A.M. with Licensed Practical Nurse (LPN) #800 confirmed the PICC line dressing to Resident #11's upper arm was not dated, and the nurse was unsure when it had been applied.
Interview on 03/04/24 at 11:29 A.M. with LPN #800 confirmed Resident #11 did not have physician orders to change the dressing to the resident's PICC line. LPN #800 confirmed PICC line dressings should be changed every seven days at a minimum.
Interview on 03/04/24 at 11:33 A.M. with Director of Nursing (DON) confirmed Resident #11 was admitted with a PICC line and the facility did not have physician's orders regarding care and treatment of the PICC line site. The DON further confirmed they did not know when the dressing to the resident's PICC line had been placed, but she thought it had been present upon Resident #11's admission to the facility on [DATE].
Review of facility policy titled Intravenous Therapy: Preventing Catheter-Related Infections dated October 2010 revealed PICC line dressing should be changed ever seven days or more frequently if needed.
This deficiency represents non-compliance investigated under Complaint Number OH00151489.
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
Based on medical record review, staff interview and review of the facility policy, the facility failed to ensure resident safety during a two-staff assisted transfer. This affected one (Resident #30) ...
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Based on medical record review, staff interview and review of the facility policy, the facility failed to ensure resident safety during a two-staff assisted transfer. This affected one (Resident #30) of three reviewed for safe transfers. The facility census was 65.
Findings include:
Review of the medical record for Resident #30 revealed admission date of 05/14/23 with diagnoses including convulsions, migraine, fatigue, anxiety disorder, hyperlipidemia, and major depressive disorder.
Review of plan of care for Resident #30 dated 05/17/23 revealed the required staff assistance with activities of daily living (ADLs.) Interventions included the resident required weight-bearing assistance including holding, lifting, or supporting the trunk or limbs and required non-weight bearing assistance including steadying, contact guard assistance or guided maneuvering when transferring between surfaces.
Review of the therapy progress note for Resident #30 dated 09/13/23 revealed the resident was working with the occupational therapy department at the facility and required moderate assistance to sit and stand during pivot transfers.
Review of Minimum Data Set (MDS) quarterly assessment for Resident #30 dated 09/21/23 revealed the resident required extensive two staff assistance for bed mobility and transfers.
Review of pain assessment for Resident #30 dated 09/21/23 timed at 2:45 P.M. revealed the resident complained of throbbing pain to the left ankle which the resident rated as five on a scale of one to 10 with 10 being the worst pain.
Review of progress note for Resident #30 dated 09/21/23 timed at 2:47 P.M. revealed while the resident was being transferred by staff his left foot shifted causing pain. The nurse called the nurse practitioner (NP) and obtained an order for an x-ray to the left ankle.
Review of x-ray report for Resident #30 dated 09/22/23 timed at 1:53 P.M. revealed the x-ray showed a possible fracture to the left ankle of indeterminate age.
Review of the change in condition evaluation for Resident #30 dated 09/22/23 timed at 5:42 P.M. revealed the resident facility provided the resident with Tylenol and assisted with leg elevation for pain the left ankle and obtained an order for the resident to be sent to the emergency room for evaluation of a possible fracture.
Review of the hospital left foot x-ray for Resident #30 result dated 09/22/23 timed 9:41 P.M. revealed the resident had mild osteopenia and mild soft tissue swelling to the left ankle but there was no acute fracture or dislocation.
Review of the progress note for Resident #30 dated 09/23/23 timed at 2:02 A.M. revealed the resident returned from the hospital with a boot and copies of hospital x-rays revealing a sprain to the left ankle but no fracture.
Interview on 03/05/24 at 9:26 A.M. with Resident #30 confirmed during a two-person transfer on 09/21/23 his left leg got caught under the bed. Resident #30 reported initially the x-ray taken at the facility indicated he had an ankle fracture, but the hospital x-ray said it was a sprain. Resident #30 confirmed State Tested Nursing Assistants (STNAs) #802 and #804 were completing a two-person transfer and one STNA had a bad wrist. Resident #30 confirmed while being transferred his foot got caught under lower frame of bed and he asked the STNAs to stop. Resident #30 confirmed one of the STNAs stopped but the other did not.
Interview on 03/05/24 at 10:22 A.M. with STNA #802 confirmed she was not the assigned nurse aide for Resident #30 but was asked on 09/21/23 by STNA #804 to assist in the transfer. STNA #802 confirmed while assisting STNA #804 with a manual transfer, STNA #804's wrist gave out and caused Resident #30 to dip down on left side. STNA #802 confirmed Resident #30's left foot slipped under the bed during transfer. STNA #802 confirmed STNA #804 was wearing a wrist brace at time of incident and Resident #30 verbalized pain when he dipped down on left side. STNA #802 confirmed they re-stabilized Resident #30 to keep him from falling, got him into the bed, and went to get nurse. STNA #802 confirmed when they re-stabilized Resident #30 his foot came out from under bed.
Interview on 03/05/24 at 10:56 A.M. with STNA #804 confirmed she was unable to remember the details of the wheelchair to bed transfer for Resident #30 on 09/21/23. STNA #804 confirmed Resident #30's left leg got hit or tangled up during the transfer. STNA #804 confirmed she was Resident #30's assigned nurse aide and had asked for help from STNA #802 for a two-person arm and arm transfer from wheelchair to bed. STNA #804 confirmed Resident #30 told them to stop during the transfer. STNA #804 confirmed she could not recall if she was wearing a wrist brace on 09/21/23.
Interview on 03/05/24 at 11:01 A.M. with Certified Occupational Therapist Assistant (COTA) #808 confirmed Resident #30 was a two person transfer at the time of the incident in September 2023.
Interview on 03/05/24 at 11:10 A.M. with Licensed Practical Nurse (LPN) #809 confirmed she was notified by an STNA on 09/21/23 that Resident #30 had twisted his ankle and was complaining of pain following a pivot transfer. LPN #809 confirmed she was unable to remember which STNA had notified her, but the resident complained of pain and discomfort to the ankle, and she elevated Resident #30's foot and obtained a physician's order for a left ankle x-ray.
Interview on 03/05/24 at 1:06 P.M. with the Director of Nursing (DON) confirmed was notified Resident #30 had complained of ankle pain following a transfer on 09/21/23 but she he was unaware Resident #30's foot had gotten stuck and was unsure if STNA #804 wore a wrist brace. The DON confirmed if a staff member had an injury, they should notify human resources and a two-person arm and arm transfer would be unsafe if a staff member had a physical injury.
Interview on 03/05/24 at 1:16 P.M. with Human Resources Director (HRD) #810 confirmed she was unaware of STNA #804 wearing a wrist brace on 09/21/23.
Interview on 03/05/24 at 1:53 P.M. with STNA #802 confirmed she and STNA #804 had not been using a gait belt when transferring Resident #30 on 09/21/23. STNA #802 confirmed gait belts were available for use, but she had held onto Resident #30's right arm and the back of his pants during the transfer.
Interview on 03/05/24 at 2:46 P.M. with COTA #808 confirmed staff should utilize a gait belt when performing a manual resident transfer.
Review of the facility policy titled Safe Lifting and Movement of Residents dated July 2017 revealed in order to protect the safety and well-being of staff and residents and to promote quality care the facility utilized appropriate techniques and devices to lift and move residents. Staff responsible for direct care would be trained in the use of gait belts.
This deficiency represents non-compliance investigated under Complaint Number OH00151192.
Aug 2023
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
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
Based on observation and interview the facility failed to provide privacy during incontinence care. This affected two of three sampled residents (#13 and #35), one which was observed during a random o...
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Based on observation and interview the facility failed to provide privacy during incontinence care. This affected two of three sampled residents (#13 and #35), one which was observed during a random observation. The facility census was 60.
Findings include:
1. Observation from the hallway outside of Resident #13's room on 08/30/23 at 6:01 A.M. revealed State Tested Nursing Assistant (STNA) #200 providing incontinence care to Resident #13. The door to Resident #13's room was open and the privacy curtain was not pulled around the bed. Resident #13 was not interviewable.
2. Observation of incontinence care on 08/30/23 at 6:12 A.M. with STNA #200 for Resident #35 revealed STNA #200 did not close the door or pull the privacy curtain prior to beginning incontinence care. Interview with STNA #200 at time of observation revealed the door and/or the privacy curtain should have been closed prior to beginning incontinence care. Resident #35 was not interviewable.
This deficiency represents non-compliance investigated under Complaint Number OH00145488.
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 observation, interview and record review the facility failed to ensure timely incontinence care was provided. This affe...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure timely incontinence care was provided. This affected one resident (#58) of two observed for incontinence care. The facility census was 60.
Findings include:
Review of Resident #58's medical records revealed an admission date of 06/28/22. Diagnoses included muscle weakness and dementia. Review of Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #58 had intact cognition, required extensive assistance with toileting and was incontinent of bowel and bladder. Review of Resident #58's care plan dated 07/19/23 revealed Resident #58 was incontinent of bowel and bladder. Interventions included provide incontinence care every two hours and as needed.
Observation of incontinence care on 08/30/23 at 6:48 A.M. with State Tested Nursing Assistant (STNA) #205 and #206 for Resident #58 revealed Resident #58 was incontinent of a large of amount of urine and stool. Further observation revealed Resident #58 was wearing an incontinence liner inside of the incontinence brief and both were soaked with dark stale smelling urine and urine had soaked through to Resident #58's pants, sheets and onto the mattress. STNA #205 stated she was unable to recall when she had last provided Resident #58 with incontinence care. Resident #58 was not interviewable.
This deficiency represents non-compliance investigated under Complaint Number OH00145488.
Jul 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0569
(Tag F0569)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure Resident #64's monies that were held by the facility were forwarded to the resident's estate within 30 days. This affected one resid...
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Based on interview and record review, the facility failed to ensure Resident #64's monies that were held by the facility were forwarded to the resident's estate within 30 days. This affected one resident (Resident #64) of three residents reviewed for the facility returning monies owed to former resident's estates. The facility census was 63.
Findings include:
Review of the medical record for Resident #64 revealed an admission date of 01/14/22 with diagnoses including diabetes mellitus and heart failure. Resident #64 passed away and was discharged from the facility on 01/24/23.
Review of the billing statements from 11/02/22 through 07/02/23 revealed Resident #64 had a credit on his statement. The statement dated 07/02/23 revealed he had a credit of $3,884.00 on his account.
Review of the Resident Credit Release Form dated 04/10/23 revealed $4,600.00 was returned to Resident #64's sister. No other monies were released to his estate.
Interview on 07/19/23 at 10:32 A.M. with Business Office Manager (BOM) #203 verified Resident #64 had a credit to his billing account of $3,884.00. She stated she was not responsible for the billing account, only the personal funds account and could not answer as to why the credit on his account was not released to his estate.
This deficiency represents non-compliance investigated under Complaint Number OH00144357.
Jun 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview, and facility policy review the facility failed to ensure interventions were in p...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview, and facility policy review the facility failed to ensure interventions were in place to aid in the prevention of falls. This affected one resident (#17) of three residents reviewed for falls. The facility census was 58.
Findings include:
Review of the medical record for the Resident #17 revealed an admission date of 08/30/22 with diagnoses included ataxia (difficulty walking), osteoarthritis, anemia, and vitamin D deficiency.
Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #17 was severely cognitively impaired. The resident required extensive assistance of one person for bed mobility, transfers, and ambulation.
Review of the fall risk assessment dated [DATE] revealed the resident was at high risk for falls.
Review of the plan of care dated 12/21/22 revealed the resident was at risk for falls due to difficulty walking. Interventions included the call light being in reach, a perimeter mattress to bed, bolsters to the air mattress, wheelchair brake extenders, and non-skid footwear or shoes when out of bed.
Review of physician orders for June 2023 identified orders for a perimeter mattress to bed.
Review of the nurse's notes dated 04/01/23 at 2:15 P.M. revealed Resident #17 had an unwitnessed fall. The State Tested Nurse's Aide (STNA) was answering the resident's call light when she was observed Resident #17 on the floor lying on her left side in a lateral position next to her bed with the wheelchair behind her. When asked what happened, she replied she was not sure, but believed she was fixing her wheelchair. An assessment was done, and no injuries were noted.
Review of the fall investigation dated 04/01/23 revealed no evidence of a perimeter mattress, non-skid socks, bed bolsters, or wheelchair brake extenders being in place at the time of the fall. The care plan was updated to include a Dycem (non-slip pad) to be placed in the wheelchair.
Observation on 06/20/23 at 11:48 A.M. of Resident #17 revealed she was sitting in her wheelchair in the dining room. A Dycem was observed in use on the wheelchair and wheelchair brake extenders were in place.
Interview on 06/20/23 at 2:15 P.M. with the Director of Nursing (DON) confirmed no evidence of a perimeter mattress, non-skid socks, bed bolsters, or wheelchair brake extenders being in place at the time of the fall.
Observation on 06/20/23 at 2:31 P.M. of the Resident #17's room revealed no evidence of a perimeter mattress on her bed and no bed bolsters. Interview at the time of the observation with the DON confirmed there was no perimeter mattress on the bed, and a set of bed bolsters resting against the wall behind a chair and wrapped in plastic.
Review of the facility policy titled Fall Management, dated 01/29/20, revealed the facility would implement interventions to manage falls.
This deficiency represents noncompliance investigated under Complaint Number OH00143558.
Mar 2023
1 deficiency
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 F0804
(Tag F0804)
Could have caused harm · This affected most or all residents
Based on observation, interview, and policy review the facility failed to serve food at a safe/palatable temperature. This had the potential to affect 56 residents who ate meals from the facility's ki...
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Based on observation, interview, and policy review the facility failed to serve food at a safe/palatable temperature. This had the potential to affect 56 residents who ate meals from the facility's kitchen. No residents were identified as receiving nothing by mouth. The facility census was 56.
Findings include:
Observation of tray line on 03/16/23 from 7:30 A.M. through 8:10 A.M. revealed food was above 165 degrees Fahrenheit (F) on the tray line, preferences were honored, condiments were available, and every tray had appropriate silverware including adaptive equipment.
Observation of test tray and interview on 03/16/23 at 8:21 A.M. with Administrator revealed scrambled eggs were 105 degrees F, grits were 118 degrees F and milk was 60 degrees F. Eggs tasted cold and grits tasted lukewarm. The Administrator verified the temperatures at the time of the observation.
Interview on 03/16/23 at 11:00 A.M. with Dietary Manager #189 revealed dietary has gotten better and will work on breakfast temperatures. She stated that there were no residents receiving nothing by mouth.
Review of the facility policy titled Test Tray and Point of Service Temperatures, dated 03/16/23, revealed food should be served palatable, attractive and at an appetizing temperature as determined by the type of food to ensure the resident's satisfaction, while minimizing the risk for scalding and burns.
This deficiency represents non-compliance investigated under Complaint Number OH00140813 and OH00140750.
Apr 2022
24 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** Based on record review and staff interview the facility failed to ensure accurate advanced directive information was present thr...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure accurate advanced directive information was present throughout the medical record. This affected one (Resident #11) of one resident reviewed for advanced directives. The facility census was 54.
Findings include:
Review of the medical record revealed Resident #11 was admitted to the facility on [DATE] with diagnoses including dysphagia, dementia, and muscle weakness. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #11 had severe cognitive impairment and required the extensive assistance of two staff for activities of daily living.
Review of the physicians' orders for Resident #11 revealed an ordered dated [DATE] for Do Not Resuscitate Comfort Care (DNRCC) code status signifying cardiopulmonary resuscitative (CPR) measures were not to be conducted in case of cardiac or respiratory arrest.
Review of the care plan dated [DATE] revealed Resident #11's code status was DNRCC.
Review of the signed electronic documents section of Resident #11's medical record revealed a signed Do Not Resuscitate Comfort Care Arrest (DNRCCA) code status form dated [DATE] indicating providers will treat patient as any other without a DNR order until the point of cardiac or respiratory arrest at which point all interventions will cease and the DNR comfort care protocol will be implemented.
Social Service Designee #820 verified the inconsistent advanced directives during an interview on [DATE] at 3:05 P.M.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a wheelchair was in good working order for Resi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a wheelchair was in good working order for Resident #8. This affected one (Resident #8) of one resident reviewed for wheelchair condition. The facility census was 54.
Findings include:
Review of the medical record for Resident #8 revealed an admission date of 11/21/16 with diagnoses including unsteadiness on feet, difficulty walking, hypertension, type one diabetes mellitus, major depressive disorder, and vascular dementia without behavioral disturbance.
Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #8 was cognitively impaired and utilized a wheelchair for mobility.
Review of the physician's orders for April 2022 identified orders for Occupational Therapy (OT) to evaluate and treat per the plan of care, including wheelchair management.
On 04/10/22 at 11:18 A.M., interview with Resident #8 revealed she needed a new wheelchair. Observation at the time of interview revealed Resident #8's wheelchair was in disrepair.
On 04/13/22 at 12:05 P.M., interview with Licensed Practical Nurse (LPN) #807 verified Resident #8's wheelchair needed repaired or replaced. LPN #807 stated the therapy department handled wheelchair repairs and replacements.
On 04/13/22 at 12:11 P.M., interview with Physical Therapy Assistant (PTA) #825 also confirmed Resident #8's wheelchair was in disrepair. PTA #825 reported Resident #8 had been assessed for a new wheelchair on 04/12/22 and it just needed to be ordered.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Assessments
(Tag F0636)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to accurately and timely complete Minimum Data Set (MDS) 3.0 asse...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to accurately and timely complete Minimum Data Set (MDS) 3.0 assessments. This affected two (Resident's #1 and #35) of 26 residents reviewed for resident assessments. The facility census was 54.
Findings include:
1. Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses including fractured vertebra, post-traumatic stress disorder, and major depressive disorder. Review of census records revealed Resident #1 discharged home from the facility on 12/24/21.
Review of the MDS 3.0 assessment records for Resident #1 revealed an admission and Medicare Five-Day MDS 3.0 assessment were completed on 11/26/21. No other assessments including a discharge assessment were completed for Resident #1.
The Administrator verified the lack of the required Discharge MDS 3.0 assessment during an interview on 04/12/22 at 10:15 A.M.
2. Review of the medical record revealed Resident #35 was admitted to the facility on [DATE] with diagnoses including repeated falls, paranoid schizophrenia, dementia, malignant neoplasm of the prostate, and a localized mass and lump of right lower limb. Resident #35 was transferred to the hospital on [DATE] and was admitted for a change in mental status. He was readmitted from the hospital on [DATE].
Review of the admission MDS 3.0 assessment dated [DATE] revealed the assessment was not thoroughly completed as Section H -Bowel and Bladder was left blank.
Interview with the Director of Nursing (DON) on 04/14/22 at 1:30 P.M. verified Section H -Bowel and Bladder on the admission MDS 3.0 assessment dated [DATE] for Resident #35 was left blank.
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 observation, interview, and record review, the facility failed to ensure assessments were completed accurately. This af...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure assessments were completed accurately. This affected three (Resident's (#250, #19 and #248) of 26 residents reviewed for accurate assessments and had the potential to affect all 54 residents residing in the facility.
Findings include:
1. Review of the medical record for Resident #250 revealed an admission date of 03/10/22 with diagnoses including hemiplegia and hemiparesis affecting right dominant side, chronic obstructive pulmonary disease, anemia, hyperlipidemia, and encephalopathy.
Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated Resident #250 was cognitively intact and did not use tobacco.
Review of the assessment titled Smoking Assessment - V 1, dated 03/10/22, indicated Resident #250 was not a smoker. Review of the assessment titled admission Assessment with Baseline Care Plan - v.4 - V 3, dated 03/10/22, also indicated Resident #250 was not a smoker.
Review of the nurses note dated 04/03/22 at 8:20 A.M. revealed Resident #250 was observed smoking in his room. A progress note dated 04/04/22 at 3:57 P.M. revealed Resident #250 was a smoker and smoked four times daily.
Review of the care plan dated 04/10/22 revealed Resident #250 was a smoker. Interventions included inform resident or family of the facility's smoking rules, designated smoking areas, and storage of smoking materials, and monitor the resident's safety during smoking.
Interview on 04/10/22 at 2:08 P.M. with Resident #250 revealed the resident smoked daily.
Interview on 04/10/22 at 3:08 P.M. the Director of Nursing (DON) verified the smoking assessment dated [DATE] was inaccurate because Resident #250 was a smoker.
2. Review of the medical record for Resident #19 revealed an admission date of 01/11/22 with diagnoses including type two diabetes mellitus, hyperlipidemia, hypertension, morbid obesity, and schizophrenia.
Review of the physician's orders for April 2022 identified no orders for fall interventions.
Review of the comprehensive MDS 3.0 assessment dated [DATE] revealed Resident #19 was cognitively impaired, required extensive assistance for bed mobility and transfers, and had not experienced any falls.
Review of the assessment titled Embassy Fall Risk Evaluation v.2, dated 04/11/22, indicated Resident #19 was at moderate risk for falls. The assessment also indicated the resident had experienced one to two falls within the last three months.
Review of the progress notes dated 01/11/22 through 04/04/22 revealed no documentation of falls.
Interview on 04/13/22 at 12:30 P.M. with the DON verified the fall risk evaluation dated 04/11/22 was incorrect because Resident #19 had not experienced any falls while in the facility.
3. Review of the medical record for Resident #248 revealed an admission date of 02/25/22 with diagnoses included edema, morbid obesity, schizophrenia, hypertension, congestive heart failure, major depressive disorder, and type two diabetes mellitus.
Review of the comprehensive MDS 3.0 assessment dated [DATE] revealed Resident #248 was cognitively intact, required extensive assistance of two staff for toileting, and was always incontinent of bowel and bladder.
Review of the admission assessment dated [DATE] indicated Resident #248 was continent of bowel and bladder.
Interview on 04/18/22 at 11:26 A.M. with Licensed Practical Nurse (LPN) #800 verified the admission assessment dated [DATE] was incorrect because Resident #248 was always incontinent of bowel and bladder.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0645
(Tag F0645)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure level one screening for mental illness and a Pre-admiss...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure level one screening for mental illness and a Pre-admission Screen and Resident Review (PASARR) for residents were completed as required. This affected three (Resident's #24, #37 and #40) of four residents reviewed for PASARR status. The facility census was 54.
Findings include:
1. Review of the medical record revealed Resident #24 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD), bipolar disorder, conversion disorder, and panic disorder. Resident #24 was discharged home on [DATE].
Review of the medical record for Resident #24 revealed a PASARR form was completed on 03/29/22. There was no documented evidence of a level one screening as required.
2. Review of the medical record revealed Resident #37 was admitted to the facility on [DATE] with diagnoses including heart attack, gout, arthritis, and type two diabetes mellitus. Review of the admission records for Resident #37 revealed Resident #37 was admitted to the facility on a hospital exemption dated 02/04/22 indicating the facility had 30 days to complete a full 3622 PASARR form if the resident remained in the facility beyond 30 days. Resident #37 remained in the facility at the start of the annual survey on 04/10/22.
Review of the medical record for Resident #24 revealed no documented evidence a 3622 PASARR form was completed as required.
3. Review of the medical record revealed Resident #40 was admitted to the facility on [DATE] with diagnoses including delusional disorder, bipolar disorder, and schizoid personality disorder.
Review of the medical record for Resident #40 revealed a PASARR form was completed on 04/05/22. There was no documented evidence of a level one screening as required.
Social Service Designee #820 verified the lack of timely PASARR assessments during an interview on 04/13/22 at 1:45 P.M.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure insulin was administered according to the physi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure insulin was administered according to the physician's orders. This affected one (Resident #19) of three residents reviewed during medication administration. The facility census was 54.
Findings include:
Review of the medical record revealed Resident #19 was admitted to the facility on [DATE] with diagnoses including hypertension, type II diabetes, gastro esophageal reflux disease, and schizophrenia.
Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #19 had moderate cognitive impairment and required extensive assistance of two staff for bed mobility, dressing, toilet use, and personal hygiene.
Review of the insulin order dated 03/13/22 revealed Resident #19 was to receive Humalog Kwik Pen 100 unit/milliliter (ml) per sliding scale before meals and at bedtime.
Observation of medication administration on 04/10/22 at 8:30 A. M. with Registered Nurse (RN) #809 revealed the nurse checked Resident #19's blood glucose level with an Accu-Chek glucometer. The blood glucose reading was 179. Review of the sliding scale revealed Resident #19 should receive two units of insulin via the Kwik pen. RN #809 obtained the two units of insulin and administered it to the resident.
Interview with Resident #19 on 04/10/22 at 9:00 A.M. stated that he had breakfast about an hour ago, and they did not check his blood glucose level or give him his insulin until after he ate.
Interview with RN #809 on 04/10/22 at 9:15 A.M. revealed that he was tied up meeting the needs of the other resident before he could get to Resident #19 to give him is insulin. He verified that he did not follow the physician's order.
CONCERN
(D)
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 record review, observation, and interview the facility failed to ensure physician's orders for urinary catheter care an...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview the facility failed to ensure physician's orders for urinary catheter care and failed to ensure routine urinary catheter care was administered. This affected one (Resident #35) of two residents reviewed for urinary catheters. The facility census was 54.
Findings include:
Review of the medical record revealed Resident #35 was admitted to the facility on [DATE] with diagnoses including repeated falls, paranoid schizophrenia, dementia, malignant neoplasm of the prostate, and a localized mass and lump of the right lower limb. He was transferred to the hospital on [DATE] and was admitted for a change in mental status. Resident #35 was readmitted to the facility from the hospital on [DATE].
Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #35 had moderate cognitive impairment and required extensive assistance of one to two staff for bed mobility, transfers, dressing, toilet use, and personal hygiene. The resident had a urinary catheter in place.
Review of the readmission orders dated 02/12/22 revealed no order for urinary catheter care. An order written on 02/16/22 stated to monitor the urinary catheter for bleeding, contact the physician if bleeding occurs, irrigate the urinary catheter, and change as needed for bleeding.
Review of the Medication Administration Record (MAR) and Treatment Administration Record (TAR) for the month of February 2022 revealed no documented evidence urinary catheter care was provided.
Further review of the physician orders revealed on 03/01/22 the physician ordered a urinary catheter size 16 French with a 10 cubic centimeter (cc) balloon for a diagnosis of obstruction, secure the indwelling catheter tubing using an anchoring device to prevent movement and urethral traction every shift, and
urinary catheter care every shift.
Observation of Resident #35 on 04/11/22 at 9:15 A.M. with Licensed Practical Nurse (LPN) #814 verified the resident did not have a securement device in place for the urinary catheter. When LPN #814 was asked about catheter securement devices, she stated Resident #35 hasn't had one since he was readmitted from the hospital with a urinary catheter on 02/12/22. LPN #814 stated catheter care is supposed to be done every shift by the state tested nursing assistant (STNA).
Observation of Resident #35 on 04/12/22 at 10:30 A.M. with STNA #813 verified Resident #35 did not have a securement device in place as ordered. Interview STNA #813 revealed a securement device was only used when a physician ordered it.
Interview with the Director of Nursing (DON) on 04/13/22 at 11:15 A.M. verified when Resident #35 was readmitted from the hospital on [DATE] he had a urinary catheter in place, but there was no order for catheter care until 03/01/22. The DON also verified there was no documented evidence catheter care was provided daily per protocol. She further verified Resident #35 did have an order for a securement device for the catheter tubing, and the resident did not have one in place.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure Resident #47 was provided fresh water daily. T...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to ensure Resident #47 was provided fresh water daily. This affected one (Resident #47) of three residents reviewed for hydration. The facility census was 54.
Findings include:
Review of the medical record revealed Resident #47 was admitted to the facility on [DATE] with diagnoses including pain in the left hand, type II diabetes, heart failure, hypertension, hemiplegia, and malignant neoplasm of the stomach.
Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #47 had moderate cognitive impairment and required extensive assistance of one staff for most of her activities of daily living (ADL).
Observation of Resident #47 on 04/11/22 at 8:40 A.M. revealed the resident sitting up in her wheelchair yelling for someone to please get her some ice and water. Observation of Resident #47's beside table as well as her over bed table revealed no cup in place. Interview with the resident at this time revealed she never gets fresh water and must ask for it daily.
Interview with State Tested Nursing Assistant (STNA) #901 at on 04/11/22 at 9:00 A.M. revealed she came on duty this morning and was just coming in to get Resident #47 washed up. She stated she was not aware the resident didn't have any water and would take care of it.
Observation on 04/11/22 at 10:35 A.M. revealed Resident #47 wheeling herself to the nurse's station yelling for someone to get her some ice and water. Licensed Practical Nurse (LPN) #810 was at the nurse's station and assured the resident she would get her fresh water.
Interview with Resident #47 on 04/11/22 at 1:45 P.M. verified LPN #810 did get her fresh water.
Observation of Resident #47 on 04/12/22 at 8:30 A.M. revealed Resident #47 had fresh water and a cup of 140 cubic centimeters (cc) orange liquid which the resident said was soda.
Observation of Resident #47 on 04/13/22 at 8:15 A.M. revealed the resident still had 140 cc of orange soda in her cup. She did have another cup which was empty. Resident #47 stated she did not receive fresh water again today.
Interview with STNA #813 on 04/13/22 at 8:30 A.M. revealed she was not aware Resident #47 needed fresh water and would get her some. STNA #813 proceeded to get the resident a tall Styrofoam cup full of ice and water.
Observation of Resident #47 on 04/14/22 at 8:40 A.M. revealed the resident still had the cup of 140 cc of orange soda. Interview with the resident at this time verified the orange soda in the cup was from a couple of days ago, and she stated she did not have fresh water again today. During this interview LPN #814 walked into the resident's room. The resident told LPN #814 she does not get fresh water every day. LPN #814 assured Resident #47 she would take care of it. At 8:55 A.M., LPN #814 walked into the resident's room with two big plastic cups filled with water and ice.
Interview with STNA #813 on 04/14/22 at 1:00 P.M. verified the STNAs are to pass fresh water to residents at the beginning of their shift. She also stated she passed fresh water to the residents at 7:00 A.M. this morning. When asked why Resident #47 did not have any fresh water, she stated she did not know.
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 interview, and record review, the facility failed to ensure insulin orders for residents were written with the correct method of administration. This affected three residents (Resident's #19,...
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Based on interview, and record review, the facility failed to ensure insulin orders for residents were written with the correct method of administration. This affected three residents (Resident's #19, #37 and #98) of three residents reviewed for insulin administration. The facility census was 54.
Findings include:
1. Review of the medical record revealed Resident #19 had a physician's order dated 03/13/22 to administer Humalog Kwik Pen 100 units/milliliter (ml) solution per sliding scale intradermally (a shallow or superficial injection of a substance into the dermis, which is located between the epidermis and hypodermis) before meals and at bedtime.
Interview with the Director of Nursing (DON) on 04/13/22 at 10:00 A.M. revealed all the orders the facility receives from the physician are sent to the pharmacy, and the pharmacy did not correct the order to read subcutaneously (administered into the subcutis, the layer of skin directly below the dermis and epidermis).
2. Review of the medical record revealed Resident #37 had a physician's order dated 02/23/22 to administer Humalog Kwik Pen 100 units/ml per sliding scale to be given intradermally every six hours for diabetes.
Interview with the DON on 04/13/22 at 10:00 A.M. verified Resident #37's insulin order was written to be administered intradermally rather than subcutaneously.
3. Review of the medical record revealed Resident #98 had a physician's order dated 03/19/22 to administer Humalog Kwik Pen 100 unit/ml solution to be give per sliding scale intradermally before meals and at bedtime.
Interview with the DON on 04/13/22 at 10:00 A.M. verified Resident #98's insulin order was written to be administered intradermally rather than subcutaneously.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0810
(Tag F0810)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and staff interviews the facility failed to ensure residents were provided with eat...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and staff interviews the facility failed to ensure residents were provided with eating equipment to maintain independence while eating. This affected two (Resident's #26 and #40) of two residents reviewed for adaptive eating equipment. The facility census was 54.
Findings include:
1 Review of the medical record for Resident #26 revealed an admission date of 01/14/22 with diagnoses including diabetes mellitus, end stage renal disease, and proliferative diabetic retinopathy of the right eye. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #26 had intact cognition and required supervision with set-up only for eating.
Review of the physician's orders for April 2022 revealed a diet order for renal, low concentrated sweets diet, regular texture, thin liquid consistency with double portions. Resident #26 also had an order for a plate guard with meals.
Review of the care plan dated 01/19/22 revealed Resident #26 was at risk for altered nutritional status related to end stage renal disease. Interventions included to have a plate guard with meals.
2. Review of the medical record for Resident #40 revealed an admission date of 09/17/20 and a readmission date of 01/12/21 with diagnoses including delusional disorders, end stage renal disease, and bilateral proliferative diabetic retinopathy with macular edema. Review of the quarterly MDS 3.0 assessment dated [DATE] revealed Resident #40 had moderately impaired cognition and was independent with set-up only for eating.
Review of the physician's orders for April 2022 revealed a diet order for no added salt, low concentrated sweets diet, regular texture, thin liquid consistency with double portions and low potassium. Resident #40 also had an order for a scoop plate.
Review of the care plan dated 03/24/22 revealed Resident #40 was at risk for altered nutritional status related to end stage renal disease. Interventions included to have a scoop plate with meals.
Observation of breakfast tray line on 04/10/22 at 7:45 A.M. revealed one cook and one dietary aide in the kitchen. They were serving breakfast on paper products and no adaptive equipment was provided to residents during the meal. Dietary Aide #816 verified the observation.
Interview on 04/18/21 at 2:17 P.M. with the Director of Nursing revealed there was no policy for adaptive equipment.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure a complete and accurate medical record for two (Resident's #4...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure a complete and accurate medical record for two (Resident's #41 and #11) of 28 residents reviewed for the annual survey. The facility census was 54.
Findings include:
1. Review of the medical record revealed Resident #41 was admitted to the facility on [DATE] with diagnoses including traumatic brain injury, muscle weakness, and major depressive disorder. Review of the census records for Resident #41 revealed she was sent to and admitted to an acute care hospital on [DATE]. Resident #41 returned to the facility on [DATE].
Further review of the medical record revealed no documentation or evidence as to why Resident #41 was sent to the hospital. The nurse's notes noted an unrelated progress note related to an appointment on 02/23/22, and the next progress note noted in the medical record was from 03/04/22 stating Resident arrived at 12:40 P.M. via stretcher with ambulance, no complaints of pain, no lumps, bumps or bruises, lung sounds clear, and bowel sound present.
The Director of Nursing (DON) verified the lack of documentation during an interview on 04/11/22 at 4:00 P.M.
2. Review of the medical record revealed Resident #11 was admitted to the facility on [DATE] with diagnoses including dysphagia, dementia, and muscle weakness. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was severely cognitively impaired and required the extensive assistance of two staff for activities of daily living. Further review of the medical record noted Resident #11 as receiving end of life hospice services.
Review of the face sheet for Resident #11 revealed he had a guardian. Review of the electronic documents section of Resident #11's medical record revealed no evidence of guardianship paperwork or guardianship appointment for the guardian listed in Resident #11's medical record.
Review of the electronic documents section of Resident #11's medical record revealed a different guardian who was not noted on Resident #11's face sheet was appointed on 05/30/18.
Social Service Designee #995 verified the incorrect guardianship information during an interview on 04/11/22 at 3:05 P.M.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview the facility failed to ensure call lights were within reach and accessible. T...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview the facility failed to ensure call lights were within reach and accessible. This affected five (Resident's #20, #31, #34, #35 and #43) of 54 residents reviewed for call light placement. The facility census was 54.
Findings include:
1. Record review revealed Resident #20 was admitted to the facility on [DATE] with diagnoses including atherosclerotic heart disease, mixed hyperlipidemia, and osteoarthritis. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #20 was cognitively intact and required extensive assistance of one staff for mobility, toilet, and personal hygiene.
Observation of Resident #20 on 04/10/22 at 11:08 A.M. revealed Resident #20 was lying in bed with his eyes open. The call light was noted to be out of reach of Resident #20.
Review of the care plans dated 10/28/21 with a revision date of 03/08/22 revealed Resident #20 had a potential risk for falls related to decreased mobility and incontinent of bowel and bladder. Interventions included but not limited to call light within reach.
Interview with Restorative State Tested Nursing Assistant (STNA) #822 on 04/10/22 at 11:08 A.M. verified the call light was out of reach, and Resident #20 would be able to use the call light if it was within reach.
2. Record review revealed Resident #31 was admitted to the facility on [DATE] with a readmission date of 02/03/21 with diagnoses including multiple sclerosis, major depressive disorder, and anxiety disorder. Review of the most recent MDS 3.0 assessment dated [DATE] revealed Resident #31 was cognitively intact and required extensive assistance of one staff for mobility, toileting, and personal hygiene.
Observation of Resident #31 on 04/10/22 at 11:08 A.M. revealed Resident #31 was lying in bed with her eyes open. The call light was noted to be out of reach of Resident #31.
Review of the care plans dated 01/04/21 with a revision date of 02/04/21 revealed Resident #31 had acute confusion (delirium) related to acute disease process. Interventions included but not limited to call light within reach while in bed.
Interview with Restorative STNA #822 on 04/10/22 at 11:08 A.M. verified the call light was out of reach, and Resident #31 would be able to use the call light if it was within reach.
3. Record review revealed Resident #34 was admitted to the facility on [DATE] with diagnoses including chronic kidney disease, diabetes mellitus, and cerebral infarction. Review of the most recent MDS 3.0 assessment dated [DATE] revealed Resident #34 was cognitively intact and required extensive assistance of two staff for mobility, transfer, toileting, and personal hygiene.
Observation of Resident #34 on 04/10/22 at 11:08 A.M. revealed Resident #31 was lying in bed, and the call light was laying over the nightstand and out of reach of Resident #34.
Review of the care plans dated 02/11/22 revealed Resident #34 required assistance with activities of daily living (ADL) related to acute kidney failure, restlessness, and agitation. Interventions included but were not limited to call light within reach while in bed.
Interview with Housekeeper #811 on 04/10/22 at 12:01 P.M. verified the call light was out of reach.
4. Record review revealed Resident #35 was admitted to the facility on [DATE] with diagnoses including paranoid schizophrenia, malignant neoplasm of prostate, and dementia without behavioral disturbance. Review of the most recent MDS 3.0 assessment dated [DATE] revealed Resident #35 had moderate cognitive impairment and required extensive assistance of two staff for mobility, toileting, and transfer.
Observation of Resident #35 on 04/10/22 at 3:12 P.M. revealed Resident #35 was lying in bed, and his call light was lying on the floor. The call light was noted to be out of reach of Resident #35.
Review of the care plans dated 01/04/21 with a revision date of 02/02/21 revealed Resident #35 had an ADL self-care performance deficit related to generalized weakness. Interventions included but were not limited to call light within reach while in bed.
Interview with STNA #813 on 04/10/22 at 3:12 P.M. verified the call light was out of reach, and Resident #35 would be able to use the call light if it was within reach.
5. Record review revealed Resident # 43 was admitted to the facility on [DATE] with diagnoses including unspecified fracture of lower end of left femur, anxiety disorder, major depressive disorder, and history of falling. Review of the most recent MDS 3.0 assessment dated [DATE] revealed Resident #43 was cognitively impaired and required extensive assistance of one staff for mobility, toileting, and transfer.
Observation of Resident #35 on 04/10/22 at 3:12 P.M. revealed Resident #42 was lying in bed and her touch pad call light was lying on the floor. The call light was noted to be out of reach of Resident #43.
Review of the care plans dated 01/04/21 with a revision date of 08/31/21 revealed Resident #43 had an ADL self-care performance deficit and was at risk for falls related to history of falls and recent fractures. Interventions included but were not limited to call light within reach.
Interview with Restorative STNA #822 on 04/10/22 at 7:53 A.M. verified the call light was out of reach, and Resident #20 would be able to use the call light if it was within reach.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0568
(Tag F0568)
Could have caused harm · This affected multiple residents
Based on record review and staff interview the facility failed to ensure resident and/or responsible parties received quarterly statements of resident personal needs account activity as required. This...
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Based on record review and staff interview the facility failed to ensure resident and/or responsible parties received quarterly statements of resident personal needs account activity as required. This affected seven (Resident's #8, #16, #17, #25, #29, #30 and #31) of seven residents reviewed for personal funds. This had the potential to affect 13 additional residents (Resident's #3, #6, #7, #9, #11, #12, #14, #15, #20, #27, #32, #33 and #47) who also had personal needs bank accounts at the facility. The facility census was 54.
Findings include:
Review of the resident funds list provided by the facility during the annual survey beginning on 04/10/22 revealed 20 (Resident's #8, #16, #17, #25, #29, #30, #31, #3, #6, #7, #9, #11, #12, #14, #15, #20, #27, #32, #33 and #47) had an account that was actively managed by the facility. Review of seven (Resident's #8, #16, #17, #25, #29, #30 and #31) of the 20 personal funds accounts revealed no documented evidence was provided by the facility indicating the residents and/or responsible parties were given a quarterly statement of transactions in their personal needs account as required.
Business Office Manager #909 verified there was no documented evidence of quarterly statements given to residents and/or responsible parties during an interview on 04/12/22 at 3:30 P.M.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0569
(Tag F0569)
Could have caused harm · This affected multiple residents
Based on record review and staff interview the facilities failed to notify residents when their resident funds accounts were within $200.00 of the Medicaid resource limit as required. This affected fo...
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Based on record review and staff interview the facilities failed to notify residents when their resident funds accounts were within $200.00 of the Medicaid resource limit as required. This affected four (Resident's #8, #29, #30 and #31) of six residents reviewed for personal funds. The facility census was 54.
Findings include:
1. Review of the banking records for Resident #8 revealed she had a current balance of $5,236.13 and was over the Medicaid resource limit of $2,000 as of 02/23/22.
Further review of the banking records for Resident #8 on 04/12/22 revealed no notification of spend down was provided to the resident as required. The facility provided a spend down letter which was signed by Resident #8 on 04/12/22.
2. Review of the banking records for Resident #29 revealed she had a current balance of $2,560.73 and was over the Medicaid resource limit of $2,000 as of 02/23/22.
Further review of the banking records for Resident #29 on 04/12/22 revealed no notification of spend down was provided to the resident as required. The facility provided a spend down letter which was signed by Resident #29 on 04/12/22.
3. Review of the banking records for Resident #30 revealed she had a current balance of $15,348.27 and was over the Medicaid resource limit of $2,000 as of 01/03/22.
Further review of the banking records for Resident #30 on 04/12/22 revealed no notification of spend down was provided to the resident as required. The facility provided a spend down letter which was signed by Resident #30 on 04/12/22.
4. Review of the banking records for Resident #31 revealed she had a current balance of $10,844.09 and was over the Medicaid resource limit of $2,000 as of 03/25/22.
Further review of the banking records for Resident #31 on 04/12/22 revealed no notification of spend down was provided to the resident as required. The facility provided a spend down letter which was verbally acknowledged by Resident #31 on 04/12/22 and mailed to her responsible party on 04/12/22.
Business Office Manager #909 verified no spend down letters/notifications were provided to Resident's #8, #29, #30 and #31 or their responsible parties during an interview on 04/12/22 at 3:30 P.M.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0625
(Tag F0625)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure hospitalized residents on leave of absence from the fac...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure hospitalized residents on leave of absence from the facility were given copies of resident bed hold status as required. This affected four (Resident's #18, #34, #35 and #41) of four residents reviewed for hospitalization. The facility census was 54.
Findings include:
1. Review of the medical record revealed Resident #18 was admitted to the facility on [DATE] with diagnoses including dysphagia, type two diabetes, and muscle weakness. Review of the census records for Resident #18 revealed he was sent to and admitted to an acute care hospital on [DATE]. Resident #41 returned to the facility on [DATE].
Review of the electronic medical record revealed no evidence Resident #18 was given a copy of his current bed hold status and facility bed hold information as required.
2. Review of the medical record revealed Resident #34 was admitted to the facility on [DATE] with diagnoses including chronic kidney disease, type two diabetes, and high blood pressure. Review of the census records for Resident #34 revealed he was sent to and admitted to an acute care hospital on [DATE]. Resident #41 returned to the facility on [DATE].
Review of the electronic medical record revealed no evidence Resident #34 was given a copy of his current bed hold status and facility bed hold information as required.
3. Review of the medical record revealed Resident #35 was admitted to the facility on [DATE] with diagnoses including schizophrenia, muscle weakness, and hypoxemia. Review of the census records for Resident #35 revealed he was sent to and admitted to an acute care hospital on [DATE]. Resident #41 returned to the facility on [DATE].
Review of the electronic medical record revealed no evidence Resident #35 was given a copy of his current bed hold status and facility bed hold information as required.
4. Review of the medical record revealed Resident #41 was admitted to the facility on [DATE] with diagnoses including traumatic brain injury, muscle weakness, and major depressive disorder. Review of the census records for Resident #41 revealed she was sent to and admitted to an acute care hospital on [DATE]. Resident #41 returned to the facility on [DATE].
Review of the electronic medical record revealed no evidence Resident #41 was given a copy of her current bed hold status and facility bed hold information as required.
Interview on 04/11/22 at 2:05 P.M. with Administrator revealed there were no bed hold notifications for past three months.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure care plans were developed timely and care plan interventions ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure care plans were developed timely and care plan interventions were implemented. This affected four (Resident's #20, #33, #35 and #248) of 32 residents whose care plans were reviewed. The facility census was 54.
Findings include:
1. Review of the medical record revealed Resident #20 was admitted to the facility on [DATE] with diagnoses including gastroesophageal reflux disease, history of COVID-19, coronary angioplasty implant and graft, and hypotension.
Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #20 had severe cognitive impairment. Resident #20 required extensive assistance of one staff for bed mobility, transfers, dressing, toilet use, and personal hygiene.
Review of the plan of care dated 04/23/21 revealed Resident #20 was at risk for impaired skin integrity related to dementia, and incontinence of bowel and bladder. Interventions included: Assist resident with turning and repositioning as needed; Complete Braden Scale (for predicting pressure ulcer risk) as needed; Encourage good nutrition and hydration; and complete a skin inspection every seven to ten days and as needed.
Review of facility assessments and nursing progress notes from September 2021 to present revealed Resident #20 had a skin assessment performed every seven to ten days as ordered until the end of September 2021. There was one skin assessment completed on 10/25/21 for October. There are no skin assessments for the months of November 2021 and December 2021. There was a skin assessment completed on 01/01/22.
Interview with the Director of Nursing (DON) regarding resident skin assessments on 04/11/22 at 10:40 A.M. revealed skin assessments are not only documented in the nursing progress noted but also under skin observations section of the assessment tab. Further review of this section revealed no further skin assessments from October, November, and December of 2021.
2. Review of the medical record revealed Resident #33 was admitted to this facility on 02/28/19 with diagnoses including chronic obstructive pulmonary disease, heart failure, kidney failure, major depressive disorder, syncope and collapse.
Review of the MDS 3.0 assessment dated [DATE] revealed Resident #33 had severe cognitive impairment and required extensive assistance of one staff for bed mobility, transfers, dressing, toilet use, and personal hygiene.
Review of the plan of care dated 11/17/21 revealed Resident #33 had a nutritional risk related to dementia, depression, unintended weight flux with weight loss noted, and chronic obstructive pulmonary disease. Interventions included: administer medications and/or vitamin mineral supplements per the physician orders; hold breakfast until the resident is up and ready to eat; monitor for signs/symptoms of dehydration, acute weight loss, or decreased urine output; and monitor meal percentage intake for changes in the resident's eating habits.
Review of the meal intakes for Resident #33 for the past month revealed her meal intakes were only documented for 03/31/22 and 04/17/22. On 03/31/22, the meal intake was 75 to 100% and on 04/17/22, the intake stated the resident was unavailable.
Review of the dietician note dated 03/08/22 at 10:03 A.M. revealed meal intakes were difficult to determine due to limited documentation. Further interview with the DON on 04/18/22 at 2:17 P.M. verified meal intakes for Resident #33 were not consistently documented.
3. Review of the medical record revealed Resident #35 was admitted to the facility on [DATE] with diagnoses including repeated falls, paranoid schizophrenia, dementia, malignant neoplasm of the prostate, and a localized mass and lump of right lower limb. Resident #35 was transferred to the hospital on [DATE] and was admitted for a change in mental status. He was readmitted from the hospital on [DATE].
Review of the MDS 3.0 assessment dated [DATE] revealed Resident #35 had moderate cognitive impairment and required extensive assistance of one to two staff for bed mobility, transfers, dressing, toilet use, and personal hygiene. Resident #35 had a urinary catheter in place.
Review of the plan of care dated 04/08/22 revealed Resident #35 had a potential for complications related to urinary catheter use. Interventions included: change urinary catheter bag according to facility policy; obtain urine output for each shift and total for 24 hours daily; and to position the catheter bag and tubing below the level of the bladder. Further review of the date of this plan of care revealed it was initiated 54 days after Resident #35 was readmitted with a urinary catheter which did not meet the time requirement of 14 days.
Interview with MDS Nurse #800 on 04/18/22 at 9:10 A.M. verified the care plan was not initiated until 04/08/22.
4. Review of the medical record for Resident #248 revealed an admission date of 02/25/22 with diagnoses including edema, morbid obesity, schizophrenia, hypertension, congestive heart failure, major depressive disorder, and type two diabetes mellitus.
Review of the comprehensive MDS 3.0 assessment dated [DATE] revealed Resident #248 was cognitively intact, required extensive assistance of two staff for toileting, and was always incontinent of bowel and bladder.
Review of the care plans revealed no care plan was developed for incontinence care for Resident #248.
On 04/18/22 at 11:26 A.M., interview with Licensed Practical Nurse (LPN) #800 verified Resident #248 did not have a care plan for incontinence care.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Review of the medical record revealed Resident #23 was admitted to the facility on [DATE] with diagnoses including dementia, ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Review of the medical record revealed Resident #23 was admitted to the facility on [DATE] with diagnoses including dementia, muscle weakness, and Vitamin D deficiency. Review of the most recent MDS 3.0 assessment dated [DATE] revealed Resident #23 was moderately cognitively impaired and required hands on assistance for her ADL, including bathing.
Interview with Resident #23 on 04/10/22 at 11:10 A.M. revealed she hardly ever gets showered at all.
Review of shower sheets from 01/01/22 through 04/13/22 revealed Resident #23 refused a shower on 02/09/22 and bathed herself on 02/15/22 and 03/05/22. No other documented refusals or attempts at bathing/showers were noted in the medical record.
The DON verified the lack of shower documentation and attempts during an interview on 04/13/22 at 9:15 A.M.
Based on record review and interview, the facility failed to ensure shower/bed baths were given to residents. This affected four (Resident's #23, #38, #43, and #47) of five residents reviewed for showers. The facility census was 54.
Findings Include:
1. Review of the medical record revealed Resident #38 was admitted to the facility on [DATE] with diagnoses including acute cystitis with hematuria, type II diabetes, heart failure, ileus, atrial fibrillation, and anxiety disorder.
Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #38 was alert and oriented times to person, place, and time. He required extensive assistance of two staff for transfers, dressing, toilet use, and personal hygiene.
Review of the plan of care dated 07/21/21 revealed Resident #38 had an activities of daily living (ADL) self-care performance deficit related to impaired mobility. Interventions included: assist the resident with ADL (i.e., dressing, grooming, personal hygiene, locomotion, oral care, etc.) as needed.
Review of the shower log revealed Resident #38 was to receive showers on Monday and Wednesday on the 3:00 P.M. to 11:00 P.M. shift. Review of Resident #38's shower sheets revealed he received one shower in the month of March 2022 and one shower in the month of April 2022.
Interview with Resident #38 on 04/12/22 at 9:30 A.M. revealed he does not get offered a shower or a bath regularly. He further stated he only had one shower for the month of April.
2. Review of the medical record revealed Resident #43 was admitted to the facility on [DATE] with admitting diagnoses included fracture of lower end of left femur, dementia, anxiety disorder, fracture of right wrist/hand, history of falls, and major depressive disorder.
Review of the MDS 3.0 assessment dated [DATE] revealed Resident #43 had severe cognitive impairment and required extensive assistance of one staff for bed mobility, transfers, dressing, and toilet use.
Review of the plan of care dated 01/04/21 revealed Resident #43 had an ADL performance deficit related to dementia, history of falls and recent fractures. Interventions included: involve the resident with choosing own clothing; place the call light within reach; provide cues and assist as needed to accomplish daily tasks; report changes in ADL abilities to the nurse and the physician as needed; and the resident needs total assistance with ADL including dressing, grooming, personal hygiene, and oral care.
Review of the shower log revealed Resident #43 was supposed to receive a shower on Tuesdays and Thursdays on the evening shift. Review of Resident #43's shower sheets revealed she received one shower in January 2022, two showers in February 2022, one shower in March 2022 and one shower in April 2022.
Interview with the Director of Nursing (DON) on 04/13/22 at 10:05 A.M. verified Resident #43 did not receive her showers as ordered.
3. Review of the medical record revealed Resident #47 was admitted to the facility on [DATE]with diagnoses including pain in her left hand, type II diabetes, heart failure, hypertension, hemiplegia, and malignant neoplasm of the stomach.
Review of the MDS 3.0 assessment dated [DATE] revealed Resident #47 had moderate cognitive impairment and required extensive assistance of one staff for showers.
Review of the plan of care dated 01/04/21 revealed Resident #47 had an ADL self-care performance deficit related to central venous attack. Interventions included: assist with ADL including dressing, grooming, personal hygiene, and oral care; encourage participation in daily care and provide positive reinforcement for activities attempted; encourage the resident to use her call light when assistance was needed; honor the resident's preferences whenever possible; and monitor for pain during ADL tasks; and provide medication per the physician's order.
Review of the shower log revealed Resident #47 was to receive showers on Monday and Thursday on the 3:00 P.M. to the 11:00 P.M. shift. Review of the shower sheets revealed Resident #47 received no showers in the month of January or February 2022. She received three showers in March 2022 and as of 04/13/22, Resident #47 had only received one shower in the month of April 2022.
Interview with the DON on 04/13/22 at 10:05 A.M. verified the documentation revealed Resident #47 was not offered and/or did not receive a shower twice a week as ordered.
Interview with Resident #47 on 04/18/22 at 10:30 A.M. revealed she consistently did not receive showers but since the survey team came into the facility, she received a shower this morning.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0726
(Tag F0726)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, review of Centers for Medicare and Medicaid Services (CMS) memorandums, Food and...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, review of Centers for Medicare and Medicaid Services (CMS) memorandums, Food and Drug Administration (FDA) Warning about drawing insulin from pens, and manufacturer's instruction on how to use insulin pens, the facility failed to ensure nurses knew how to administer insulin using an insulin pen correctly. In addition, the facility failed to ensure non-licensed nursing staff demonstrated competencies in skills and techniques necessary to care for residents needs prior to providing care and services to residents. This had the potential to affect all 54 residents residing in the facility.
Findings include:
Record review of Resident #19 revealed an admission date of 01/11/22 with diagnoses including diabetes mellitus and morbid obesity. Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #19 had moderately impaired cognition and required extensive assistance of two staff for activities of daily living, except eating which required supervision with set-up only. Resident #19 received five insulin injections during the assessment reference period.
Review of the physician's orders dated 02/26/22 revealed Resident #19 was ordered a Humalog Kwik pen 100 unit/milliliter (ml) solution pen and was to receive insulin per sliding scale before meals and at bedtime for diabetes mellitus.
Observation of medication administration on 04/10/22 at 8:30 A.M. of Registered Nurse (RN) #809 administering medications to Resident #19 revealed Resident #19 had a blood sugar check which resulted in a blood sugar of 179. According to the sliding scale order written on 02/26/22, Resident #19 was to receive two units of Humalog insulin via a Kwik Pen. RN #809 proceeded to wipe off the top of the Kwik pen and then inserted the needle of an insulin syringe into the rubber tip of the Kwik pen. RN #809 proceeded to draw two units of Humalog insulin out of the Kwik pen via insulin syringe proceeded to administer it to the resident. Interview with RN #809 at the time of the observation stated he was unsure how to administer the insulin via the Kwik pen.
Interview with the Director of Nursing (DON) on 04/12/22 at 9:35 A.M. revealed all nurses at the facility were in-serviced on the use of the Kwik pen. She further stated the administration of insulin via the insulin pens are also covered in nursing school.
Review of the FDA safety warning dated 02/15/28 titled, FDA Safety Warning: Patients, Caregivers Withdrawing insulin from pens, revealed that using a syringe to draw medicine from an insulin pen is an unsafe practice.
Review of the Humalog Kwik pen 100 unit/ml solution pen revealed instructions on how to administer insulin using the pen with no mention that a syringe should be used to withdraw the insulin.
2. Review of the personnel file for Staff #826 revealed a hire date of 02/15/22. Staff #826 was hired as Non-Certified Nurse Aide under the staffing waiver program for COVID-19. Staff #826 was not a State Tested Nursing Assistant (STNA). There was no documented evidence of competencies being evaluated prior to Staff #826 providing care and services to the residents.
Interview with the Director of Human Resources (HR) #821 on 04/13/22 at 11:25 A.M. verified Staff #826 was not a STNA and there was no documented evidence of Staff #826 having demonstrated competencies in skills and techniques to care for residents.
Review of the CMS memorandum titled Updates to Long-Term Care (LTC) Emergency Regulatory Waivers issued in response to COVID-19, dated 04/08/21, and reference number QSO-21-17-NH revealed to help with nursing homes staffing shortage, CMS provided a blanket waiver for the nurse aide training and certification.
This deficiency substantiates Complaint Number OH00131465.
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** 2. Observation on [DATE] of the medication cart on the 100/200 halls at 9:40 A.M. revealed a Lantus Kwik pen for Resident #3's w...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Observation on [DATE] of the medication cart on the 100/200 halls at 9:40 A.M. revealed a Lantus Kwik pen for Resident #3's was not dated at the time it was opened. Further review revealed another Lantus Kwik pen for Resident #29 was not dated at the time it was opened.
Interview with Registered Nurse (RN) #809 on [DATE] at 10:00 A.M. verified the Lantus Kwik pens for Resident's #3 and #29 were not dated when they were opened.
Based on observation and interview, the facility failed to ensure Insulin Kwik pens were dated when opened. This affected two (Resident's #3 and #29) of two residents reviewed for Lantus Kwik pens. In addition, the facility failed to ensure expired stock over-the-counter Colace and baby aspirin used for multiple residents were removed from the medication carts. This had the potential to affect six (Resident's #4, #5, #26, #32, #34 and #35) of six residents who received baby aspirin and five (Resident's #14, #31, #43, #47 and #198) of five residents who received Colace. The facility census was 54.
Finding include:
1. Observation on [DATE] at 9:32 A.M. of the medication cart on the 300-hall with Licensed Practical Nurse (LPN) # 810 revealed an over-the-counter bottle of Colace (stool softener) with an expiration date of 03/2022, and an over-the-counter bottle of baby aspirin with an expiration date of 02/2022.
Review of the residents receiving baby aspirin on the 300-hall included Resident's #4, #5, #26, #32, #34 and #35.
Review of the residents receiving Colace on the 300-hall included Resident's #14, #31, #43 and #47.
Interview on [DATE] at 9:45 A.M. with LPN #810 verified the bottle of baby aspirin and the bottle of Colace were expired.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0725
(Tag F0725)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, and staff interview the facility failed to ensure it was sufficiently staffed to mee...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, and staff interview the facility failed to ensure it was sufficiently staffed to meet the needs of the residents. This had the potential to affect all 54 residents residing in the facility.
Findings include:
1. Interview with State Tested Nursing Assistant (STNA) #801 on 04/10/22 at 10:10 A.M. revealed the facility has no idea how to staff correctly and it's a struggle to get work completed.
2. Interview with Resident #47 on 04/10/22 at 12:33 P.M. revealed there is not enough staff, and staff just sits at the desk and ignores what the resident needs.
3. Interview with Resident #45 on 04/10/22 at 2:20 P.M. revealed the facility is understaffed, and call light response is poor.
4. Interview with Resident #40 on 04/10/22 at 2:34 P.M. noted Resident #40 commenting on the need for more staff, and staff often looking overwhelmed and overlooking basic aspects of care.
5. Interview with Resident #15 on 04/10/22 at 2:41 P.M. revealed there is not enough staff because it takes too long to answer call lights and sometimes, they don't answer call lights at all.
6. Interview with Resident #248 on 04/10/22 2:34 P.M. revealed Resident #248 stated she was aware she required a lot of assistance, and she doesn't get it timely.
7. Review of the facility staffing schedule and completion of the staffing tool for 03/19/22 and 03/20/22 revealed the facility did not meet the required minimum direct care daily average of 2.50 hours on 03/19/22 and 03/20/22. The staffing tool noted 2.41 hours of direct resident care hours on 03/19/22 and 1.88 hours of direct care hours on 03/20/22.
8. Review of the medical record revealed Resident #23 was admitted to the facility on [DATE] with diagnoses including dementia, muscle weakness, and Vitamin D deficiency. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident was moderately cognitively impaired and required hands on assistance for activities of daily living, including bathing.
Interview with Resident #23 on 04/10/22 at 11:10 A.M. revealed she hardly ever gets showered at all.
Review of shower sheets from 01/01/22 through 04/13/22 revealed Resident #23 refused a shower on 02/09/22 and bathed herself on 02/15/22 and 03/05/22. No other documented refusals or attempts at bathing/showers for Resident #23 were noted in the medical record.
The Director of Nursing verified the lack of shower documentation and attempts during an interview on 04/13/22 at 9:15 A.M.
On 04/18/22 at 9:37 A.M. interview with Human Resources Director #821 verified the lack of staffing levels to meet the requirements.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0802
(Tag F0802)
Could have caused harm · This affected most or all residents
Based on observation, interview, record review and review of the Facility Assessment, the facility failed to ensure sufficient dietary staffing to provide residents with a dignified dining experience....
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Based on observation, interview, record review and review of the Facility Assessment, the facility failed to ensure sufficient dietary staffing to provide residents with a dignified dining experience. This affected 52 of 54 residents who consumed meals in the facility. Two (Resident's #37 and #249) received nothing by mouth. The facility census was 54.
Findings include:
Observation of breakfast tray line on 04/10/22 at 7:45 A.M. revealed there was one cook and one dietary aide in the kitchen. They were serving breakfast on paper products, and no adaptive equipment was given to residents during the meal. [NAME] #815 and Dietary Aide #816 revealed they were using paper products because they were the only two dietary staff scheduled for the weekend, and they can't do what they normally do when there were three staff on duty. [NAME] #815 stated there are two dietary staff that work 12-hour shifts on the weekend. The two dietary staff had to prepare, serve, and clean up for all three meals.
When they asked for more assistance, the dietary manager would say it wasn't in the budget.
Observation and interview on 04/13/22 at 9:00 A.M. revealed [NAME] #817 at the dish machine assisting with breakfast dishes. [NAME] #817 stated there was not enough staff and she was called into work because the Department of Health was in the building. [NAME] #817 stated there were only two dietary staff each weekend who were scheduled 12-hour shifts.
Interview on 04/11/22 at 2:09 P.M. with Dietary Manager #818 revealed she had a patient plate for day (PPD), and the cook and dietary aide work together on the dish machine to get the work done.
Review of the dietary staffing schedule dated 04/03/22 through 04/16/22 revealed Fridays, Saturdays, and Sundays there were two dietary staff scheduled from 6:30 A.M. to 6:00 P.M., which equated to 22 hours if the two dietary staff took an unpaid half-hour break.
Record review of the Facility Assessment, dated 01/22/22, revealed there was no representative from dietary included in the development of the staffing plan for dietary services. The number of beds listed on the assessment was 75 with a 55 percent (%) average daily census. There was no total number of dietary staff needed on the assessment.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0921)
Could have caused harm · This affected most or all residents
Based on observation and interview, the facility failed to maintain a clean, safe, and sanitary environment throughout the facility. This affected 26 (Residents #3, #7, #11, #12, #14, #16, #19, #20, #...
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Based on observation and interview, the facility failed to maintain a clean, safe, and sanitary environment throughout the facility. This affected 26 (Residents #3, #7, #11, #12, #14, #16, #19, #20, #21, #22, #25, #27, #31, #32, #34, #35, #38, #41, #43, #44, #45, #46, #251, #252, #253 and #254) and had the potential to affect all 54 residents in the facility.
Findings include:
1. On 04/10/22 from 7:41 A.M. to 8:32 A.M., observations of the facility revealed no door thresholds in place for the main doors leading to the nursing units and no door thresholds in place for the rooms of Resident's #7, #11, #12, #14, #27, #32, #35, #41, #44, #45, #46, #252, and #253.
On 04/10/22 at 3:15 P.M., interview with Maintenance Director #804 verified the missing door thresholds. He stated the door thresholds were removed for safety due to being loose.
2. On 04/10/22 from 7:41 A.M. to 10:56 A.M., observations of the facility revealed stained carpeting in the hallways, torn carpeting in the hallway on the 100-unit, a cracked tile in Resident #25's room, and dirty carpet in Resident #251's room.
On 04/10/22 at 7:47 A.M., interview with State Tested Nurse Aide (STNA) #801 verified the torn carpet in the hallway on the 100-unit.
On 04/10/22 at 3:15 P.M., interview with Maintenance Director #804 verified the floors needed repaired.
On 04/12/22 at 11:39 A.M., interview with Housekeeper #805 verified the carpets were dirty and needed cleaned.
3. On 04/10/22 at 11:40 A.M., interview with Resident #254 revealed the toilet was leaking water onto the floor in the bathroom. Observation of the bathroom at the time of the interview revealed water on the floor under and behind the toilet.
On 04/10/22 at 3:15 P.M., interview with Maintenance Director #804 verified there was water leaking from the toilet onto the bathroom floor in Resident #254's room.
4. On 04/10/22 at 2:05 P.M., observation of Resident #22's bathroom revealed the toilet seat was orange and pink in color with streaks from dripping liquid visible in the discoloration.
On 04/12/22 at 11:12 A.M., interview with Housekeeper #824 verified the condition of the toilet seat in Resident #22's bathroom and stated it needed to be replaced.
5. On 04/10/22 from 8:10 A.M. to 1:03 P.M., observations of the facility revealed Resident's #12, #16 and #21 had dirty linens on their beds, and Resident #21 had a dirty mattress on the floor next to his bed.
On 04/10/22 at 8:10 A.M., interview with STNA #801 verified Resident #21 had dirty linens on his bed and a dirty mattress in the floor next to the bed.
On 04/10/22 at 11:12 A.M., interview with STNA #822 verified Resident #12 had dirty linens on her bed.
On 04/12/22 at 11:59 A.M., interview with Licensed Practical Nurse (LPN) #812 verified Resident #16's linens were dirty and stated the resident often refused to let staff launder his linens and blankets.
6. On 04/11/22 at 7:02 A.M., observation of Resident #38's room revealed two large dents and tears in the wall behind the resident's bed.
On 04/12/22 at 11:02 A.M., interview with LPN #807 verified the damage to the wall behind Resident #38's bed.
7. On 04/10/22 at 2:28 P.M., observation of Resident #3's room revealed there was no door on the bathroom inside the resident's room. Interview at the time of observation with Registered Nurse (RN) #809 verified Resident #3 did not have a door for the bathroom.
On 04/10/22 at 3:15 P.M., interview with Maintenance Director #804 revealed the bathroom door had been removed for repairs and would not be replaced for at least three days due to the wood glue drying time.
8. On 04/12/22 at 2:46 P.M., observation of the laundry room revealed missing ceiling tiles, evidence of water damage on the ceiling and walls, and the disintegrating remains of a fallen ceiling tile behind the washing machine. Interview at the time of observation with Housekeeper #806 verified there was a water leak that had to be repaired and the ceiling tiles had not been replaced. She also confirmed the water damage to the ceiling and walls, as well as the damaged ceiling tiles.
MINOR
(C)
Minor Issue - procedural, no safety impact
Deficiency F0577
(Tag F0577)
Minor procedural issue · This affected most or all residents
Based on record review and staff interview the facility failed to ensure the most recent state survey results were readily available to staff and the public. This had the potential to affect all 54 re...
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Based on record review and staff interview the facility failed to ensure the most recent state survey results were readily available to staff and the public. This had the potential to affect all 54 residents residing in the facility.
Findings include:
Observation of the front desk area noted a wall file folder with the description Gateway Healthcare Center State Survey Results (the facility is currently under new ownership since 09/01/21 and has a new name). No results were noted in the wall file folder.
The Ohio Department of Health conducted surveys at the facility on the following dates:
•
03/12/22 Complaint Survey
•
01/25/22 Complaint Survey
•
08/30/21 Complaint Survey (violations issued)
•
06/17/21 Complaint Survey
•
04/26/21 Complaint Survey
•
02/04/21 Complaint Survey
•
01/11/21 Complaint Survey (violations issued)
State Tested Nursing Assistant (STNA) #997 verified the lack of survey results available for review during an interview on 04/10/22 at 8:15 A.M.
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 its posted nursing staff information was up to date as required. This had the potential to affect all residents. The facility cen...
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Based on observation and staff interview the facility failed to ensure its posted nursing staff information was up to date as required. This had the potential to affect all residents. The facility census was 54.
Findings include:
Observation of the posted nursing staff information on 04/10/22 at 7:45 A.M. revealed the information was from 04/07/22 and 04/08/22.
State Tested Nursing Assistant (STNA) #997 verified the posted nursing staff information was not up to date during an interview on 04/10/22 at 7:49 A.M.
Jun 2019
4 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview the facility failed to ensure a clean and safe environment for Resident #35 an...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview the facility failed to ensure a clean and safe environment for Resident #35 and Resident #9. This affected two of 49 residents sampled residents. The facility census was 49.
Findings include:
1. Resident #35 was admitted to the facility on [DATE] with diagnoses including stroke, right side paralysis and depression.
The Minimum Data Set Assessment (MDS) dated [DATE] indicated he had mild cognitive impairment, needed staff assistance for all activities of daily living and was dependent on tube feeding as his only source of nutrition and hydration.
Observation on 06/03/19 at 2:01 P.M. revealed Resident #35 laying in his bed in his room. He had a tube feeding pump next to his bed with tube feeding solution infusing. All along the pole and the feet of the pole on which the tube feeding bag was hung, on the hand rail of the bed, the bed frame and an approximate two feet by two feet area of the floor around the pole was a heavy, dried, sticky, beige collection of what appeared to be tube feeding formula residue. On the wall directly behind Resident #35's bed were multiple two to three feet long brown stains of an unknown dried substance. On the wall to the right side of the resident's head was an approximate three feet by two feet area of heavy black scuff marks.
An interview was conducted on 06/03/19 at 2:06 P.M. with Resident #35 who was alert and oriented to person, place and time. Resident #35 revealed he spent most of his time in his room per his choice.
An observation was conducted on 06/04/19 at 9:14 A.M. of Resident #35 laying in bed in his room. On his left side next to the tube feeding pump a pool of tube feeding solution was collecting on his white blanket. The infusion pump was running, but the feeding tube was disconnected from port of the tube that that was inserted into his stomach. A gnat was resting in the pool of tube feeding solution. The stains and scuff marks on his walls and the dried beige build up of residue remained on the floor, tube feeding pole and feet, bed hand rail and the bed frame.
An observation was conducted on 06/04/19 at 9:16 A.M. of Resident #35 in his room with Regional Director of Clinical Services #900 and Licensed Practical Nurse (LPN) #903. Both verified there was a gnat insect sitting on the pool of tube feeding formula next to the open port of the resident's disconnected feeding tube and both verified the wall stains, wall scuffs and dried residue on the resident's bed, equipment and floor.
Review of the facility document titled Daily Room Cleaning Policy, undated, revealed it did not indicate walls, bed frames and tube feeding equipment should be kept clean. The document did identify that floors were to be mopped.
2. Resident #9 was admitted to the facility on [DATE] with diagnoses including stroke, depression and vascular dementia.
The MDS dated [DATE] indicated he had mild cognitive impairment and needed set up and supervision by staff for his activities of daily living.
An observation and interview were conducted on 06/04/19 at 8:59 A.M. of Resident #9 sitting in a wheelchair watching television in his room. Resident #9 indicated there were two holes in his window screen which he had stuffed with paper towels so the bugs could not get in. The window was propped open with a wooden block and at the bottom of the screen closest to the bottom sill was one tennis ball sized hole and one golf ball sized hole stuffed with paper towel. Resident #9 stated the holes had been there for quite a while.
An observation was conducted on 06/04/19 at 9:33 A.M. with the Administrator who verified the holes in the window screen and said she would have a maintenance employee fix the screen as soon as possible.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure Resident #46's meal intakes were consistently monitored per h...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure Resident #46's meal intakes were consistently monitored per her care plan for nutrition and failed to ensure Resident #46's care plan for the use of an indwelling urinary catheter included ordered catheter care. This affected one resident (Resident #46) out of four residents reviewed for nutrition and one resident (Resident #46) of one resident reviewed for the use of a urinary catheter.
Findings include:
Resident #46 was admitted to this facility on 03/26/19. Her admitting diagnoses included dementia, cerebral infarction, and neurogenic bladder (lack of bladder control due to nerve damage). The resident had an indwelling urinary catheter (a tube inserted through the urethra into the bladder for the purpose of draining urine) in place due to a diagnosis of neurogenic bladder.
Review of this resident's Minimum Data Set 3.0 (MDS) dated [DATE] revealed the resident had moderate cognitive impairment.
1. Review of the plan of care dated 04/16/19 showed that Resident #46 was at risk for decreased nutritional status and/or dehydration secondary to dementia, advanced age, fair meal intake, weight loss prior to admission and bilateral lower extremity edema. Interventions included: Observe for, document, and repot to the physician as needed any signs/symptoms of dysphagia, choking, pocketing of food or refusing to eat. Obtain and monitor lab and diagnostic test values as ordered. Provide and serve supplements as ordered. Provide and serve diet as ordered and monitor intake and record for every meal.
Review of the meal intake forms from 05/07/19 to 06/05/19 revealed inconsistent monitoring of the meal intakes. On 05/07/19, 05/10/19, 05/11/19, 05/12/19, 05/13/19, 05/2319, 05/25/19, 05/30/19, 06/01/19 and 06/02/19, the meal intake was not recorded for all three meals. From 05/26/19 to 05/29/19 there was no meal intake recorded at all.
On 06/06/19 at 11:30 A.M. the Director of Nursing (DON) verified meal intakes were not recorded consistently and according to the resident's plan of care
2. Review of the physician orders for the month of May 2019 revealed an order dated 05/05/19 for an indwelling 18 French, urinary catheter to be inserted with continuous drainage due to a diagnoses of neurogenic bladder. On 05/05/19 she was also ordered to have urinary catheter care done twice daily and as needed.
Review of the resident's plan of care dated 05/06/19 revealed Resident #46 had an indwelling urinary catheter in place due to neurogenic bladder and urinary retention. Interventions included: Change catheter as needed. Position catheter bag and tubing below the level of the bladder. Check tubing for kinks as needed. Clean peri area front to back and observe for and report to the physician any signs/symptoms of a urinary tract infection. The ordered catheter care, to be done twice a day, was not listed as an intervention.
On 06/06/19 at 12:10 P.M. the DON verified catheter care was not included on the resident's plan of care.
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 record review, observation and interview the facility failed to ensure foods were stored under sanitary conditions in unit refrigerators. This had the potential to affect 48 of 49 residents c...
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Based on record review, observation and interview the facility failed to ensure foods were stored under sanitary conditions in unit refrigerators. This had the potential to affect 48 of 49 residents currently residing in the facility who received foods from the kitchen. The facility identified Resident #35 as not taking anything by mouth.
Findings include:
An observation was conducted on 06/05/19 at 10:08 A.M. with Licensed Practical Nurse (LPN) #903 of the 100/200 unit refrigerator used to store resident foods and snacks. There was no temperature log available to review. The internal thermometer read 38 degrees Fahrenheit (F). The general appearance of the unit indicated it had not been cleaned recently. The entire inside had multiple areas of spills and dried on food substances on all shelves and storage compartments. LPN #903 verified the temperature log was missing and the unit needed to be cleaned.
An observation was conducted on 06/05/19 from 10:14 A.M. to 10:18 A.M. with LPN #904 of the 300/400 unit refrigerator used to store resident foods and snacks. LPN #904 indicated the temperature log was missing. The internal thermometer was reading in the red zone at 45 degrees F. The entire inside of the unit was laden with multiple spills and dried on food substances indicating it had not been recently cleaned. There was a quart size container of opened, thickened water dated 02/25/19, one opened quart of thickened apple juice dated 02/25/19, one pint sized cup of yellow pudding with cookies with a store label on it without a name or date, a plate of two hot dogs on buns and macaroni salad without a name or date and a half full quart of potato salad without a name or date on it. LPN #904 verified all the above findings and said it was the responsibility of housekeeping to clean the unit and nursing to make sure foods were marked with a resident name and date and discarded after three days. LPN #904 discarded all the contents of the unit into the trash.
Review of the facility policy titled Foods Brought by Family/Visitors, dated 02/2014 revealed perishable foods were to be stored under refrigeration, labeled with the resident name, the item and the use by date, and discarded if not consumed within three days.
MINOR
(C)
Minor Issue - procedural, no safety impact
Transfer Notice
(Tag F0623)
Minor procedural issue · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure the state Ombudsman was notified when Residents #40, #204, an...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure the state Ombudsman was notified when Residents #40, #204, and #46 were discharged to an acute care facility. This affected three of four residents reviewed for hospitalization. The facility census was 49.
Findings include:
1. Resident #40 was admitted to the facility on [DATE] with diagnoses including Parkinson's disease and facial pain caused by trigeminal neuralgia.
A progress note dated 04/06/19 at 5:15 P.M. revealed she had a flare up of trigeminal neuralgia and was discharged to the hospital emergency room. A progress note dated 04/11/19 at 5:42 P.M. revealed she was readmitted to the facility.
2. Resident #204 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's dementia and type two diabetes mellitus.
A progress note dated 05/07/19 at 2:38 P.M. indicated she had a change in mental status and was discharged to the hospital. A progress note dated 05/16/19 at 1:27 P.M. indicated she was readmitted to the facility.
3. Resident #46 was admitted to the facility on [DATE]. Her admitting diagnoses included dementia, cerebral infarction and a neurogenic bladder.
A progress note dated 03/28/19 at 5:57 A.M. revealed the resident was having heart palpitations and was discharged to the hospital. A progress dated 04/07/19 at 10:55 A.M. indicated Resident #46 was readmitted to the facility.
Another progress note for this resident dated 04/22/19 at 10:14 P.M. revealed the resident was having an episode of severe left upper and lower extremity pain. The physician ordered for the resident to be transferred to the hospital. A progress note dated 04/26/19 at 2:15 PM indicated the resident was readmitted to this facility.
Interview on 06/05/19 at 3:10 P.M. with Social Service Director (SSD) #902 revealed she kept a log of all discharges and readmission dates for residents on a form called the Monthly Discharge Tracker. SSD #902 reported that prior to 02/04/19 she had been notifying the state Ombudsman's office of all discharges via email but effective 02/04/19 she began sending the Monthly Discharge Tracker to Ombudsman's office monthly.
Review of the Monthly Discharge Tracker document dated 02/04/19 to 05/31/19 revealed it did not include any discharge or readmission information for Residents #40, #46 or #204.
On 06/06/19 at 10:35 A.M. SSD #902 verified Residents #40, #46 and #204 were not listed on the Monthly Discharge Tracker sent to the Ombudsman's office.
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
- • 52 deficiencies on record, including 1 serious (caused harm) violation. Ask about corrective actions taken.
- • Grade C (50/100). Below average facility with significant concerns.
- • 69% turnover. Above average. Higher turnover means staff may not know residents' routines.
Bottom line: Mixed indicators with Trust Score of 50/100. Visit in person and ask pointed questions.
✓ Report will be sent to your email
About This Facility
What is Embassy Of Euclid's CMS Rating?
CMS assigns EMBASSY OF EUCLID 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 Embassy Of Euclid Staffed?
CMS rates EMBASSY OF EUCLID's staffing level at 2 out of 5 stars, which is below average compared to other nursing homes. Staff turnover is 69%, which is 23 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 67%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.
What Have Inspectors Found at Embassy Of Euclid?
State health inspectors documented 52 deficiencies at EMBASSY OF EUCLID during 2019 to 2024. These included: 1 that caused actual resident harm, 46 with potential for harm, and 5 minor or isolated issues. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.
Who Owns and Operates Embassy Of Euclid?
EMBASSY OF EUCLID is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by EMBASSY HEALTHCARE, a chain that manages multiple nursing homes. With 75 certified beds and approximately 65 residents (about 87% occupancy), it is a smaller facility located in EUCLID, Ohio.
How Does Embassy Of Euclid Compare to Other Ohio Nursing Homes?
Compared to the 100 nursing homes in Ohio, EMBASSY OF EUCLID's overall rating (3 stars) is below the state average of 3.2, staff turnover (69%) 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 Embassy Of Euclid?
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 Embassy Of Euclid Safe?
Based on CMS inspection data, EMBASSY OF EUCLID 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 Embassy Of Euclid Stick Around?
Staff turnover at EMBASSY OF EUCLID is high. At 69%, the facility is 23 percentage points above the Ohio average of 46%. Registered Nurse turnover is particularly concerning at 67%. 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 Embassy Of Euclid Ever Fined?
EMBASSY OF EUCLID 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 Embassy Of Euclid on Any Federal Watch List?
EMBASSY OF EUCLID 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.