ARBORS AT FAIRLAWN THE
For profit - Corporation
88 Beds
ARBORS AT OHIO
Data: November 2025
1 Immediate Jeopardy citation
Trust Grade
8/100
#594 of 913 in OH
Photo by Arbors at Fairlawn
Photo by Arbors at Fairlawn
Photo by Arbors at Fairlawn
1 / 5 photos
Last Inspection: June 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Arbors at Fairlawn has received a Trust Grade of F, indicating significant concerns and poor performance compared to other nursing homes. It ranks #594 out of 913 facilities in Ohio, placing it in the bottom half, and #27 out of 42 in Summit County, meaning there are better local options available. The facility's trend is stable, with 8 issues reported consistently over the last two years. Staffing is rated average with a 3/5 star rating, but a 54% turnover rate is concerning as it means staff may not stay long enough to build relationships with residents. Unfortunately, the facility has also incurred $63,642 in fines, which is higher than 86% of Ohio facilities and indicates potential compliance issues. Specific incidents of concern include a critical failure to timely recognize and treat a resident's serious medical condition, leading to life-threatening harm, and a serious incident where a resident sustained a severe injury during a transfer due to inadequate assistance. Additionally, there were failures in preventing pressure ulcers for residents who required extensive care, indicating a lack of proper attention to residents' needs. While the facility does have some average staffing levels, the overall picture reveals significant weaknesses that families should consider carefully.
- Trust Score
- F
- In Ohio
- #594/913
- Safety Record
- High Risk
- Inspections
- Holding Steady
- Staff Stability ⚠ Watch
- 54% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ✓ Good
- $63,642 in fines. Lower than most Ohio facilities. Relatively clean record.
- Skilled Nurses ⚠ Watch
- Each resident gets only 26 minutes of Registered Nurse (RN) attention daily — below average for Ohio. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 45 deficiencies on record. Higher than average. Multiple issues found across inspections.
8/100
Bottom 35%
Review needed
8 → 8 violations
★★☆☆☆
2.0
Overall Rating
★★★☆☆
3.0
Staff Levels
★★★☆☆
3.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2024: 8 issues
2025: 8 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in fire safety.
The Bad
2-Star Overall Rating
Below Ohio average (3.2)
Below average - review inspection findings carefully
Staff Turnover: 54%
Near Ohio avg (46%)
Higher turnover may affect care consistency
Federal Fines: $63,642
Above median ($33,413)
Moderate penalties - review what triggered them
Chain: ARBORS AT OHIO
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 45 deficiencies on record
1 life-threatening 4 actual harm
May 2025
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
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.
Bas...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.
Based on record reviews and interviews with staff the facility failed to notify Resident #90's physician and daughter of notification of changes. This affected one resident of three reviewed for notifications of change. The census was 80.
Findings include:
Review of the closed medical record for Resident #90 revealed an initial admission date of 08/23/24 and re-admission date of 04/05/25 with diagnoses including chronic obstructive pulmonary disorder, diabetes and congestive heart failure. Resident #90 was discharged on 04/18/25.
Review of the profile tab in the electronic medical record revealed Resident #90 was listed first as his own responsible party then his daughter as the second contact.
Review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #90 was cognitively intact. He was independent with chair to chair transfers.
Review of Resident #90's progress note on 02/05/25 at 8:30 P.M. revealed Resident #90 wanted to go to the hospital. The resident was sent to the emergency room (ER). Resident was his own responsible party. There was no evidence his daughter was notified.
Review of Resident #90's progress note on 03/16/25 at 9:06 A.M., 03/17/25 at 8:52 A.M., 03/18/25 at 9:38 A.M. and 12:38 P.M. and 03/19/25 at 7:41 A.M. revealed Resident #90 refused either treatments such as dialysis or vitals signs, and/or medications. There was no evidence Resident #90's physician or daughter was notified of the refusals.
Review of Resident #90's progress note on 03/21/25 at 2:58 P.M. revealed Resident #90 was sent to the ER. There was no evidence Resident #90's daughter was notified.
Review of Resident #90's progress notes dated 04/18/25 at 11:49 P.M. and authored by Licensed Practical Nurse (LPN) #265 revealed the day nurse reported Resident #90 signed himself out on an LOA. The resident had not returned yet. Resident #90's note dated 04/19/25 at 4:03 A.M. authored by LPN #265 indicated LOA. There was no evidence Resident 90's physician or daughter were notified of the resident not returning from LOA.
Review of two progress notes dated 04/19/25 at 9:30 A.M. authored by LPN #211 stated Resident #90's daughter called the facility stating he passed away and the second note revealed LPN #211 informed the Director of Nursing and the physician assistant.
Interview on 05/12/25 at 3:53 P.M. with the Director of Nursing (DON) confirmed there were inconsistencies in when the facility notified Resident #90's physician and daughter related to hospitalization, refusals of treatments, and not returning from LOA.
The deficient practice was corrected on 04/24/25 when the facility implemented the following corrective actions:
•
On 04/19/25 the DON suspended LPN #265 and gave her a final written warning. LPN #265 was educated by the DON on notifications of refusals of medications and treatments.
•
On 04/20/25 the DON audited all residents progress notes, Medication Administration Records (MARs) and Treatment Administration Records (TARs), new orders and alerts for the past seven days for proper notifications of refusals or other changes.
•
The DON or designee educated all nurses on notification on refusals of medications and treatments by 04/22/25.
•
All residents' notes, MARs, TARs, orders and alerts reviewed at clinical meeting by the team (DON, Administrator, Unit Manager, MDS nurse and SSD) Monday through Friday for proper notifications of refusals and other changes.
•
DON/Designee will interview five nurses weekly for four weeks on documenting refusals and notifications.
•
Ad Hoc QAPI meeting was held on 04/21/25 including the Medical Director, Administrator and DON.
•
Interdisciplinary team will identify residents who refuse treatments and medications or require notifications and ensure they are completed timely during the clinical meeting Monday through Friday.
•
Results of audits will be reviewed at QAPI meeting for one month with revisions to the plan or changes deemed necessary by the team.
Review of the facility policy titled Notification of Changes, revised 08/29/25 revealed the facility should ensure to promptly inform the resident, physician and notify the resident representative when there is a change requiring notification such as but not limited to: accidents, significant changes like deterioration in health, mental or psychosocial status or a circumstance requiring a need to alter treatment, exacerbation of a chronic condition or a transfer or discharge from the facility. When a resident is mentally competent, a designated family member should be notified of significant changes because the resident may not be able to notify them personally.
This deficiency represents non-compliance investigated under OH00165215.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interview, the facility failed to ensure Resident #90's safety after not returning timely after a le...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interview, the facility failed to ensure Resident #90's safety after not returning timely after a leave of absence (LOA). This affected one resident (Resident #90) of three residents reviewed for LOA's. The census was 80.
Findings include:
Review of closed medical record for Resident #90 revealed an initial admission date of [DATE] and re-admission date of [DATE] with diagnoses included chronic obstructive pulmonary disorder, diabetes and congestive heart failure. Resident #90 was discharged on [DATE].
Review of the profile tab in the electronic medical record revealed Resident #90 listed first as his own responsible party then his daughter as the second contact.
Review of the care plan dated [DATE] revealed the facility would honor Resident #90's preferences including leaving the building unsupervised and traveling throughout the community in his powerchair via public transport.
Review of the elopement assessment dated [DATE] for Resident #90 revealed he was not at risk for elopement.
Review of Resident #90's [DATE] orders revealed an order for LOA independently without medication effective [DATE].
Review of the admission Minimum Data Set (MDS) dated [DATE] revealed Resident #90 was cognitively intact and independent with chair to chair transfers.
Review of Resident #90's LOA sheets from [DATE] through [DATE] revealed he returned prior to midnight of same day for all of his outings. Review of entry on [DATE] revealed he signed out at 11:55 A.M. with Barberton as his destination.
Review of Resident #90's progress notes dated [DATE] at 11:49 P.M. and authored by Licensed Practical Nurse (LPN) #265 revealed the day nurse reported Resident #90 signed himself out on an LOA. The resident had not returned yet. Resident #90's note dated [DATE] at 4:03 A.M. authored by LPN #265 indicated LOA.
Review of two progress notes dated [DATE] at 9:30 A.M. authored by LPN #211 stated Resident #90's daughter called the facility stating he passed away and the second note revealed LPN #211 informed the Director of Nursing and the physician assistant.
Review of a progress note dated [DATE] at 4:21 P.M. authored by DON revealed she had spoken to the hospital case manager who stated Resident #90 arrived from the grocery store to the emergency room at 3:16 P.M. on [DATE]. He had expired from acute pulmonary arrest at 10:45 P.M.
Interview on [DATE] at 2:14 P.M. with LPN #211 revealed she worked on [DATE]. When she learned Resident #90 was not back yet she reviewed the LOA book to see he logged out on [DATE] at 11:55 A.M. She stated she tried to call Resident #90's cell phone between 9:00 A.M. and 9:30 A.M. but there was no voicemail. About the same time the, Resident #90's daughter called the facility to notify them of his death. LPN #211 described Resident #90's routine LOA as taking public transport to nearby city via public transportation where he hung out with friends in stores of an area shopping plaza. She stated he had mentioned to her one time to contact the women at the one store if they needed to find him. She stated he would stay out past 10:00 P.M. some nights but had always returned before midnight. LPN #211 stated she was unsure if LPN #265 tried to call Resident #90's cell phone the night he didn't return, but her expectation was that he would be called. She was uncertain if management was notified on [DATE] that he had not returned from his LOA.
Interview on [DATE] at 2:33 P.M. with Social Service Designee (SSD) #258 revealed she felt Resident #90 was going to do what he wanted. She stated her expectation was a call be made to the missing resident and a search take place. She was uncertain of what his care plan was at the time of interview.
Interview on [DATE] at 2:53 P.M. with the Administrator revealed Resident #90 had been told in the past to be back in the facility by midnight. Her expectation would be to call his cell phone then call the hospitals and to search grounds in case his motorized wheelchair battery died.
Interview on [DATE] at 3:53 P.M. with the Director of Nursing (DON) revealed her expectation, if a resident was not back as anticipated by midnight, staff were to call resident's cell phone, call the hospitals and to start looking for him. She stated LPN #265 had texted her at almost midnight on [DATE] that Resident #90 did not return from his LOA, and DON stated to call his cell phone. When she did not get a response DON texted and told her to call the hospitals. DON's expectation was to start searching for him if not at hospital. DON stated she fell back asleep but had no messages from the facility on her phone when she got up on [DATE]. She was not sure if he returned yet or not. DON called the facility around 9:00 A.M. and spoke to LPN #211 who told her Resident #90 had not returned. Within five minutes of their conversation LPN #211 had learned through a phone call from the hospital and a separate call from the daughter he had been at a local hospital where he passed away. The DON discovered LPN #265 never called the hospitals or daughter. LPN #265 was suspended and given a final written warning.
Interview on [DATE] at 4:15 P.M. with LPN #265 revealed she worked on [DATE] from 6:00 P.M. to 6:00 A.M. She stated she called Resident #90's cell phone with no response. She stated she texted the DON who responded telling her to call the hospitals. She stated she did not call the hospitals because she was too busy. She stated she figured dayshift would do it. LPN #265 stated Resident #90 had always come back before midnight from his LOAs.
Interview on [DATE] at 4:40 P.M. with DON revealed LPN #265 told her she didn't call the hospitals because she figured the hospital would call the facility.
Review of the facility policy titled Resident Appointment/Outing including overnights (not transfer/discharge), dated [DATE] revealed the policy was to assure resident safety and staff knowledge of resident's whereabouts by signing out on the log. Residents should note destination and approximate time of return. The policy stated it should be documented in the medical record what time the resident left, with who and other pertinent information.
This deficiency represents non-compliance investigated under Complaint Number OH00165215.
Mar 2025
4 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, record review, and review of the facility policy, the facility failed to ensure fall in...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, record review, and review of the facility policy, the facility failed to ensure fall interventions were in place for a resident with a history of falls and was a fall risk. This affected one (Resident #68) of three residents reviewed for falls. The facility census was 73.
Findings include:
Record review for Resident #68 revealed an admission date of 09/19/19. Diagnoses included dementia, anxiety disorder, history of falling, unsteadiness on feet, muscle weakness, and need for assistance with personal care. Review of the census revealed Resident #68 moved from 100 hall to 200 hall on 12/11/24.
Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #68 was moderately cognitively impaired. Resident #68 used a wheelchair for mobility, required supervision or touching assistance with personal hygiene, transfers, and toilet transfers. Resident #68 had no falls since prior assessment.
Review of the care plan for Resident #68 updated 11/13/23 revealed Resident #68 was at risk for falls related to cognitive impairment, dementia, anxiety, depression, vision, incontinence, decreased safety awareness, and history of falls including fall with fracture. Interventions included hipsters as tolerated dated 09/24/23, call light within reach dated 09/24/23, call before fall sign in room dated 09/24/23, and remove the wheelchair from the room while in bed dated 09/24/23, and the resident to be up in common area as tolerated dated 11/25/24.
Review of the fall risk evaluation dated 11/09/24 revealed Resident #68 had a score of eight. The evaluation did not explain what level the score of eight was.
Review of the fall history for Resident #68 from 11/01/24 through 03/05/25 revealed Resident #68 had a fall on 11/05/24, 11/10/24, 11/14/24, 01/02/25, 01/26/25 (injuries included bleeding from previous skin tear left forearm), 02/05/25, 02/21/25 (injuries included obtained a skin tear to the right leg), and 02/28/25 (injuries included skin tear to the right arm).
Observation on 03/05/25 at 8:52 A.M. revealed Resident #68 was lying in bed awake. Observation revealed Resident #68's wheelchair was next to her bed. There was no call before you fall sign, and the call light was dangling between the mattress and transfer bar onto the floor.
Observation on 03/05/25 at 8:54 A.M. with Medication Technician #203 confirmed Resident #68 was awake, lying in bed. Resident #68's call light was not within reach, there was no sign in the room to remind Resident #68 to call before you fall, and the wheelchair was next to the bed. Medication Technician #68 verified Resident #68 had frequent falls and she kept her wheelchair by the bed. Medication Technician #203 then left the room without moving the wheelchair.
Interview and observation on 03/05/25 at 9:04 A.M. with Certified Nursing Assistant (CNA) #202 stated she will assist Resident #68 up out of bed around 10:00 A.M. CNA #202 stated Resident #68 was up once this morning and put herself back to bed. At 9:10 A.M., CNA #202 stated she was ready now to get Resident #68 up. CNA #202 assisted Resident #68 to the wheelchair then transferred Resident #68 to the toilet. Resident #68 did not have hipsters on. CNA #202 assisted Resident #68 with peri care, dressing, and transferred her back to her wheelchair. CNA #202 never offered to assist Resident #68 to put on her hipsters. CNA #202 then transferred Resident #68 back to her bed. CNA #202 then asked Resident #68 if she was going to use her wheelchair or walker. Resident #68 replied her walker. CNA #202 said, Ok, well then I will leave it right here next to your bed. CNA #202 left the wheelchair and walker near Resident #68 before exiting the room. CNA #202 stated when Resident #68 was on the 100-hall, she wore hipsters but has not worn any while on the 200-hall. CNA #202 returned to Resident #68's room and verified Resident #68 did not have hipsters available in her room. CNA #202 stated she was unsure why Resident #68 did not wear hipsters anymore. CNA #202 again left the wheelchair and walker near Resident #68 before exiting the room.
Interview on 03/11/25 at 2:37 P.M. with the Director of Nursing (DON) confirmed Resident #68 was at a high risk for falls. The DON confirmed Resident #68's fall interventions still included hipsters as tolerated, the call light within reach, a call before fall sign in room and remove the wheelchair from her reach while she was in bed. The DON stated she also put into place that Resident #68 was to be up in the common area when was awake due to her frequent falls.
Review of the facility policy titled Accidents and Supervision revised 12/27/23 revealed each resident will be assessed for accident risk and will receive care in accordance with their individualized care plan.
This deficiency represents noncompliance investigated under Complaint Number OH00162486.
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, resident and staff interview, record review, and review of the facility policy, the facility failed to ens...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interview, record review, and review of the facility policy, the facility failed to ensure the residents received timely incontinence care. This affected three (Residents #9, #49, and #56) of three residents reviewed for incontinence care. The facility census was 73.
Findings include:
1. Record review for Resident #9 revealed an admission date of 01/08/25. Diagnoses included chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), obstructive and reflux uropathy, abnormalities of gait and mobility, muscle weakness and need for assistance with personal care.
Review of the Medicare five-day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #9 was cognitively intact. Resident #9 had an indwelling catheter and was always incontinent of bowel. Resident #9 used a wheelchair for mobility, required substantial/maximum assistance with toileting hygiene, lower body dressing, partial/moderate assistants for bed mobility, and dependent on staff with transfers.
Review of the care plan for Resident #9 dated 01/09/25 revealed Resident #9 had episodes of bowel incontinence related to benign prostatic hyperplasia, generalized weakness and pain. Interventions included to assist resident with toileting needs and check at regular intervals and change as needed.
Observation and interview on 03/05/25 at 9:43 A.M. revealed Resident #9 was lying in bed. Resident #9 had an odor of stool. Resident #9 confirmed he had a bowel movement (BM) but they have not changed him yet.
Observation on 03/05/25 at 10:50 A.M. with Certified Nursing Assistant (CNA) #241 and #278 of incontinence care for Resident #9 revealed Resident #9 was still in bed. CNA #241 confirmed she was Resident #9's primary CNA and stated she had not been in yet on this day to change Resident #9. CNA #241 stated their shift started at 6:00 A.M. Observation of incontinence care revealed Resident #9's had a large BM. CNA #241 confirmed she never checked on Resident #9 for incontinence care needs until the surveyor requested to observe incontinence care for Resident #9.
2. Record review for Resident #49 revealed an admission date of 02/24/23. Diagnoses included Alzheimer's disease, muscle weakness and need for assistance with personal care.
Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #49 was moderately cognitively impaired. Resident #49 used a wheelchair for mobility, was always incontinent of bowel and bladder, required substantial/maximal assistance with toileting hygiene, personal hygiene, upper and lower body dressing and bed mobility.
Review of the care plan dated 10/30/23 revealed Resident #49 had an activities of daily living (ADL) self-care performance deficit. Interventions included one-person assistance for toileting, and personal hygiene.
Review of the care plan dated 10/30/23 revealed Resident #49 had incontinent episodes of bladder/bowel related to debility and impaired mobility. Interventions included to assist resident with toileting needs, and check resident at regular intervals and change as needed.
Observation on 03/05/25 at 11:22 A.M. of incontinence care for Resident #49 completed by Certified Nursing Assistant (CNA) #241 revealed Resident #49's brief was saturated with urine and bowel movement (BM). Resident #49's buttocks was red and the skin on the buttocks and back was creased and wrinkled from the wrinkled bedding she had been lying on. CNA #241 stated this was the first time on this shift she had checked Resident #49 for incontinence needs due to being busy with other residents.
3. Record review for Resident #56 revealed an admission day of 05/15/23. Diagnoses included adult failure to thrive, overactive bladder, and muscle weakness.
Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #56 was cognitively intact. Resident #56 used a walker and a wheelchair for mobility. Resident #56 was frequently incontinent of bowel and bladder. Resident #56 required supervision or touch assistance for toileting hygiene, partial/moderate assistance for upper body dressing, substantial/maximal assistance for lower body dressing, and partial moderate assistance for personal hygiene.
Review of the care plan dated 09/20/23 revealed Resident #56 had an activity of daily living (ADL) self-care performance deficit. Interventions included supervision with ambulation, and one person assistant with toileting and personal hygiene.
Review of the care plan dated 05/06/24 revealed Resident #56 had episodes of functional bowel and bladder incontinence. Interventions included to assist the resident with toileting needs, and check resident at regular intervals and change as needed.
Observation on 03/05/25 at 11:38 A.M. of incontinence care for Resident #56 completed by Certified Nursing Assistant (CNA) #241 revealed Resident #56 was sitting up in her bed. Resident #56 had a hospital gown on with one gown in the front and an additional gown in the back covering her back side. Resident #56 stated she was saturated with urine and had been waiting all day to be changed. Resident #56 had a foul odor of urine. Observation revealed CNA #241 ambulated with Resident #56 using a rollator to the bathroom. Resident #56's gown was saturated with urine covering the entire back side. The sheet and bed pad where Resident #56 was sitting was also saturated with urine. Resident #56's saturated brief was bulging with urine. CNA #241 confirmed this was the first time today getting to Resident #56 to assist with incontinence care.
Interview on 03/05/25 at 11:49 A.M. with the Director of Nursing (DON) stated residents were checked and changed per plan of care and every two hours. The DON confirmed day shift started at 6:00 A.M. until 2:00 P.M. The DON stated by 8:30 A.M., every resident should be seen, checked and changed if needed.
Review of the facility policy titled Incontinence revised 10/26/23 revealed based on a resident's comprehensive assessment, all residents that are incontinent will receive appropriate treatment and services. Residents that are incontinent of bladder or bowel will receive appropriate treatment to prevent infections and to restore continence to the extent possible.
This deficiency represents noncompliance investigated under Complaint Number OH00161403.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interview, record review, and review of the facility policy, the facility failed to ens...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interview, record review, and review of the facility policy, the facility failed to ensure residents who were dependent on staff for activities of daily living (ADL) received assistance with bathing/showers. This affected four (Resident #9, #13, #38, and #46) of five residents reviewed for ADLs. The facility census was 73.
Findings include:
1. Record review for Resident #46 revealed an admission date of 07/08/24. Diagnoses included cerebral infarction, foot drop right foot, acquired absence of left fingers, muscle weakness and need for assistance with personal care.
Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #46 was cognitively intact. Resident #46 required supervision or touch assistants with bathing and tub/shower transfers.
Review of the facility tasks revealed Resident #46 preferred showers every Tuesday and Friday. Record review from 02/26/25 through 03/11/25 of scheduled showers revealed Resident #46 did not receive or refuse the scheduled shower/bath on 02/28/25 or 03/07/25.
Interview on 03/05/25 at 3:12 P.M. with Resident #46 stated the facility was shorthanded. Resident #46 stated a lot times he was scheduled for baths but did not receive it due to being staff shortage.
Interview on 03/05/25 at 3:42 P.M. with Certified Nursing Assistant (CNA) #206 verified Resident #46 did not receive showers as scheduled and resident preference. CNA #206 stated there were staffing issues, and at times, the CNAs were unable to provide resident their showers because there was not enough staff.
2. Record review for Resident #38 revealed an admission date of 05/10/23. Diagnoses included spondylosis with myelopathy cervical region, radiculopathy cervical region, muscle weakness, quadriplegia, and need for assistance with personal care.
Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #38 was cognitively intact. Resident 38 was dependent on staff for bathing and dressing.
Review of the care plan dated 09/18/23 for Resident #38 revealed Resident #38 had an ADL self-care performance deficit. Interventions included one-person assistance for bathing.
Review of the facility tasks revealed Resident #38 preferred showers every Tuesday and Saturday. Record review from 02/15/25 through 03/11/25 of scheduled showers revealed Resident #38 did not receive the shower /bath on 02/15/25 or 03/01/25. There was no record of Resident #38 refusing on 02/15/23 or 03/01/25. All documentation of completed baths revealed Resident #38 only received bed baths.
Interview on 03/04/25 at 3:45 P.M. with Resident #38 stated he was not getting his showers like he should. Resident #38 stated there were days they switch staff, his showers were Tuesdays and Saturdays but they will just do a bed bath when he wants a shower because it was easier for staff to do a bed bath. Resident #38 stated, I feel forced at times to do a bed bath but depending on the nursing aide, some don't clean you up as well as others.
Interview on 03/04/25 at 4:01 P.M. with Certified Nursing Assistant (CNA) #224 verified Resident #38 did not receive showers as scheduled. CNA #224 explained there was not enough staff to provide residents with a shower during her shift. CNA #224 stated she may have to do bed baths for the residents instead of showers because there was not enough time.
3. Record review for Resident #9 revealed an admission date of 01/08/25. Diagnoses included chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), obstructive and reflux uropathy, abnormalities of gait and mobility, muscle weakness and need for assistance with personal care.
Review of the Medicare five-day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #9 was cognitively intact. Resident #9 required substantial/maximal assistance with bathing and personal hygiene.
Review of the facility tasks revealed Resident #9 preferred showers on Friday and Tuesday. Record review from 02/26/25 through 03/11/25 of scheduled showers revealed Resident #9 did not receive or refuse a shower/bath on 03/07/25. Documentation revealed all other bed baths/showers were given as scheduled.
Interview and observation on 03/04/25 at 4:07 P.M. with Resident #9 revealed the resident was lying in bed in his pajamas. Resident #9's hair was very oily, Resident #9 had a strong body odor. His finger nails were dirty and uneven. Resident #9 stated he was not getting his baths as scheduled.
Interview and observation on 03/05/24 at 10:50 A.M. with Certified Nursing Assistant (CNA) #241 confirmed Resident #9 had a foul odor.
4. Record review for Resident #13 revealed an admission date of 10/16/24. Diagnoses included hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting left nondominant side, abnormalities of gait and balance and need for assistance with personal care.
Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #13 was cognitively intact. Resident #13 had impairment on one side of the upper and lower extremity, required set up or clean up assistance with toileting hygiene, supervision or touch assistance with showers and partial/moderate assistance with transfers and dressing.
Review of the facility tasks revealed Resident #13 preferred showers every Thursday and Sunday. Record review from 02/15/25 through 03/11/25 of scheduled showers revealed Resident #13 did not receive/refuse a shower/bath on 02/16/25, 02/27/25, 03/06/25, or 03/09/25.
Interview on 03/11/25 at 1139 A.M. with Resident #13 confirmed he did not receive showers every Thursday and Sunday as scheduled consistently and stated did not receive a shower on the previous Sunday (03/09/25) because the staff told him they were short staffed.
Interview on 03/11/25 at 2:37 P.M. with the Director of Nursing (DON) confirmed Resident #13 did not receive his shower or bed bath the previous Sunday and stated the CNA who was assigned to him was required to float between both ends of the facility.
Review of the facility policy titled, Activities of Daily Living revised 12/28/23 revealed a resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.
This deficiency represents noncompliance investigated under Complaint Number OH00161403.
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 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 observation, resident and staff interview, record review, and review of the facility policy, the facility failed to pro...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interview, record review, and review of the facility policy, the facility failed to provide sufficient staff to ensure the residents received timely assistance with showers/bathing, incontinence care, dressing, personal hygiene, and changing of soiled sheets. This affected six of six residents (Resident #9, #13, #38, #46, #49, and #56) reviewed for sufficient staffing and had the potential to affect all residents residing at the facility. The facility census was 73.
Findings include:
1. Record review for Resident #46 revealed an admission date of 07/08/24. Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #46 was cognitively intact. Resident #46 required supervision or touch assistants with bathing and tub/shower transfers.
Review of the facility tasks revealed Resident #46 preferred showers every Tuesday and Friday. From 02/26/25 through 03/11/25, Resident #46 did not receive or refuse the scheduled shower/bath on 02/28/25 or 03/07/25.
Interview on 03/05/25 at 3:12 P.M. with Resident #46 stated the facility was shorthanded. Resident #46 stated a lot times he was scheduled for baths but did not receive it due to being staff shortage.
Interview on 03/05/25 at 3:42 P.M. with Certified Nursing Assistant (CNA) #206 verified Resident #46 did not receive showers as scheduled and resident preference. CNA #206 stated there were staffing issues, and at times, the CNAs were unable to provide resident their showers because there was not enough staff.
2. Record review for Resident #38 revealed an admission date of 05/10/23. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #38 was cognitively intact. Resident 38 was dependent on staff for bathing and dressing.
Record review from 02/15/25 through 03/11/25 of scheduled showers revealed Resident #38 did not receive the shower /bath on 02/15/25 or 03/01/25. There was no record of Resident #38 refusing on 02/15/23 or 03/01/25. All documentation of completed baths revealed Resident #38 only received bed baths.
Interview on 03/04/25 at 3:45 P.M. with Resident #38 stated he was not getting his showers like he should. Resident #38 stated there were days they switch staff, his showers were Tuesdays and Saturdays but they will just do a bed bath when he wants a shower because it was easier for staff to do a bed bath. Resident #38 stated, I feel forced at times to do a bed bath but depending on the nursing aide, some don't clean you up as well as others.
Interview on 03/04/25 at 4:01 P.M. with Certified Nursing Assistant (CNA) #224 verified Resident #38 did not receive showers as scheduled. CNA #224 explained there was not enough staff to provide residents with a shower during her shift. CNA #224 stated she may have to do bed baths for the residents instead of showers because there was not enough time.
3. Record review for Resident #13 revealed an admission date of 10/16/24. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #13 was cognitively intact and required supervision or touch assistance with showers and partial/moderate assistance with transfers and dressing.
Record review from 02/15/25 through 03/11/25 of scheduled showers revealed Resident #13 did not receive/refuse a shower/bath on 02/16/25, 02/27/25, 03/06/25, or 03/09/25.
Interview on 03/11/25 at 1139 A.M. with Resident #13 confirmed he did not receive showers every Thursday and Sunday as scheduled consistently and stated did not receive a shower on the previous Sunday (03/09/25) because the staff told him they were short staffed.
4. Record review for Resident #9 revealed an admission date of 01/08/25. Review of the Medicare five-day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #9 was cognitively intact. Resident #9 required substantial/maximal assistance with bathing and personal hygiene. Resident #9 had an indwelling catheter and was always incontinent of bowel.
4a. Record review from 02/26/25 through 03/11/25 of scheduled showers revealed Resident #9 did not receive or refuse a shower/bath on 03/07/25. Documentation revealed all other bed baths/showers were given as scheduled.
Interview and observation on 03/04/25 at 4:07 P.M. with Resident #9 revealed the resident was lying in bed in his pajamas. Resident #9's hair was very oily, Resident #9 had a strong body odor. His finger nails were dirty and uneven. Resident #9 stated he was not getting his baths as scheduled.
Observation and interview on 03/05/25 at 9:43 A.M. revealed Resident #9 was lying in bed. Observation revealed Resident #9's sheet and blanket was wet with a large spill. Resident #9 stated he spilled his whole cup of coffee when he was eating breakfast. Resident #9 stated he was not burned from the coffee but confirmed his blanket and sheet was wet.
Observation and interview on 03/05/25 at 10:50 A.M. with Certified Nursing Assistant (CNA) #241 and #278 verified Resident #9 was still in bed. Resident #9 was still covered with the sheet and blanket that had the coffee spilled onto it at breakfast time. CNA #241 confirmed she was Resident #9's primary CNA and stated Resident #9 spilled his coffee on the blanket and sheet he was covering up with. CNA #241 confirmed she was aware of the spill but did not have time to assist him with any morning care until now stating she was busy with other residents. CNA #241 stated she still had three residents to go after Resident #9 for their first set of rounds of the day to check and change them. CNA #241 stated she started her shift at 6:00 A.M. and confirmed she had not been in yet on this day to provide morning care for Resident #9.
4b. Observation and interview on 03/05/25 at 9:43 A.M. revealed Resident #9 was lying in bed. Resident #9 had an odor of stool. Resident #9 confirmed he had a bowel movement (BM) but they have not changed him yet.
Observation on 03/05/25 at 10:50 A.M. with Certified Nursing Assistant (CNA) #241 and #278 of incontinence care for Resident #9 revealed Resident #9 was still in bed. CNA #241 confirmed she was Resident #9's primary CNA and stated she had not been in yet on this day to change Resident #9. CNA #241 stated their shift started at 6:00 A.M. Observation of incontinence care revealed Resident #9's had a large BM. CNA #241 confirmed she never checked on Resident #9 for incontinence care needs until the surveyor requested to observe incontinence care for Resident #9.
5. Record review for Resident #49 revealed an admission date of 02/24/23. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #49 was moderately cognitively impaired. Resident #49 was always incontinent of bowel and bladder, required substantial/maximal assistance with toileting hygiene.
Observation on 03/05/25 at 11:22 A.M. of incontinence care for Resident #49 completed by Certified Nursing Assistant (CNA) #241 revealed Resident #49's brief was saturated with urine and bowel movement (BM). Resident #49's buttocks was red and the skin on the buttocks and back was creased and wrinkled from the wrinkled bedding she had been lying on. CNA #241 stated this was the first time on this shift she had checked Resident #49 for incontinence needs due to being busy with other residents. CNA #241 stated Resident #49 should have been up out of bed a long time ago. Resident #49 asked CNA #241 if today was her shower day. CNA #241 stated it was and asked Resident #49 if she wanted it today or tomorrow because she (CNA #241) had not had her lunch yet and she was supposed to take it at 11:30 A.M. CNA #241 stated to Resident #49 that she was sorry, she did not have time to do it today but promised she would do it tomorrow. Resident #49 agreed to take the shower the next day so CNA #241 could go to lunch. Resident #56 was Resident #49's roommate. While completing care for Resident #49, CNA #241 said to Resident #56 she would get to her as soon as she was done with Resident #49. CNA #241 then stated to Resident #56, she needed to take her break (it was now 11:32 A.M.) at 11:30 A.M. and asked Resident #56 (while still working with Resident #49) if she wanted to wait until after lunch to get changed. Resident #56 shouted, No, I do not want to sit here wet all day
6. Record review for Resident #56 revealed an admission day of 05/15/23. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #56 was cognitively intact. Resident #56 was frequently incontinent of bowel and bladder. Resident #56 required supervision or touch assistance for toileting hygiene.
Observation on 03/05/25 at 11:38 A.M. of incontinence care for Resident #56 completed by Certified Nursing Assistant (CNA) #241 revealed Resident #56 was sitting up in her bed. Resident #56 had a hospital gown on with one gown in the front and an additional gown in the back covering her back side. Resident #56 stated she was saturated with urine and had been waiting all day to be changed. Resident #56 had a foul odor of urine. Observation revealed CNA #241 ambulated with Resident #56 using a rollator to the bathroom. Resident #56's gown was saturated with urine covering the entire back side. The sheet and bed pad where Resident #56 was sitting was also saturated with urine. Resident #56's saturated brief was bulging with urine. CNA #241 confirmed this was the first time today getting to Resident #56 to assist with incontinence care.
Interview on 03/05/25 at 11:49 A.M. with the Director of Nursing (DON) stated residents were checked and changed per plan of care and every two hours. The DON confirmed day shift started at 6:00 A.M. until 2:00 P.M. The DON stated by 8:30 A.M., every resident should be seen, checked and changed if needed.
This deficiency represents non-compliance investigated under Complaint Number OH00161403.
Jan 2025
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
Transfer Notice
(Tag F0623)
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 #74 and resident representatives were properly noti...
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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 #74 and resident representatives were properly notified in writing of an emergency discharge for Resident #74. This affected one resident (Resident #74) of three residents reviewed for discharges. The facility census was 72.
Findings include:
Review of the closed record for Resident #74 revealed an admission date of 10/30/24 with diagnoses including schizoaffective and mood affective disorder, unspecified intellectual disabilities, sexual dysfunction not due to a substance or known physiological condition, anxiety, insomnia, manic episodes, and assistance with personal care. Resident #74 was transferred to the hospital for an acute, inpatient psychiatric stay on 12/09/24 and did not return to the facility. Resident #74 had a legal guardian of person.
Review of Resident #74's Minimum Data Set (MDS) 3.0 discharge return not anticipated assessment dated [DATE] revealed Resident #74 was modified independent for cognitive daily decision making, no delirium was noted. Resident #74 was positive for inattention, but no disorganized thinking or altered level of consciousness was noted. No hallucination noted but delusions were present. No physical behaviors towards others were displayed but verbal behaviors towards others were displayed daily. Rejection of care occurred daily and wandering occurred daily. Resident #74 was independent for eating, oral hygiene, dressing and toilet hygiene but needed supervision for showers. Resident #74 was independent with mobility such as rolling left and right in bed, sitting on the side of the bed and bed transfers but needed supervision for shower transfers. Resident #74 was independent to walk ten feet.
Review of Resident #74's care plan, dated 11/18/24 revealed Resident #74 had behaviors related to a diagnosis of schizoaffective disorder, generalized anxiety disorder, unspecified mood disorder and manic episodes, dementia as evidenced by aggressively hugging and grabbing staff, pacing throughout facility without footwear, attempts to chase after staff, nonsensical statements verbally and written notes on a note pad, taking items from residents rooms, and refused medication. Intervention included offer and provide activities of interest to keep resident engaged, administer medication as ordered, engage resident in simple, structured activities that avoid overly demanding tasks, labs as ordered, notify physician of any significant change in resident's baseline cognitive status. Physical therapy, occupational therapy and speech therapy as needed. Refer to psychological/psychiatrist as needed.
Review of the Situation Background, Assessment and Recommendation (SBAR) note dated 12/09/24 at 11:00 A.M. written by Nurse Practitioner (NP) #511 revealed Resident #74 had a change in condition with psychotic behaviors that started on 12/06/24 and have gotten worse. Worse behaviors included following staff, unable to re-direct regarding personal space. Resident refused to allow vitals to be taken. Treatment included as needed psychological medication and inpatient psych stay. Resident #74 was admitted to the nursing home for long term needs. Mental status changes included new or worsening behavior symptoms, no functional status change, no gastrointestinal change, no urine change. Problems included increased psychotic behaviors due to inability to self-regulate, medication was ineffective, inappropriate level of care in facility. It was suggested Resident #74 transfer to the hospital. Guardian was notified of erratic behaviors, ineffective medication, inability to redirect, threatening others, intrusiveness, inappropriate touching and obsession with religion. The facility notified the guardian/mother of intention to send to the emergency department and not accept Resident #74 back since this was not an appropriate environment for Resident #74 to live in.
Review of the facility document Application for Emergency Admission (commonly known as pink slip which commits the resident involuntarily to the hospital), dated 12/09/24, revealed Resident #74 represented a substantial risk of physical harm to others manifested by evidence of recent homicidal or other violent behavior and would benefit from treatment in a hospital for his mental illness and was in need of such treatment as manifested by evidence of behavior that created a grave and imminent risk to substantial right of others or himself. The documented revealed Resident #74 was exhibiting threatening, impulsive behaviors since admission. Behaviors escalated into obsession about religious persecution and ideation and threats of physical harm. Resident #74 was intrusive, threatening towards other nursing home residents and had threatened to kill staff members and was physically capable of acting out these threats. Resident #74 experienced auditory hallucinations but would not reveal what the voices said. Resident #74 had attempted to leave the facility unattended by going to the exit doors and pushing on the doors. This created a substantial risk to his safety as well as others because the facility was located on a highway exit. Resident #74 required admission to an inpatient intensive psychiatric stay to improve the quality of life and to provide safety to the community. The Application for Emergency admission was signed by the facility Medical Doctor # 513.
Review of the facility document titled Immediate Involuntary Discharge, dated 12/09/24, revealed the document indicated it was hand delivered. The document indicated Resident #74 was notified he was immediately discharged because an emergency arose in which the safety of individuals in the home was endangered. Resident #74 had the right to request an impartial hearing at the facility concerning the proposed discharge. Resident #74 could challenge the discharge and request a hearing by sending in a request by resident or sponsor for a hearing within 30 days of receipt of the notice to the Ohio Department of Health Legal Services Office. If the resident or sponsor received the request within 10 days of the date of the notice, the facility would not discharge the resident prior to the hearing. Agency contact and Ombudsman contact information was provided.
Interview on 01/08/25 at 8:18 A.M. with the hospital Supervisor of Behavior Health Social Work ( SBHSW) #510 revealed Resident #74 was sent to the in-patient psychiatric unit for help and the current nursing facility he resided in would not take him back so he was still at the hospital while they tried to find him placement. The facility dropped off his belongings with a letter of immediate discharge in the bag which was not brought to the hospital or resident's attention at the time his belongings were dropped off at the hospital. SBHSW #510 stated Resident #74's mother and guardian stated to SBHSW #510 they did not receive an immediate discharge notice from the facility.
Interview on 01/08/25 at 4:00 P.M. with Ombudsman #509 revealed the facility provided an immediate discharge notice to the hospital by placing it in Resident #74's bag of belongings the facility dropped off. Ombudsman #509 stated Resident #74's mother wanted him to return to the same nursing facility upon discharge from the hospital because he needed assistance with medication. Ombudsman #509 stated Resident #74's mother and legal guardian had not received in writing notification of emergency discharge.
Interview on 01/08/25 at 4:32 P.M. with Resident #74's Legal Guardian #507 revealed as of 01/07/25 she was transitioned as legal guardian, but Resident #74's mother still had input in Resident #74's care. Legal Guardian #507 stated the nursing facility stated they could not handle his care so they implemented an emergency discharge. Legal Guardian #507 stated the facility did not communicate when Resident #74 was admitted to the hospital therefore Resident #74's mother was not able to communicate with her son in the hospital.
Interview on 01/09/25 at 9:47 A.M. with facility Nurse Practitioner (NP) #511 revealed the facility recommended a pink slip because Resident #74 was running up the hallway, threatening staff and felt residents were not safe. NP #511 verified Resident #74 was immediately involuntarily discharged to the hospital on [DATE].
Interview on 01/09/25 at 10:37 A.M. with the facility Social Services (SS) #503 verified Resident #74 was emergently discharged from the facility on 12/09/24 because of behaviors the facility could not manage placing other residents at risk. SS #503 also verified Resident #74's guardian or mother did not receive a 30-day discharge notice or right to appeal but was sent an emergent discharge notice and she did not call the hospital for discharge planning or goals to ensure the notice in writing was received by the resident or legal guardian.
Interview on 01/09/25 at 11:00 A.M. with the Administrator who revealed the facility transportation person hand delivered the immediate discharge document to the resident in the Emergency Room, and the immediate discharge notice was sent to the Guardian and mother by mail but not certified mail so there was no evidence either had received the written notice.
Interview on 01/09/25 at 1:14 P.M. with Resident #74's mother revealed currently the hospital could not find a nursing facility for her son to live and the facility would not take her son back. The facility did not tell her Resident #74 was discharged so she thought Resident #74 would be returning to the facility. She stated she never received an immediate discharge notice. Resident #74's mother also stated at no time did she agree with the facility not to take her son back.
Interview on 01/09/25 at 1:47 P.M. with the Director of Nursing ( DON) revealed the immediate discharge letter was not sent by certified mail to Resident #74's mother or guardian therefore she had no proof the letter was sent. The DON also stated the facility did not plan to take Resident #74 back so he was discharged to the hospital with no anticipated return.
Interview on 01/09/25 at 2:13 P.M. with hospital SBHSW #510 revealed on 12/10/24 Resident #74's mother stated she wanted her son to return to the facility and did not know her son was discharged from the facility. SBHSW #510 further added the immediate discharge letter was not hand delivered to the resident. Resident #74 was in the emergency department on 12/09/24 at 5:46 P.M. and was transferred to the psychiatric unit on 12/10/24 at 1:10 A.M., and all of resident #74 's belongings were brought with him from the emergency department. On 12/10/24 at 2:55 P.M. hospital security notified her Resident #74's belongings were dropped off on the second floor of the hospital. When SBHSW #510 inspected the bag on the unit the immediate discharge letter was in the bag of resident's belongings which the resident did not have access to.
Review of facility policy titled readmission to Facility dated 07/28/20 revealed if the facility does not permit the resident to return to the facility, the facility must notify the resident and resident representative in writing of the discharge including appeal rights.
This deficiency represents non-compliance investigated under Complaint Number OH00160679.
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
Safe Transfer
(Tag F0626)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and review of facility policy, the facility failed to collaborate with the hospital to ascerta...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview and review of facility policy, the facility failed to collaborate with the hospital to ascertain an accurate status of Resident #74's condition before refusing to allow Resident #74 to return to the facility after hospitalization. This affected one resident (Resident #74) of three residents reviewed for discharges. The facility census was 72.
Findings include:
Review of the closed record for Resident #74 revealed an admission date of 10/30/24 with diagnoses including schizoaffective and mood affective disorder, unspecified intellectual disabilities, sexual dysfunction not due to a substance or known physiological condition, anxiety, insomnia, manic episodes, and assistance with personal care. Resident #74 was transferred to the hospital for an acute, inpatient psychiatric stay on 12/09/24 and did not return to the facility. Resident #74 had a legal guardian of person.
Review of Resident #74's Minimum Data Set (MDS) 3.0 discharge return not anticipated assessment dated [DATE] revealed Resident #74 was modified independent for cognitive daily decision making, no delirium was noted. Resident #74 was positive for inattention, but no disorganized thinking or altered level of consciousness was noted. No hallucination noted but delusions were present. No physical behaviors towards others were displayed but verbal behaviors towards others were displayed daily. Rejection of care occurred daily and wandering occurred daily. Resident #74 was independent for eating, oral hygiene, dressing and toilet hygiene but needed supervision for showers. Resident #74 was independent with mobility such as rolling left and right in bed, sitting on the side of the bed and bed transfers but needed supervision for shower transfers. Resident #74 was independent to walk ten feet.
Review of Resident #74's care plan, dated 11/18/24 revealed Resident #74 had behaviors related to a diagnosis of schizoaffective disorder, generalized anxiety disorder, unspecified mood disorder and manic episodes, dementia as evidenced by aggressively hugging and grabbing staff, pacing throughout facility without footwear, attempts to chase after staff, nonsensical statements verbally and written notes on a note pad, taking items from residents rooms, and refused medication. Intervention included offer and provide activities of interest to keep resident engaged, administer medication as ordered, engage resident in simple, structured activities that avoid overly demanding tasks, labs as ordered, notify physician of any significant change in resident's baseline cognitive status. Physical therapy, occupational therapy and speech therapy as needed. Refer to psychological/psychiatrist as needed.
Review of the Situation Background, Assessment and Recommendation (SBAR) note dated 12/09/24 at 11:00 A.M. written by Nurse Practitioner (NP) #511 revealed Resident #74 had a change in condition with psychotic behaviors that started on 12/06/24 and have gotten worse. Worse behaviors included following staff, unable to re-direct regarding personal space. Resident refused to allow vitals to be taken. Treatment included as needed psychological medication and inpatient psychiatric stay. Resident #74 was admitted to the nursing home for long term needs. Mental status changes included new or worsening behavior symptoms, no functional status change, no gastrointestinal change, no urine change. Problems included increased psychotic behaviors due to inability to self-regulate, medication was ineffective, inappropriate level of care in facility. It was suggested Resident #74 transfer to the hospital. Guardian was notified of erratic behaviors, ineffective medication, inability to redirect, threatening others, intrusiveness, inappropriate touching and obsession with religion. The facility notified the guardian/mother of intention to send to the emergency department and not accept Resident #74 back since this was not an appropriate environment for Resident #74 to live in.
Review of an interdisciplinary progress note dated 12/09/24 at 12:58 P.M. written by Licensed Practical Nurse (LPN)/Unit Manager (UM) #502 revealed Resident #74 stated he heard voices. Resident #74 stated the voices told him to do things he did not want to do. When asked if the voices were telling Resident #74 to harm himself or others, Resident #74 refused to answer and walked away.
Review of the Social Services progress note dated 12/09/24 at 5:35 P.M. revealed the Director of Nursing (DON) and medical doctor planned for Resident #74 to transfer to the emergency room for psychological evaluation and treatment. It was reported that over the weekend Resident #74 had increased agitation, disruptive behavior in group settings and during church services. Resident #74 was placed on a one-on-one monitoring but too much stimulation according to social services. Resident #74 paced around common areas, did not respect others space, raised his voice, unpredictable and was not appropriate for this setting. The note indicated the facility was working with Resident #74's case manager to find alternative placement for him.
Review of the interdisciplinary progress note dated 12/09/24 written by Registered Nurse (RN) #500 revealed Resident #74 disrupted church service by attempting to take the pastor's bible. Resident #74 stated he was the dark angel and you need to hear what I have to say. Resident was unable to be re-directed. Resident #74 stated don't you know who I am, we are all going to be murdered like the CEO of United Healthcare and there's nothing you can do to stop it. Resident #74 was approached by RN #500 and agreed to go in his room to watch football. Resident #74 was medicated with evening medication and as needed Zyprexa (antipsychotic medication) was provided. One-on-one continued.
Review of the facility document Application for Emergency Admission (commonly known as pink slip which commits the resident involuntarily to the hospital), dated 12/09/24, revealed Resident #74 represented a substantial risk of physical harm to others manifested by evidence of recent homicidal or other violent behavior and would benefit from treatment in a hospital for his mental illness and was in need of such treatment as manifested by evidence of behavior that created a grave and imminent risk to substantial right of others or himself. The documented revealed Resident #74 was exhibiting threatening, impulsive behaviors since admission. Behaviors escalated into obsession about religious persecution and ideation and threats of physical harm. Resident #74 was intrusive, threatening towards other nursing home residents and had threatened to kill staff members and was physically capable of acting out these threats. Resident #74 experienced auditory hallucinations but would not reveal what the voices said. Resident #74 had attempted to leave the facility unattended by going to the exit doors and pushing on the doors. This created a substantial risk to his safety as well as others because the facility was located on a highway exit. Resident #74 required admission to an inpatient intensive psychiatric stay to improve the quality of life and to provide safety to the community. The Application for Emergency admission was signed by the facility medical doctor # 513.
Further review of Resident #74's medical record revealed no documentation after 12/09/24 that attempts had been made by the facility, the facility physician or nurse practitioner to collaborate with the hospital to assess Resident #74's mental health status to determine if he was stable for discharge back to the facility.
Review of the facility document titled Immediate Involuntary Discharge, dated 12/09/24, revealed the document indicated it was hand delivered. The document indicated Resident #74 was notified he was immediately discharged because an emergency arose in which the safety of individuals in the home was endangered. Resident #74 had the right to request an impartial hearing at the facility concerning the proposed discharge. Resident #74 could challenge the discharge and request a hearing by sending in a request by resident or sponsor for a hearing within 30 days of receipt of the notice to the Ohio Department of Health Legal Services Office. If the resident or sponsor received the request within 10 days of the date of the notice, the facility would not discharge the resident prior to the hearing. Agency contact and Ombudsman contact information was provided.
Interview on 01/08/25 at 8:18 A.M. with the hospital Supervisor of Behavior Health Social Work ( SBHSW) #510 revealed Resident #74 was sent to the in-patient psychiatric unit for medication management and psychiatric stabilization and the current nursing facility he resided in would not take him back so he was still at the hospital while they tried to find him placement. The facility dropped off his belongings with a letter of immediate discharge in the bag which was not brought to the hospital or resident's attention at the time his belongings were dropped off at the hospital. SBHSW #510 stated Resident #74's mother and guardian stated to SBHSW #510 they did not receive an immediate discharge notice from the facility. SBHSW #510 stated the facility refused to perform an onsite visit of Resident #74. SBHSW #510 stated the worst of Resident #74's behaviors consisted of raised voice but was redirectable, there was no sexually inappropriate touching, or need for physical restraints while admitted to the hospital the past 29 days or a need for seclusion. Resident #74 took his medication, and the last time Resident #74 needed as needed medication was 01/06/25 per physician progress notes. SBHSW #510 stated at no time did the nursing facility physician or nurse practitioner reach out to the hospital social worker or physician regarding discharge needs. SBHSW #510 stated Resident #74 was stable and ready for discharge back to the nursing facility which he considered his home.
Interview on 01/08/25 at 4:00 P.M. with Ombudsman #509 revealed the facility provided an immediate discharge notice to the hospital by placing it in his bag of belongings the facility dropped off. Ombudsman #509 stated Resident #74's mother wanted him to return to the same nursing facility upon discharge from the hospital because he needed assistance with medication. Ombudsman #509 stated the facility had not sent a liaison to the hospital to assess if Resident #74 was appropriate for re-admission to the facility.
Interview on 01/08/25 at 4:32 P.M. with Resident #74's Legal Guardian #507 revealed as of 01/07/25 she was transitioned as legal guardian but Resident #74's mother still had input in Resident #74's care. Legal Guardian #507 stated the nursing facility stated they could not handle his care but in the hospital emergency room he did not display the same behaviors. Legal Guardian #507 stated the facility did not communicate when Resident #74 was admitted to the hospital therefore Resident #74's mother was not able to communicate with her son in the hospital. At no time had the facility physician or nurse practitioner reached out to Legal Guardian #507. Legal Guardian stated they would like Resident #74 back in the nursing facility.
Interview on 01/09/25 at 9:47 A.M. with facility Nurse Practitioner (NP) #511 revealed the facility recommended a pink slip because Resident #74 was running up the hallway, threatening staff and felt residents were not safe. NP #511 verified she did not reach out the hospital to assess if Resident #74 was safe for discharge back to the facility. NP #511 stated as of her assessment , the nursing facility was meeting Resident #74's needs. NP #511 verified she did not speak with Legal Guardian #507 or Resident #74's mother regarding discharge from the facility.
Interview on 01/09/25 at 10:37 A.M. with the facility Social Services (SS) #503 verified she did not speak with the hospital regarding if Resident #74 was stable or appropriate to return to the nursing facility, and the hospital only spoke with the Administrator. SS #503 verified the facility had been looking into placing him at another facility but Resident #74's guardian or mother did not receive a 30-day discharge notice or right to appeal, but instead was sent an emergent discharge notice. SS #503 verified she did not call the hospital for discharge planning or goals.
Interview on 01/09/25 at 11:00 A.M. with the Administrator revealed the police were called regarding Resident #74's behaviors but no reports were made by the police because Resident #74 did not display behavior in front of the police. The Administrator stated the facility transportation person hand delivered the immediate discharge document to the resident in the Emergency Room. The immediate discharge notice was sent to the Guardian and mother by mail but not certified mail. The Administrator stated the hospital had stated Resident #74 was stable and the facility physician had not reached out to the hospital. The Administrator further stated the facility intention on 12/09/24 was to send Resident #74 to the hospital to stabilize and he would come back. She did not believe the hospital version of stable was the same version of stable as the nursing facility. The Administrator stated the facility could not take Resident #74 because the facility did not provide enough structure and there were some concerns for elopement. The Administrator stated Resident #74's mother did stated she wanted Resident #74 in a nursing home and to return back to his facility not back to his previous facilities.
Interview on 01/09/25 at 11:35 A.M. with psychiatric NP #512 revealed Resident #74 displayed no physical abuse towards other resident , and Resident #74 did not make clear homicidal or suicidal indication during her assessment. Resident #74 needed one-on-one supervision because she felt he could be a threat to other residents. NP #512 stated the facility was capable of handling Resident #74's behavior. NP #512 did not recall that Resident #74 displayed violent or physical abuse to other residents in the nursing facility. NP #512 stated she assessed Resident #74 on her initial visit 11/11/24 and planned on visiting him every one to two months. NP #512 stated she was planned to see Resident #74 again but he was sent out to the hospital. NP #512 verified she did not speak with the hospital because she did not know he was sent to the hospital and felt Resident #74 could come back to the facility if Resident #74's mood and behavior was well managed such as 24/7 supervision.
Interview on 01/09/25 at 12:29 P.M. with Unit Manager LPN # 502 revealed Resident #74 was not able to take his own medication and needed supervision with showers. Resident #74 did not physically assault another resident, and did not verbally or sexually assault another resident while admitted to the facility. Unit Manager LPN #502 verified she had not spoken with the hospital regarding Resident #74 status or visit Resident #74 on site. LPN #502 stated once Resident #74 stated he wanted to hurt himself but did not have a plan.
Interview on 01/09/25 at 12:35 P.M. with Registered Nurse (RN) #500 revealed she worked the day Resident #74 was sent to the hospital. Resident #74 was hard to redirect, yelled and ran down the hallway. RN #500 stated Resident #74 never hit another resident or had an incident of sexual assault to another resident. Resident #74 could be verbally assaultive but could not provide an instance.
Interview on 01/09/24 at 12:55 P.M. with Certified Nurse Assistant (CNA) #504 revealed the facility had educated staff on behavior management of residents and Resident #74 threatened staff but not residents. Resident #74 did not display physical or sexual assault to another resident.
Interview on 01/09/25 at 1:12 P.M. with CNA #514 revealed the facility educated her on behavior management of residents and stated one time Resident #74 grabbed another resident's wheel chair but Resident #74 thought he was helping. Resident #74 did not physically hit another resident only threatened staff. Resident #74 did not sexually assault anyone but was verbally inappropriate. CNA #514 stated the facility was equipped to manage residents with behavior problems.
Interview on 01/09/25 at 1:14 P.M. with Resident #74's mother revealed currently the hospital could not find a nursing facility for her son to live and the facility would not take her son back. The facility did not tell her Resident #74 was discharged . She stated she never received a 30-day discharge notice nor the immediate discharge notice. Resident #74's mother also stated at no time did she agree with the facility not to take her son back.
Interview on 01/09/25 at 1:47 P.M. with the Director of Nursing ( DON) revealed the immediate discharge letter was not sent by certified mail to Resident #74's mother or guardian therefore she had no proof the letter was sent. The DON also stated the facility did not plan to take Resident #74 back so he was discharged to the hospital with no anticipated return.
Interview on 01/09/25 at 2:13 P.M. with hospital SBHSW #510 revealed on 12/10/24 Resident #74's mother stated she wanted her son to return to the facility and did not know her son was discharged from the facility. The immediate discharge letter stated it was hand delivered but it was not. On 12/11/24 the hospital social worker reached out to the facility stating Resident #74 was safe for discharge, but the facility responded Resident #74 was an immediate discharge and would not take Resident #74 back. On 12/12/24 the hospital reached out to the facility stating Resident #74's medication was changed and Resident #74 was compliant and able to be redirected. The hospital offered an on-site visit, but the facility responded, not able to accept patient. On 12/19/24 the hospital SW reached out to the facility, but the Administrator responded the denial was upheld by the facility. Resident #74 had stated to the hospital the facility was his home, and he wanted to return. SBHSW #510 further added the immediate discharge letter was not hand delivered to the resident. Resident #74 was in the emergency department on 12/09/24 at 5:46 P.M. and was transferred to the psychiatric unit on 12/10/24 at 1:10 A.M., and all of resident #74 's belongings were brought with him from the emergency department. On 12/10/24 at 2:55 P.M. hospital security notified her Resident #74's belongings were dropped off on the second floor of the hospital. When SBHSW #510 inspected the bag on the unit the immediate discharge letter was in the bag of resident's belongings.
Review of facility policy titled readmission to Facility dated 07/28/20 revealed if a resident was transferred to the hospital due to a resident's clinical or behavioral condition, the facility would evaluate the resident to determine if the resident still required the services of the facility and was eligible for Medicare skilled nursing facility or Medicaid nursing facility services. The facility would also determine the accurate status of a resident's condition to ensure the resident's needs were within the facilities scope of care.
This deficiency represents non-compliance investigated under Complaint Number OH00160679.
Oct 2024
2 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
Accident Prevention
(Tag F0689)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of the ambulance run report, review of hospital documents, review of the facility Self-Re...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of the ambulance run report, review of hospital documents, review of the facility Self-Reported Incident (SRI) investigation, and interviews, the facility failed to ensure Resident #73 was provided a transfer to bed in a safe manner to prevent an incident/accident with major injury.
Actual harm occurred on 08/25/24 when Resident #73, who was severely cognitively impaired and dependent on two staff with maximal assistance needed for transfers, sustained a 10-centimeter laceration that went to the bone with profuse bleeding to her right calf during a staff assisted transfer. As a result of the incident/injury, Resident #73 was emergently transferred to the local hospital on [DATE] for treatment which included 21 sutures to the wound. The resident also exhibited increased pain because of the injury as evidenced by her yelling out following the incident.
This affected one resident (Resident #73) of four residents reviewed for accident hazards. The facility census was 69.
Findings include:
Review of Resident #73's medical record revealed an admission date of 08/12/24 with diagnoses including Alzheimer's disease with late onset, dementia, cerebral vascular accident, hemiplegia, hemiparesis affecting the right dominant side, chronic kidney disease (Stage 3B), and hypertension. Resident #73 was discharged on 08/25/24 to the local hospital and then discharged home with her family from the hospital on [DATE].
Review of Resident #73's care plan which was initiated on 08/12/24 revealed a care plan related to the resident having an activity of daily living (ADL) self-care performance deficit with interventions including one person assist for bed mobility, toileting/incontinence care, supervision with meals with staff to offer assistance with meal setup as needed. Additionally, there was an intervention initiated on 08/28/24 for a transfer status requiring two staff members and the use of the Hoyer(mechanical) lift.
Review of Resident #73's physician orders dated August 2024 revealed there were no orders indicating how the resident should be transferred.
Review of Resident #73's progress notes revealed there was an entry made on 08/25/24 at 11:10 P.M. authored by Licensed Practical Nurse (LPN) #655 indicating she was called into the resident's room for bleeding. LPN #655 pulled the resident's pant leg back and noticed excessive bleeding. The nurse applied pressure, cleaned and wrapped the resident's leg and called 911 for the resident to go to the emergency room (ER). There was no documentation explaining how the injury happened or whether the family or the physician were notified of the resident's transfer to ER.
Review of the ambulance run report dated 08/25/24 revealed a 911 call was received at 9:39 P.M., the ambulance was dispatched to the facility at 9:41 P.M., arrived on scene at 9:48 P.M., made first contact with Resident #73 at 9:51 P.M., and departed the facility with Resident #73 at 10:07 P.M. The report revealed Emergency Medical Services (EMS) were dispatched to the facility for a female resident with a leg injury. Upon arrival EMS found the resident in bed, with her lower right leg wrapped. A nurse in the room advised EMS the resident had a six-inch laceration down to the bone and it was unknown how it happened. The nurse stated the leg was spurting blood. EMS were unable to examine the wound because the resident was not allowing them to touch her leg.
Review of the local hospital paperwork revealed Resident #73 was brought to the emergency room on [DATE] at 10:24 P.M. and discharged home with her family on 08/27/24. The findings at the hospital included the resident had a 10-centimeter laceration to her right calf exposing bone and requiring 21 sutures. The laceration was thought to be caused by an accident at the facility. Resident #73 was not able to provide any history due to severe dementia and the resident's daughter said they did not know how the injury occurred but verified it did occur at the facility. Diagnostic work up included x-rays/scans to the head, pelvis and lower extremities. Besides the soft tissue swelling at the site of the laceration on the right calf, there were no additional findings of fractures or other acute injuries. There were no indications of infection related to the laceration.
Review of Resident #73's discharge Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had severely impaired cognition. The assessment revealed Resident #73 required set-up or clean up assistance for eating and was dependent on staff for all other ADL care including oral hygiene, toileting, showers, dressing, personal hygiene, and bed mobility. The assessment indicated Resident #73 was dependent on maximal assistance from two staff members for all transfers.
Review of a facility Self-Reported Incident (SRI) dated 08/26/24 revealed the facility reported an injury of unknown origin involving Resident #73. Information contained in the SRI revealed Resident #73 sustained a laceration to the right lower extremity on 08/25/24 while being transferred to bed by State Tested Nursing Assistant (STNA) #640 and STNA #658. The SRI noted the facility did not determine the incident was a result of resident abuse.
Review of a witness statement dated 08/25/24 and authored by Licensed Practical Nurse (LPN) #655 revealed she had been sitting at the nurse's station when both aides came to me stating (resident's name) was bleeding from leg. I went to room, pulled down resident pant legs and notice blood and deep cut. I asked what happen, both aides stated they did not know. Resident was screaming in pain. I applied pressure to wound cleaned and called 911 to be sent out.
Review of a witness statement dated 08/25/24 and authored by STNA #626 revealed Resident #73 had been sitting at the nurse's station until it was time for her to go to bed. Around 9:30 P.M. two aides (no names specified) went into her room to put her to bed, and one came back out yelling she was bleeding and went into the bathroom to clean up. STNA #626 went to help the nurse with Resident #73 and Resident #73 was laying in bed yelling while the nurse pulled up the resident's pant leg back and that was when STNA #626 saw the wound and blood all on the floor. There was no indication in the witness statement that Resident #73 had been bleeding while in the hallway prior to being transferred to bed by STNA #640 and STNA #658.
Review of a witness statement dated 08/25/24 and authored by STNA #640 revealed she took Resident #73 to the nurse's station after dinner. At 9:30 P.M. she transferred Resident #73 to her bed with the assistance of STNA #658 and noticed blood. Before dinner, STNA #640 and STNA #658 had stood Resident #73 up to check her brief and it was dry, so they took her to the dining room for dinner. There was no indication in the witness statement that Resident #73 had been bleeding while at dinner prior to being transferred to bed by STNA #640 and STNA #658.
Interview on 10/01/24 at 1:18 P.M. with Family Member #800 revealed they initially were told by the facility staff that the staff did not know how the injury occurred, however, after asking multiple questions they stated STNA #640 and STNA #658 explained to them it happened during the transfer from the resident's transport chair to the resident's bed. Family Member #800 stated STNA #640 and STNA #658 told them when they were transferring the resident with only two staff members it was difficult to do the transfer, and they should have been using a Hoyer lift on her. Family Member #800 felt the injury could have been avoided if they were transferring the resident correctly.
Interview on 10/02/24 at 9:40 A.M. with LPN #655 revealed on 08/25/24 Resident #73 was taken down to her room so she could be put to bed. One STNA came out of the resident's room yelling the resident was bleeding and she had blood all over her pants and hands. The nurse went to the resident's room immediately and found the resident was laying in bed, she had on grey sweatpants and the resident's right leg was wet with blood, so she pulled the resident's pant leg back and found a bleeding laceration with blood coming out very fast, so she immediately applied pressure. LPN #655 stated there was a second nurse in the room who went to get supplies to dress the laceration. LPN #655 then stated she called the Director of Nursing (DON) on facetime to show her the resident's leg. The DON directed her to dress it and to call 911 to have the resident go to the emergency room (ER). LPN #655 stated she knew the resident would need stitches. She stated two STNAs transferred the resident to bed. When asked when the last time she saw the resident she stated just prior to the STNAs putting her to bed at the nurse's station. LPN #655 stated there was no blood at the nurse's station, however there was blood on the resident's floor next to and under her bed. LPN #655 did state she spoke to the resident's daughter and son. She stated Resident #73's son did call back in and began to ask questions on how the injury happened. LPN #655 stated she told the son it happened when the two STNAs transferred Resident #73 to bed. LPN #655 stated they told the resident's son she did not know exactly what happened though due to not being in the room for the transfer. LPN #655 also stated she had not received any education recently on gait belt use, resident transfer status, or with reporting changes. She stated she did not attend an in-person training, nor did she receive any messages from the facility regarding any education following the incident.
Interview on 10/02/24 at 1:00 P.M. with the DON verified Resident #73 required the use of a mechanical (Hoyer) lift with two staff members for transfers since her admission on [DATE]. The DON then stated there had been a communication breakdown between therapy and the nursing department on Resident #73's transfer status. She also confirmed at this time there were no behaviors documented for Resident #73, although she was anxious and would become resistive to care at times.
Interview on 10/02/24 at 1:14 P.M. with Physical Therapist (PT) #675 revealed he completed an initial therapy assessment on Resident #73, and he was able to transfer the resident with a stand pivot technique. He stated he felt if the staff on the floor were to transfer the resident with two staff members, they would be able to complete the transfer with no issues but had heard some of the STNAs were having difficulty with this type of transfer. PT #675 denied being asked to re-evaluate the resident's transfer status. PT #675 stated after the incident on 08/25/24 he completed re-assessments on resident's related to their transfer status to ensure all were correct and adjustments were made if needed.
Interview on 10/02/24 at 1:30 P.M. with Certified Occupational Therapy Assistant (COTA) #676 revealed Resident #73 did receive Occupational Therapy (OT) where they did stretch exercises with the resident. COTA #676 stated she remembered hearing Resident #73 was difficult to transfer.
Interview on 10/02/24 at 2:05 P.M. with the DON revealed the facility had not completed any type of inspection on the resident's wheelchair (which had been brought with her at the time of admission). She stated the family brought the resident to the facility in a transport chair and they did not issue the resident a standard wheelchair. The family came in at around 7:00 A.M. on 08/26/24 and took all the residents' belongings including the transport chair.
Interview on 10/02/24 at 3:07 P.M. with STNA #640 revealed she was assigned to Resident #73 on 08/25/24. STNA #640 stated she waited to put the resident to bed until last and had her at the nurse's station due to the resident being a fall risk. STNA #640 stated once STNA #658 came back in from supervising a smoke break with other residents between 9:30 P.M. and 9:45 P.M. STNA #658 stated Resident #73 was a two-assist transfer so both STNA's transferred the resident to her bed. As STNA #658 was lifting Resident #73's legs into the bed Resident #73 began to scream my leg, my Leg!. STNA #640 stated STNA #658 had blood all over her hands and on her pants. STNA #640 stated as STNA #658 ran out of the room she yelled to the nurse the resident was bleeding. STNA #640 stated there was a puddle of blood on the floor and the resident's sweatpants were soaked in blood on the right pant leg. STNA #640 stated when the resident first arrived at the facility no one informed her how to transfer the resident and Resident #73 was a very difficult two- person transfer. STNA #640 stated she felt the resident should have been a Hoyer lift. STNA #640 stated the resident was not able to help with the transfer as she could not or would not bear weight on her right leg as it was affected from when the resident had a previous stroke prior to coming to the facility. STNA #640 stated the resident was not anxious or combative with care as she was joking with STNA #658 prior to the transfer and hugged her. STNA #640 stated she was unsure what the resident cut her leg on but knew it happened during the transfer. There was no information provided during the interview to indicate the staff used a mechanical (Hoyer) lift at the time of this transfer.
Interviews conducted on 10/02/24 at 3:55 P.M. with STNA #614 and at 3:59 P.M. with Registered Nurse (RN) #612 revealed they had not received any education recently on gait belt use, resident transfer status, or with reporting changes. They stated they did not attend any type of in-person training, nor did they receive any messages from the facility regarding education following the incident with Resident #73 on 08/25/24.
Interview on 10/03/24 at 4:21 P.M. with STNA #658 verified she helped put Resident #73 to bed the night of 08/25/24. STNA #658 stated she was unsure of the time, but stated it was after the 9:00 P.M. smoke break. She stated Resident #73 did not bear weight and they would have to physically pick the resident up when transferring her to bed. The STNA also stated she did not believe the resident was using an appropriate wheelchair as the family brought her to the facility in a transport chair and they were not issued a standard wheelchair for the resident. STNA #658 stated she and STNA #640 manually transferred Resident #73 to bed and were picking up the resident's legs when they felt something wet. When she looked down there was blood all over her hands and on her pant leg. STNA #658 stated she ran out of the room and yelled for the nurse and ran to the bathroom to wash her hands and pant leg. STNA #658 stated she went back down to the room and found two nurses and STNA #640 applying pressure to the resident's leg and trying to dress it. STNA #658 stated there was blood dripping on the floor in a puddle and there was blood all over the resident's bed. STNA #658 stated an ambulance showed up and took the resident to the hospital, and the resident did not return to the facility. STNA #658 stated she was unsure what the resident cut her leg on but knew it happened during the transfer. There was no information provided during the interview to indicate the staff used a mechanical (Hoyer) lift at the time of this transfer.
Interview on 10/08/24 at 5:23 P.M. with the DON confirmed Resident #73 had a transfer status in her care plan initiated on the day of admission [DATE] indicating the resident was to be transferred with the use of two staff members. The DON stated this was triggered from answers given during the completion of the admission assessment. The DON stated she was unsure who completed the admission assessment.
Review of the facility policy titled Accidents and Supervision, date revised 12/27/23, revealed each resident would be assessed for accident risk and would receive care and services in accordance with their individualized care plan. Each resident would receive adequate supervision and assistive devices to prevent accidents including identifying, evaluating and analyzing hazards and risks, implementing interventions to reduce hazards and risks and monitoring effectiveness and modifying interventions when necessary. An accident was defined as any unexpected or unintentional incident which resulted in injury or illness to the resident. Hazards referred to elements in the resident environment that had the potential to cause injury or illness. Risk referred to any external factor, facility characteristics (e.g.: staffing or physical environment) or characteristic of an individual resident that increases the likelihood of an accident. Supervision/Adequate Supervision referred to intervention and means of mitigating risk of an accident. The facility should make a reasonable effort to identify the hazards and risks for each resident. The facility should use specific interventions to try to reduce a resident's risk from hazards including providing training to staff, communicating the interventions to relevant staff and implementing specific interventions as part of the care plan.
This deficiency represents non-compliance investigated under Complaint Number OH00157777.
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, record review, and interviews the facility failed to ensure all treatments were completed per physician or...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews the facility failed to ensure all treatments were completed per physician orders for Resident #39. This affected one resident (Resident #39) of four residents reviewed for treatment administration. The facility census was 69.
Findings include:
Review of the medical record for Resident #39 revealed an admission date of 02/24/23 with diagnoses including malignant neoplasm of the skin, hypothyroidism, dementia, Alzheimer's disease, and hypertension.
Review of Resident #39's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had impaired cognition. Resident #39 required set up help only for eating, partial to moderate assistance for oral hygiene, substantial to maximal assistance for toileting, dressing, personal hygiene, and bed mobility. Resident #39 was dependent for showers.
Review of Resident #39's physician orders dated August 2024, September 2024, and October 2024 revealed orders to cleanse biopsy sites with soap and water, Mupirocin two percent (2%) cream to be applied to biopsy sites and covered with a bandage daily for 10 to 14 days post procedure.
Review of Resident #39's Treatment Administration Record (TAR) dated August 2024 and September 2024 revealed the treatment to her biopsy sites were not completed on 08/28/24, 08/29/24, 09/07/24, 09/08/24, 09/23/24, 09/26/24, 09/29/24, and 09/30/24.
Interviews conducted throughout the survey on 10/01/24 at 2:18 P.M. with Registered Nurse (RN) #605, on 10/02/24 at 9:40 A.M. with Licensed Practical Nurse (LPN) #655 and on 10/03/24 at 3:52 P.M. to 3:59 P.M. with RN #612 and RN #648 verified there were times when Resident #39 did not have her treatment to the biopsy sites completed as ordered by the physician.
Interview conducted on 10/01/24 at 3:02 P.M. with Resident #13, on 10/02/24 at 11:00 A.M. and 2:15 P.M. with Resident #65 and Resident #64, and on 10/03/24 between 3:48 P.M. to 4:02 P.M. with Resident #53, #69 and #70 revealed at times their treatments were not completed as ordered.
This deficiency represents non-compliance investigated under Complaint Number OH00157498.
Jun 2024
5 deficiencies
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 observation, interview, record review and facility policy review, the facility failed to ensure appropriate orders and ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and facility policy review, the facility failed to ensure appropriate orders and monitoring were in place regarding a urinary catheter. This affected one resident (#112) of two residents reviewed for urinary catheters. The facility census was 59.
Findings include:
Review of Resident #112's record revealed an admission date of 05/22/24 and diagnoses including Parkinson's disease without dyskinesia, ulcerative colitis, hypertension, iron deficiency anemia, anxiety, insomnia, constipation, depression and bipolar disorder.
Review of Resident #112's admission minimum data set (MDS) 3.0 assessment dated [DATE] revealed Resident #112 was moderately cognitively intact and had an indwelling catheter.
Review of Resident #112's current physician's orders revealed there were no orders to change the urinary catheter bag monthly or as needed, to monitor urine from the indwelling catheter or to change the catheter as needed prior to 06/10/24.
Interview on 06/10/24 at 10:10 A.M. with the Director of Nursing (DON) revealed Resident #112 was on enhanced barrier precautions due to an indwelling catheter.
Interview on 06/10/24 at 10:36 A.M. with Resident #112 revealed staff did not clean the catheter where it entered her body. Resident #112 indicated since she had been at the facility, the collection bag and the catheter tubing had not needed to be changed. Observation during the interview revealed Resident #112 was nude from the waist down and had a urinary catheter draining into a collection bag located to her left and attached to her bed frame.
Interview on 06/12/24 at 9:03 A.M. with Stated Tested Nursing Assistant (STNA) #339 revealed Resident #112 had her urinary catheter since admission and staff just had to empty the catheter bag as Resident #112 would clean her perineal area herself.
Interview on 06/12/24 at 9:20 A.M. with Licensed Practical Nurse (LPN) #315 revealed Resident #112 had a urinary catheter upon admission to the facility. LPN #314 indicated nurses were to check the color and qualities of the urine in the collection bag and STNAs were to clean the tubing where it entered the body and empty the bag each shift. When asked if there were any orders regarding Resident #112's catheter including changing the tubing or collection bag if needed, LPN #315 verified there were no orders relative to Resident #112's catheter present in the medical record prior to 06/10/24.
Revised policy, Catheterization, revised 01/01/22 revealed indwelling urinary catheters will be utilized in accordance with current standards of practice with interventions to prevent complications to the extent possible. The plan of care will address the use of an indwelling urinary catheter including strategies to prevent complications.
Review of the facility policy, Catheter Irrigation, revised 12/28/23 revealed orders shall include the frequency, type, and amount of irrigating solution or medications.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. A review of medical records for Resident #19 revealed a date of admission of 02/28/24 with diagnoses including chronic obstru...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. A review of medical records for Resident #19 revealed a date of admission of 02/28/24 with diagnoses including chronic obstructive pulmonary disease, hypertension and severe protein calorie malnutrition.
Resident #19's physician orders included oxygen at four liters per minute via nasal cannula continuously, change oxygen tubing every week and date and initial oxygen tubing.
Review of Resident #19's admission minimum data set assessment (MDS) revealed a BIMS of 15 (cognitively intact).
A care plan dated 02/29/24 revealed Resident #19 has impaired pulmonary/respiratory status. Interventions included observe for signs and symptoms of respiratory distress (increased respiration rate, low oxygen saturation levels, cyanosis (a bluing of the skin due to low oxygen), increased heart rate, restlessness, diaphoresis, headaches, increased lethargy, increased confusion) report to physician and administer oxygen as ordered.
A review of the medication administration record and treatment administration record for May 2024 revealed no documented oxygen tubing changes for the entire month of May 2024.
A review of the medication administration record and treatment administration record for June 2024 revealed no documented oxygen tubing change for month of June 2024 until 06/10/24.
On 06/10/24 at 9:37 A.M. an observation of Resident #19 revealed an oxygen tubing with no date. An interview with LPN #308 at the time of the observation verified the oxygen tubing for Resident #19 was not dated. LPN #308 stated oxygen tubing was to be changed weekly.
A review of the policy titled, Oxygen Administration dated 10/26/23 stated on page one, point five, subsection b to change oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated.
Based on observation, interview and review of the facility policy, the facility failed to ensure respiratory equipment was dated and monitored for routine replacement. This affected three residents (#19, #35 and #113) of four residents reviewed for respiratory care. The facility census was 59.
Findings include:
1. Review of Resident #35's medical record revealed an admission date of 06/25/23 and diagnoses including depression, acute and chronic respiratory failure, malignant neoplasm of lower lobe, right bronchus or lung, chronic obstructive pulmonary disease (COPD) and obstructive sleep apnea.
Review of Resident #35's annual minimum data set (MDS) 3.0 assessment dated [DATE] revealed Resident #35 was cognitively intact and used oxygen.
Review of Resident #35's physician's orders as of 06/10/24 revealed an order dated 06/25/23 for oxygen at three liters/minute via nasal cannula continuous every day and night shift for COPD. No orders for replacing oxygen tubing on a routine basis were available in the medical record prior to 06/10/24.
Observation on 06/11/24 at 8:25 A.M. revealed Resident #35's oxygen tubing did not have a date on it.
Interview on 06/11/24 at 8:26 A.M. with Licensed Practical Nurse (LPN) #338 revealed oxygen tubing was supposed to be changed weekly and dated at that time. Observation of Resident #35's oxygen tubing with LPN #338 during the interview confirmed no date was present and should have been.
2. Review of Resident #113's medical record revealed an admission date of 05/24/24 and diagnoses including type two diabetes, chronic obstructive pulmonary disease (COPD), acute respiratory failure with hypoxia, chronic congestive heart failure, depression, insomnia and hyperlipidemia.
Review of Resident #113's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #113 was cognitively intact but did not code him as utilizing oxygen.
Review of Resident #113's physician's orders as of 06/10/24 revealed an order dated 05/28/24 for two liters of oxygen as needed at night for shortness of breath every 12 hours. No orders for replacing oxygen tubing on a routine basis were available in the medical record prior to 06/10/24.
Observation of 06/10/24 at 10:15 A.M. revealed Resident #113's oxygen tubing did not have a date on it.
Interview on 06/10/24 at 10:18 A.M. with Registered Nurse (RN) #331 revealed oxygen tubing was to be dated. Observation of Resident #331's oxygen tubing with RN #331 during the interview confirmed no date was present and should have been.
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 interview, record review, and facility policy review the facility failed to monitor residents using anticoagulant and p...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and facility policy review the facility failed to monitor residents using anticoagulant and psychotropic medications. This affected one resident (#113) out of five residents reviewed for unnecessary medications. The facility census was 59.
Findings include:
Review of Resident #113's medical record revealed an admission date of 05/24/24 and diagnoses including type two diabetes, chronic obstructive pulmonary disease, acute respiratory failure with hypoxia, chronic congestive heart failure, depression, insomnia and hyperlipidemia.
Review of Resident #113's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #113 was cognitively intact and was coded as taking an antidepressant, a hypnotic medication, an anticoagulant, an antibiotic, a diuretic, an opioid and a hypoglycemic medication.
Review of Resident #113's physician's orders as of 06/10/24 revealed an order dated 05/24/24 for Eliquis (anticoagulant) oral tablet five milligrams (mg) and an order dated 05/24/24 for Sertraline hydrochloride (antidepressant) oral tablet 100 mg. Further review of Resident #113's physician's orders revealed no evidence of monitoring for side effects relative to his anticoagulant and antidepressant medications.
Review of Resident #113's Medication Administration Records (MARs) and Treatment Administration Records (TARs) for May 2024 and June 2024 revealed no evidence of monitoring for side effects relative to his anticoagulant and antidepressant medications.
Review of Resident #113's plan of care dated 05/26/24 for risk for abnormal bleeding or hemorrhage related to anticoagulant therapy and recent surgery had the following interventions included:
•
Observe for and report to physician as needed any signs and symptoms of abnormal bleeding: blood-tinged or frank blood in urine, black tarry stools, dark or bright red blood in stools, sudden severe headaches, nausea, vomiting, diarrhea, muscle joint pain, lethargy, bruising, blurred vision, shortness of breath, loss of appetite, sudden changes in mental status, significant or sudden changes in vital signs.
•
Report to nurse any signs or symptoms of bleeding such as black tarry stool, bruising, bleeding gums, blood-tinged urine, excessive bleeding when shaving.
Review of an additional plan of care dated 06/10/24 for Resident #113's impaired mood/psychiatric status related to depression, anxiety, insomnia, antidepressant medication use and Melatonin use had the following interventions included:
•
Observe for and report to physician any signs/symptoms for change in mood/acute psychosis from resident's baseline (hallucinations, delusions, inability to concentrate, depression, sleeping too much or too less, feelings of worthlessness or guilt, loss of pleasure or interest in activities, change in psychomotor skills, anxiety, suicidal thoughts, paranoia).
•
Observe for and report to physician any signs of mania or hypomania, racing thoughts or euphoria, increased irritability, frequent mood changes, pressured speech, flight of ideas, marked changes in agitation or hyperactivity.
Interview on 06/12/24 at 8:49 A.M. with State Tested Nursing Assistant (STNA) #332 revealed their point-of-care charting did not include monitoring medication side effects.
Interview on 06/12/24 at 9:03 A.M. with STNA #339 revealed the STNAs did not document anything relative to medications or their side effects.
Interview on 06/12/24 at 9:20 A.M. with Licensed Practical Nurse (LPN) #315 revealed usually there was an order on the MAR or the TAR to check for signs of bleeding, mood changes and side effects for anticoagulant and antidepressant medications respectively. LPN #315 verified Resident #113's record lacked such orders for monitoring these medications during the interview.
Interview on 06/12/24 at 9:58 A.M. with the DON revealed the expectation for medication monitoring included monitoring for signs and symptoms of bleeding as well as side effects for anticoagulants and antidepressants respectively. The DON verified Resident #113's ancillary orders were not done yet which included medication monitoring and should have been completed already as the Unit Manager would put these orders in within five days of the resident's admission.
Review of the facility policy, Medication-Psychotropic, revised on 10/30/23 revealed the effects of the psychotropic medications on a resident's physical, mental and psychosocial well-being will be evaluated on an on-going basis, including in accordance with nurse assessments and medication monitoring parameters consistent with clinical standards of practice, manufacturer's specifications and the resident's comprehensive plan of care.
Review of the facility policy, Medication-Adverse Drug Consequence or Event, revised 01/17/24 revealed the facility would establish a mechanism to ensure that adverse drug reactions are systematically reported, monitored, evaluated and documented in order to prevent future recurrences. All medications have the potential to cause an adverse drug event and all residents will be monitored appropriately. Care plan interventions will be documented for residents receiving high risk medications for monitoring of and preventing adverse drug events.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, review of the facility policy and review of guidance from the Centers for Diseas...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, review of the facility policy and review of guidance from the Centers for Disease Control (CDC), the facility failed to ensure adequate signage was posted to instruct staff and visitors of proper precautions to take for a resident on enhanced-barrier precautions (EBP). This affected one resident (#112) of three residents reviewed for transmission-based precautions. The facility census was 59.
Findings include:
Review of Resident #112's record revealed an admission date of 05/22/24 and diagnoses including Parkinson's disease without dyskinesia, ulcerative colitis, hypertension, iron deficiency anemia, anxiety, insomnia, constipation, depression and bipolar disorder.
Review of Resident #112's physician's orders on 06/10/24 revealed an order dated 05/24/24 for enhanced barriers while performing high-contact activity with the resident. No rationale for enhanced barrier precautions (EBP) was specified in the order.
Observation on 06/10/24 at 9:52 A.M. revealed Resident #112's door had a yellow personal protective equipment (PPE) hanger over the door with respirator masks, disposable gowns, red trash bags and gloves. No sign was noted on the door or near the door to communicate why PPE was on Resident #112's door and what PPE was needed to enter the room.
Observation on 06/10/24 at 10:10 A.M. with the Director of Nursing (DON) revealed Resident #112 did not have any signage on her door or near the PPE hanger. Interview with the DON at the time of observation verified signage should have been present as Resident #112 was on EBP due to an indwelling catheter.
Interview on 06/12/24 at 8:49 A.M. with State Tested Nursing Assistant (STNA) #332 revealed Resident #112 had her catheter since admission and for any room with the yellow PPE hanger the nurse would tell them why the resident was on isolation and what PPE was needed to enter the room.
Interview on 06/12/24 at 9:03 A.M. with STNA #339 revealed Resident #112 had been on EBP since admission and shared care staff found out about which residents were on transmission-based precautions and what PPE was required based on review of the [NAME] (care card) or through a verbal report from the nurse.
Interview on 06/12/24 at 9:20 A.M. with Licensed Practical Nurse (LPN) #315 revealed Resident #112 had been on EBP since admission and shared staff would verbally ask the nurse about a PPE hanger to obtain further information on why a resident was on transmission-based precautions and what PPE was needed.
Follow-up interview on 06/12/24 at 9:58 A.M. with the DON revealed while the facility would put information about a resident's isolation status in the [NAME], a sign should still be present to give direction to anyone who entered the resident's room regarding what PPE was required. The DON was made aware the facility policy on EBP provided lacked guidance on signage during the interview.
Review of the facility policy, Enhanced Barrier Precautions (EBP), revised 03/26/24 defined EBP as infection control interventions designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and gloves during high-contact resident care activities. No guidance on signage was provided in the policy.
Review of the CDC guidance, Frequently Asked Questions (FAQs) about Enhanced Barrier Precautions in Nursing Homes, dated 05/20/24 revealed signs were intended to signal to individuals entering the room the specific actions they should take to protect themselves and the resident. To do this effectively, the sign must contain information about the type of precautions and the recommended PPE to be worn when caring for the resident.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0583
(Tag F0583)
Could have caused harm · This affected multiple residents
Based on observation and staff interview the facility failed to ensure the security and confidentiality of resident medical records. This affected thirteen (Residents #5, #10, #12, #16, #18, #20 #36,#...
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Based on observation and staff interview the facility failed to ensure the security and confidentiality of resident medical records. This affected thirteen (Residents #5, #10, #12, #16, #18, #20 #36,#42 #262, #263, #264, #265 #266) of thirty six sampled residents. The facility census was 59.
Findings Include:
Observation on 06/10/24 at 5:15 P.M. of the facilities information board on the wall after the main entrance area noted information such as contact information for advocacy agencies (i.e local social security office, local area agency on aging and local ombudsman office), resident rights, state agency contact information and numerous other important information for residents. On the wall was also a plastic file holder. In that filed holder was a file that was easily accessible that contained the following information
-Specific information regarding medications taken by Residents #5, #10, #12, #16, #18, #20 #36,#42 #262, #263, #264, #265 #266.
-Skilled therapy information for Resident #263.
-Information concerning bowel movements for Residents #18 and #42.
The Administrator verified that the records noted above were unsecure and easily accessible to the general public in an interview on 06/10/24 at 5:20 P.M.
Feb 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
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.
Bas...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.
Based on medical record review, interviews, policy review, and review of the investigation notes for self-reported incident (SRI) #243949 the facility failed to prevent staff to resident abuse. This affected one resident (#32) of three residents reviewed for abuse. The facility census was 56.
Findings Include:
Review of the medical record for Resident #32 revealed an admission date of 01/27/24 with diagnoses including chronic osteomyelitis (infection of bone) of the left thigh, local infection of the skin and subcutaneous tissue, unstageable pressure ulcer, Sjogren syndrome (an immune system illness that mainly causes dry eyes and dry mouth), major depression, and history of respiratory failure.
Review of the admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #32 had intact cognition and minimal signs of depression. Further review of the MDS assessment revealed Resident #32 was dependent for toileting, had a stage four pressure ulcer, and frequently suffered from severe pain during the five days prior to the assessment.
Review of the progress note dated 02/08/24 revealed Resident #32 reported that State tested nurse aide (STNA) #351 left her on a bedpan too long and was too rough when turning her. The progress note further revealed an investigation was initiated, the STNA was suspended, the police were notified, and skin and pain assessments were completed on Resident #32 on 02/08/24 with no new findings.
Review of the care plan dated 02/09/24 revealed Resident #32 had a self-care deficit in the performance of activities of daily living (ADLs) and required one-person assistance with toileting and bed mobility. Further review of the care plan revealed Resident #32 was at risk for impaired skin integrity and staff were to assist with repositioning as needed.
Interview on 02/22/24 at 4:15 P.M. with Resident #32 revealed STNA #351 placed her on the bedpan wrong and when she asked to be repositioned, the STNA was rough when repositioning her and then she still felt poorly positioned and uncomfortable on the bedpan. Resident #32 stated she begged STNA #351 not to leave her like that and STNA #351 told her in an irritated tone that she would be fine as she proceeded to exit the room. Resident #32 further explained she was uncomfortable and felt she was not on the bedpan correctly, so she started yelling out for assistance when a nurse entered and helped her get better positioned on the bedpan. When STNA #351 came back, she would not remove the bedpan, telling Resident #32 she needed to get a second person to assist. Resident #32 reported STNA #351 was gone so long, Resident #32 fell asleep on the bedpan. Once the STNA returned, she returned without another staff member. Resident #32 felt like her skin was adhered to the bedpan and was fearful it may have damaged her skin. STNA #351 instructed Resident #32 not to reach back there because she could cause her skin to bleed. Resident #32 denied new or worsening wounds related to the incident.
Interview on 02/22/24 at 4:38 P.M. with the Administrator revealed STNA #351 was suspended immediately upon report of the incident on 02/08/24, and subsequently terminated on 02/13/24. The facility investigation substantiated abuse occurred on 02/07/24 during second shift when STNA left Resident #32 on the bedpan too long and was not responsive to Resident #32's requests to help reposition her appropriately and timely. The Administrator indicated Resident #32 was impacted at the time of the incident with no ongoing affects.
Review of written statements dated 02/08/24 from Resident #32 and Social Worker #350, and the written statements dated 02/09/24 from Licensed practical nurse (LPN) #316, and STNA #353 revealed supportive statements by each that Resident #32 was placed on the bedpan by STNA #351 on 02/07/24. Further review of the statements revealed STNA #351 did not obtain assistance from another staff member with removing Resident #32 from the bedpan and Resident #32 reported increased pain when placed on the bedpan on the evening of 02/07/24 by STNA #351.
Review of the facility policy and procedure titled Abuse, Neglect, and Exploitation revised on 01/10/24 revealed procedures to prevent all types of abuse, neglect, misappropriation, and exploitation.
The deficient practice was corrected on 02/16/24 when the facility implemented the following corrective actions.
•
On 02/08/24, STNA #351 was suspended immediately upon report of the allegation.
•
On 02/08/24, the Director of Nursing (DON) performed a skin assessment and inspected Resident #32's wound with no new skin issues or deterioration in wound noted.
•
On 02/08/24, The DON conducted a pain assessment on Resident #32 with no increase in pain from baseline.
•
On 02/08/24, the Unit Manager reviewed Resident #32's medication administration record with no increased use of prescribed pain medication from time of incident to time of report.
•
On 02/08/24, Social Services Director #350 conducted a Patient Health Questionnaire-9 (PHQ-9), a depression screening tool, with no worsening depression noted, per the scale, from the score from the admission PHQ-9.
•
On 02/08/24, the Administrator spoke to Resident #32 regarding the alleged incident and to make sure Resident #32 felt safe at the facility; Resident #32 stated she did.
•
On 02/08/24, the Administrator called the police to have them speak to Resident #32. No charges were filed at that time.
•
On 02/08/24, the Administrator and Social Services Director #350 surveyed other interviewable residents in the facility to assess any other issues regarding staff and whether they felt safe at the facility. No new issues were noted, and all felt safe residing in the facility.
•
On 02/09/24, the Administrator spoke to nursing staff that were scheduled on same day on same shift about their involvement or recollection of the events on 02/07/24. Written statements were obtained from LPN #316 and STNA #353, who were assigned to the same unit as STNA #351.
•
Social Services Director #350 followed-up with Resident #32 for 72 hours post incident to make sure there was no residual emotional effects from the incident. Resident #32's mood was stable, and she was content during the 72 hour period.
•
On 02/13/24, the Administrator finalized the termination of STNA #351 at which time the DON reported STNA #351 to the Nurse Aide Registry.
•
On 02/14/24, The DON conducted a facility audit of all residents with bedpans which revealed Resident #32 was the only resident in the facility who used a bedpan.
•
On 02/14/24, an Ad hoc Quality Assurance Performance Improvement (QAPI) meeting took place to review quality concerns and plan of compliance for the incident.
•
By 02/16/24, the DON/designee completed skin assessments and pain assessments on all residents residing in the facility who were not interviewable with no identified concerns.
•
By 02/16/24, the DON/designee educated all STNAs on bedpan etiquette. Bedpan placement competency training with checklists would be included in STNA new hire training indefinitely.
•
By 02/16/24, the DON/designee educated all nursing staff on expectations to review the residents' [NAME] for resident needs. The [NAME] training would be included in new hire training indefinitely.
•
By 02/26/24, the DON/designee educated all nursing staff on the use of the communication board in Point Click Care (PCC). The PCC communication board training would be included in new hire training indefinitely.
•
The following audits commenced on or before 02/16/24:
a. Visual rounds of bedpan placement and time resident spent on the bedpan on various shifts five days a
week for four weeks completed by the DON/designee.
b. Staff interviews of knowledge of [NAME] and communication board; two direct care staff on various
shifts, five days a week for four weeks completed by the DON/designee.
c. Interviews of five facility staff weekly for four weeks on the facility abuse/neglect policy with immediate
education if discrepancies identified completed by the Administrator.
d. Interview of five interviewable residents weekly for four weeks regarding the facility's abuse/neglect policy
with any identified concerns reported to the facility abuse coordinator immediately completed by the Social
Services Director.
e. Completion of skin and pain assessments on five residents who were unable to be interviewed for
abuse/neglect weekly for four weeks completed by the DON/designee.
f. Results of the above audits to be reviewed in one month by the QAPI Committee and
revisions/changes would be made to compliance monitoring as deemed necessary by the QAPI Committee.
This deficiency represents non-compliance investigated under Control Number OH00151147.
Feb 2023
9 deficiencies
1 IJ
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Free from Abuse/Neglect
(Tag F0600)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff and resident interviews, physician interview, review of an emergency medical services (EMS...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff and resident interviews, physician interview, review of an emergency medical services (EMS) run report, review of hospital documentation including a surgical operative note, medication manufacture guidelines, review of Centers for Disease Control guidance on sepsis, and review of facility policies regarding abuse, change of condition, and sepsis protocol, the facility failed to prevent an incident of neglect involving Resident #2 following an acute change in condition when the change was not timely identified and medical treatment was not timely obtained. This resulted in Immediate Jeopardy and serious life-threatening harm on 01/23/23 when Resident #2 experienced a low blood pressure of 81/50 and had an unwitnessed fall, abdominal pain and distention, nausea, vomiting and signs of gastrointestinal (GI) bleeding, telling staff he had an upset stomach, did not feel well, was bloated, and continued to receive medications for high blood pressure. Resident #2 experienced a second unwitnessed fall (on 01/25/23) with a low blood pressure of 67/38, pulse of 147 (tachycardia) and respirations of 38. Following this incident, on 01/25/23, Resident #2 requested to be transported and was sent via Emergency Medical Services (EMS) to the local hospital Emergency Department where he was assessed to have a life-threatening deterioration in condition requiring urgent intervention. This affected one resident (#2) of three residents reviewed for neglect. The facility census was 54.
On 01/30/23 at 11:58 A.M. the Director of Nursing (DON) and Administrator were notified Immediate Jeopardy began on 01/23/23 at 2:57 P.M. when Resident #2 was first assessed to have an acute change in condition (hypotension) with no new orders/treatment. Between 01/23/23 through 01/24/23 Resident #2 had an unwitnessed fall, continued hypotension, emesis and complained of bloating, upset stomach and reported he did not feel well (all reflective of an acute change in condition) with no new treatment or interventions. On 01/25/23 Resident #2 sustained a second unwitnessed fall. The resident's vital signs included blood pressure 67/38 (hypotensive), pulse 147 (tachycardic) and respirations 38. The resident continued to complain of dizziness and had a small emesis. At this time, per Resident #2's request, he was transported to the local hospital Emergency Department and admitted to the hospital with septic shock (widespread infection causing organ failure and dangerously low blood pressure). Resident #2's blood work showed worsening kidney function, elevated white blood cell count, lactic acid of 5.2 (used to determine septic shock). Resident #2 was given a sepsis bolus and started on broad spectrum antibiotics (Vancomycin and Cefepime) with concern for possible spontaneous bacterial peritonitis (SBP). Resident #2 had greater than 1000 milliliters (ml) output from a nasogastric tube concerning for likely bowel obstruction. Resident #2 had severe abdominal pain and a CT scan showed possible pneumatosis intestinalis and portal venous gas (associated with bowel ischemia). Resident #2 was rushed urgently to surgery. Resident #2 had an exploratory laparotomy (surgical incision into the abdominal cavity), lysis of adhesions (procedure to destroy scar tissue causing abdominal pain), and release of small bowel obstruction. The post operative diagnosis was small bowel obstruction, ischemic bowel, severe sepsis and peritonitis.
The Immediate Jeopardy was removed on 01/31/23 when the facility implemented the following corrective actions:
•
Resident #2 was transferred and admitted to the hospital on [DATE]. The facility identified a plan to ensure Resident #2 would be re-assessed upon readmission to facility.
•
On 01/30/23 the facility identified all residents to be potentially affected by incidents of neglect.
•
On 01/30/23 at 3:00 P.M. the Director of Nursing (DON) accessed the vital sign exception report triggered from the facility electronic system and set vital parameters for all residents. This report was sent to Medical Director #326, who reviewed and signed the report. Medical Director (MD) #326 added new parameters for four of the 23 residents identified with triggered vital signs on the report.
•
As of 01/30/23 the facility indicated all residents would have vital signs monitored, as ordered by the physician, with a follow up assessment completed if warranted and reported to the physician by facility nursing staff. All residents with a change of condition (identified to include gastrointestinal (GI) upset, nausea, vomiting, bloating, change in bowel) would have a Situation Background Appearance Review (SBAR) completed and MD #326, Certified Nurse Practitioner (CNP) #324 would be notified by facility nursing staff. The plan also required any resident who sustained a fall to have post fall assessments completed every 12 hours for 72 hours.
•
On 01/30/23 the facility Quality Assurance and Performance Improvement (QAPI) committee reviewed the following policies to ensure compliance with federal and state guidelines.
o Abuse and neglect policy
o Notification of change policy
o Sepsis signs and symptoms
•
On 1/31/23 the DON, Unit Manager (UM) #342, Registered Nurse (RN) #304 and Licensed Practical Nurse (LPN) #301 reviewed all residents through visual observation and interviews with facility direct care staff. Interventions were implemented for any resident with any identified change of condition. The vital signs exception report was reviewed (includes hypotension) with MD #326 and no new orders were given on this date.
•
On 01/31/23 the DON and/or designee completed education for all nurses and State Tested Nursing Assistant (STNA) staff which included eight RNs, eight LPNs and 23 STNAs on the following topics:
o When residents have abnormal vital signs, the physician was to be notified and follow-up vital signs were to be observed.
o An SBAR was o be completed on any resident who had a change in condition and the physician notified, as well as completing a follow up assessment and notification accordingly.
o SBAR pathways were located in a binder at the nurses' station, and there were specific assessments related to different situations/body systems.
o Residents with change in condition including GI upset, nausea, vomiting, bloating, or change in bowel habits needed an SBAR completed and MD #326, CNP #324 notified and documented.
o Residents who had a fall would have a post-fall assessment completed every 12 hours as triggered by the electronic medical record for 72 hours.
o STNAs were education to complete a stop and watch pointe of care (POC) alert in the electronic medical record for any
resident who had a change in condition, as well as tell the nurse verbally. The nurse would complete the SBAR in the electronic medical record on the resident and notify the physician and responsible party of the change of condition and document any new orders received as well as any follow-up assessments. The facility implemented a plan to ensure no staff would work before receiving the education.
•
On 01/31/23 Staff Development Coordinator (SCD) #327 educated eight RNs, eight LPNs and 23 STNAs on the signs and symptoms of sepsis, the facility Abuse and Neglect policy and procedure and the facility Notification of Change policy and procedure.
•
On 01/30/23 at 3:36 P.M. the Director of Nursing was educated by the Regional Director of clinical services regarding daily review in clinical meeting of the Residents' 24-hour report to validate residents with an acute change of condition were identified and had been treated by MD #326 and/or CNP #324.
•
By 01/31/23 by 11:59 P.M. all facility nurses (eight LPNs and eight RNs) were to be educated on completing post-fall assessments every 12 hours for 72 hours by the Director of Nursing or Designee.
•
On 01/31/23 by 11:59 P.M. Facility Medical Director #326 counseled CNP #324 regarding the events of the Immediate Jeopardy with a plan for CNP #324 to collaborate with Medical Director #326.
•
The facility implemented a plan, beginning on 01/31/23 for the DON/designee to review resident vital signs, 24-hour resident report, stop and watch tool every eight hours for one week to ensure that appropriate follow up assessment and notification occurred. After the one week of audits were completed, vital signs and appropriate follow up documentation would be reviewed by the DON/designee every 24 hours for one week with results to be reviewed by the QAPI committee for compliance and further recommendations.
Although the Immediate Jeopardy was removed on 01/31/23, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action plan and monitoring to ensure on-going compliance.
Findings include:
Review of Resident #2's medical record revealed an admission date of 06/15/22 with diagnoses including malignant neoplasm of unspecified part of unspecified bronchus or lung, hypertension, chronic obstructive pulmonary disease, and type two diabetes mellitus.
Review of Resident #2's Fall Risk Evaluation, dated 06/15/22 revealed Resident #2 was at high risk for falls.
Review of Resident #2's blood pressures from 06/15/22 through 11/07/22 revealed a range from 90/50 through 158/73 with no specific frequency or orders for monitoring during this time period.
Review of Resident #2's physician medication orders, dated 06/16/22 revealed an order for Lisinopril 10 milligrams (mg), give one tablet by mouth in the morning for hypertension. The resident had an order, dated 09/15/22 for Metoprolol Tartrate tablet 50 mg, one tablet by mouth every morning and at bedtime for hypertension. Further review did not reveal any blood pressure parameters for the administration of the medications ordered to treat hypertension.
Review of the resident's medical record revealed the resident had a history of falls and/or incidents of hypotension not comprehensively assessed or monitored including the following:
a. Review of Resident #2's progress note, dated 10/31/22 at 1:24 A.M., revealed Resident #2 had an unwitnessed fall, Resident #2 was found on the floor, in a sitting position next to his bed. Resident #2 stated he attempted to go to the bathroom, became weak and ended up on the floor. Record review revealed there were no vital signs including blood pressure documented when the fall occurred. Further review of the medical record did not reveal vital signs, including a blood pressure were taken on this date until 10/31/22 at 11:03 P.M.
b. Review of Resident #2's progress notes dated 11/07/22 at 7:16 A.M., revealed staff responded to a call light and Resident #2 stated he fell around midnight and turned on his call bell. Resident #2 stated he was attempting to go to the bathroom and fell. When staff responded the resident was back in bed.
Review of Resident #2's progress notes dated 11/07/22 at 7:24 A.M. revealed Resident #2's blood pressure was 74/44. Further review of Resident #2's medical record, including Medication Administration Record (MAR) revealed Metoprolol Tartrate 50 mg was administered on 11/07/22 in the morning between 7:00 A.M. and 10:00 A.M. and held on 11/07/22 at bedtime.
Review of Resident #2's progress noted dated 11/07/22 as a late entry note for 7:11 A.M., stated to hold Resident #2's morning administration of Metoprolol Tartrate 50 mg. There was no documentation Resident #2's physician was notified of the blood pressure of 74/44 and no order to hold Resident #2's Metoprolol. No further blood pressures were documented until 01/23/23 at 3:00 P.M.
Review of Resident #2's physician Encounter Note dated 11/09/22 and signed by Medical Director (MD) #326, included a box was checked next to the statement vital signs were checked and were stable unless noted. There was no mention of a blood pressure of 74/44 in the note.
Review of Resident #2's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 11/21/22, revealed Resident #2 was cognitively intact. The assessment revealed Resident #2 was independent for activity of daily living care and required staff set-up help with bed mobility, transfers, and toilet use. The assessment revealed the resident was occasionally incontinent of urine and always continent of bowel.
Review of Resident #2's plan of care, dated 01/09/23 revealed a plan reflecting the resident had hypertension (HTN). The goal developed was for the resident to remain free of complications related to hypertension through review date. Interventions included to administer anti-hypertensive medications as ordered and monitor for side effects such as orthostatic hypotension and increased heart rate (Tachycardia) and effectiveness. The care plan did not specify if or how often Resident #2's blood pressure and pulse should be monitored. Resident #2 was also on Aspirin (ASA) therapy. The goal for this plan included Resident #2 would be free from discomfort or adverse reactions related to anticoagulant use through the next review date. Interventions included to monitor, document, report to the physician as needed adverse reactions such as nausea, vomiting, diarrhea, lethargy, bruising, loss of appetite, sudden changes in mental status, significant or sudden changes in vital signs. An additional plan of care revealed Resident #2 was at risk for return to the hospital related to comorbidities with a goal to have reduced risk to return to the hospital through related disease process and symptom management. Interventions included to notify the physician of changes in condition.
Review of Resident #2's progress note, dated 01/23/23 at 12:44 P.M. revealed Resident #2 was administered two chewable Calcium Carbonate 500 mg tablets for indigestion.
Review of Resident #2's progress note, dated 01/23/23 at 2:57 P.M. revealed Resident #2 complained of his blood pressure feeling low. The resident's blood pressure was checked and noted to be 80/51 (hypotensive) with a pulse rate of 59/minute. The note indicated Nurse Practitioner (NP) #324 was notified. The medical record did not identify the follow-up response from NP #324.
Review of Resident #2's progress note, dated 01/23/23 at 3:08 P.M. and 3:19 P.M. revealed staff assisted Resident #2 off the floor after he attempted to transfer, no injuries were noted and his vital signs included blood pressure 81/50 (hypotensive), pulse 59, respirations 18, temperature 98 degrees Fahrenheit, and oxygen saturation 94 percent on room air. The note revealed Resident #2 had refused breakfast and lunch. The DON, NP #324, and the resident's power of attorney (POA) were notified. The medical record did not identify any follow-up response from the parties notified.
Review of Resident #2's progress note, dated 01/23/23 at 5:04 P.M. revealed Resident #2 had a brown watery emesis and NP #324 was notified. The medical record did not identify the follow-up response from NP #324.
Review of Resident #2's progress note, dated 01/23/23 at 7:07 P.M. revealed Resident #2 had an emesis, NP #324 was notified and an order was given for STAT blood work including a complete blood count (CBC) and basic metabolic panel (BMP).
Review of Resident #2's progress notes from 01/23/23 at 7:07 P.M. through 01/25/23 at 12:19 A.M. revealed no evidence of monitoring or follow-up documentation related to Resident #2's condition including blood pressure, abdomen and/or nausea/vomiting.
Review of Resident #2's bowel movement records from 01/23/23 through 01/25/23 revealed on 01/23/23 at 1:29 P.M. Resident #2 was incontinent of a large diarrhea bowel movement. Documentation on 01/23/23 at 9:02 P.M. and 11:55 P.M. revealed Resident #2 was incontinent of a large bowel movement, but it was not documented if it was diarrhea. On 01/24/23 at 11:52 A.M. Resident #2 was incontinent of a diarrhea bowel movement. There were no other bowel movements documented.
Review of Resident #2's Medication Administration Record (MAR) revealed on 01/23/23 at bedtime (between 8:00 P.M. and 11:00 P.M.) Resident #2 was administered Metoprolol Tartrate 50 mg. On 01/24/23 in the morning (between 7:00 A.M. and 10:00 A.M.) Resident #2 received Lisinopril 10 milligram (mg) and Metoprolol Tartrate 50 mg. Further review revealed he was administered Metoprolol Tartrate 50 mg on 01/24/23 at bedtime.
Review of Resident #2's blood pressure records, dated 01/23/23 through 01/25/23 revealed on 01/23/23 at 3:00 P.M. and 3:43 P.M. Resident #2's blood pressure was documented 81/50. On 01/24/23 at 4:36 A.M. Resident #2's blood pressure was 96/51 and on 01/25/23 his blood pressure was 67/38.
Review of Resident #2's Fall Follow-Up, from the fall on 01/23/23, dated 01/24/23 at 4:34 A.M., revealed Resident #2 had a blood pressure of 96/51 lying in bed, pulse was 100, temperature 97.2 Fahrenheit and respirations were 18 per minute with an oxygen saturation of 98 percent. The assessment stated Resident #2 had no nausea or vomiting. There were no further Fall Follow-Up assessments documented in Resident #2's medical record or follow up to Resident #2's blood pressure.
Review of Resident #2's progress note, dated 01/25/23 at 12:19 A.M. revealed Resident #2 had shortness of breath and the head of his bed was flat. Resident #2's head of bed was elevated, and resident was educated on the importance of a raised head of bed for decreased shortness of breath. The note indicated would monitor.
Review of Resident #2's progress note, dated 01/25/23 at 2:35 A.M. revealed Resident #2 had an unwitnessed fall and was found sitting on his buttocks next to his bed with no injury was noted. Resident #2 was very short of breath, oxygen was administered at three liters via nasal cannula, his blood pressure was taken three times and was 68/51, 78/43 and 67/38 with a heart rate ranging from 149 to 153 and respirations were 38. The nurse was unable to obtain an oxygen saturation. There was a small amount of emesis noted on the bed and Resident #2 complained of feeling dizzy. Per the resident's request at this time, a call was placed to 911 for Emergency Medical Services due to the resident's respiratory status and blood pressure. EMS arrived and transported Resident #2 to the local hospital Emergency Department.
Review of Resident #2's local fire department/EMS report, dated 01/25/23, incident number 2023-0000163 revealed a call was received on 01/25/23 at 12:42 A.M. and Emergency Medical Services were on the scene at 12:51 A.M. Resident #2 experienced difficulty breathing and hypotension. Resident #2 was alert and oriented, in moderate distress, and stated he felt like he was dying. Resident #2's blood pressure was 56/33, pulse of 143, and respirations were 30. The EMS report revealed staff stated the issue started on 01/24/23 with increasing respiratory effort and gradually decreasing blood pressure. Staff called 911 due to the resident's blood pressure of 68/51. Staff stated Resident #2 had a fall due to dizziness and fell on his bottom. The report also noted Resident #2 would like transport to the local Emergency department, and his abdomen was quite distended. Resident #2 complained of dizziness and nausea with no emesis.
Review of Resident #2's Emergency Department to Hospital admission notes, dated 01/25/23, revealed Resident #2 arrived at the hospital Emergency Department on 01/25/23 at 1:29 A.M. with a blood pressure of 58/34 and a pulse of 135. Resident #2 was in acute distress and ill-appearing. Resident #2's chief complaints were hypotension, distended abdomen, abdominal pain, nausea, vomiting, diarrhea, shortness of breath, and a history of having radiation for lung cancer. Resident #2 was alert and oriented, tired appearing and had a fall at the facility with no loss of consciousness and no injuries. Resident #2 stated he had the facility call Emergency Medical Services (EMS) because he felt like he was going to die. Resident #2 stated he had worsening hypotension, increased abdominal distention as well as shortness of breath. Resident #2 had a history of chronic obstructive pulmonary disease (COPD) and a lung mass. Resident #2 stated his symptoms worsened over the last ten days, he had poor intake by mouth, nausea, vomiting, and diarrhea. Resident #2 wanted everything (medically) done. Further review revealed sepsis was identified at 1:45 A.M. and Resident #2 had septic shock (widespread infection causing organ failure and dangerously low blood pressure). Resident #2's bloodwork showed worsening kidney function, elevated white blood cell count, lactic acid of 5.2 (used to determine septic shock). Resident #2 was given a sepsis bolus and started on broad spectrum antibiotics (Vancomycin and Cefepime) with concern for possible spontaneous bacterial peritonitis (SBP). Resident #2 had greater than 1000 milliliters (ml) output from a nasogastric tube concerning for likely bowel obstruction. There was a high probability of clinically significant, life-threatening deterioration in the patient's condition which required urgent intervention.
Review of Resident #2's Department of Surgery Operative Note, dated 01/25/23 revealed Resident #2 was admitted acutely ill last night with severe abdominal pain and a computerized tomography (CT) scan showed possible pneumatosis intestinalis and portal venous gas (associated with bowel ischemia). Resident #2 was rushed urgently to surgery. Resident #2 had an exploratory laparotomy, lysis of adhesions, and release of a small bowel obstruction. The post operative diagnosis was small bowel obstruction, ischemic bowel, severe sepsis and peritonitis (usually infectious, often life-threatening, caused by a leakage or hole in the intestines).
On 01/25/23 at 10:45 A.M. interview with Registered Nurse (RN) #304 revealed on 01/23/23 Resident #2 had an emesis on the floor of his room and was incontinent of bowel (diarrhea). RN #304 stated there was feces on the toilet seat and bathroom floor, emesis on the floor of his room and Resident #2's room was not cleaned immediately. RN #304 stated she did not know what time Resident #2 had the emesis or was incontinent of diarrhea, but he was sitting in a wheelchair in his room around 3:00 P.M. while his room was being cleaned. RN #304 revealed Resident #2 told an unidentified State Tested Nursing Assistant (STNA) he thought his blood pressure was dropping, and the STNA had RN #304 come to the room. RN #304 took Resident #2's blood pressure, and it was 81/50 with a pulse of 59. RN #304 noticed Resident #2 was a little short of breath, did not have his oxygen on via nasal cannula, and put his oxygen back on him before she left the room. RN #304 left the room and immediately text Nurse Practitioner (NP) #324 to notify her Resident #2's blood pressure was 81/50. NP #324 text back OK, thanks but did not give RN #304 orders or instructions concerning the low blood pressure. Approximately ten minutes after his blood pressure was 81/50, Resident #2 had an unwitnessed fall and RN #304 text NP #324 again to notify her of Resident #2's fall. NP #324 text back thanks but did not give RN #304 orders or instructions for Resident #2. At around 5:00 P.M. Resident #2 had a brown, watery emesis, his blood sugar was 150 and he refused his insulin. RN #304 text NP #324 again to notify her. Resident #2 had another emesis around 7:00 P.M., NP #324 was notified via text and a laboratory testing, a stat CBC and BMP were ordered, but no questions, instructions or orders were given concerning Resident #2's low blood pressure or emesis. RN #304 stated it was a very busy day and she did not think she took Resident #2's blood pressure again. RN #304 stated she worked day shift on 01/24/23 and Resident #2 stated he felt better, but his abdomen was bloated. RN #304 stated Resident #2's blood pressure on night shift was 96/51, taken while he was lying in bed. RN #304 indicated she administered Resident #2's blood pressure medications (Metoprolol Tartrate 50 mg and Lisinopril 10 mg) on 01/24/23 and did not check his blood pressure. RN #304 stated NP #324 was notified of the results of the stat bloodwork drawn (CBC and BMP), which were a little bit off. No further orders were given.
On 01/25/23 at 5:41 P.M. interview with NP #324 revealed she was informed Resident #2's blood pressure was 81/50 and was not concerned. NP #324 stated Resident #2's blood pressure goes up and down and it was not unusual for him to have a low blood pressure and he also had heart failure. When asked if NP #324 would expect the blood pressure to be checked again she stated the blood pressure should have been checked per the fall protocol but did not know what the facility fall protocol was. NP #324 confirmed she did not ask for Resident #2's blood pressure to be rechecked or ask any questions regarding the low blood pressure or emesis. NP #324 indicated she was not aware Resident #2 had an emesis. NP #324 revealed she asked for stat bloodwork to be drawn (CBC and BMP). When asked if Resident #2's Metoprolol Tartrate 50 mg and Lisinopril should have been held NP #324 stated the nurses were supposed to call if the systolic blood pressure was less than 100. NP #324 stated nurses did not need an order to take a blood pressure.
On 01/26/23 at 7:55 A.M. interview with RN #333 revealed she spoke with a nurse at the hospital regarding Resident #2 and was told he was pretty sick, and it was good he got to the hospital when he did. RN #333 stated the nurse told her Resident #2's nasogastric tube drained three liters of coffee ground fluid (appearance comes from old and coagulated blood in the gastrointestinal tract; a sign of internal bleeding).
On 01/26/23 at 9:00 A.M. interview with STNA #330 revealed when she arrived for work on 01/23/23 at 6:00 A.M. Resident #2's sheets and toilet were smeared with feces, and he had thrown up during the night before she arrived. STNA #330 stated she saw a watery emesis on the floor of his room but could not say what color it was. STNA #330 indicated Resident #2 did not eat breakfast, lunch or dinner on this date and kept asking for TUMS (antacid), saying he did not feel well. STNA #330 stated Resident #2's stomach was bloated. STNA #330 stated she told RN #304 Resident #2's stomach was hurting and he wanted TUMS. STNA #330 indicated she worked day shift on 01/24/23 and Resident #2 refused to get out of bed, wanted the door closed and the room light turned off. STNA #330 stated Resident #2 kept asking for ice water, which was unusual for him, and he only drank fluids offered to him during the day. STNA #330 stated she saw a big splotch of dark, watery, dried emesis at the head of his bed, and the emesis was also splattered under his bed and dresser.
On 01/26/23 at 12:00 P.M. interview with the DON revealed on 01/23/23 in the afternoon Resident #2 had an unwitnessed fall and she was notified his blood pressure was 81/50. The DON stated she would expect the nurses to look at Resident #2's history of blood pressures and initiate some orthostatic blood pressures throughout the day. The DON stated Resident #2 had low blood pressures in the past, but he also had a fall, and she would expect to see the blood pressure taken again in an hour. The DON stated she did not know if Resident #2's blood pressure was rechecked. The DON revealed according to the fall protocol the follow up assessments including blood pressure were completed every twelve hours for three days, but this was not done for Resident #2. The DON indicated Resident #2's blood pressure should have been checked more often, and his blood pressure medication held if it was low. The DON stated NP #324 came to the facility every Monday morning and did not come back after that to evaluate residents.
On 01/26/23 at 4:00 P.M. telephone interview with Resident #2 revealed he was still a patient at the local hospital. Resident #2 stated he felt so much better now and felt really sick while he was at the facility. Resident #2 stated he requested to be transported to the Emergency Department because he felt so ill. Resident #2 indicated he had two surgeries since he was admitted , one to place a sensor in his wrist to monitor his blood pressure (arterial line), and the second surgery was on his abdomen. Resident #2 stated while at the facility he could not eat, was throwing up, and he felt very ill. Resident #2 stated he had two falls, and he was so weak he could not assist staff when they were helping him off the floor. Resident #2 indicated he told the nurses and aides he felt really sick, but no one was paying attention to him because they were too busy fighting with each other over who was going to do the work that needed done. Resident #2 stated he was just going to ride it out. Resident #2 stated the staff had bad attitudes and at shift change it could be anywhere from one and half to four hours before his call light was answered. Resident #2 indicated his appetite was really poor, he could not eat and thought if he drank coca cola it would soothe his upset stomach and also put something in his stomach.
On 01/30/23 at 6:00 P.M. telephone interview with Medical Director (MD) #326 revealed he did not have access to a computer with Resident #2's information prior to calling and could not comment on specific details. Discussion following the statement made by MD #326 revealed MD #326 felt a blood pressure of 81/50 would not always be a reason to be concerned and it would depend on the circumstances. MD #326 stated Resident #2 had heart failure and there were reasons to keep a resident on a beta blocker (Metoprolol) in face of heart failure. When told the surveyor was unable to find heart failure documented in Resident #2's record, MD #326 stated the DON told him Resident #2 had heart failure. MD #326 stated he could not check Resident #2's record to confirm heart failure as a diagnosis for the resident at that time. MD #326 indicated since Resident #2 had a fall ten minutes after his blood pressure was 81/50 his condition needed explored further. MD #326 stated the blood pressure of 81/50 could have been an early sign of sepsis. MD #326 stated Resident #2's blood pressure should have been rechecked and the nurses should have assessed his blood pressure on a routine basis. MD #326 indicated Resident #2's blood pressure could have been checked hourly or every four hours. MD #326 stated he was not happy with the situation, there were gaps in the notes that could not be accounted for, and when Resident #2's blood pressure was 81/50 things should have been escalated. MD #326 stated they were all taking the situation seriously.
On 01/31/23 at 1:28 P.M. interview with the DON revealed she could not find documentation in Resident #2's medical record reflecting a diagnosis of heart failure. The DON stated she had staff from Medical Records check Resident #2's medical record and they could not find documentation related to heart failure. The DON denied reporting the resident had a dia[TRUNCATED]
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, record review, facility policy and procedure review and interview, the facility failed to ensure intervent...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, facility policy and procedure review and interview, the facility failed to ensure interventions were implemented to prevent and timely identify the development of pressure ulcers and/or to ensure adequate treatments were in place to promote healing. This affected two residents (#25 and #40) of three residents reviewed for pressure ulcers. The facility census was 54.
Actual Harm occurred on 12/06/22 when Resident #40, who required extensive assistance from two staff for bed mobility, developed a new, in-house acquired deep tissue injury to the sacrum without evidence of adequate preventative interventions including turning and repositioning. The facility failed to identify the pressure ulcer prior to it being identified as a deep tissue injury.
Actual Harm occurred on 01/10/23 when Resident #25, who required extensive assistance from one staff member for bed mobility, developed a red, blanchable area to her right buttock and the area was not further evaluated until 01/24/23 when the right buttock was identified as having a new unstageable (full thickness tissue loss in which the actual depth of the ulcer is completely obscured by slough [yellow, tan, gray, green or brown] and/or eschar [tan, brown or black] in the wound bed) pressure injury.
Findings include:
1. Review of Resident #40's medical record revealed an admission date of 02/10/21 with diagnoses including acute and chronic respiratory failure with hypoxia, schizophrenia, and type two diabetes mellitus without complications.
Review of Resident #40's Braden Scale for Predicting Pressure Sore Risk dated 08/11/22, revealed Resident #40 was at a moderate risk for developing a pressure ulcer, injury.
Review of Resident #40's medical record including State Tested Nursing Assistant (STNA) charting dated 11/01/22 through 12/06/22, revealed the charting lacked evidence turning and repositioning was completed.
Review of Resident #40's Braden Scale for Predicting Pressure Sore Risk dated 12/06/22, revealed Resident #40 was assessed to be at a high risk for developing a pressure ulcer, injury.
Review of Resident #40's Skin and Wound Evaluation dated 12/06/22, revealed Resident #40 had a new pressure injury, a suspected deep tissue injury to the sacrum. Measurements were a length of 1.75 centimeters (cm), width of 0.84 cm, and depth unable to be determined.
Review of Resident #40's Surgical Wound Care Services Notes dated 12/06/22, revealed Resident #40 had a new, deep tissue injury to the sacrum. The wound was non blanchable and had purple discoloration.
Review of Resident #40's physician's orders, dated 12/06/22 revealed orders to turn and reposition Resident #40 every two hours.
Review of Resident #40's annual Minimum Data Set (MDS) 3.0 assessment, dated 12/19/22, revealed Resident #40 was cognitively intact. Resident #2 required extensive assistance of two staff members for bed mobility and toilet use. Resident #2 had total dependence of two staff for transfers and was always incontinent of urine and bowel. Resident #2 had an unstageable pressure ulcer presenting as a deep tissue injury, not present on admission.
Review of Resident #40's care plan dated, 01/06/23 included Resident #40 was at risk for pressure ulcers related to type two diabetes mellitus, history of pressure ulcers and impaired mobility. The care plan reflected Resident #40 had a sacral pressure ulcer identified 12/06/22. The goal developed was for Resident #40 to have no area of skin impairment through the review date. Interventions included to turn and reposition Resident #40 every two hours and as needed; pressure relieving cushion to wheelchair; follow facility policies and protocols for the prevention and treatment of skin breakdown; inform the physician, nurse practitioner and family of any new area of skin breakdown; monitor, document and report any changes in skin status; low air loss (LAL) mattress to bed, check function every shift and as needed.
Observation on 01/23/23 at 8:00 A.M. and 9:42 A.M. of Resident #40 revealed she was lying on her back in bed with the head of the bed elevated about 30 degrees, and her knees elevated above her ankles. There was no observation of staff turning and repositioning Resident #40 or encouraging Resident #40 to turn and reposition during this time period.
Observation on 01/23/23 at 11:13 A.M. of Resident #40 revealed she was lying on her back in back in bed with the head of the bed elevated about 30 degrees, and her knees elevated above her ankles. State Tested Nursing Assistant (STNA) #330 walked in the room to provide incontinence care. STNA #330 stated it had been a busy morning, this was the first time she was in Resident #40's room today to provide care, and confirmed she had not turned and repositioned the resident (as ordered/care planned). Resident #40's incontinence brief was very wet, and Resident #40 stated it had not been changed since 4:00 A.M. STNA #330 provided incontinence care according to standards of practice and observation of Resident #40's sacrum revealed a wound approximately one inch by one half inch with a pink wound bed and small amounts of yellowish colored tissue, with a small amount of yellowish drainage. STNA #330 stated the wound was not getting better. STNA #330 left the room to find ET mix (Aquafor and stoma adhesive powder) to apply to the wound. While STNA #330 was out of the room Resident #40 stated staff did not turn her every two hours. STNA #330 found the ET mix, applied the ointment to Resident #40's sacrum, assisted Resident #40 to put on a flowered dress, and stated she was going to have another STNA assist with a mechanical lift to place Resident #40 in her padded wheelchair.
Observation on 01/23/23 at 4:19 P.M. of Resident #40 revealed she was sitting in a padded wheelchair in her room and State Tested Nursing Assistant's (STNA's) #303 and #338 were using a mechanical lift to assist Resident #40 into her bed. STNA #338 stated Resident #40 should have been put to bed before now, she had been in the padded wheelchair since 11:30 A.M. and that was a long time. Observation of Resident #40's sacrum revealed an open area approximately one inch by one half inch. The wound bed was pink with a small amount of yellowish tissue, and the wound was draining a small amount of yellow colored fluid. There was no dressing on the wound. The Director of Nursing (DON) walked in the room and confirmed Resident #40 had an open pressure ulcer on her sacrum, and stated dressings were not used on sacral areas because they became soiled easily. The DON stated the pressure ulcer was treated with ET mix (Aquaphor and stomahesive paste), and felt it worked very well to heal pressure ulcers.
Observation on 01/24/23 at 12:12 P.M. of Wound Nurse Practitioner (WNP) #325 treating Resident #40's sacral pressure ulcer revealed a sacral wound with a pink wound bed and small amount of yellow tissue. The wound was draining a small amount yellowish fluid and the wound was approximately one inch by one half inch. WNP #325 indicated a foam dressing was not used for the sacral pressure ulcer because it would become soiled and deteriorate. WNP #325 stated ET mix was to be used three times a day and as needed and worked very well to protect and heal the wound. WNP #325 indicated she believed Resident #40's wound was improving and looked a lot better today.
Interview on 01/24/23 at 12:25 P.M. with DON revealed she recently became the Wound Nurse because Wound Nurse #332 resigned her position last week. The DON confirmed Resident #40 developed a new deep tissue injury, first identified on 12/06/22. The DON stated she was given the resident's wound information but did not have all the progress notes from WNP #325 and would have WNP #325 send the missing wound notes.
Review of Resident #40's Surgical Wound Care Services note, dated 01/24/23 revealed Resident #40's unstageable pressure ulcer to the sacrum was improved with a scant amount of serosanguinous drainage. The wound bed had slough and pink tissue.
Review of Resident #40's Skin and Wound Evaluation dated, 01/24/23 included Resident #40 had an in-house acquired unstageable pressure ulcer to the sacrum identified on 12/06/22. Measurements were length 1.5 cm, width 0.8 cm, and the depth was unable to be determined.
Review of the facility policy titled Pressure Injury Prevention and Management, dated 01/01/21, included evidence-based interventions for prevention would be implemented for all residents who were assessed at risk or who have a pressure injury present. Basic or routine care interventions could include but were not limited to redistribute pressure such as repositioning, protecting and or offloading heals etcetera, minimize exposure to moisture and keep skin clean, especially of fecal contamination.
2. Review of Resident #25's medical record revealed an admission date of 06/10/22 with diagnoses including multiple sclerosis, chronic kidney disease and polyneuropathy.
Review of Resident #25's Braden Scale for Predicting Pressure Sore Risk dated 08/11/22, revealed Resident #25 was at moderate risk for developing a pressure injury.
Review of Resident #25's Braden Scale for Predicting Pressure Sore Risk dated 11/28/22, revealed Resident #25 was at high risk for developing a pressure injury.
Review of Resident #25's physician's orders, dated 12/06/22, revealed to turn and reposition Resident #25 every two hours.
Review of Resident #25's quarterly MDS 3.0 assessment, dated 12/22/22 revealed Resident #25 was cognitively intact. Resident #25 required extensive assistance of one staff member for bed mobility, total dependence of two staff members for transfers, and total dependence of one staff member for toilet use. Resident #25 was always incontinent of urine and bowel.
Review of Resident #25's Skin assessment dated , 01/09/23 revealed her right buttock had a reddened area.
Review of Resident #25's physician's orders dated 01/10/23, revealed orders to apply Calmoseptine ointment (skin protective ointment) to right buttock every shift and as needed after incontinence episodes.
Review of Resident #25's Skin assessment dated [DATE] did not include any documentation regarding Resident #25's right buttock.
Review of Resident #25's Surgical Wound Care Services notes, dated 01/17/23 revealed no documentation of a right buttock wound.
Review of Resident #25's care plan dated, revised 01/17/23, revealed Resident #25 had impaired skin integrity in the form of moisture associated skin dermatitis (MASD) related to moisture associated skin damage to the left buttock. The goal developed was for the MASD to heal without becoming infected. Interventions included to observe area for increased redness, drainage, edema, and notify the physician as needed; skin assessments weekly and as needed; turn and reposition every two hours; use care when moving resident to prevent friction and shear as much as possible and as much as the resident can/will allow.
Review of Resident #25's medical record including State Tested Nursing Assistant charting dated 12/01/22 through 01/24/23, revealed the charting lacked evidence turning and repositioning was completed every two hours, every shift.
Observation on 01/23/23 at 9:44 A.M. revealed STNA #322 and STNA #330 used a mechanical lift to transfer Resident #25 from her bed to a padded wheelchair.
Observation on 01/23/23 at 10:27 A.M. revealed Resident #25 was sitting in a padded wheelchair in her room. At the time of the observation, interview with Resident #25 revealed she had a sore on her bottom, it did not hurt, but she knew it was there. Observation revealed there was not a low air mattress (LAL) mattress on Resident #25's bed.
Observation on 01/23/23 at 11:00 A.M. revealed Resident #25 was sitting in a padded wheelchair in her room.
Observation on 01/23/23 at 2:10 P.M. and 3:15 P.M. and 4:43 P.M. revealed Resident #25 sitting in padded wheelchair in the activity room. There were no observations of staff asking Resident #25 if she needed to reposition in the wheelchair or asking her if she wanted to lay down in her bed. Resident #25 had been observed sitting in the wheelchair since 9:30 A.M.
Observation on 01/23/23 at 5:05 P.M. revealed STNA #317 was pushing Resident #25 who was still in her wheelchair to her room. STNA #317 stated she would not put Resident #25 back in bed until after her dinner. When STNA #317 was told Resident #25 had been in the wheelchair since 9:30 A.M. she changed her mind and found another STNA to assist her with the mechanical lift to put Resident #25 back in bed. STNA #317 stated the reason Resident #25 was in her wheelchair for such a long time was because a few of the mechanical lift batteries did not charge properly. STNA #317 stated only a couple batteries charged when placed on the battery charger and it made it kind of cutthroat, because the aides had to wait to use the mechanical lifts. Observation of Resident #25's incontinence care revealed Resident #25's pants and back of her shirt were soaked with urine, her incontinence brief was soaked with urine and a wound was noted on her right buttock. The wound was approximately a three-inch circle, was at the crease of Resident #25's buttock and posterior upper thigh, and the wound bed was pink with yellow spots and couple black areas. After surveyor intervention, Registered Nurse (RN) #304 walked in Resident #25's room and confirmed the presence of the wound on Resident #25's buttock and posterior upper thigh
Observation on 01/24/23 at 12:19 P.M. with Wound Nurse Practitioner #325 and the DON of Resident #25 revealed Resident #25 was sitting in a padded wheelchair in her room. WNP #325 proceeded to evaluate Resident #25's right and left foot wounds (right medial foot venous ulcer, healed 01/24/23 and left foot venous ulcer , healed 01/24/23) and was getting ready to leave the room because she was finished. WNP #325 and the DON stated Resident #25 did not have any other wounds to evaluate and were told by the surveyor Resident #25 had a right buttock wound. After surveyor intervention Resident #25 was placed in bed using a mechanical lift and WNP #325 and the DON confirmed she did have a right buttock wound. Resident #25's incontinence brief was very wet and she had a moderate size brown, formed bowel movement. WNP #325 stated Resident #25 had a new unstageable pressure ulcer to her right buttock. WNP #325 told the DON, therapy should evaluate Resident #25's padded wheelchair and cushion, and Resident #25 needed a low air loss (LAL) mattress. WNP #325 further stated it was important to reposition Resident #25 and the standard of care was to turn and reposition every two hours, and also ordered ET mix to treat the wound every eight hours and as needed. The DON stated she recently became the Wound Nurse because the wound nurse no longer worked at the facility and no one told her Resident #25 had a wound to her right buttock.
Review of Resident #25's physician's orders dated, 01/24/23 and 01/25/23, revealed orders to clean Resident #25's right ischium with soap and water, and apply ET mix to open area three times a day and as needed after incontinent episodes. Orders included a LAL mattress with perimeter, check function each shift, and a daily skin assessment.
Interview on 01/25/23 at 11:30 A.M. with the DON revealed on 01/10/23 Licensed Practical Nurse (LPN) #331 documented Resident #25 had a red, blanchable area on her right buttock and started a treatment with Calmoseptine ointment, but did not notify anyone of the area from 01/10/23 through 01/24/23.
Review of Resident #25's Surgical Wound Care Services note, dated 01/24/23 revealed Resident #25 had a new unstageable pressure ulcer to her right buttock. The wound bed had slough, necrotic and pink tissue with serosanguinous drainage.
Review of Resident #25's Skin and Wound Assessment, dated 01/24/23 revealed Resident #25 had an in-house acquired, unstageable pressure ulcer to her right ischial tuberosity. Measurements were length 1.3 cm, width 3.67 cm, and depth was 0.1 cm.
Review of Resident #25's Braden Scale For Predicting Pressure Sore Risk, dated 01/25/23 revealed Resident #25 was at high risk for developing a pressure injury.
Review of the facility policy titled Pressure Injury Prevention and Management, dated 01/01/21, included evidence-based interventions for prevention will be implemented for all residents who were assessed at risk or who have a pressure injury present. Basic or routine care interventions could include but are not limited to redistribute pressure such as repositioning, protecting and or offloading heals etcetera, minimize exposure to moisture and keep skin clean, especially of fecal contamination.
This deficiency represents non-compliance investigated under Complaint Number OH00137120.
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 timely assess and treat Resident #40's skin impairmen...
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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 timely assess and treat Resident #40's skin impairment to the anterior upper thigh. This affected one resident (Resident #40) of three residents reviewed for skin impairments.
Findings include:
Review of Resident #40's medical record revealed an admission date of 02/10/21 and diagnoses included acute and chronic respiratory failure with hypoxia, schizophrenia, and type two diabetes mellitus without complications.
Review of Resident #40's Annual Minimum Data Set (MDS) 3.0 assessment dated [DATE], revealed Resident #40 was cognitively intact. Resident #2 required extensive assistance of two staff members for bed mobility and toilet use. Resident #2 had total dependence of two staff for transfers and was always incontinent of urine and bowel.
Review of Resident #40's care plan dated 01/06/23 revealed Resident #40 was at risk for pressure ulcers related to type two diabetes mellitus, history of pressure ulcers and impaired mobility. Resident #40 would have no area of skin impairment through the review date. Interventions included to turn and reposition Resident #40 every two hours and as needed; follow facility policies and protocols for the prevention and treatment of skin breakdown; inform the physician, nurse practitioner and family of any new area of skin breakdown; monitor, document and report any changes in skin status.
Review of Resident #40's aide charting in the electronic medical record (EMR) for Skin Observation dated 01/12/23 at 10:30 P.M. revealed State Tested Nursing Assistant (STNA) #303 charted Resident #40 had a reddened skin area. The charting did not specify where the reddened skin area was.
Review of Resident #40's medical record including assessments and progress notes, dated 01/12/23, did not reveal documentation Resident #40 had a new reddened skin area.
Observation on 01/23/23 at 11:13 A.M. of Resident #40 revealed she was lying on her back in back in bed, the head of the bed was elevated about 30 degrees, and her knees were elevated above her ankles. State Tested Nursing Assistant (STNA) #330 walked in the room to provide incontinence care. STNA #330 stated it had been a busy morning and this was the first time she was in Resident #40's room today to provide care, and confirmed she had not turned and repositioned her. Resident #40's incontinence brief was very wet, and Resident #40 stated it had not been changed since 4:00 A.M. Observation of Resident #40's thighs after her incontinence brief was removed revealed a dark red mark on her upper right thigh approximately six inches long and a half inch wide. The red mark blanched very slowly, and Resident #40 stated the red area was painful. STNA #330 stated the incontinence brief caused the red mark on Resident #40's upper thigh. STNA #330 provided incontinence care according to standards of practice and observation of Resident #40's sacrum revealed a wound approximately one inch by one half inch, wound bed pink and small amounts of yellowish colored tissue, with a small amount of yellowish drainage. STNA #330 stated the wound was not getting better. STNA #330 left the room to find ET mix (Aquafor and stoma adhesive powder) to apply to the wound. While STNA #330 was out of the room Resident #40 stated staff did not turn her every two hours. STNA #330 found the ET mix, applied the ointment to Resident #40's sacrum, assisted Resident #40 to put on a flowered dress, and stated she was going to have another STNA assist with a mechanical lift to place Resident #40 in her padded wheelchair.
Observation on 01/23/23 at 4:19 P.M. of Resident #40 revealed she was sitting in a padded wheelchair in her room and State Tested Nursing Assistant's (STNA's) #303 and #338 were using a mechanical lift to assist Resident #40 into her bed. STNA #338 stated Resident #40 should have been put to bed before now, she had been in the padded wheelchair since 11:30 A.M. and that was a long time. The DON walked in the room and confirmed the presence of a six inch dark red mark on Resident #40's anterior thigh and stated it was caused from the incontinence brief. The DON confirmed the area blanched very slowly. The DON stated the STNA's should have told the nurse about the red mark on Resident #40's anterior thigh.
Interview on 01/23/23 at 5:38 P.M. with STNA #303 revealed the dark red mark on Resident #40's anterior thigh was there for several days, and the first day he noted it he told the nurse, but he could not remember which nurse he told. STNA #303 stated he charted it in the aide charting in the electronic medical record (EMR) every day he saw the red mark.
Interview on 01/23/23 at 5:40 P.M. with the DON revealed alerts for abnormal skin checks was in the electronic record but she had not checked the resident alerts today because she was very busy and didn't have time to review the alerts.
Observation on 01/24/23 at 12:12 P.M. with Wound Nurse Practitioner (WNP) #325 of Resident #40's right upper thigh reddened area revealed the area blanched and WNP #325 indicated the area was probably an abrasion from the incontinence brief.
Review of Resident #40's physician orders dated, 01/24/23, revealed cleanse right upper leg with wound cleanser, pat dry, and apply hydrocolloid every night shift every Tuesday, Thursday and as needed.
Review of Resident #40's Skin assessment dated [DATE], revealed Resident #40 had a new abnormal skin area noted. The assessment stated Resident #40 had a reddened area on her right upper leg.
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 interview, record review, review of customer service discipline and review of facility policy, the facility failed to e...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, review of customer service discipline and review of facility policy, the facility failed to ensure Resident #38 received proper shower assistance to prevent a fall while in the shower room. This affected one resident (Resident #38) out of three residents reviewed for falls. The facility census was 54.
Findings include:
Review of Resident #38's medical record revealed an admission date of 11/02/21 and diagnoses included enterocolitis due to clostridium difficile recurrent, hypertensive heart disease with heart failure, and bipolar disorder.
Review of Resident #38's Fall Risk Evaluation dated 11/02/21, revealed Resident #38 was at a high risk for falls.
Review of Resident #38's care plan dated 11/03/21, included Resident #38 required staff assistance with Activities of Daily Living (ADL) related to general weakness, impaired cognition. Resident #38 would improve current level of function in transfers, ambulation by review date. Interventions included Resident #38 required staff assistance with bath, shower times one assist.
Review of Resident #38's Annual Minimum Data Set (MDS) 3.0 assessment dated [DATE], revealed Resident #38 was cognitively intact. Resident #38 was independent with set-up help only for bed mobility, required limited assistance of one person for transfers and toilet use. Resident #38 required physical help in part of bathing activity and was a one person physical assist.
Review of Resident #38's Fall Risk Evaluation dated 01/16/23, revealed Resident #38 was at risk for falls and interventions were required.
Review of Resident #38's progress notes dated 01/22/2023 at 9:30 A.M. revealed Registered Nurse (RN) #316 was called to the shower room by an unidentified STNA. Resident #38 was observed sitting on buttocks on floor in shower. Resident #38 stated I bumped my head. Resident #38 was assessed and a small lump was felt at back of her head, occipital area. Neuro checks initiated and were without deficit. No other injury observed. Resident #38 had full range of motion to all extremities and denied pain with range of motion. Resident #38 was assisted up with three assist to shower chair. Shower completed. Resident #38 stated that she bent over in the chair to get her shampoo and slid out of chair. New intervention to assure all items were in resident reach in shower room. The nurse practitioner was notified, and a new order to send Resident #38 to the emergency room for CT (computerized tomography) scan due to anticoagulant therapy. Resident #38's POA (power of attorney) was notified. Resident #38 was transported to the local hospital Emergency Department by paramedics, and left the facility at 10:00 A.M.
Interview on 01/18/23 at 10:21 A.M. with Friend #334 revealed the aides left Resident #38 alone in the shower room and did not stay with her. Friend #334 stated Resident #38 was a fall risk. Friend #334 stated the aides did what they wanted to do and did not understand what being a fall risk meant.
Interview on 01/23/23 at 10:45 A.M. with Resident #38 revealed her tail bone hurt and she had a headache. Resident #38 stated yesterday (01/22/23) she was left in the shower room by herself. Resident #38 stated she was always left alone in the shower room. Resident #38 stated she fell out of the shower chair because the brakes were unlocked on the shower chair, and when she leaned over to retrieve her shampoo which had fallen the chair went out from underneath her. Resident #38 stated she hit her head and tailbone and was sent to the hospital Emergency Department.
Interview 01/23/23 at 1:53 with State Tested Nursing Assistant (STNA) #322 revealed on 01/22/23 she was assisting STNA #327 and offered to provide Resident #38's shower. STNA #322 stated Resident #38 gathered her bathroom items after breakfast and STNA #322 assisted her to the bathroom. STNA #322 stated it was chaotic after breakfast and she left Resident #38 alone in the shower room because Resident #38 told her she was alright to be alone. STNA #322 stated she kept checking on Resident #38 and Resident #38 stated she was OK. STNA #322 stated she told Resident #38 to activate the shower room call light if she needed anything and Resident #38 stated OK. STNA #322 indicated approximately ten minutes after she last checked on Resident #38 she heard STNA #334 ask where Resident #38 was, STNA #334 checked on Resident #38 and found her on the floor of the shower room. STNA #322 stated she immediately went to assist in the shower room and observed Resident #38, soaking wet, lying on the floor. STNA #322 indicated Resident #38 stated she bent over to get shampoo and went on the floor. STNA #322 stated she was panicking because she assisted Resident #38 to the shower room and left her alone. STNA #322 indicated RN #316 checked Resident #38 and after she was checked STNA #322 and RN #316 assisted Resident #38 off the floor and back into the shower chair. STNA #322 stated she felt so bad this happened and told Resident #38 she would not leave her alone in the shower room going forward. STNA #322 stated residents were not left alone in the shower room, but Resident #38 told her she was fine being alone. STNA #322 stated Resident #38 hit her head and when she washed Resident #38's hair she noticed a bump on the back of her head and said she had a headache. STNA #322 told RN #316 Resident #38 had a bump on the back of her head and had a headache, and Resident #38 was transported to the Emergency Department. STNA #322 stated the shower chair was locked while Resident #38 was in the shower room.
Review of a one to one In-service Record dated, 01/23/23, revealed STNA #322 was educated by the Director of Nursing (DON) for leaving a resident unattended in the shower. The education included STNA #322 would not leave residents unattended in the shower, and was signed by both the DON and STNA #322.
Interview on 01/24/23 at 8:25 A.M. with RN #316 revealed on 01/22/23, she was in the hall administering resident medications, Resident #38 was in the shower room, and RN #316 saw STNA #322 walk in and out of the shower room. RN #316 indicated another aide (STNA #334) walked down the hall and asked where Resident #38 was and was told Resident #38 was in the shower room. STNA #334 checked on Resident #38 in the shower room and found Resident #38 on the floor. RN #316 stated Resident #38 said she dropped her shampoo, reached down to retrieve it and fell out of the shower chair. RN #316 stated the wheels were locked on the wheelchair. RN #316 indicated Resident #38 bumped her head, and did not mention her tailbone hurt, but she told the hospital staff and had X-rays at the hospital. RN #316 stated Resident #38 was alone in the shower when the fall occurred. RN #316 stated Resident #38 was transported to the local hospital Emergency Department.
Review of the facility policy titled Fall Prevention Program, revised, 01/01/22, included each resident would be assessed for the risks of falling, and would receive care and services in accordance with the level of risk to minimize the likelihood of falls.
This deficiency represents non-compliance investigated under Complaint Number OH00138770.
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 F0757
(Tag F0757)
Could have caused harm · This affected 1 resident
Based on interview, record review and review of the facility policy, the facility failed to ensure Resident #2's blood pressure was appropriately monitored related to medication use for hypertension. ...
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Based on interview, record review and review of the facility policy, the facility failed to ensure Resident #2's blood pressure was appropriately monitored related to medication use for hypertension. This affected one resident (Resident #2) out of three residents reviewed for blood pressure monitoring. The facility census was 54.
Findings include:
Review of Resident #2's medical record revealed an admission date of 06/15/22 with diagnoses including malignant neoplasm of unspecified part of unspecified bronchus or lung, hypertension, chronic obstructive pulmonary disease, and type two diabetes mellitus.
Review of Resident #2's Fall Risk Evaluation, dated 06/15/22 revealed Resident #2 was at high risk for falls.
Review of Resident #2's blood pressures from 06/15/22 through 11/07/22 revealed a range from 90/50 through 158/73 with no specific frequency or orders for monitoring during this time period.
Review of Resident #2's physician medication orders, dated 06/16/22 revealed an order for Lisinopril 10 milligrams (mg), give one tablet by mouth in the morning for hypertension. The resident had an order, dated 09/15/22 for Metoprolol Tartrate tablet 50 mg, one tablet by mouth every morning and at bedtime for hypertension. Further review did not reveal any blood pressure parameters for the administration of the medications ordered to treat hypertension.
Review of Resident #2's progress note, dated 10/31/22 at 1:24 A.M., revealed Resident #2 had an unwitnessed fall, Resident #2 was found on the floor, in a sitting position next to his bed. Resident #2 stated he attempted to go to the bathroom, became weak and ended up on the floor. Record review revealed there were no vital signs including blood pressure documented when the fall occurred. Further review of the medical record did not reveal vital signs, including a blood pressure were taken on this date until 10/31/22 at 11:03 P.M.
Review of Resident #2's progress notes dated 11/07/22 at 7:16 A.M., revealed staff responded to a call light and Resident #2 stated he fell around midnight and turned on his call bell. Resident #2 stated he was attempting to go to the bathroom and fell. When staff responded the resident was back in bed.
Review of Resident #2's progress notes dated 11/07/22 at 7:24 A.M. revealed Resident #2's blood pressure was 74/44. Further review of Resident #2's medical record, including Medication Administration Record (MAR) revealed Metoprolol Tartrate 50 mg was administered on 11/07/22 in the morning between 7:00 A.M. and 10:00 A.M. and held on 11/07/22 at bedtime.
Review of Resident #2's progress noted dated 11/07/22 as a late entry note for 7:11 A.M., stated to hold Resident #2's morning administration of Metoprolol Tartrate 50 mg. There was no documentation Resident #2's physician was notified of the blood pressure of 74/44 and no order to hold Resident #2's Metoprolol. No further blood pressures were documented until 01/23/23 at 3:00 P.M.
Review of Resident #2's physician Encounter Note dated 11/09/22 and signed by Medical Director (MD) #326, included a box was checked next to the statement vital signs were checked and were stable unless noted. There was no mention of a blood pressure of 74/44 in the note.
Review of Resident #2's quarterly Minimum Data Set (MDS) 3.0 assessment, dated 11/21/22, revealed Resident #2 was cognitively intact. The assessment revealed Resident #2 was independent for activity of daily living care and required staff set-up help with bed mobility, transfers, and toilet use. The assessment revealed the resident was occasionally incontinent of urine and always continent of bowel.
Review of Resident #2's plan of care, dated 01/09/23 revealed a plan reflecting the resident had hypertension (HTN). The goal developed was for the resident to remain free of complications related to hypertension through review date. Interventions included to administer anti-hypertensive medications as ordered and monitor for side effects such as orthostatic hypotension and increased heart rate (Tachycardia) and effectiveness. The care plan did not specify if or how often Resident #2's blood pressure and pulse should be monitored. Resident #2 was also on Aspirin (ASA) therapy. The goal for this plan included Resident #2 would be free from discomfort or adverse reactions related to anticoagulant use through the next review date. Interventions included to monitor, document, report to the physician as needed adverse reactions such as nausea, vomiting, diarrhea, lethargy, bruising, loss of appetite, sudden changes in mental status, significant or sudden changes in vital signs. An additional plan of care revealed Resident #2 was at risk for return to the hospital related to comorbidities with a goal to have reduced risk to return to the hospital through related disease process and symptom management. Interventions included to notify the physician of changes in condition.
Review of Resident #2's progress note, dated 01/23/23 at 2:57 P.M. revealed Resident #2 complained of his blood pressure feeling low. The resident's blood pressure was checked and noted to be 80/51 (hypotensive) with a pulse rate of 59/minute. The note indicated Nurse Practitioner (NP) #324 was notified. The medical record did not identify the follow-up response from NP #324.
Review of Resident #2's progress note, dated 01/23/23 at 3:08 P.M. and 3:19 P.M. revealed staff assisted Resident #2 off the floor after he attempted to transfer, no injuries were noted and his vital signs included blood pressure 81/50 (hypotensive), pulse 59, respirations 18, temperature 98 degrees Fahrenheit, and oxygen saturation 94 percent on room air. The note revealed Resident #2 had refused breakfast and lunch. The DON, NP #324, and the resident's power of attorney (POA) were notified. The medical record did not identify any follow-up response from the parties notified.
Review of Resident #2's progress notes from 01/23/23 at 7:07 P.M. through 01/25/23 at 12:19 A.M. revealed no evidence of monitoring or follow-up documentation related to Resident #2's condition including blood pressure, abdomen and/or nausea/vomiting.
Review of Resident #2's Medication Administration Record (MAR) revealed on 01/23/23 at bedtime (between 8:00 P.M. and 11:00 P.M.) Resident #2 was administered Metoprolol Tartrate 50 mg. On 01/24/23 in the morning (between 7:00 A.M. and 10:00 A.M.) Resident #2 received Lisinopril 10 milligram (mg) and Metoprolol Tartrate 50 mg. Further review revealed he was administered Metoprolol Tartrate 50 mg on 01/24/23 at bedtime.
Review of Resident #2's blood pressure records, dated 01/23/23 through 01/25/23 revealed on 01/23/23 at 3:00 P.M. and 3:43 P.M. Resident #2's blood pressure was documented 81/50. On 01/24/23 at 4:36 A.M. Resident #2's blood pressure was 96/51 and on 01/25/23 his blood pressure was 67/38.
Review of Resident #2's progress note, dated 01/25/23 at 2:35 A.M. revealed Resident #2 had an unwitnessed fall and was found sitting on his buttocks next to his bed with no injury was noted. Resident #2 was very short of breath, oxygen was administered at three liters via nasal cannula, his blood pressure was taken three times and was 68/51, 78/43 and 67/38 with a heart rate ranging from 149 to 153 and respirations were 38. The nurse was unable to obtain an oxygen saturation. There was a small amount of emesis noted on the bed and Resident #2 complained of feeling dizzy. Per the resident's request at this time, a call was placed to 911 for Emergency Medical Services due to the resident's respiratory status and blood pressure. EMS arrived and transported Resident #2 to the local hospital Emergency Department.
On 01/25/23 at 10:45 A.M. interview with Registered Nurse (RN) #304 revealed on 01/23/23 Resident #2 had an emesis on the floor of his room and was incontinent of bowel (diarrhea). RN #304 stated there was feces on the toilet seat and bathroom floor, emesis on the floor of his room and Resident #2's room was not cleaned immediately. RN #304 stated she did not know what time Resident #2 had the emesis or was incontinent of diarrhea, but he was sitting in a wheelchair in his room around 3:00 P.M. while his room was being cleaned. RN #304 revealed Resident #2 told an unidentified State Tested Nursing Assistant (STNA) he thought his blood pressure was dropping, and the STNA had RN #304 come to the room. RN #304 took Resident #2's blood pressure, and it was 81/50 with a pulse of 59. RN #304 noticed Resident #2 was a little short of breath, did not have his oxygen on via nasal cannula, and put his oxygen back on him before she left the room. RN #304 left the room and immediately text Nurse Practitioner (NP) #324 to notify her Resident #2's blood pressure was 81/50. NP #324 text back OK, thanks but did not give RN #304 orders or instructions concerning the low blood pressure. Approximately ten minutes after his blood pressure was 81/50, Resident #2 had an unwitnessed fall and RN #304 text NP #324 again to notify her of Resident #2's fall. NP #324 text back thanks but did not give RN #304 orders or instructions for Resident #2. At around 5:00 P.M. Resident #2 had a brown, watery emesis, his blood sugar was 150 and he refused his insulin. RN #304 text NP #324 again to notify her. Resident #2 had another emesis around 7:00 P.M., NP #324 was notified via text and a laboratory testing, a stat CBC and BMP were ordered, but no questions, instructions or orders were given concerning Resident #2's low blood pressure or emesis. RN #304 stated it was a very busy day and she did not think she took Resident #2's blood pressure again. RN #304 stated she worked day shift on 01/24/23 and Resident #2 stated he felt better, but his abdomen was bloated. RN #304 stated Resident #2's blood pressure on night shift was 96/51, taken while he was lying in bed. RN #304 indicated she administered Resident #2's blood pressure medications (Metoprolol Tartrate 50 mg and Lisinopril 10 mg) on 01/24/23 and did not check his blood pressure. RN #304 stated NP #324 was notified of the results of the stat bloodwork drawn (CBC and BMP), which were a little bit off. No further orders were given.
On 01/25/23 at 5:41 P.M. interview with NP #324 revealed she was informed Resident #2's blood pressure was 81/50 and was not concerned. NP #324 stated Resident #2's blood pressure goes up and down and it was not unusual for him to have a low blood pressure and he also had heart failure. When asked if NP #324 would expect the blood pressure to be checked again she stated the blood pressure should have been checked per the fall protocol but did not know what the facility fall protocol was. NP #324 confirmed she did not ask for Resident #2's blood pressure to be rechecked or ask any questions regarding the low blood pressure or emesis. NP #324 indicated she was not aware Resident #2 had an emesis. NP #324 revealed she asked for stat bloodwork to be drawn (CBC and BMP). When asked if Resident #2's Metoprolol Tartrate 50 mg and Lisinopril should have been held NP #324 stated the nurses were supposed to call if the systolic blood pressure was less than 100. NP #324 stated nurses did not need an order to take a blood pressure.
On 01/26/23 at 12:00 P.M. interview with the DON revealed on 01/23/23 in the afternoon Resident #2 had an unwitnessed fall and she was notified his blood pressure was 81/50. The DON stated she would expect the nurses to look at Resident #2's history of blood pressures and initiate some orthostatic blood pressures throughout the day. The DON stated Resident #2 had low blood pressures in the past, but he also had a fall, and she would expect to see the blood pressure taken again in an hour. The DON stated she did not know if Resident #2's blood pressure was rechecked. The DON revealed according to the fall protocol the follow up assessments including blood pressure were completed every twelve hours for three days, but this was not done for Resident #2. The DON indicated Resident #2's blood pressure should have been checked more often, and his blood pressure medication held if it was low. The DON stated NP #324 came to the facility every Monday morning and did not come back after that to evaluate residents.
On 01/26/23 at 4:00 P.M. telephone interview with Resident #2 revealed he was still a patient at the local hospital. Resident #2 stated he felt so much better now and felt really sick while he was at the facility. Resident #2 stated he requested to be transported to the Emergency Department because he felt so ill. Resident #2 indicated he had two surgeries since he was admitted , one to place a sensor in his wrist to monitor his blood pressure (arterial line), and the second surgery was on his abdomen. Resident #2 stated while at the facility he could not eat, was throwing up, and he felt very ill. Resident #2 stated he had two falls, and he was so weak he could not assist staff when they were helping him off the floor. Resident #2 indicated he told the nurses and aides he felt really sick, but no one was paying attention to him because they were too busy fighting with each other over who was going to do the work that needed done. Resident #2 stated he was just going to ride it out. Resident #2 stated the staff had bad attitudes and at shift change it could be anywhere from one and half to four hours before his call light was answered. Resident #2 indicated his appetite was really poor, he could not eat and thought if he drank coca cola it would soothe his upset stomach and also put something in his stomach.
On 01/30/23 at 6:00 P.M. telephone interview with Medical Director (MD) #326 revealed he did not have access to a computer with Resident #2's information prior to calling and could not comment on specific details. Discussion following the statement made by MD #326 revealed MD #326 felt a blood pressure of 81/50 would not always be a reason to be concerned and it would depend on the circumstances. MD #326 stated Resident #2 had heart failure and there were reasons to keep a resident on a beta blocker (Metoprolol) in face of heart failure. When told the surveyor was unable to find heart failure documented in Resident #2's record, MD #326 stated the DON told him Resident #2 had heart failure. MD #326 stated he could not check Resident #2's record to confirm heart failure as a diagnosis for the resident at that time. MD #326 indicated since Resident #2 had a fall ten minutes after his blood pressure was 81/50 his condition needed explored further. MD #326 stated the blood pressure of 81/50 could have been an early sign of sepsis. MD #326 stated Resident #2's blood pressure should have been rechecked and the nurses should have assessed his blood pressure on a routine basis. MD #326 indicated Resident #2's blood pressure could have been checked hourly or every four hours. MD #326 stated he was not happy with the situation, there were gaps in the notes that could not be accounted for, and when Resident #2's blood pressure was 81/50 things should have been escalated. MD #326 stated they were all taking the situation seriously.
Interview on 01/31/23 at 1:00 P.M. with the DON confirmed Resident #2's documentation on 11/07/22 did not have evidence the physician was notified of Resident #2's blood pressure of 74/44 or evidence of a physician order to hold the Metoprolol. The DON stated it happened too long ago and she did not remember the incident.
On 01/31/23 at 1:28 P.M. interview with the DON revealed she could not find documentation in Resident #2's medical record reflecting a diagnosis of heart failure. The DON stated she had staff from Medical Records check Resident #2's medical record and they could not find documentation related to heart failure. The DON denied reporting the resident had a diagnosis of heart failure to MD #326.
Review of the manufacturer's recommendations titled Metoprolol dated, 07/01/22, included Metoprolol was contraindicated in patients with a systolic blood pressure < 100 mmHg.
Review of facility policy titled Medication Administration, revised, 01/01/22, included medications were administered by licensed nurses, or other staff who were legally authorized to do so, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. Obtain and record vital signs, when applicable or per physician orders. When applicable, hold medication for those vital signs outside the physician's prescribed parameters. Report and document any adverse side effects or refusals.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected multiple residents
**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 incontinence car...
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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 incontinence care for Resident's #25, #37 and #40 was provided timely, and failed to assist Resident #1 with ambulation per care planned interventions. This affected four residents (Resident #1, #25, #37 and #40) out of five residents reviewed for residents needing staff assistance with care. The facility census was 54.
Findings include:
1. Review of Resident #40's medical record revealed an admission date of 02/10/21 and diagnoses included acute and chronic respiratory failure with hypoxia, schizophrenia, and type two diabetes mellitus without complications.
Review of Resident #40's Annual Minimum Data Set (MDS) 3.0 assessment dated [DATE], revealed Resident #40 was cognitively intact. Resident #2 required extensive assistance of two staff members for bed mobility and toilet use. Resident #2 had total dependence of two staff for transfers and was always incontinent of urine and bowel.
Review of Resident #40's care plan dated 01/06/23 revealed Resident #40 was at risk for pressure ulcers related to type two diabetes mellitus, history of pressure ulcers and impaired mobility. Resident #40 would have no area of skin impairment through the review date. Interventions included to turn and reposition Resident #40 every two hours and as needed; follow facility policies and protocols for the prevention and treatment of skin breakdown; inform the physician, nurse practitioner and family of any new area of skin breakdown; monitor, document and report any changes in skin status.
Review of Resident #40's aide charting in the electronic medical record (EMR) for Skin Observation dated 01/12/23 at 10:30 P.M. revealed State Tested Nursing Assistant (STNA) #303 charted Resident #40 had a reddened skin area. The charting did not specify where the reddened skin area was.
Review of Resident #40's medical record including assessments and progress notes, dated, 01/12/23, did not reveal documentation Resident #40 had a new reddened skin area.
Observation on 01/23/23 at 11:13 A.M. of Resident #40 revealed she was lying on her back in back in bed, the head of the bed was elevated about 30 degrees, and her knees were elevated above her ankles. State Tested Nursing Assistant (STNA) #330 walked in the room to provide incontinence care. STNA #330 stated it had been a busy morning and this was the first time she was in Resident #40's room today to provide care, and confirmed she had not turned and repositioned her. Resident #40's incontinence brief was very wet, and Resident #40 stated it had not been changed since 4:00 A.M. Observation of Resident #40's thighs after her incontinence brief was removed revealed a dark red mark on her upper right thigh approximately six inches long and a half inch wide. The red mark blanched very slowly, and Resident #40 stated the red area was painful. STNA #330 stated the incontinence brief caused the red mark on Resident #40's upper thigh. STNA #330 provided incontinence care according to standards of practice and observation of Resident #40's sacrum revealed a wound approximately one inch by one half inch, wound bed pink and small amounts of yellowish colored tissue, with a small amount of yellowish drainage. STNA #330 stated the wound was not getting better. STNA #330 left the room to find ET mix (aquafor and stoma adhesive powder) to apply to the wound. While STNA #330 was out of the room Resident #40 stated staff did not turn her every two hours. STNA #330 found the ET mix, applied the ointment to Resident #40's sacrum, assisted Resident #40 to put on a flowered dress, and stated she was going to have another STNA assist with a mechanical lift to place Resident #40 in her padded wheelchair.
Observation on 01/23/23 at 4:19 P.M. of Resident #40 revealed she was sitting in a padded wheelchair in her room and State Tested Nursing Assistant's (STNA's) #303 and #338 were using a mechanical lift to assist Resident #40 into her bed. STNA #338 stated Resident #40 should have been put to bed before now, she had been in the padded wheelchair since 11:30 A.M. and that was a long time. Observation of Resident #40's sacrum revealed an open area approximately one inch by one half inch. The wound bed was pink with a small amount of yellowish tissue, and the wound was draining a small amount of yellow colored fluid. There was no dressing on the wound. The DON walked in the room and confirmed Resident #40 had an open pressure ulcer on her sacrum, and stated dressings were not used on sacral areas because they became soiled easily. The DON stated the pressure ulcer was treated with ET mix (Aquaphor and stomahesive paste), and it worked very well to heal pressure ulcers. The DON confirmed the presence of a six inch dark red mark on Resident #40's anterior thigh and stated it was caused from the incontinence brief. The DON confirmed the area blanched very slowly. The DON stated the STNA's should have told the nurse about the red mark on Resident #40's anterior thigh.
Interview on 01/23/23 at 5:38 P.M. with STNA #303 revealed the dark red mark on Resident #40's anterior thigh was there for several days, and the first day he noted it he told the nurse, but he could not remember which nurse he told. STNA #303 stated he charted it in the aide charting in the electronic medical record (EMR) every day he saw the red mark.
Interview on 01/23/23 at 5:40 P.M. with the DON revealed alerts for abnormal skin checks was in the electronic record but she had not checked the resident alerts today because she was very busy and didn't have time to review the alerts.
Observation on 01/24/23 at 12:12 P.M. of Wound Nurse Practitioner (WNP) #325 treating Resident #40's sacral pressure ulcer revealed a sacral wound, the wound bed was pink, with a small amount of yellow tissue. The wound was draining a small amount yellowish fluid and the wound was approximately one inch by one half inch. WNP #325 indicated a foam dressing was not used for the sacral pressure ulcer because it would become soiled and deteriorate. Observation of Resident #40's right upper thigh reddened area with WNP #325 revealed the area blanched and was probably an abrasion from the incontinence brief.
Review of Resident #40's physician orders dated, 01/24/23, revealed cleanse right upper leg with wound cleanser, pat dry, and apply hydrocolloid every night shift every Tuesday, Thursday and as needed.
Review of Resident #40's Skin assessment dated [DATE], revealed Resident #40 had a new abnormal skin area noted. The assessment stated Resident #40 had a reddened area on her right upper leg.
Review of facility policy titled Incontinence, revised, 01/01/22, revealed based on the resident's comprehensive assessment, all residents that were incontinent would receive appropriate treatment and services. Resident that were incontinent of bladder or bowel would receive appropriate treatment to prevent infections.
2. Review of Resident #25's medical record revealed an admission date of 06/10/22 and diagnoses included multiple sclerosis, chronic kidney disease and polyneuropathy.
Review of Resident #25's Quarterly MDS 3.0 assessment dated , 12/22/22, revealed Resident #25 was cognitively intact. Resident #25 required extensive assistance of one staff member for bed mobility, total dependence of two staff members for transfers, and total dependence of one staff member for toilet use. Resident #25 was always incontinent of urine and bowel.
Review of Resident #25's orders dated 01/10/23, revealed orders to apply calmoseptine ointment to right buttock every shift and as needed after incontinence episodes.
Review of Resident #25's care plan dated, revised 01/17/23, included Resident #25 had impaired skin integrity in the form of moisture associated skin dermatitis related to moisture associated skin damage (MASD) to the left buttock. MASD would heal without becoming infected. Interventions to observe area for increased redness, drainage, edema, and notify the physician as needed; skin assessments weekly and as needed; turn and reposition every two hours; use care when moving resident to prevent friction and shear as much as possible and as much as the resident can/will allow.
Observation on 01/23/23 at 9:44 A.M. revealed State Tested Nursing Assistant's (STNA's) #322 and #330 used a mechanical lift to transfer Resident #25 from her bed to a padded wheelchair.
Observation on 01/23/23 at 10:27 A.M. revealed Resident #25 was sitting in a padded wheelchair in her room.
Observation on 01/23/23 at 11:00 A.M. of Resident #25 sitting in a padded wheelchair in her room.
Observation on 01/23/23 at 2:10 P.M. and 3:15 P.M. and 4:43 P.M. of Resident #25 sitting in padded wheelchair in the activity room. There were no observations of staff asking Resident #25 if she needed to reposition in the wheelchair or asking her if she wanted to lay down in her bed. Resident #25 was observed sitting in the wheelchair since 9:30 A.M.
Observation on 01/23/23 at 5:05 P.M. of Resident #25 revealed STNA #317 pushing Resident #25 who was still in her wheelchair to her room. STNA #317 stated she would not put Resident #25 back in bed until after her dinner. When STNA #317 was told Resident #25 had been in the wheelchair since 9:30 A.M. she changed her mind and found another STNA to assist her with the mechanical lift to put Resident #25 back in bed. Resident #25's pants and back of her shirt were soaked with urine, her incontinence brief was soaked with urine and a wound was noted on her right buttock. The wound was approximately a three inch circle, was at the crease of Resident #25's buttock and posterior upper thigh, and the wound bed was pink with yellow spots and couple black areas. After surveyor intervention Registered Nurse (RN) #304 walked in Resident #25's room and confirmed the presence of the wound on Resident #25's buttock and posterior upper thigh.
Observation on 01/24/23 at 12:19 P.M. with Wound Nurse Practitioner #325 and the Director of Nursing (DON) of Resident #25 revealed Resident #25 was sitting in a padded wheelchair in her room. WNP #325 proceeded to evaluated Resident #25's right and left foot wounds and was getting ready to leave the room because she was finished. WNP #325 and the DON stated Resident #25 did not have any other wounds to evaluate and were told Resident #25 had a right buttock wound. After surveyor intervention Resident #25 was placed in bed using a mechanical lift and WNP #325 and the DON confirmed she did have a right buttock wound. Resident #25's incontinence brief was very wet and she had a moderate size brown, formed bowel movement. WNP #325 stated Resident #25 had a new unstageable pressure ulcer to her right buttock. WNP #325 told the DON therapy should evaluate Resident #25's padded wheelchair and cushion, and Resident #25 needed a low air loss (LAL) mattress. WNP #325 further stated it was important to reposition Resident #25 and the standard of care was to turn and reposition every two hours, and also ordered ET mix to treat the wound every eight hours and as needed. The DON stated she recently became the Wound Nurse because the wound nurse no longer worked at the facility and no one told her Resident #25 had a wound to her right buttock.
Review of Resident #25's orders dated 01/24/23 and 01/25/23, revealed orders to clean Resident #25's right ischium with soap and water, and apply ET mix to open area three times a day and as needed after incontinent episodes. Orders included a LAL mattress with perimeter, check function each shift, and a daily skin assessment.
Review of facility policy titled Incontinence, revised, 01/01/22, included based on the resident's comprehensive assessment, all residents that were incontinent would receive appropriate treatment and services. Resident that were incontinent of bladder or bowel would receive appropriate treatment to prevent infections.
3. Review of Resident #37's medical record revealed an admission date of 10/11/22 and diagnoses included type two diabetes mellitus with diabetic nephropathy, congestive heart failure, obesity and schizoaffective disorder, depressive type.
Review of Resident #37's care plan dated 10/17/22, included Resident #37 had bladder incontinence. Resident #37 would remain free from skin breakdown due to incontinence and brief use through the review date. Interventions included Resident #37 used disposable briefs, check every two hours and change as needed; provide perineal care with each incontinence episode.
Review of Resident #37's Quarterly MDS 3.0 assessment dated , 01/07/23, revealed Resident #37 was cognitively intact. Resident #37 required extensive assistance of one staff member for bed mobility and toilet use, and extensive assistance of two staff members for transfers. Resident #37 was always incontinent of urine and frequently incontinent of bowel.
Review of the staff assignment sheet from 2:00 P.M. through 10:00 P.M. dated 01/17/23, revealed STNA #338 called off work, and STNA's #314 and #317 worked from 2:00 P.M. until 10:00 P.M. Unit Manager #342 worked as an STNA from 2:00 P.M. through 6:00 P.M. No other STNA's were scheduled to work from 2:00 P.M. to 10:00 P.M. Further review of the assignment sheet revealed Licensed Practical Nurse (LPN) #332 worked from 2:00 P.M. through 5:00 P.M. and Registered Nurse (RN) #304 worked from 2:00 P.M. through 6:00 P.M. RN #333 and LPN #331 worked from 6:00 P.M. through 10:00 P.M. Further review revealed three STNA's (STNA's #315, #324, and #328) and two nurses (RN #333 and LPN #331) worked from 10:00 P.M. through 6:00 A.M.
Review of Resident #37's medical record STNA charting dated, 01/17/23 and 01/18/23, revealed there was no documentation on 01/17/23 from 2:00 P.M. through 11:59 P.M. Resident #37's incontinence brief was checked and changed. Further review on 01/18/23 from 12:00 A.M. through 7:00 A.M. revealed there was one documentation note at 6:50 A.M. Resident #37's incontinence brief was changed.
Interview on 01/18/23 at 3:03 P.M. with Resident #37 revealed there was not enough staff working in the facility, and last night there were only two nurses and two aides working. Resident #37 stated she usually was changed three to four times a night and it did not happen last night. Resident #37 stated she asked STNA #315 to change her incontinence brief when she came to work around 10:00 P.M. Resident #37 stated she was changed around 2:00 A.M. and had not been changed until 9:00 A.M.
Interview on 01/18/23 at 7:00 P.M. with State Tested Nursing Assistant (STNA) #315 revealed she worked night shift on 01/17/23 from 10:00 P.M. to 6:00 A.M. STNA #315 stated when she arrived for work there were only two STNA's working on second shift and it was a very busy evening. STNA #315 indicated Unit Manager (UM) #342 worked as an aide from 2:00 P.M. through 6:00 P.M. and left at 6:00 P.M. STNA #315 stated she had to change a few residents when she arrived because they had not been changed for awhile and Resident #37 was one of them. Resident #37 told STNA #315 she had not had her incontinence brief changed since 6:00 P.M., STNA #315 changed her and stated Resident #37's incontinence brief was very wet and needed changed. STNA #315 stated night shift was very busy due to only three STNA's working.
Review of facility policy titled Incontinence, revised, 01/01/22, included based on the resident's comprehensive assessment, all residents that were incontinent would receive appropriate treatment and services. Resident that were incontinent of bladder or bowel would receive appropriate treatment to prevent infections.
4. Review of Resident #1's medical record revealed an admission date of 11/13/22 and diagnoses included Huntington's disease, major depressive disorder, and dysphagia.
Review of Resident #1's admission MDS 3.0 assessment dated , 11/19/22, revealed Resident #1 had severe cognitive impairment. Resident #1 required extensive assistance of two staff members for bed mobility and transfers, and required extensive assistance of one staff member for locomotion on and off the unit. When walking, and turning around and facing the opposite direction while walking Resident #1 was not steady, and only able to stabilize with staff assistance.
Review of Resident #1's care plan dated 11/30/22, included Resident #1 had depression related to disease process (Huntington's Disease). Resident #1 would remain free of signs and symptoms of distress, anxiety, sad mood through the review date. Interventions included to assist Resident #1 in developing and providing Resident #1 with a program of activities that was meaningful and of interest; encourage and provide opportunities for exercise, physical activity. Resident #1 had an alteration in neurological status related to Huntington's Disease. Resident #1 would be able to function at the fullest potential possible as
outlined by the interdisciplinary team through the review date. Interventions included to reposition, ambulate as tolerated, but the interventions did not specify the frequency this should occur.
Review of Resident #1's State Tested Nursing Assistance charting in the medical record dated, 01/04/23 through 01/25/23, did not reveal documentation Resident #1 was provided assistance to walk in the hall.
Review of Resident #1's physician orders dated 01/23/23, revealed restorative consult, would like to ambulate two times per week.
Interview on 01/23/23 at 10:01 A.M. with Family Member (FM) #330 revealed Resident #1 was admitted to the facility at the beginning of 11/2022. FM #330 stated the facility was short-staffed and Resident #1 waited 45 minutes for someone to assist her after she activated her call light, and had an accident of urine or bowel while waiting. FM #330 indicated the staff did not walk Resident #1, she was able to walk when she was admitted , and thought she could still walk but she never saw the staff walking with her or encouraging her to walk. FM #330 stated the food was always cold and she did not know if Resident #1 lost weight. FM #330 was concerned because Resident #1 still had her sleeping attire on and it was now after 10:00 A.M. in the morning.
Observation on 01/23/23 at 10:01 A.M. of Resident #1 revealed she was sitting on her bed, with a gown on, her hair was disheveled State Tested Nursing Assistant (STNA) #330 walked in the room to provide care. STNA #330 stated it had been a busy morning and this was the first time she was in Resident #1's room today to provide care. STNA #330 stated Resident #1 takes herself to the bathroom and she did not have to walk with her.
Interview on 01/23/23 at 8:07 A.M. with Unit Manager (UM) #342 revealed she was the restorative nurse for the facility, but was not provided training, and wasn't sure what she was supposed to do, and had not provided restorative services for the residents. UM #342 stated she had not assisted Resident #1 to walk, but thought therapy was helping her with walking.
Interview on 01/25/23 at 2:52 P.M. with Family Member (FM) #331 revealed she did not think Resident #1 was getting the care she needed, and one reason was because the facility was short staffed. FM #331 stated she was concerned because when she visited she did not see any staff walking with Resident #1 or encouraging her to walk. FM #331 indicated Resident #1 was at a high risk for choking and aspiration. FM #331 stated there was a sign over the bed that said take small bites of food and chew, and Resident #1 should be in a chair for eating, but she did not know if there was an order for that. FM #331 stated Resident #1 walked approximately four times since she was admitted and she could really use the walking because it soothed her and helped her mental state. FM #331 stated Resident #1 was continent and wore incontinence briefs.
Review of the facility policy titled Activities of Daily Living (ADL's), revised, 01/01/22, included the facility would ensure a resident's abilities in ADL's do not deteriorate unless deterioration was unavoidable. This included the resident's ability to transfer and ambulate. A resident who was unable to carry out activities of daily living would receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.
This deficiency represents non-compliance investigated under Complaint Number OH00138326.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
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 the facility policy the facility failed to ensure restorative services...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, review of the facility policy the facility failed to ensure restorative services were provided for the residents. This affected one resident (Resident #1) with the potential to affect all five residents (Resident's #1, #4, #6, #39, and #41) recommended for restorative services in the facility. The facility census was 54.
Findings include:
Review of Resident #1's medical record revealed an admission date of 11/13/22 and diagnoses included Huntington's disease, major depressive disorder, and dysphagia.
Review of Resident #1's admission MDS 3.0 assessment dated [DATE], revealed Resident #1 had severe cognitive impairment. Resident #1 required extensive assistance of two staff members for bed mobility and transfers, and required extensive assistance of one staff member for locomotion on and off the unit. When walking, and turning around and facing the opposite direction while walking Resident #1 was not steady, and only able to stabilize with staff assistance.
Review of Resident #1's care plan dated 11/30/22, revealed Resident #1 had depression related to disease process (Huntington's Disease). Resident #1 would remain free of signs and symptoms of distress, anxiety, sad mood through the review date. Interventions included to assist Resident #1 in developing and providing Resident #1 with a program of activities that was meaningful and of interest; encourage and provide opportunities for exercise, physical activity. Resident #1 had an alteration in neurological status related to Huntington's Disease. Resident #1 would be able to function at the fullest potential possible as
outlined by the interdisciplinary team through the review date. Interventions included to reposition, ambulate as tolerated, but the interventions did not specify the frequency this should occur.
Review of Resident #1's State Tested Nursing Assistance charting in the medical record dated, 01/04/23 through 01/25/23, did not reveal documentation Resident #1 was provided assistance to walk in the hall.
Review of Resident #1's physician orders dated, 01/23/23, revealed restorative consult, would like to ambulate two times per week.
Interview on 01/23/23 at 10:01 A.M. with Family Member (FM) #330 revealed Resident #1 was admitted to the facility at the beginning of 11/2022. FM #330 stated the facility was short-staffed and Resident #1 waited 45 minutes for someone to assist her after she activated her call light, and had an accident of urine or bowel while waiting. FM #330 indicated the staff did not walk Resident #1, she was able to walk when she was admitted , and thought she could still walk but she never saw the staff walking with her or encouraging her to walk.
Observation on 01/23/23 at 10:01 A.M. of Resident #1 revealed she was sitting on her bed, with a gown on, her hair was disheveled State Tested Nursing Assistant (STNA) #330 walked in the room to provide care. STNA #330 stated it had been a busy morning and this was the first time she was in Resident #1's room today to provide care. STNA #330 stated Resident #1 takes herself to the bathroom and she did not have to walk with her.
Interview on 01/25/23 at 8:07 A.M. with Unit Manager (UM) #342 revealed she was the restorative nurse for the facility, but was not provided training, and wasn't sure what she was supposed to do, and had not provided restorative services for the residents. UM #342 stated Resident #1 did not receive restorative services at this time. UM #342 stated she had not assisted Resident #1 to walk, but thought therapy was helping her with walking.
Interview on 01/25/23 at 9:10 A.M. with STNA #330 revealed she was the restorative aide for the facility. STNA #330 stated she had not provided restorative services for six months to one year because she was too busy with other assignments.
Interview on 01/25/23 at 9:28 A.M. with Physical Therapist (PT) #335 revealed he had not recommended residents for restorative because he did not know who the restorative nurse was. PT #335 stated he gave residents he discharged from therapy exercises to do on their own.
Interview on 01/25/23 at 2:52 P.M. with Family Member (FM) #331 revealed she did not think Resident #1 was getting the care she needed, and one reason was because the facility was short staffed. FM #331 stated she was concerned because when she visited she did not see any staff walking with Resident #1 or encouraging her to walk. FM #331 stated Resident #1 walked approximately four times since she was admitted and she could really use the walking because it soothed her and helped her mental state.
Review of list of residents Physical Therapist #335 would recommend for restorative services if there was an active restorative program revealed he would recommend Resident #1, Resident #4, Resident #6, Resident #39 and Resident #41. The list revealed Resident #4 refused therapy, and Resident's #6 and #41 had started receiving therapy services again.
Review of the facility policy titled Activities of Daily Living (ADL's), revised, 01/01/22, included the facility would ensure a resident's abilities in ADL's do not deteriorate unless deterioration was unavoidable. This included the resident's ability to transfer and ambulate. A resident who was unable to carry out activities of daily living would receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.
Review of the facility policy titled Restorative Nursing Programs, revised 01/01/22, included the goal of Restorative Nursing included improving and or maintaining independence in activities of daily living and mobility. A Restorative Nursing Program, when appropriate was based on th comprehensive assessment and resident. The following types of residents could benefit from a Restorative program but limited to contracture prevention and or management, bowel and or bladder continence programs, skills practice, training in ADL's, communication, contracture prevention and management, dining, mobility. Anyone could make a referral to the Restorative Nursing Program including physicians, dietary, activities, social services, nursing, therapy, or anyone who identified a change in the resident's condition.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and review of facility policy, the facility failed to ensure Resident #1 was prov...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and review of facility policy, the facility failed to ensure Resident #1 was provided assistance with eating, failed to ensure Resident #40 was provided personal adaptive utensils for assistance with eating, and failed to ensure Resident's #2, #29, #42, and #47 were provided nutritional supplements per physician orders. This affected six residents (Resident's #1, #2, #29, #40, #42 and #47) out of seven residents reviewed for nutrition. The facility census was 54.
Findings include:
1. Review of Resident #1's medical record revealed an admission date of 11/13/22 and diagnoses included Huntington's disease, major depressive disorder, and dysphagia.
Review of Resident #1's Nutrition Data Collection and Evaluation dated, 11/15/22, revealed Resident #1 had a regular diet, dysphagia mechanical soft, thin liquids and Resident #1 required assistance with meals. Resident #1 used a scooped plate and bowl and curved spork with meals.
Review of Resident #1's admission MDS 3.0 assessment dated [DATE], revealed Resident #1 had severe cognitive impairment. Resident #1 required extensive assistance of two staff members for bed mobility and transfers, and required extensive assistance of one staff member for eating.
Review of Resident #1's care plan dated 11/30/22, revealed Resident #1 needed Activities of Daily Living (ADL's) assistance related to Huntingtons Disease, depression, generalized weakness. Anticipated decline would be managed by ongoing reassessments of activities of daily living. Interventions included Resident #1 required assistance of one staff member for eating. Resident #1 had the potential for nutritional deficits related to Huntington's disease and other diagnoses. Resident #1's body mass index (BMI) indicated she was overweight, skin alteration, mechanically altered diet. Resident #1 would maintain adequate nutritional status as evidenced by no unplanned significant weight changes, no signs and symptoms of malnutrition, and consuming adequate intakes to meet estimated nutrition needs daily through review date. Interventions included to monitor, document, report to nurse, physician as needed any signs and symptoms of dysphagia such as pocketing, choking, coughing, drooling, holding food in mouth, several attempts at swallowing, refusing to eat, appears concerned during meals. Interventions included to monitor, record, report to the physician as needed signs and symptoms of malnutrition including a significant weight loss greater than 5 percent in a month, greater than 7.5 percent in three months and greater than 10 percent in six months; provide and serve diet as ordered.
Observation on 01/18/23 at 8:23 A.M. of Resident #1 revealed she was sitting in her room with her breakfast tray on a bedside table in front of her. There was no staff in the room assisting Resident #1 with her meal.
Interview on 01/23/23 at 10:01 A.M. with Family Member (FM) #330 revealed Resident #1 was admitted to the facility at the beginning of 11/2022. FM #330 stated the facility was short-staffed and Resident #1's call light sometimes took 45 minutes to be answered. FM #330 stated the food was always cold and she did not know if Resident #1 lost weight.
Observation on 01/23/23 at 5:38 P.M. revealed a cart in the hall of one of the nursing units revealed pitchers of drinks in a metal bin with ice, empty glasses on the cart, and coffee in individual cups with plastic lids. There was no hot water on the drink cart for residents who liked tea. Observation revealed STNA's #303 and #317 passing meal trays. STNA #317 stated it took longer to pass the meal trays to the residents when they also had to serve drinks, the food was often cold and the residents deserved warm food. There was no kitchen manager available to take temperatures of a food tray, but a cup of coffee was taken to the kitchen and [NAME] #332 took the temperature of the coffee and it was 118 Fahrenheit. Palatability of the coffee revealed it was barely lukewarm.
Review of Resident #1's medical record including weights dated 01/24/23, revealed a weight of 160.0 pounds. Review of Resident #1's weight dated 02/03/23, revealed a weight of 147.4 pounds. This was a significant weight loss of less than a month of 7.88 percent. Further review of the medical record progress notes did not reveal Resident #1's physician or power attorney was notified of the significant weight loss and the medical record did not have documentation Resident #1's weight was rechecked.
Interview on 01/25/23 at 9:10 A.M. with State Tested Nursing Assistant (STNA) #348 revealed none of the residents on the nursing unit she was assigned including Resident #1 required assistance with eating, confirmed Resident #1 does not receive assistance with eating.
Interview on 01/25/23 at 2:39 P.M. with the Director of Nursing revealed if a resident required extensive assistance of one staff member when eating she would expect to see a staff member at the resident's bedside providing assistance with eating as needed during the meal time.
2. Review of Resident #40's medical record revealed an admission date of 02/10/21 and diagnoses included acute and chronic respiratory failure with hypoxia, schizophrenia, and type two diabetes mellitus without complications.
Review of Resident #40's Nutrition Data Collection and Evaluation dated 12/13/22, included Resident #40's current diet order was CCD (carbohydrate controlled diet), level three (dysphagia advanced), finger foods, thin liquids. Resident #40 used adaptive equipment, divided plate, plate guard, built up utensils, and a two handled cup. Resident #40 had significant weight loss at 90 and 180 days.
Review of Resident #40's Annual Minimum Data Set (MDS) 3.0 assessment dated , 12/19/22, revealed Resident #40 was cognitively intact. Resident #2 required extensive assistance of two staff members for bed mobility and toilet use. Resident #2 had total dependence of two staff for transfers and was always incontinent of urine and bowel. Resident #2 required limited assistance and was a one person physical assist for eating. Resident #2 had a weight loss of 5 percent or more in the last month or loss of 10 percent in the last six months, and was not on a prescribed weight-loss regimen.
Interview on 01/25/23 at 9:10 A.M. with State Tested Nursing Assistant (STNA) #348 revealed Resident #40 did not require assistance with eating.
Observation on 01/25/23 at 9:15 A.M. of Resident #40 revealed she was lying in bed with the head of her bed elevated and had a breakfast meal tray on the bedside table in front of her. Observation of Resident #40's food plate revealed runny scrambled eggs were untouched, and the rest of the food was pushed around the plate and over the sides of the plate, had spilled onto Resident #40's clothing and the bedside table. Resident #40 stated she did the best she could to eat, it was hard, and staff insisted she eat by herself. Resident #40 indicated she could not eat the runny scrambled eggs because they were not cooked thoroughly. Resident #40 stated she did not have her personal built-up utensils to eat. Resident #40 stated her utensils had her name written on them, and she had no idea where they were. Observation of built up utensils on Resident #40's tray indicated they did not have her name on them.
Interview on 01/26/23 at 12:49 P.M. with Dietary Supervisor (DS) #333 revealed she was aware Resident #40 had her own built up utensils, and would try to locate them.
3. Review of Resident #29's medical record revealed an admission date of 07/28/21 and diagnoses included Parkinson's Disease, heart failure, and malignant neoplasm of the breast.
Review of Resident #29's physician orders dated, 04/01/22, revealed nutritional juice with meals.
Review of Resident #29's meal ticket dated 01/25/23, revealed nutritional juice, one serving.
Observation on 01/25/23 at 8:15 A.M. of Resident #29's meal tray revealed there was no nutritional juice on the tray. STNA #322 confirmed there was no nutritional juice on Resident #29's meal tray.
Interview on 01/18/23 at 1:59 P.M. with STNA #322 revealed the residents did not always get the correct meal, the meal trays often did not have everything ordered on them and the aides had to run to the kitchen a lot to make sure the residents had what they were supposed to have. STNA #322 stated the entrees did not always come with hot plates underneath them.
Observation on 01/25/23 at 8:15 A.M. of the meal cart for the above resident revealed there was no coffee, condiments, butter or hot water for tea and STNA's #322 and #307 had to go to the kitchen for the missing items. Further review revealed there was glasses of juice missing from quite a few meal trays.
Interview on 01/25/23 at 1:15 P.M. with Registered Nurse (RN) #316 revealed often meal trays arrived with no supplements on them. RN #316 stated she knew this because she always looked to see if supplements were on the trays and how much of the supplements were consumed by the residents. RN #316 stated she charted a zero in the residents Medication Administration Record on the days the supplements were not on the resident meal trays.
4. Review of Resident #2's medical record revealed an admission date of 06/15/22 and diagnoses included malignant neoplasm of unspecified part of unspecified bronchus or lung, hypertension, chronic obstructive pulmonary disease, and type two diabetes mellitus.
Review of Resident #2's physician orders dated 11/20/22, revealed mighty shakes three times a day.
Review of Resident #2's Medication Administration Record (MAR) dated 01/01/23, 01/12/23, 01/17/23 through 01/23/23 revealed there were zeros on the MAR for consumption of mighty shakes for the breakfast and lunch meals.
Observation on 01/25/23 at 8:15 A.M. of Resident #2's meal tray revealed there was no mighty shake on the tray. STNA #322 confirmed there was no mighty shake on Resident #2's meal tray.
Interview on 01/18/23 at 1:59 P.M. with STNA #322 revealed the residents did not always get the correct meal, the meal trays often did not have everything ordered on them and the aides had to run to the kitchen a lot to make sure the residents had what they were supposed to have. STNA #322 stated the entrees did not always come with hot plates underneath them.
Observation on 01/25/23 at 8:15 A.M. of the meal cart for the above resident revealed there was no coffee, condiments, butter or hot water for tea and STNA's #322 and #307 had to go to the kitchen for the missing items. Further review revealed there was glasses of juice missing from quite a few meal trays.
Interview on 01/25/23 at 1:15 P.M. with RN #316 revealed often meal trays arrived with no supplements on them. RN #316 stated she knew this because she always looked to see if supplements were on the trays and how much of the supplements were consumed by the residents. RN #316 stated she charted a zero in the residents Medication Administration Record on the days the supplements were not on the resident meal trays.
5. Review of Resident #42's medical record revealed an admission date of 07/01/21 and diagnoses included hypertensive chronic kidney disease with stage one through stage four chronic kidney disease, type two diabetes mellitus with diabetic polyneuropathy, and major depressive disorder.
Review of Resident #42's physician orders dated 10/21/22, revealed nutritional juice two times a day.
Review of Resident #42's meal ticket dated 01/25/23, revealed nutritional juice, one serving.
Observation on 01/25/23 at 8:15 A.M. of Resident #42's meal tray revealed there was no nutritional juice on the tray. STNA #322 confirmed there was no nutritional juice on Resident #42's meal tray.
Interview on 01/18/23 at 1:59 P.M. with STNA #322 revealed the residents did not always get the correct meal, the meal trays often did not have everything ordered on them and the aides had to run to the kitchen a lot to make sure the residents had what they were supposed to have. STNA #322 stated the entrees did not always come with hot plates underneath them.
Observation on 01/25/23 at 8:15 A.M. of the meal cart for the above resident revealed there was no coffee, condiments, butter or hot water for tea and STNA's #322 and #307 had to go to the kitchen for the missing items. Further review revealed there was glasses of juice missing from quite a few meal trays.
Interview on 01/25/23 at 1:15 P.M. with RN #316 revealed often meal trays arrived with no supplements on them. RN #316 stated she knew this because she always looked to see if supplements were on the trays and how much of the supplements were consumed by the residents. RN #316 stated she charted a zero in the residents Medication Administration Record on the days the supplements were not on the resident meal trays.
6. Review of Resident #47's medical record revealed an admission date of 09/19/19 and diagnoses included acute and chronic respiratory failure with hypoxia, dementia, unspecified protein-calorie malnutrition.
Review of Resident #47's physician orders dated, 11/09/22, revealed mighty shakes in the morning. Further review of the orders revealed magic cup in the morning for supplement, fortified pudding may be substituted as appropriate.
Review of Resident #47's MAR dated, 01/21/23, 01/22/23, 01/25/23 through 01/27/23, and 01/31/23 revealed zeros were charted for magic cup, fortified pudding in the morning for supplement. Further review of the MAR revealed zeros were charted on 01/21/23, 01/22/23, 01/25/23 through 01/27/23 and 01/31/23 for mighty shakes in the morning.
Review of Resident #47's meal ticket dated, 01/25/23, revealed fortified pudding parfait, one half cup, and house shake, one serving.
Observation on 01/25/23 at 8:15 A.M. of Resident #47's meal tray revealed there was no mighty shake, and there was no magic cup or fortified pudding on the tray. STNA #322 confirmed there was no mighty shake, magic cup or fortified pudding on the tray.
Interview on 01/18/23 at 1:59 P.M. with STNA #322 revealed the residents did not always get the correct meal, the meal trays often did not have everything ordered on them and the aides had to run to the kitchen a lot to make sure the residents had what they were supposed to have. STNA #322 stated the entrees did not always come with hot plates underneath them.
Observation on 01/25/23 at 8:15 A.M. of the meal cart for the above resident revealed there was no coffee, condiments, butter or hot water for tea and STNA's #322 and #307 had to go to the kitchen for the missing items. Further review revealed there was glasses of juice missing from quite a few meal trays.
Interview on 01/25/23 at 1:15 P.M. with RN #316 revealed often meal trays arrived with no supplements on them. RN #316 stated she knew this because she always looked to see if supplements were on the trays and how much of the supplements were consumed by the residents. RN #316 stated she charted a zero in the residents Medication Administration Record on the days the supplements were not on the resident meal trays.
Review of facility policy titled Nutritional Management revised, 01/01/22, included the facility provided care and services to each resident to ensure the resident maintained acceptable parameters of nutritional status in the context of his or her overall condition. Interventions would be individualized to address the specific needs of the resident. Examples included physical assistance or provision of assistive devices.
This deficiency substantiates Complaint Number OH00139034 Complaint Number OH00138770.
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 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 observation, interview, record review and review of facility policy, the facility failed to ensure sufficient staffing ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and review of facility policy, the facility failed to ensure sufficient staffing to meet the needs of the residents related to incontinence care, restorative services, and showers. This had the potential to affect all 54 residents in the facility.
Findings include:
1. Review of Resident #1's medical record revealed an admission date of 11/13/22 and diagnoses included Huntington's disease, major depressive disorder, and dysphagia.
Review of Resident #1's admission MDS 3.0 assessment dated , 11/19/22, revealed Resident #1 had severe cognitive impairment. Resident #1 required extensive assistance of two staff members for bed mobility and transfers, and required extensive assistance of one staff member for locomotion on and off the unit. When walking, and turning around and facing the opposite direction while walking Resident #1 was not steady, and only able to stabilize with staff assistance.
Review of Resident #1's care plan dated, 11/30/22, included Resident #1 had depression related to disease process (Huntington's Disease). Resident #1 would remain free of signs and symptoms of distress, anxiety, sad mood through the review date. Interventions included to assist Resident #1 in developing and providing Resident #1 with a program of activities that was meaningful and of interest; encourage and provide opportunities for exercise, physical activity. Resident #1 had an alteration in neurological status related to Huntingtons Disease. Resident #1 would be able to function at the fullest potential possible as outlined by the interdisciplinary team through the review date. Interventions included to reposition, ambulate as tolerated, but the interventions did not specify the frequency this should occur.
Review of Resident #1's physician orders dated 01/23/23, revealed restorative consult, would like to ambulate two times per week.
Review of Resident #1's State Tested Nursing Assistance charting in the medical record dated 01/04/23 through 01/25/23, did not reveal documentation Resident #1 was provided assistance to walk in the hall.
Interview on 01/23/23 at 10:01 A.M. with Family Member (FM) #330 revealed Resident #1 was admitted to the facility at the beginning of 11/2022. FM #330 stated the facility was short-staffed and Resident #1 waited 45 minutes for someone to assist her after she activated her call light, and had an accident of urine or bowel while waiting. FM #330 stated she did not know if it was urine or bowel but it smelled horrible. FM #330 indicated the staff did not walk Resident #1, she was able to walk when she was admitted , and thought she could still walk but she never saw the staff walking with her or encouraging her to walk. FM #330 stated the food was always cold and she did not know if Resident #1 lost weight. FM #330 was concerned because Resident #1 still had her sleeping attire on and it was now after 10:00 A.M. in the morning.
Observation on 01/23/23 at 10:01 A.M. of Resident #1 revealed she was sitting on her bed, with a gown on, her hair was disheveled State Tested Nursing Assistant (STNA) #330 walked in the room to provide care. STNA #330 stated it had been a busy morning and this was the first time she was in Resident #1's room today to provide care. STNA #330 stated Resident #1 takes herself to the bathroom and she did not have to walk with her.
Interview on 01/25/23 at 8:07 A.M. with Unit Manager (UM) #342 revealed she was the restorative nurse for the facility, but was not provided training, and wasn't sure what she was supposed to do, and had not provided restorative services for the residents. UM #342 stated she had not assisted Resident #1 to walk, but thought therapy was helping her with walking.
Interview on 01/25/23 at 9:10 A.M. with State Tested Nursing Assistant (STNA) #330 revealed she was the restorative aide for the facility. STNA #330 stated she had not provided restorative services for six months to one year because she was too busy with other assignments.
Interview on 01/25/23 at 2:52 P.M. with Family Member (FM) #331 revealed she did not think Resident #1 was getting the care she needed, and one reason was because the facility was short staffed. FM #331 stated she was concerned because when she visited she did not see any staff walking with Resident #1 or encouraging her to walk. FM #331 indicated Resident #1 was at a high risk for choking and aspiration. FM #331 stated there was a sign over the bed that said take small bites of food and chew, and Resident #1 should be in a chair for eating, but she did not know if there was an order for that. FM #331 stated Resident #1 walked approximately four times since she was admitted and she could really use the walking because it soothed her and helped her mental state. FM #331 stated Resident #1 was continent and wore incontinence briefs.
2. Interviews on 01/18/23 between 8:05 A.M. and 8:20 A.M. with Registered Nurse (RN) #304 and STNA #330 revealed there was not enough staff working in the facility to meet the residents needs. STNA #330 stated day shift staffing was usually alright but second shift often did not have enough nurses and aides working.
Interviews on 01/18/23 between 8:25 A.M. and 8:53 A.M. with Registered Nurse (RN) #333, Licensed Practical Nurse (LPN) #332 and STNA's #307 and #322 revealed LPN #332 stated she just arrived for work could not arrive at 6:00 A.M. because she had to drop her child off at daycare and the day care did not open at 6:00 A.M. LPN #332 stated the night nurse stayed over to cover her assignment until she arrived. STNA's #307 and #322 stated today there was enough staff working but sometimes if there were call offs and staff on vacations it impacted staffing. STNA's #307 and #322 stated the facility tried to get coverage and were usually unsuccessful and at those times management staff did not help with resident care. RN #333 stated she worked day shift and night shift to help staff the facility, and on night shift there were not always enough STNA's to provide care for the residents.
Interview on 01/23/23 at 1:08 P.M. with Director of Nursing (DON) revealed the facility hired two second shift STNAs last week, one started training, and one was giving notice. The DON stated the facility placed adds on internet hiring sites, offered a referral bonus, there was a nursing wage increase in December 2022 and the wages were now competitive. DON stated sign-on bonuses were offered, there was a weekend [NAME] program. DON indicated second shift was always a challenge to staff and the facility offered bonuses if shifts were picked up by the STNA's.
3. Review of Resident #37's medical record revealed an admission date of 10/11/22 and diagnoses included type two diabetes mellitus with diabetic nephropathy, congestive heart failure, obesity and schizoaffective disorder, depressive type.
Review of Resident #37's care plan dated 10/17/22, included Resident #37 had bladder incontinence. Resident #37 would remain free from skin breakdown due to incontinence and brief use through the review date. Interventions included Resident #37 used disposable briefs, check every two hours and change as needed; provide perineal care with each incontinence episode.
Review of Resident #37's Quarterly MDS 3.0 assessment dated , 01/07/23, revealed Resident #37 was cognitively intact. Resident #37 required extensive assistance of one staff member for bed mobility and toilet use, and extensive assistance of two staff members for transfers. Resident #37 was always incontinent of urine and frequently incontinent of bowel.
Review of the staff assignment sheet from 2:00 P.M. through 10:00 P.M. dated, 01/17/23, revealed STNA #338 called off work, and STNA's #314 and #317 worked from 2:00 P.M. until 10:00 P.M. Unit Manager #342 worked as an STNA from 2:00 P.M. through 6:00 P.M. No other STNA's were scheduled to work from 2:00 P.M. to 10:00 P.M. Further review of the assignment sheet revealed Licensed Practical Nurse (LPN) #332 worked from 2:00 P.M. through 5:00 P.M. and Registered Nurse (RN) #304 worked from 2:00 P.M. through 6:00 P.M. RN #333 and LPN #331 worked from 6:00 P.M. through 10:00 P.M. Further review revealed three STNA's (STNA's #315, #324, and #328) and two nurses (RN #333 and LPN #331) worked from 10:00 P.M. through 6:00 A.M.
Review of Resident #37's medical record STNA charting dated 01/17/23 and 01/18/23, revealed there was no documentation on 01/17/23 from 2:00 P.M. through 11:59 P.M. Resident #37's incontinence brief was checked and changed. Further review on 01/18/23 from 12:00 A.M. through 7:00 A.M. revealed there was one documentation note at 6:50 A.M. Resident #37's incontinence brief was changed.
Interview on 01/18/23 at 1:59 P.M. with STNA #322 revealed day shift staffing was usually alright, but second and third shift staffing was challenging. STNA #322 stated she worked double shifts once or twice a week due to staffing issues. STNA #322 stated last night (01/17/23) several residents were incontinent and not changed timely. STNA #322 stated Resident #37 was one resident who wore an incontinence brief and it was not changed timely last night.
Observation on 01/18/23 at 3:03 P.M. of Resident #37 revealed she was lying in bed with the head of her bed elevated. Resident #37 stated there was not enough staff working in the facility, and last night there were only two nurses and two aides working. Resident #37 stated she usually was changed three to four times a night and it did not happen last night. Resident #37 stated she asked STNA #315 to change her incontinence brief when she came to work around 10:00 P.M. Resident #37 stated she was changed around 2:00 A.M. and had not been changed until 9:00 A.M.
Interview on 01/18/23 at 7:00 P.M. with State Tested Nursing Assistant (STNA) #315 revealed she worked night shift on 01/17/23 from 10:00 P.M. to 6:00 A.M. STNA #315 stated when she arrived for work there were only two STNA's working on second shift and it was a very busy evening. STNA #315 indicated Unit Manager (UM) #342 worked as an aide from 2:00 P.M. through 6:00 P.M. and left at 6:00 P.M. STNA #315 stated she had to change a few residents when she arrived because they had not been changed for awhile and Resident #37 was one of them. Resident #37 told STNA #315 she had not had her incontinence brief changed since 6:00 P.M., STNA #315 changed her and stated Resident #37's incontinence brief was very wet and needed changed. STNA #315 stated night shift was very busy due to only three STNA's working.
4. Review of staff assignment sheets dated, 12/31/22, revealed from 6:00 A.M. to 2:00 P.M. there were three STNA's scheduled (STNA's #305, #334, and #327) and two nurses scheduled (LPN's #301 and #343). From 2:00 P.M. to 10:00 P.M. there were three STNA's (STNA's #303, #317 and #326) scheduled and one STNA (STNA #334) worked from 2:00 P.M. to 6:00 P.M., LPN's #301 and #343 worked from 2:00 P.M. to 6:00 P.M., and LPN #331 and RN #306 worked from 6:00 P.M. until 10:00 P.M., and four STNA's (#303, #315, #324, and #336) worked from 10:00 P.M. until 6:00 A.M.
Review of the residents' shower schedule dated 12/31/22, revealed Resident's #2, #4, #6, #10, #13, #16, #24, #27, #30, #35, #40, #43, #47, #48, #50, #54 were scheduled to have showers. Review of the shower sheets dated 12/31/22, revealed only Resident #47 received a shower on 12/31/22. The facility was unable to provide evidence of additional showers given on this date.
Interview on 01/18/22 at 2:17 P.M. with Unit Manager (UM) #342 revealed staffing could be a challenge. UM #342 stated she wished the facility had a shower aide (State Tested Nursing Assistant) because typically there were three to four STNA's scheduled to work, and the residents did not always get showers when they were supposed to. UM #342 stated if there was another STNA scheduled for showers, the residents would receive showers on the days the showers were scheduled. UM #342 indicated it would be great to have a shower aide on all shifts, but now the aides were so busy, were usually working short-staffed and have to fit showers in.
Interview on 01/18/23 at 4:05 P.M. with STNA #305 revealed she worked day shift on 12/31/22 and there was not enough staff scheduled to work. STNA #305 stated LPN #343 was late for her shift starting at 6:00 A.M. and did not arrive until 9:00 A.M. or 9:30 A.M. STNA #305 stated the night shift nurse stayed awhile then left and only one nurse was in the facility until LPN #343 arrived. STNA #305 stated all the staff were worried something bad would happen to the residents because there was only one nurse and three aides in the facility. STNA #305 stated the management staff was called but there was no response. STNA #305 stated there was usually not enough staff working second shift (2:00 P.M. to 10:00 P.M.) and sometimes the staff were mandated to work.
Interview on 01/23/23 at 9:30 A.M. with LPN #343 revealed she worked day shift on 12/31/22 and was late to work because she overslept. LPN #343 stated she arrived to the facility around 9:00 A.M. or 9:30 A.M. LPN #343 confirmed there was only one nurse and three aides working when she arrived.
This deficiency represents non-compliance investigated under Complaint Number OH00139034 and Complaint Number OH00139005.
Aug 2022
10 deficiencies
1 Harm
SERIOUS
(G)
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** 2. Review of Resident #47's medical record revealed an admission date of 06/12/16 and diagnoses included dementia, chronic obstr...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of Resident #47's medical record revealed an admission date of 06/12/16 and diagnoses included dementia, chronic obstructive pulmonary disease, and history of transient ischemic attacks and cerebral infarction without residual deficits.
Review of Resident #47's physician orders dated 06/12/19 revealed turn and reposition frequently every day and night shift.
Review of Resident #47's Braden Scale For Predicting Pressure Sore Risk dated 06/15/22 revealed the resident was at high risk for developing a pressure ulcer.
Review of Resident #47's quarterly MDS assessment dated , 06/16/22 revealed the resident had severe cognitive impairment. Resident #47 required extensive assistance of one staff member for bed mobility and toilet use and had total dependence on two staff members for transfers. Resident #47 was always incontinent of urine and bowel and did not have a pressure ulcer.
Review of Resident #47's physician orders dated 07/08/22 revealed Resident #47 was discontinued from hospice services.
Review of Resident #47's care plan dated 07/20/22 included Resident #47 was at risk for pressure ulcer development related to incontinence, restricted mobility, mood and diagnoses. Resident #47's risk of significant skin injury would be reduced, minimized through the review date. Interventions included to apply barrier cream as ordered; Resident #47 needed reminding, assistance to turn and reposition frequently, at least every two hours, more often as needed or requested; monitor and document, report as needed any changes in skin status: appearance, color.
Review of Resident #47's Skin assessment dated [DATE] revealed Resident #47 had no new abnormal skin areas.
Review of Resident #47's Braden Scale For Predicting Pressure Sore Risk dated 08/09/22 revealed the resident was at high risk for developing a pressure ulcer.
Observation on 08/09/22 at 8:15 A.M. and 12:30 P.M. of Resident #47 revealed he was laying in bed, flat on his back with the head of his bed elevated.
Interview on 08/09/22 at 3:15 P.M. with Certified Nursing Assistant (CNA) #127 revealed she had not taken care of Resident #47 for a couple days but he allowed her to change him when he needed it. CNA #127 stated when she provided Resident #47's incontinence care previously she noticed he had a little redness on his bottom.
Observation on 08/09/22 at 3:59 P.M. of Certified Nursing Assistant (CNA) #127 providing incontinence care for Resident #47 revealed Resident #47's incontinence brief was saturated with urine. Resident #47's buttocks were very red and an open area about the size of a quarter was noted on the right buttock close to the sacrum and coccyx. Resident #47 cried out in pain when CNA #127 cleaned his buttocks and sacrum. CNA #127 did not apply barrier cream and was preparing to put a clean incontinence brief on Resident #47. After surveyor intervention CNA #127 confirmed Resident #47 had an open area on his right buttock. Registered Nurse (RN) #120 walked into the room and CNA #127 informed RN #120 about the open area on Resident #47's right buttock. RN #120 measured the wound for a length of 3.1 centimeters (cm), width 1.9 cm, depth of less than 0.1 cm. RN #120 sprayed the area with Skin prep (protective barrier) and applied a border gauze dressing. Resident #47 stated his bottom hurt and after surveyor intervention a pillow was placed under his right side.
Review of Resident #47's progress notes dated 08/09/22 timed 5:53 P.M. revealed an STNA notified the nurse Resident #47 had a new area of skin impairment on his right buttocks. RN #120 assessed the area on the right buttocks which measured 3.1 cm by 1.9 cm by less than 0.1 cm depth. No drainage was noted, the wound bed was pink. The peri-wound (tissue surrounding wound) was within normal limits. The area was cleansed with normal saline, Skin prep applied topically and covered with small border foam gauze. Resident #47 repositioned for comfort. nurse practitioner notified, no further orders. Resident #47's guardian aware.
Observation on 08/10/22 at 7:35 A.M. of Resident #47 revealed he was lying in bed, flat on his back with the head of his bed elevated.
Observation on 08/10/22 at 9:21 A.M. of Resident #47 revealed he was lying in bed in the same position as 7:35 A.M., on his back with the head of his bed elevated.
Observation on 08/10/22 at 10:15 A.M., and 08/10/22 at 11:47 A.M. of Resident #47 revealed he was lying in bed, flat on his back with the head of his bed elevated. Resident #47 was in the same position observed earlier in the day.
Interview on 08/10/22 at 11:42 A.M. with STNA #159 revealed she did not ask Resident #47 if he wanted to get out of bed. STNA #159 stated she changed Resident #47's incontinence brief, but she did not reposition him or encourage him to let her reposition him at any time during her shift. STNA #159 stated Resident #47 liked to lay flat on his back.
Interview on 08/10/22 at 3:45 P.M. of Licensed Practical Nurse/Wound Nurse (LPN/WN) #147 revealed she was not notified about Resident #47's wound on his right buttock. When asked why Resident #47 was not on a low air loss mattress due to his high risk for developing a pressure ulcer LPN/WN #147 stated Resident #47 was on hospice services and they did not use a low air loss mattress for him. LPN/WN #147 stated Resident #47 was no longer on hospice and she thought it was discontinued in 06/2022.
Review of the facility policy titled Pressure Ulcer/Skin Breakdown-Clinical Protocol, revised 01/01/22 included based on comprehensive assessment of a resident, a resident received care consistent with professional standards of practice, to prevent pressure ulcers and did not develop pressure ulcers unless the individual's clinical condition demonstrated they were unavoidable. A resident with pressure ulcers received necessary treatment and services consistent with professional standards of practice to promote healing, prevent infection and prevent new ulcers from developing. The plan of care for prevention and or treatment of pressure ulcer, injury would be developed based on assessment to include turning schedule, off-loading, moisture and incontinence management.
Based on observation, interview, and record review, the facility failed to timely provide care and treatment to ensure one resident (Resident #50) did not develop a pressure injury of the sacrum. Actual harm occurred when Resident #50 developed a Stage 4 (Full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone in the ulcer. Slough and/or eschar may be visible on some parts of the wound bed. Epibole [rolled edges], undermining and/or tunneling often occur. Depth varies by anatomical location.) of the sacrum. The facility also failed to ensure pressure injuries of a lower stage did not develop for Resident #47. This affected two of three residents (#47, #50, and #57) reviewed for pressure injuries. The facility identified five resident with pressure ulcers. The census was 58.
Findings include:
1. Review of the medical record for Resident #50 revealed an admission date of 08/12/20. Diagnoses included Stage 4 pressure ulcer of the sacral region , type 2 diabetes mellitus (DM), morbid obesity, and Alzheimer's disease.
Review of the skin assessment dated [DATE] revealed no new or existing abnormal skin areas.
Review of the care plan dated 05/31/22 revealed Resident #50 had impaired skin integrity in the form of pressure wound to the sacrum. Interventions included medications and treatments as ordered; observe area for increased redness, drainage, and edema; observe for signs of pain and administer analgesics as ordered; turn and reposition frequently as tolerated by resident; and pressure redistribution mattress.
Review of the skin and wound evaluation dated 05/31/22 revealed Resident #50 had a Stage 4 pressure ulcer that was in-house acquired on the sacrum which measured 3.7 centimeters (cm) in length, 2.1 cm in width, and depth not applicable. The wound bed was pink and moist with light amount of drainage and no odor. The Peri-wound was approximately 1.0 cm out from the wound bed and was blanchable erythema. The skin appeared fragile and at-risk for breakdown.
Review of the wound nurse practitioner note dated 05/31/22 revealed a new Stage 4 pressure ulcer on sacrum. The wound bed had slough and was necrotic with pink tissue. The peri wound was intact and fragile.
Review of the dietary progress note dated 06/21/22 timed 3:47 P.M. revealed a wound review note indicating Resident #50 with pressure injury to sacrum. Diet order was carbohydrate-controlled diet (CCD), regular texture, thin liquids and intakes recorded were 25-50% on average with resident refusing meals on rare occasion. Supplements included Med Pass 120 milliliters (ml) three times per day with intakes 50-100% to provide 240 calories and 10 grams of protein per serving. Resident reported eating not so good due to being sore all over. Resident missing some teeth. Midline catheter in place for hydration, with one liter of normal saline administered on 06/14/22. Updated food preferences to include likes pudding and ice cream. Weight stable. No new registered dietitian (RD) recommendations at this time.
Review of the skin and wound evaluation dated 06/28/22 revealed the Stage 4 pressure ulcer measured 1.1 cm in length x 0.6 cm width, and depth was not applicable. There was no evidence of infection, and the surrounding tissue was fragile skin. No pain noted and the wound was improving.
Review of a physician order dated 07/11/22 revealed an order for barrier cream to peri area and buttocks during incontinence care.
Review of the annual Minimum Data Set 3.0 (MDS) assessment dated [DATE] revealed Resident #50 had impaired cognition, required extensive assistance of two staff for bed mobility, total dependence of two staff for transfer, supervision of one staff for eating, extensive assistance of one staff for toilet use. Resident #50 had one Stage 4 unhealed pressure ulcer/injury.
Review of the skin and wound evaluation dated 07/26/22 revealed the Stage 4 pressure ulcer measured 1.5 cm in length x 1.0 cm in width and depth 2.7 cm. No pain was noted. Cat Scan (CT) to pelvis was done to rule out osteomyelitis (bone infection), results were without definitive evidence of osteomyelitis. CT showed subcutaneous emphysema to coccyx area. Follow-up Magnetic Resonance Imaging (MRI) scheduled to rule out osteomyelitis. Wound culture of area as well. Wound bed area was unchanged since last assessment. Granulation tissue present. Moderate amount of serous drainage. Peri wound was intact, fragile, and at-risk for breakdown
Review of the skin and wound evaluation dated 08/02/22 revealed the Stage 4 pressure ulcer measured 0.9 cm in length x 1.1 cm in width, and depth 3.0 cm. No pain noted. CT to pelvis done to rule out osteomyelitis, results were without definitive evidence of osteomyelitis. CT showed subcutaneous emphysema to coccyx area. Follow-up MRI scheduled on 08/19/22 to rule out osteomyelitis. Wound bed area was unchanged since last assessment. Granulation tissue present. Moderate amount of serous drainage. Peri wound was intact, fragile, and at-risk for breakdown.
Review of physician orders dated 08/02/22 revealed an order for Dakins (1/2 strength) Solution 0.25 % (Sodium Hypochlorite) apply to sacrum wound topically every morning and at bedtime for wound care, and an order to cleanse sacrum with Dakins soaked gauze, irrigate wound with Dakins solutions, cover with ABD (large bulky gauze pad), and secure with tape every morning and at bedtime and as needed.
Review of the skin and wound evaluation dated 08/09/22 revealed the Stage 4 pressure ulcer measured 0.9 cm in length x 1.0 cm width and depth 2.0 cm. Noted resident complained of pain seven out of 10. Wound bed was unchanged, pink, and moist. Granulation tissue noted to 100% of wound bed. Moderate amount of serous drainage noted. No signs or symptoms of infection. Peri-wound was intact, fragile, erythema noted. Resident #50 voiced discomfort/pain during wound assessment and dressing change. New order to medicate prior to dressing change.
Review of the wound nurse practitioner note dated 08/09/22 revealed the Stage 4 pressure ulcer status was unchanged, wound bed had granulation tissue, pink tissue, and the periwound was intact and fragile. There was also new moisture associated skin dermatitis (MASD) due to friction or contact to body fluids on on the left buttock.
Observation on 08/10/22 at 10:35 A.M. of Licensed Practical Nurse/Wound Nurse (LPN/WN) #147 with the assistance of State Tested Nursing Assistant (STNA) #142 providing Resident #50's sacral dressing change revealed the following: Observation of Resident #50's sacrum after removal of an ABD pad and calcium alginate revealed the sacral area, bilateral buttocks, and posterior upper thighs were very red and several open areas were noted on both the right and left buttocks. A small amount of reddish drainage was noted from the open areas on the bilateral buttocks, and an open area approximately the size of a dime was noted on Resident #50's sacral area. Observation of the dime sized wound revealed the wound bed could not be visualized due to depth of the wound. LPN/WN #147 stated she would get a light so the wound bed could be visualized. LPN/WN #147 found a light and returned to the room with the Director of Nursing (DON). LPN/WN #147 illuminated Resident #50's sacral wound bed with the light and another piece of calcium alginate was found and removed. The DON stated a long piece of calcium alginate should be used instead of two short pieces. Resident #50's sacral wound bed was pink with a small amount of slough noted in the upper right-hand area of the wound. LPN/WN #147 stated she did not measure the wounds because she measured them on 08/09/22, but the open areas on Resident #50's left buttock were not present on 08/09/22 and she would measure the wounds later today and document the measurements in Resident #50's medical record. LPN/WN #147 irrigated and cleansed the dime size wound with Dakin's solution, applied a long piece of calcium alginate, used Calmoseptine (barrier) ointment to the open areas on Resident #50's bilateral buttocks stating the open areas on the buttocks were MASD. LPN/WN #147 placed an ABD pad over the area and taped and dated the dressing.
Interview on 08/11/22 at 8:39 A.M. with STNA #150 revealed Resident #50 was compliant with care. Prior to finding the wound Resident #50 complained of her bottom hurting her and she did not want to get up in her chair due to the pain. STNA #150 stated it was hard to find the wound; they had to spread her buttock cheeks open to find it. STNA #150 stated she alerted the nurse when she had found the wound during resident care.
Interview on 08/11/22 at 8:45 A.M. with STNA #130 revealed she remember seeing Resident #50's wound when it was a small opening. STNA #130 notified the nurse when she noticed the opening getting deeper. STNA #130 indicated when it was a small hole they were putting cream on it. Prior to the wound being found Resident #50 had been crying and complaining of pain but they were not able to find anything. STNA #130 stated they had to spread open her buttock cheeks to find the wound. STNA #130 stated Resident #50 was heavier, so to ensure the resident was thoroughly cleaned when completing incontinence care and bathing, staff were to spread her buttock cheeks. STNA #130 stated when she noticed the wound getting deeper, she notified Registered Nurse (RN) #153. STNA #130 could not remember the time frames.
Interview on 08/11/22 at 8:53 A.M. with RN #153 revealed she couldn't recall any of the exact dates or timeframe but stated STNA #130 had informed her Resident #50's wound was getting deeper. RN #153 assessed the wound and then informed LPN/WN #147. LPN/WN #147 told RN #153 they were already aware. LPN/WN #147 stated the resident had been complaining of her bottom hurting and she had not been getting out bed much and couldn't turn herself.
Interview on 08/11/22 at 9:15 A.M. with LPN/WN #147 indicated she believed she was working the evening of 05/31/22 when the aide notified her Resident #50 had something on her bottom when they were doing incontinence care. LPN/WN #147 was not sure who the aide was that notified her. LPN/WN #147 stated because of the resident's anatomy and the location of the wound by the time it was noticed it was definitely at Stage 4. LPN/WN #147 stated the preventive measures that were in place prior to the development of the wound included incontinence care, turning and repositioning, house barrier cream, and a nutritional supplement that was started in February 2022. LPN/WN #147 stated the nurses completed weekly head to toe skin assessments. LPN/WN #147 stated when she assessed the wound on 05/31/22 it measured 3.7 centimeters (cm) in length, 2.1 cm in width, and 0.1 cm in depth, and the skin around it was fragile. LPN/WN #147 stated the current treatment included to clean with alginate to wound bed, cover with foam border dressing every night shift and as needed. LPN/WN #147 stated the wound was stable but as of 08/10/22 the resident acquired MASD because of the tape used to secure the dressing. A new order was obtained to use a silicone border foam that was gentler on the skin. LPN/WN #147 stated Resident #50 still had pain with the dressing changes. LPN/WN #147 stated when the wound was identified she notified the regional dietitian who was covering on 05/31/22 and then again on 06/14/22. LPN/WN #147 confirmed there was no nutritional re-assessment or new recommendations around that time period, but Resident #50 was on a nutritional supplement, Med pas, three times per day.
Interview on 08/11/22 at 9:49 A.M. with Registered Dietitian (RD) #168 revealed she started working at the facility on 06/14/22 and first addressed Resident #50's nutritional status related to her wound on 06/21/22. RD #168 stated the nutritional assessment prior to 06/21/22 was dated 04/01/22. RD #168 stated when a dietitian is notified of wounds, they should address them as soon as possible.
Interview on 08/11/22 at 11:52 A.M. with Wound Nurse Practitioner (WNP) #176 revealed she starting working at the facility sometime in June 2022. WNP #176 agreed Resident #50's wound to the sacrum was a Stage 4 pressure ulcer. WNP #176 said she would need more history on the resident to call it something else such as a pilonidal cyst. WNP #176 stated wounds could deteriorate to a Stage 4 fast depending on the preventative measures in place and nutrition was also an important role. WNP #176 stated Resident #50's wound was a Stage 4 when she got involved.
Interview on 08/11/22 at 2:40 P.M. with the DON revealed she observed Resident #50's wound for the first time today. The DON felt it may not be pressure but something else such as a cyst that opened because the wound looked too perfect for a pressure ulcer. DON verified the skin assessment dated [DATE] documented no new skin issues. The DON stated Resident #50 had C-diff during that time, so she knew staff were observing the resident's skin during incontinence care. The DON confirmed documentation and treatment indicated a Stage 4 pressure ulcer.
Interview on 08/11/22 at 2:57 P.M. with LPN #111 revealed when she completed Resident #50's skin assessment on 05/27/22 she didn't see anything. LPN #111 was informed on report by another nurse that something was found. LPN #111 stated when she first observed the wound after being told something was found it was a small, white circle or slit. LPN #111 stated there was not redness and she had to search for the wound to find it. LPN #111 had seen the wound recently and said it had gotten worse, much bigger, and it looked terrible now. LPN #111 stated Resident #50 had been complaining of pain on her bottom for two weeks prior to the wound being identified.
Review of the facility's policy titled Pressure Ulcer/Skin Breakdown-Clinical Protocol revised 01/01/22 revealed based on the comprehensive assessment of a resident, a resident received care, consistent with professional standards of practice, to prevent pressure ulcers and did not develop pressure ulcers unless the individual's clinical condition demonstrated that they were unavoidable; and a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice to promote healing, prevent infection, and prevent new ulcers from developing.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
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 Residents #47 and...
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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 Residents #47 and #56 were treated with respect by facility staff. This affected two of three residents reviewed for respect and dignity, Resident's #47 and #56. The facility census was 58.
Findings include:
1. Review of Resident #56's medical record revealed an admission date of 07/15/22 and diagnoses included dementia without behavioral disturbances, developmental disorder of scholastic skills, need for assistance with personal care and glaucoma.
Review of Resident #56's admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #56 was unable to complete an interview for cognitive status. Resident #56 required extensive assistance of two staff members for bed mobility, transfers, and toilet use.
Review of Resident #56's care plan dated, 07/16/22 included Resident #56 had impaired cognitive function, dementia or impaired thought processes related to dementia, developmentally delayed and alcohol dependency. Resident #56 was alert to self and significant others only. Resident #56 had severely impaired decision making skills. Resident #56's needs would be anticipated by staff through the review date. Interventions included to ask yes and no questions in order to determine needs; communicate with resident, family, caregivers regarding resident's capabilities and needs; use Resident #56's preferred name, identify yourself at each interaction, face Resident #56 when speaking and make eye contact; cue, reorient and supervise as needed.
Interview on 08/08/22 at 10:13 A.M. with Family Member (FM) #191 revealed Resident #56 had a bowel movement, an aide provided care but left the bathroom with feces on the floor and all over the toilet and there was feces on Resident #56's fitted sheet on his bed. FM #191 stated Resident #56 did not have a sheet to cover himself, the bed only had a fitted sheet.
Observation on 08/08/22 at 10:13 A.M. of Resident #56's room revealed the fitted sheet on his bed had feces in three separate areas on it. One spot of feces was about the size of a fifty cent piece, and two other spots were about dime sized. Resident #56's bed did not have a flat sheet or blanket the resident could use to cover himself. Further observation of Resident #56's bathroom revealed large smears of bowel movement on the floor by the toilet, and the toilet had a large amount of bowel movement and toilet paper stuck to the rim of the toilet seat. FM #191 stated the sheet with feces on it and bowel movement in the bathroom had been like that since he arrived at 9:00 A.M.
Observation on 08/08/22 at 10:13 A.M. revealed FM #191 asking State Tested Nursing Assistant (STNA) #104 to change Resident #56's sheet due to feces on it and pointing out the bathroom with the large amount of bowel movement on the floor and toilet. STNA #104 stated housekeeping would get to it. FM #191 told STNA #104 again the sheet had feces on it and needed changed and STNA #104 stated yeah, yeah I will tell housekeeping, they will get to it and walked away from FM #191 without changing the sheet or cleaning the bathroom. FM #191 asked another unidentified staff walking by the room about Resident #56's dirty sheet and bathroom and the staff kept going without addressing the concern.
Observation on 08/08/22 at 10:38 A.M. of Resident #56's room revealed the sheet with feces was still on the bed and the bowel movement in the bathroom had not been cleaned.
Observation on 08/08/22 at 10:48 A.M. revealed FM #191 ripping the sheet with feces off the bed and stopping Licensed Practical Nurse (LPN) #135 and telling her Resident #56's sheet needed changed due to feces on it. LPN #135 called STNA #104 over and told her Resident #56's sheet needed changed because it had feces on it. STNA #104 told LPN #135 she was too busy now to change the sheet and walked away. LPN #135 proceeded to change Resident #56's sheet. After changing the sheet LPN #135 found housekeeping and had the bathroom cleaned.
Interview on 08/08/22 at 10:48 A.M. with FM #191 revealed Resident #56 was blind in one eye and had a hard time keeping the toilet from getting bowel movement all over it. FM #191 stated the bowel movement on the floor and on the toilet was a continuous problem he encountered almost every day when he arrived at the facility.
2. Review of Resident #47's medical record revealed an admission date of 06/12/16 and diagnoses included dementia, chronic obstructive pulmonary disease, and history of transient ischemic attacks and cerebral infarction without residual deficits.
Review of Resident #47's Braden Scale For Predicting Pressure Sore Risk dated 06/15/22 revealed the resident was at high risk for developing a pressure ulcer.
Review of Resident #47's quarterly Minimum Data Set (MDS) 3.0 assessment dated , 06/16/22 revealed Resident #47 had severe cognitive impairment. Resident #47 required extensive assistance of one staff member for bed mobility and toilet use and had total dependence on two staff members for transfers. Resident #47 required supervision of one staff member for eating.
Review of Resident #47's care plan dated 07/20/22 included Resident #47 had an activity of daily living (ADL) self-care performance deficit related to diagnoses, dementia, pain. Resident #47 would improve current level of function in ADLs through the review date. Interventions included Resident #47 was able to feed self with meal setups. He at times needed more assistance based on his mood. Assist as needed and document.
Observation on 08/09/22 at 8:15 A.M. of Resident #47 revealed he was lying almost flat in bed and his breakfast tray was placed on the bedside table. The bedside table was raised about 12 inches above Resident #47. Resident #47 stated he could not eat like that, and he could not even see what food there was to eat.
Interview on 08/09/22 at 8:26 A.M. with State Tested Nurse Aide (STNA) #159 revealed she delivered Resident #47's breakfast tray. STNA #159 stated she woke Resident #47 up, but did not assist him in any way because he was able to adjust himself. STNA #159 did not enter Resident #47's room to see if he needed any help.
Observation on 08/09/22 at 8:28 A.M. (after surveyor intervention) revealed Registered Nurse (RN) #120 entering Resident #47's room to assist him with his breakfast tray set up. RN #120 stated Resident #47's bedside table was pretty far above resident and she lowered the tray so he could eat.
Review of the facility policy titled Resident Rights revised, 01/01/22 included employees shall treat all residents with kindness, respect and dignity.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Notice
(Tag F0623)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure Resident #211 transfer notice contained the accurate state's...
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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 #211 transfer notice contained the accurate state's information under the appeal rights. This affected one resident (#211) of two residents (#210 and #211) reviewed for hospitalizations. The facility census was 58.
Findings include:
Review of the medical record for Resident #211 revealed an admission date of 06/09/22 and a discharge date of 06/20/22. Diagnoses included acute embolism and thrombosis of deep veins of lower extremity, secondary malignant neoplasm of liver and intrahepatic bile duct, Alzheimer's disease, stage two pressure ulcer on the sacral region, and an unstageable ulcer on the right hip.
Review of the admission minimum data set (MDS) assessment dated [DATE] revealed Resident #211 had severely impaired cognition and required extensive assistance of two staff for bed mobility, total dependence of two staff for transfers, and total dependence of one staff for toilet use.
Review of the nurses' notes dated 06/20/22 timed 1:07 P.M. revealed therapy was in to work with Resident #211. Resident #211 exhibited a change of mental status (not eating, drinking, or talking). Daughter at bedside. Vital signs obtained. The nurse practitioner, Director of Nursing (DON) notified. Emergency Medical Services (911) called and transported Resident #211 to the local hospital.
Review of the transfer notice dated 06/20/22 revealed, under the appeal rights section, the contact information included the Michigan Department of Licensing and Regulatory affairs and the State long term care Ombudsman located in [NAME], Michigan.
Interview on 08/10/22 at 7:48 A.M. with Social Services Director (SSD) #110 verified the contact information for the state of Michigan was provided on the transfer notice. SSD #110 said in addition to providing the notice, she contacted the families and the residents to tell them they would contact the Ohio ombudsman and department of health. SSD #110 stated she provided the transfer notice which was provided by the corporation for her to use.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0625
(Tag F0625)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure a bed hold notice was provided to Resident #211 upon hospita...
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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 bed hold notice was provided to Resident #211 upon hospitalization. This affected one resident (#211) of two residents (#210 and #211) reviewed for hospitalizations. The facility census was 58.
Findings include:
Review of the medical record for Resident #211 revealed an admission date of 06/09/22 and a discharge date of 06/20/22. Diagnoses included acute embolism and thrombosis of deep veins of lower extremity, secondary malignant neoplasm of liver and intrahepatic bile duct, Alzheimer's disease, stage two pressure ulcer on the sacral region, and an unstageable ulcer on the right hip.
Review of the admission minimum data set (MDS) assessment dated [DATE] revealed Resident #211 had a severely impaired cognition and required extensive assistance of two staff for bed mobility, total dependence of two staff for transfers, and total dependence of one staff for toilet use.
Review of the nurses' notes dated 06/20/22 timed 1:07 P.M. revealed therapy was in to work with resident. Resident #211 exhibited a change of mental status (not eating, drinking, or talking). Daughter at bedside. Vital signs obtained. The nurse practitioner, Director of Nursing (DON) notified. Emergency Medical Services (911) called and transported resident to the local hospital.
Interview on 08/10/22 at 7:57 A.M. with Social Services Director (SSD) #110 stated because Resident #211 was not on Medicaid he did not receive a bed hold notice when he was hospitalized on [DATE].
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, review of manufacturer instructions, and review of the facility policy, ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, medical record review, review of manufacturer instructions, and review of the facility policy, the facility failed to provide a safe mechanical lift transfer for Resident #24, ensure Resident #210 was provided appropriate assistance with bed mobility during incontinence care, and ensure vaping supplies were kept secured. This affected one resident (Resident #24) of 16 residents (Resident #1, #3, #4, #11, #13, #19, #22, #26, #41, #48, #49, #50, #51, #52, and #58) reviewed who required a mechanical lift for transfers, one resident (Resident #210) out of three residents reviewed for falls, and one resident (Resident #28) out of nine residents reviewed for smoking. The facility census was 58.
Findings include:
1. Review of the medical record for Resident #24 revealed an admission date of 03/29/21 and a readmission date of 10/26/21. Diagnoses included respiratory failure, paraplegia (paralysis in the lower half of the body), chronic pain, morbid obesity, heart disease, Covid-19, and pneumonia. Further review of the medical record revealed Resident #24 weighed 405 pounds (lbs) on 01/03/22.
Review of the nursing notes dated 01/05/22 at 8:00 P.M., revealed Licensed Practical Nurse (LPN) #148 was notified by a State Tested Nursing Assistant (STNA) that while transferring Resident #24 to bed by way of mechanical lift, the lift tilted forward and resulted in Resident #24 hitting her head. Further review revealed Resident #24 had complaints of head and neck pain.
Review of the nursing notes dated 01/05/22 at 10:00 P.M. revealed LPN #148 reported the incident to Certified Nurse Practitioner (CNP) #178 by way of telephone and an order was placed for a cervical spine x-ray and Oxycodone was ordered as needed for pain.
Review of the x-ray results dated 01/06/22 revealed the impression to be unremarkable for injury.
Review of the plan of care dated 06/15/22 revealed Resident #24 required two person staff assist for all transfers.
Review of physician orders dated 06/15/22 revealed a Hoyer (mechanical lift) with two staff assist to be utilized for all transfers.
Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #24 was cognitively intact, mobilized with powerchair, was incontinent of bowel and bladder, and required extensive assist of two persons for activities of daily living and transfers.
Review of the facility Incident Log dated from 08/03/21 to 07/11/22, revealed on 01/05/22 at 8:00 P.M., Resident #24 suffered a fall during a staff transfer.
Interview on 08/08/22 at 10:42 A.M. with Resident #24 revealed while being transferred by two staff members to her bed, the mechanical lift tilted forward causing her to fall on top of the mattress and to hit her head/neck on headboard. Resident #24 further stated she had a history of chronic neck and back pain and was nervous when being transferred via the mechanical lift.
Observation on 08/10/22 at 9:00 A.M. revealed four mechanical lifts, three models of the Invacare Hoyer lift Reliant 450 and one model of the Invacare Reliant 660, in good repair with a preventive maintenance date of 06/10/22. Further review revealed weight limit to be 450 lbs.
Interview with STNA #117 on 08/10/22 at 9:20 A.M. revealed a cord had been lying underneath the base of the mechanical lift during Resident #24's transfer from her powerchair to the bed. STNA #117 stated while repositioning Resident #24 over her bed by way of pulling the sling, the mechanical lift tilted forward causing Resident #24 to come to rest on top of her mattress and hitting the top of her head against the headboard.
Observation on 08/11/22 at 3:50 P.M., a mechanical lift for Resident #58 with STNA #104 and #127, from powerchair to bed revealed no concerns.
Review of the manufacturer's instructions revealed during transfer with patient suspended in a sling, DO NOT roll caster base over uneven surfaces that could cause the patient lift to tip over. Use steering handle on the mast at all times to push or pull the patient lift.
Review of the facility policy titled Safe Lifting and Movement of Residents dated 10/30/2020 revealed compliance guidelines and procedure for the safe use of mechanical lifts had not been implemented according to manufacturer's instructions in regards to the transfer of Resident #34 on 01/05/22.
2. Record review revealed Resident #210 was admitted on [DATE] and discharged on 08/10/22. Diagnoses included acute/chronic respiratory failure with hypercapnia, metabolic encephalopathy, Parkinson's disease, history of pulmonary embolism, bipolar disorder, hypereosinophilic syndrome, asthma, dementia, chronic obstructive pulmonary disease, type 1 diabetes mellitus with hyperglycemia, obesity, anemia, major depressive disorder, hypertension, and history of transient ischemic attack.
Review of the falls risk assessment dated [DATE] revealed Resident #210 was at high risk for falls.
Review of the care plan dated 07/23/22 revealed Resident #210 was at risk for falls related to acute respiratory failure, Parkinson's disease, asthma, dementia, generalized weakness, chronic obstructive pulmonary disease, and hypertension. Interventions included anticipate and meet resident's needs based on nursing assessment, call light within reach and encourage the resident to use it for assistance, bed in low position when not providing care, determine causative factors of fall and resolve or minimize, physical therapy/occupational therapy to evaluate and treat as ordered or as needed, and perimeter mattress to bed.
Review of admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #210 had severely impaired cognition and required extensive care with two assist for bed mobility and toilet use, total care with two assist with transfers with Hoyer (mechanical) lift, dressing and hygiene extensive care with one assist, eating supervision with set up help only.
Review of the fall incident report dated 07/29/22 timed 1:32 A.M. revealed incontinence care was being provided by State Tested Nurse Aide (STNA) #113 and STNA #152 and when STNA #152 turned Resident #210 to her right side the resident fell out of bed onto the floor. Resident #210 was sent to the emergency room for evaluation and returned the same day with no injuries and no new orders.
Review of progress note dated 07//29/22 timed 3:23 A.M. revealed Registered Nurse (RN) #106 was called into Resident #210's room by nurse aid due to a fall. RN #106 found Resident #210 lying on floor on her right side. Resident #210 was assisted back to bed via Hoyer lift. Resident #210 had a lump on right side of her head and complained of pain to her right hip. Vital signs were monitored. AT 7:06 A.M. notification to Director of Nursing (DON), Nurse Practitioner (NP), and resident family member. Resident #210 was sent to hospital for evaluation.
Review of Self-Reported Incident (SRI) dated 07/29/22 revealed an SRI was filed because a family representative for Resident #210 alleged physical abuse occurred. The family representative reported an aide let Resident #210 fall out of bed on purpose. The fall was witnessed by STNA #113 and STNA #152. A thorough investigation was completed, and the allegation was unsubstantiated.
Review of physician orders for July 2022 and August 2022 revealed physical therapy (PT) to evaluate and treat as indicated, occupational therapy (OT) to evaluate and treat, pressure reduction mattress to bed, bilateral grab bars to bed to increase independence with bed mobility, repositioning, and transfers, perimeter mattress to bed, and Hoyer/mechanical lift with two assist for transfers, and two assist for all care.
Observations on 08/08/22 at 10:36 A.M., 4:47 P.M., on 08/09/22 at 7:10 A.M., 12:36 P.M., 2:30 P.M., and on 08/10/22 at 7:37 A.M., 9:32 A.M., 11:43 A.M., revealed Resident #210 in her room in bed with the head of bed elevated, call light in reach, bed in low position, and perimeter mattress in place.
Interview on 08/08/22 at 1:11 P.M. with RN #102 revealed she heard about Resident #210's fall and reported she heard STNA #152 pulled a little too hard when turning her and the resident fell out of bed.
Interview on 08/10/22 at 8:47 A.M. with the DON revealed when STNA #113 and STNA #152 were providing incontinence care they turned Resident #210 on her side and pulled the bath blanket closer. When STNA #152 pulled the bath blanket, Resident #210 kept going and STNA #152 couldn't stop the resident and the resident fell out of bed. The DON reported STNA #112 and #152 tried to catch Resident #210 and they couldn't, the resident landed on the floor, complained of hip hurting and was sent to the hospital for evaluation. The DON reported Resident #210 returned to the facility the same morning with no new orders and no injuries.
Interview on 08/11/22 at 10:45 A.M. with RN #106 revealed on 07/29/22 she was called to Resident #210's room for a fall. Upon arrival Resident #210 was on the floor on her right side. RN #106 reported she assessed Resident #210 and with help of STNA #113, STNA #152, and RN #146 assisted Resident #210 back to bed via Hoyer Lift. RN #106 reported Resident #210 complained of pain to right side, right hip, right shoulder and had a lump on right side of her head. RN #106 reported notifications were done and Resident #210 was sent to the hospital for evaluation. RN #106 reported she did not witness the fall.
Interview on 08/11/22 at 1:49 P.M. with STNA #113 revealed Resident #210 was her resident that night and she got STNA #152 to help provide incontinence care. STNA #113 reported she was on the left side of the bed and STNA #152 was on the right side of the bed. When STNA #152 pulled the bath blanket she pulled it so hard and fast, Resident #210's weight came over and the resident fell. STNA #113 reported she ran to the other side of the bed and tried to catch Resident #210, it happened so fast. STNA #113 reported STNA #152 also tried to catch Resident #210. STNA #113 reported Resident #210 landed on her right side on the floor. STNA #152 went and got RN #106 and RN #146 and STNA #113 stayed with the resident. RN #106, RN #145, and STNA #152 assisted Resident #210 back to bed via Hoyer lift. STNA #113 reported Resident #210 complained of her hip hurting and she was sent to hospital for evaluation.
Interview on 08/11/22 at 2:44 P.M. with RN #146 revealed she was called to Resident #210's room for a fall. RN #146 thought Resident #210 was on the floor on her left side. RN #146, STNA #113, and STNA #152 assisted Resident #210 to bed via a Hoyer lift. Resident #210 complained of soreness to her side and hip area. Resident #210 did not report hitting her head. Notifications were completed and Resident #210 was sent out to the hospital for evaluation. RN #146 was not present when the fall occurred.
Interview on 08/11/22 at 5:24 P.M. with STNA #152 revealed she was helping STNA #113 with incontinence care on Resident #210. STNA #152 pulled Resident #210 towards herself, and the resident fell out of bed. STNA #152 said she couldn't remember how it happened because it all happened so fast. STNA #152 was on one side of the bed and STNA #113 was on the other side of the bed. STNA #152 tried to stop the fall but couldn't, it happened too quickly. STNA #152 reported Resident #210 fell on her right side. STNA #152 immediately got RN #106 and RN #146 to help. STNA #152, STNA #113, RN #106 and RN #146 assisted Resident #210 back to bed via a Hoyer lift. STNA #152 reported the nurses checked Resident #210 out and Resident #210 was sent to the hospital.
Review of the facility policy, Falls - Clinical Protocol, revised 01/01/22, revealed to prevent falls while maintaining and/or improving resident abilities and quality of life.
3. Review of the facility supervised smoke break times dated 11/27/17 (provided by the facility upon request) revealed supervised smoke break times were scheduled at 9:30 A.M., 11:00 A.M., 1:00 P.M., 3:00 P.M., 7:00 P.M. and 9:00 P.M.
Review of the medical record for Resident #28 revealed an admission date of 06/15/22. Diagnoses included lung cancer, stroke, chronic obstructive pulmonary disease (COPD), and anxiety disorder
Review of the safe smoking evaluation dated 06/16/22 revealed Resident #28 was to be supervised by staff, volunteer, or family member at all times when smoking. Under the comment section there was a notation indicating Resident #28 vaped and denied smoking for last seven years.
Review of the smoking policy clarification and agreement revealed Resident #28 signed the agreement on 06/16/22.
Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #28 had intact cognition and was independent for bed mobility, ambulation, and required supervision of one staff for transfers.
Observation on 08/10/22 at 11:03 A.M. revealed Resident #28 outside sitting in his wheelchair vaping. Continued observation at 11:22 A.M. revealed Resident #28 self-propel back into the building toward his room without giving the vaping device to State Tested Nurse Aide (STNA) #130 who was supervising smoking. Resident #28 was not observed placing the vaping device in the lock box located on the table inside the building.
Interview on 08/10/22 at 11:22 A.M. with STNA #130 confirmed Resident #28 did not give the vaping device to her. STNA #130 was then observed to give the lock box to STNA #150. STNA #150 was observed asking Resident #28, who by this time was by the nursing station going toward his room, if he put the vaping device in the lock box. Resident #28 stated he did not put it back and STNA #150 took the vaping device from him.
Interview on 08/10/22 at 11:25 A.M. with STNA #150 revealed Resident #28 had given the vaping device to her after she had asked for it and she put it in the lock box. STNA #150 stated all smoking materials were given back after smoke break and kept in the lock box.
Observation on 08/10/22 at 2:30 P.M. of Resident #28 revealed the resident in his room lying in bed with what appeared to be a vaping device on his bedside tray table. It was a long white tube with a black cap like top and orange writing indicating guava mango ice along the tubing, a small 5% at the top of tube near the black cap like area, and near the bottom was also written in orange fruitia escobars. During interview with Resident #28 at the time of the observation Resident #28 identified the item as a marker indicating guava mango ice was the name of the color orange.
Observation and interview on 08/10/22 at 2:34 P.M. with STNA #127 revealed she was not sure what vaping devices looked like but STNA #127 thought the item on Resident #28's bedside table was a vaping device. STNA #127 stated she took residents out for supervised smoke breaks, and they were supposed to put all smoking materials back in the locked box.
During observation of the device with Registered Nurse (RN) #102 on 08/10/22 at 2:47 P.M., RN #102 asked Resident #28 what the device was, and Resident #28 stated it was a marker. RN #102 stated it did not look like a marker and picked it up. While in the hall on the nursing unit, an internet search of the device with RN #102 revealed it was a vaping device. RN #102 stated she thought the STNA had taken it from Resident #28 that morning and that she was going to take the vaping device to the Director of Nursing (DON).
Interview on 08/11/22 at 9:03 A.M. with the DON verified the item was a vaping device and they had Resident #28 sign a behavior contract related to use and storage of vaping devices.
Reviewed of the facility policy Smoking Policy Clarification and Agreement dated November 2017 revealed no smoking products (matches, lighters, other ignition sources, cigarettes, electronic cigarettes, cigars, pipes, tobacco and/or other inhaled tobacco substitutes) may be kept by a resident in his or her room due to safety precautions. All smoking products must be kept in a secure area as designate by the Administrator or designee. All smoking would be done under staff supervision (or other responsible party), in the designated smoking area at established times.
CONCERN
(D)
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 one resident (Res...
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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 one resident (Resident #300) known for wandering did not walk out of the facility unaccompanied by a staff member. This affected one resident (Resident #300) out of six residents (Resident's #5, #6, #7, #17, #21, #23) reviewed who were at risk for elopement. The facility census was 58.
Findings include:
Review of Resident #300 medical record revealed an admission date of 12/21/21 and diagnoses included Alzheimer's disease, atrial fibrillation, and unsteadiness on feet. Resident #300 was transferred to a sister facility with a secured unit on 06/09/22.
Review of Resident #300's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #300 had severe cognitive impairment and required extensive assistance of one person for locomotion on the nursing unit. Further review revealed Resident #300 was not steady when walking but able to stabilize without staff assistance.
Review of Resident #300's care plan dated 12/22/21 included Resident #300 was an elopement risk, a wanderer, wanted to go home related to impaired safety awareness, and wandered aimlessly. Resident #300's safety would be maintained through the review date. Interventions included to distract Resident #300 from wandering by offering pleasant diversions, structured activities, food, conversation, television, book; to identify pattern of wandering. (was wandering purposeful, aimless, or escapist? Was resident looking for something? Did it indicate the need for more exercise?) and intervene as appropriate; provide structured activities: toileting, walking inside and outside.
Review of Resident #300's assessments from 12/21/21 through 06/05/22 did not reveal an elopement, wandering risk assessment was completed.
Review of Resident #300's Social Service progress notes dated 06/02/22 included the Social Worker spoke with family about safety concerns regarding Resident #300's wandering and potential elopement risk.
Review of Resident #300's progress notes dated 06/05/22 at 3:59 P.M. revealed Resident #300 was found by an State Tested Nurse Aide (STNA) outside banging on another resident's window at 8:15 A.M. The STNA brought Resident #300 back into the building. Resident #300 was evaluated with vitals within normal limits, no noted skin issues, and no complaint of pain. The Director of Nursing (DON), Certified Nurse Practitioner (CNP) and daughter were notified. Resident #300 was placed on every 15 minute checks for 24 hours.
Review of Self-Reported Incident tracking number 222417 revealed on 06/05/22 Resident #300 wandered outside of the building and was seen knocking on a resident window to get back in. Residents were being transferred from the COVID-19 unit back to their original rooms after recovering from COVID-19. Around 8:05 A.M. Resident #300 pushed on the hall door leading to the outside and walked out of the facility. The resident in the last room of the hall saw Resident #300 pushing on the door. Resident #300 was seen at 8:15 A.M. knocking on a resident's window by a staff member in the resident's room. The staff member brought Resident #300 back inside. The weather was 70 degrees Fahrenheit and sunny. A nurse immediately performed a head-to-toe and pain assessment with negative findings. When Resident #300 was brought into the facility she was walking with her usual fast paced gait. Resident #300 could not remember why she went outside. Staff were in other resident rooms providing care or on the other side of the facility and did not hear the alarm sounding. The doors were all checked and the alarms worked appropriately, but the alarms from the west side of the facility could not be heard on the east side and the east side door alarms could not be heard on the west side. Steps were taken to correct this issue. All staff were educated on responding to door alarms and elopement drills were completed on all shifts. All future room moves between the two sides of the facility would have a staff member stationed at the nurses station monitoring all the doors until the move was completed
Review of Statement of Witness dated 06/05/22 written by STNA #145 revealed she was delivering a breakfast tray to a resident and heard knocking on glass, she turned around and saw Resident #300 standing outside the facility knocking on the residents window in room [ROOM NUMBER]. STNA #145 wrote she ran outside and on the way outside notified the nurse and another aide Resident #300 was outside the facility. STNA #145 did not hear any alarms sounding, another aide ran outside and assisted STNA #145 to bring Resident #300 inside. Resident #300 did not have a wheelchair outside with her.
Interview on 08/09/22 at 4:31 P.M. with the DON revealed Resident #300 had dementia and was on the COVID-19 unit on 06/05/22. The DON stated 06/05/22 was the last day for the COVID-19 unit to be opened and the residents were being transferred back to their regular rooms one at a time. The DON indicated Resident #300 knocked on a resident window, STNA #145 saw her and brought Resident #300 back into the facility. The DON revealed STNA #145 told the nurse Resident #300 got out. The DON stated the staff were in resident rooms providing care, and one staff member heard an alarm and one did not. The STNA who heard the alarm was in the middle of providing care and could not look into why the alarm was going off. The DON stated Resident #300 tried to leave the facility previous to 06/05/22 but had not been successful. The DON stated Licensed Practical Nurse (LPN) #135 was providing wound care to a resident with a fan on and could not hear the alarm. The DON stated the alarm system was upgraded recently and now the alarm for the east side of the facility could be heard on the west side. The DON stated if an outside door was pushed an alarm would immediately sound and if the door was pushed for 15 seconds it would open. The DON stated Resident #300 was transferred to a sister facility with a secured unit.
Interview on 08/10/22 at 8:05 A.M. with Licensed Practical Nurse (LPN) #135 revealed she remembered Resident #300 leaving the facility unaccompanied by a staff member on 06/05/22 but she could not remember if she was working that day. LPN #135 stated Resident #300 got out of the facility around the time the breakfast trays were passed to the residents and all staff were busy at that time. LPN #135 stated when breakfast trays were distributed to the residents, she would have been at the end of the hall, away from the nursing station administering medications to the residents. LPN #135 stated she was not assigned to the nursing unit Resident #300 resided on and she could not hear door the alarm from the end of the nursing unit she was on.
Interview on 08/10/22 at 10:10 A.M. with Maintenance Director (MD) #109 revealed door alarm updates were completed approximately two weeks ago. MD #109 stated before the updates were completed the east and west nursing units had their own alarms and the alarms did not sound on the other side of the building. MD #109 stated now if a resident wandered to the east side of the facility and attempted to leave through an outside door an alarm would sound on the west side of the building. MD #109 stated this wasn't necessary previously because the east side had residents and staff assigned, but now the east unit was closed so the updates were necessary. MD #109 stated the door alarms were tripped often during the day and staff did not always check the doors because they thought a resident was going outside to smoke. MD #109 stated he reminded the staff the doors needed checked every time the alarms sounded because a resident could be trying to go outside.
Observation on 08/10/22 at 10:10 A.M. with MD #109 revealed if the alarm sounded at the nursing station on the west side of the facility it could be heard at the end of resident halls away from the nursing station, but the alarm was faint. Further observation revealed the nursing station was located in the center of the nursing unit, and the halls the residents resided on all connected to the nursing station.
Interview on 08/10/22 at 2:40 P.M. with Registered Nurse (RN) #139 revealed when she arrived for work on 06/05/22 at 6:00 A.M. she learned the nurse called off who was supposed to work on the nursing unit Resident #300 resided on. RN #139 indicated RN #146 stayed over from night shift due to the call-off. RN #139 stated her assignment on 06/05/22 was to work on the COVID-19 nursing unit and the entry was at the back of the unit through an outside door. RN #139 stated STNA #130 was scheduled to work on the COVID-19 nursing unit with her, and all the residents were moving back to their permanent rooms on 06/05/22 because they had recovered from COVID-19. RN #139 indicated RN #146 assisted with moving the six residents from the COVID-19 unit on the east side of the facility back to their permanent rooms on the west side of the facility. RN #139 stated Resident #300 was anxious when she got report, and needed watched closely. RN #139 stated Resident #300 was moved first due to the need for close supervision, then the rest of the residents were moved. RN #139 stated after all the residents were moved she took a break and went outside to her car. RN #139 revealed when her break was over she found out Resident #300 had been outside unaccompanied by any staff member. RN #139 stated Licensed Practical Nurse (LPN) #135 was the nurse who reported the incident, but she was not the nurse assigned to the nursing unit Resident #300 resided on. RN #139 indicated STNA #104 was assigned to the nursing unit Resident #300 resided on and did not know if STNA #104 heard the alarm or turned the alarm off when Resident #300 exited the facility. RN #139 revealed Resident #22 heard the alarm and saw Resident #300 outside, but he could not let the staff know Resident #300 was outside the facility because he could not reach his call light. RN #139 stated STNA #104 told her no alarm went off, but when RN #139 tested all the doors in the facility for alarms on 06/05/22 all the alarms sounded.
Interview on 08/11/22 at 8:20 A.M. with STNA #104 revealed on 06/05/22 residents were moved from the COVID-19 nursing unit back to their permanent room assignment. STNA #104 stated she was assigned to the nursing unit Resident #300 resided on and Resident #300 was agitated when she was moved to her room. STNA #104 stated Resident #300 would not be still, was combative, was roaming in her room and tried to get out the door at the back of the nursing unit that opened to the outside of the facility multiple times. STNA #104 indicated she re-directed Resident #300 away from the door and had her sit at the nursing station in her wheelchair, but Resident #300 was still restless. STNA #104 stated Resident #300 was sitting at the nurses station when she entered Resident #4's room to provide care. STNA #104 revealed while she was providing Resident #4's care she heard a door alarm sounding, and after she finished with the care she saw STNA #130 standing at the door leading to the outside of the nursing unit Resident #300 resided on. STNA #104 stated STNA #130 put the code in to turn the alarm off, but neither STNA #104 or STNA #130 saw any resident or staff outside the facility. STNA #104 stated she was told Resident #300 was sitting at the nurses station by an unidentified staff member, but she did not check to make sure Resident #300 was still there before she helped pass out resident breakfast trays. STNA #104 could not remember who told her Resident #300 was still sitting at the nurses station. STNA #104 stated the incident happened around breakfast and it was not more than a few minutes between the last time she saw Resident #300 and when Resident #300 exited the facility.
Observation on 08/11/22 at 9:05 A.M. revealed Resident #22's room was the last room on the right side of the hall, and next to the door leading to the outside of the nursing unit Resident #300 resided on.
Interview on 08/11/22 at 9:06 A.M. with Resident #22 revealed Resident #300 was at the door leading to the outside of the facility constantly on 06/05/22 trying to get out. Resident #22 stated the staff would have her go back to her room. Resident #22 stated Resident #300 was right back at door within five minutes every time she was encouraged to go to her room and got out at some point. Resident #22 stated he saw Resident #300 at his window, Resident #300 knocked on his window, then moved to next window and started knocking. Resident #22 stated he could not reach his call light to activate it so he could tell a staff member Resident #300 was outside the facility. Resident #22 stated he wanted to tell staff the resident was outside.
Interview on 08/11/22 at 9:56 A.M. with STNA #130 revealed she was assigned to the COVID-19 unit on 06/05/22. STNA #130 stated there were about five residents in the COVID-19 unit scheduled to be transferred to the west side of the facility. STNA #130 indicated the staff had to rush to transfer the residents because there was a nurse call off and there was no nurse to work the COVID-19 unit. STNA #130 stated Resident #300 was brought to her room on the west side of the facility around 6:30 A.M. or 7:00 A.M., and she did not seem agitated. STNA #130 stated after the residents were transferred she was assigned to a nursing unit Resident #300 did not reside on. STNA #130 stated she did not hear an alarm because she was probably in a resident room with the door shut providing care or still on the other side of the facility. STNA #130 indicated she never heard an alarm sounding and did not know Resident #300 had left the facility until STNA #145 told her it happened. STNA #130 stated she never went to the door to see if a resident was outside, and did not punch a code in to turn the alarm off.
Review of the facility policy titled Unsafe Wandering and Elopement Prevention revised, 01/01/22 included every effort would be made to prevent unsafe wandering and elopement episodes while maintaining the least restrictive environment for residents who were at risk for elopement. It was the responsibility of all personnel to report any resident attempting to leave the premises to the licensed nurse in charge as soon as practical.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure an antipsychotic as needed medication was not ordered beyond...
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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 an antipsychotic as needed medication was not ordered beyond 14 days without first re-evaluating the resident, and ensure all psychotropic medications were reviewed to ensure the appropriateness of their use. This affected one resident (Resident #44) of five residents reviewed for unnecessary medications. The facility census was 58.
Findings include:
Record review on 08/09/22 of Resident #44 revealed the resident was admitted to the facility on [DATE] with medical diagnoses including pathological fracture in neoplastic disease, right femur; malignant neoplasm of colon, liver and interscholastic bile duct; anxiety disorder; major depressive disorder, and retention of urine. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #44 had intact cognition.
Review of physician orders for June, July and August 2022 revealed Resident #44 was ordered the antipsychotic medication Prochlorperazine Maleate (Prochlorperazine Maleate) 10 milligram (mg) tablet by mouth every six hours as needed.
Review of physician orders for August 2022 revealed Resident #44 was ordered the following psychotropic medication: Lexapro tablet 20 milligram (mg) in the morning for depression, Olanzapine (antipsychotic) 10 mg give one tablet by mouth daily at bedtime, and Prochlorperazine Maleate (antipsychotic) 10 mg by mouth every six hours as needed.
Review of the medication administration records (MARS) for June 2022, July 2022, and August 2022 revealed Prochlorperazine Maleate was not administered to Resident #44.
Review of the facility's pharmacy documentation for medication regimen review revealed a medication regimen review was not completed for Resident #44.
Interview on 08/09/22 at 8:47 A.M., with the Director of Nursing verified an evaluation of the use of psychotropic medications for Resident #44 was not performed.
Interview on 08/11/22 at 11:16 A.M. with Nurse Practitioner #178 revealed he was not notified by the facility to evaluate the as needed use of antipsychotic medication.
Review of facility policy, Use of Psychotropic Drugs and Gradual Dose Reductions, revised 01/01/22, revealed residents who use psychotropic drugs receive gradual dose reductions and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain infection control and infection prevention g...
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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 maintain infection control and infection prevention guidelines for community equipment. This affected one resident (Resident #3) out of 15 residents (Residents #3, #14, #18, #20, #21, #24, #28, #33, #37, #45, #48, #49, #50, #57) with an active physician order to monitor blood sugar. The facility failed to ensure proper hand hygiene during medication administration. This affected one resident (Resident #3) and had the potential to affect all facility residents. The facility failed to ensure staff donned proper personal protective equipment (PPE). This affected one Resident (Resident #49) and had the potential to affect all facility residents. The facility census was 58.
Findings include:
1. Observation on 08/10/22 at 7:40 A.M. of medication administration with Licensed Practical Nurse (LPN) #135 revealed no hand hygiene was observed after capillary blood draw of Resident #3. LPN #135 removed her protective gloves and proceeded to touch objects on the resident's bedside table and the community glucometer (equipment that measures blood sugar). LPN #135 returned to the medication cart and placed the glucometer in a plastic cup on top of a disinfecting wipe noted to have been in place prior to returning the equipment. LPN #135 donned gloves without performing hand hygiene and drew up insulin by way of syringe. LPN #135 proceeded to administer injection to Resident #3 as ordered, returned to cart and removed gloves without performing hand hygiene.
Interview on 08/10/22 at 8:02 A.M. with LPN #135 verified hand hygiene should be performed before and after the care of each resident and before and after removal of gloves. LPN #135 verified she placed the glucometer in the cup, on the top of an existing bleach wipe without wiping down the glucometer with the bleach wipe. LPN #136 confirmed the surface of the glucometer was to be cleansed with a new bleach wipe and left wet with solution for four minutes before reusing.
Review of the facility policy titled Blood Glucose Machine Disinfection dated 07/15/20, revealed the procedure for the disinfection of capillary-blood sampling devices to prevent transmission of blood borne diseases to residents and employees as follows: blood glucose machines were to be cleaned and disinfected after each use and according to manufacturers instructions for multi-resident use; the blood glucose machine was to be disinfected after each use and according to the manufacturer's instructions, and the last procedure was to perform hand hygiene.
Review of manufacturer instructions titled Cleaning and Disinfecting the Assure Platinum Blood Glucose Monitoring System revised 12/2017, revealed the disinfection procedure was needed to prevent the transmission of blood-borne pathogens. Guidelines for cleaning and disinfecting included to use a commercially available EPA-registered disinfectant detergent of germicide wipe.
Review of the facility policy titled Medication Administration dated 01/01/22, revealed staff were to wash hands using facility protocol and product.
The above observations and facility policy was verified on 08/11/22 at 2:25 P.M. with the Director of Nursing (DON).
2. Review of the medical record for Resident #49 revealed an admission date of 08/16/12. Diagnoses included chronic obstructive pulmonary disease (COPD), respiratory failure, diabetes mellitus, and obesity. Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed the resident had intact cognition and required extensive assistance of one staff for bed mobility and locomotion on and off the unit and total dependence of two staff for transfers.
Review of the progress note dated 08/08/22 timed 4:58 P.M. revealed Resident #49 had a non-productive cough, and shortness of breath with activity. Resident #49 was started on antibiotics and transmission-based precautions to rule out COVID-19.
Observation on 08/09/22 at 8:55 A.M. revealed Nurse Unit Manager (NUM) #136 in Resident #49's room wearing only a surgical mask and face shield. Observation outside of Resident #49's room revealed transmission-based precaution (TBP) signs and a bin with personal protective equipment (PPE). Interview with NUM #136 upon exiting Resident #49's room verified the observation, NUM #136 stated the resident was on TBP due to complaining of a cough to the nurse practitioner yesterday. NUM #136 stated Resident #49 was a smoker and had COPD.
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 observations, interview, and record review, the facility failed to maintain a clean and sanitary kitchen and nursing unit refrigerator and ensure proper food storage. This had the potential t...
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Based on observations, interview, and record review, the facility failed to maintain a clean and sanitary kitchen and nursing unit refrigerator and ensure proper food storage. This had the potential to affect all residents. The facility census was 58.
Findings include:
Observations during the initial tour of the kitchen on 08/08/22 from 8:21 A.M. to 8:33 A.M. revealed a large icicle was hanging from the fan unit onto a box of food on a shelf down to a box of buns underneath the fan unit that was sitting on a crate and onto the floor in the walk-in freezer. The walk-in cooler had a slight unpleasant odor and there was a large white bucket of pickles that was uncovered sitting on the top shelf on the left hand side of the cooler. There was food debris on the floor between the oven and steamer and on two light fixtures above the stove were heavily coated in greased dust. The reach-in cooler close to the kitchen door had a large white splatter on the inside bottom. Interview on 08/08/22 between 8:21 A.M. to 8:33 A.M. with [NAME] #164 verified the
findings.
Observation on 08/09/22 at 8:57 A.M. of the nursing unit refrigerator with Registered Nurse (RN) #136 revealed various food splatters in the freezer, and the refrigerator contained pizza boxes, a small Ziplock bag of pickles, and Styrofoam containers all which were unlabeled and undated. Additional observation revealed five eight-ounce containers of expired milk, two dated 08/02/22 and three dated 07/19/22. Interview at time of observation with RN #136 verified the findings and stated she was not sure who was responsible for the upkeep of the refrigerator.
Review of the facility's policy titled Kitchen Sanitation revised 01/01/22 revealed the food service area shall be maintained in a clean and sanitary manner.
Review of the facility's policy titled Food Receiving and Storage revised 01/01/22 revealed foods stored in the refrigerator or freezer were to be covered, labeled, and dated (opened on and use by date). Food items and snacks kept on the nursing units should be maintained as indicated: Food items to be kept below 41 degrees Fahrenheit (F) should be placed in the refrigerator located at the nurses' station and labeled with an opened on and use by date, sealed, or covered and labeled. Foods belonging to residents should be labeled with the resident's name, the item and the opened on and use by date. Partially eaten food was not to be kept in the refrigerator.
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
Observation on 08/10/22 at 8:12 A.M. of Resident #37's room revealed at least five large floor tile squares were missing from his floor at the foot of his bed.
Interview on 08/10/221 at 11:30 A.M. wi...
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Observation on 08/10/22 at 8:12 A.M. of Resident #37's room revealed at least five large floor tile squares were missing from his floor at the foot of his bed.
Interview on 08/10/221 at 11:30 A.M. with State Tested Nursing Assistant (STNA) #117 revealed Resident #37's floor tiles were missing for quite awhile and everyone knew about it including the nurses and Maintenance Director #109.
Interview on 08/10/11 at 11:35 A.M. of Maintenance Director #109 confirmed Resident #37 was missing floor tiles from the floor at the foot of his bed. Maintenance Director #109 stated he might have been told about Resident #37's missing floor tiles before today.
Based on observation and interview, the facility failed to ensure the residents' environment was maintained in a clean, sanitary, homelike condition and in good repair. This had the potential to all residents. The facility census was 58.
Findings include:
Observation on 08/08/22 at 9:40 A.M. of Resident #50 privacy curtain revealed various dried stains.
Observation on 08/08/22 at 3:21 P.M. of Residents #52 and #59's room revealed the door of the armoire to the right and the door of the armoire closer to the room door did not stay shut. Resident #52's bedside tray table was in disrepair. The hot water handle in the bathroom was missing and the floor was dirty. The blinds in the window were in disrepair and under the window near the molding, the wall was cracked.
Observation and interview on 08/10/22 from 8:27 A.M. to approximately 8:35 A.M. with Housekeeping Supervisor (HS) #169 of Resident #59's bathroom revealed the floor was dirty. HS #169 verified the observation but stated the dark areas of the floor was floor damage but the dark areas in the entryway of the bathroom was wax that he could clean up. HS #169 verified Resident #50's privacy curtain had stains and was soiled. HS #169 stated privacy curtains were swapped out monthly when the rooms were deep cleaned but could be changed sooner if they were soiled. Observation of Residents' #52 and #59's bathroom floor with HS #169 verified the floor was dirty.
Observation and on 08/10/22 from 8:50 A.M. to 9:00 A.M. with Director of Maintenance (DOM) #109 of Residents' #52 and #59 room confirmed the armoire next to door would not stay closed and the other was missing the door, the hot water handle was missing, there were cracks in wall near the window, the window blinds were in disrepair, Resident #52's bedside table in disrepair, and further observation of the air condition unit revealed it was dusty. DOM #109 stated he was responsible for dusting the air conditioner units but reported the plan was to replace them.
Aug 2019
10 deficiencies
1 Harm
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Accident Prevention
(Tag F0689)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide adequate supervision for Resident #24 during toileting. Act...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to provide adequate supervision for Resident #24 during toileting. Actual harm occurred when Resident #24 was left unsupervised in the bathroom, fell and hit her head causing a laceration requiring an emergency room visit and a staple was needed to close her head/scalp laceration. This affected one of six residents reviewed for accidents.
Findings include:
Review of Resident #24's medical record revealed the she was admitted to the facility on [DATE] with diagnoses including lack of coordination, difficulty walking and dementia without behavioral disturbance. Review of Resident #24's Minimum Data Set (MDS) 3.0 assessment dated [DATE] indicated she had severe cognitive impairment and memory impairment.
Review of Resident #24's current fall care plan revealed she was high risk for falls related to her confusion, use of psychoactive medications, unsteadiness when walking, incontinence and history of falls. Interventions dated 08/08/17 and 03/05/18 indicated staff were educated on not leaving Resident #24 alone in the bathroom. There was an additional intervention dated 05/30/19 which indicated Resident #24 was to be supervised by staff when in the bathroom.
Resident #24's [NAME] (a reference care card providing information for staff for the provision of resident care) indicated she was to be supervised by staff during toileting.
Review of Resident #24's progress note dated 07/27/19 at 2:16 P.M. indicated she was in the bathroom when she fell to the floor and was observed with blood coming from her head. Emergency Medical Services (EMS) were called and pressure with a towel was applied on the resident's head to stop the bleeding. The resident was transferred to the hospital.
Review of Resident #24's progress note dated 07/27/19 at 5:44 P.M. revealed she returned from the hospital and she had a laceration to her scalp with one staple in place, which was used to close the laceration.
Review of the undated fall witness statement authored by State Tested Nursing Assistant (STNA) #609 indicated she put Resident #24 on the toilet and left her alone in the bathroom. She left and went to provide care to another resident. When STNA #609 was done with the other resident and was coming out of the their room, she was told Resident #24 had fallen and hit her head.
Interview on 08/13/19 at 3:39 P.M. with the Director of Nursing (DON) confirmed STNA #609 left Resident #24 in the bathroom unsupervised to provide care to another resident. The DON said Resident #24 attempted to get off of the toilet by herself and fell. The DON verified this resulted in a head/scalp laceration requiring her to be transported to the hospital emergency room. A staple was placed in the back of the resident's head to close the laceration. The DON confirmed Resident #24's [NAME] indicated she was to be supervised during toileting.
Interview on 08/14/19 at 9:51 A.M. with STNA #609 confirmed she had worked in the facility approximately fourteen months but was unaware Resident #24 required continuous supervision during toileting. STNA #609 confirmed she left Resident #24 unattended on 07/27/19 while the resident was in the bathroom to answer another resident's call light and the resident fell causing a laceration to the resident's head resulting in an emergency room visit for care and treatment.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the physician was notified of abnormal glucose levels for Re...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the physician was notified of abnormal glucose levels for Resident #33. This affected one of five residents reviewed for medications.
Findings include:
Review of the record of Resident #33 revealed she was admitted to the facility on [DATE] with diagnoses including diabetes mellitus. Review of her care plan for diabetes mellitus dated 01/13/16 and updated through 10/21/19 revealed interventions to include administration of diabetes medications as ordered, fasting serum blood sugar as ordered by physician, and for staff to monitor/document/report to the physician as needed any signs or symptoms of hyperglycemia or hypoglycemia.
Review of Resident #33's current physician orders revealed an order for Lantus insulin (a long acting insulin to treat high blood sugar) to be administered twice a day, and for a routine dose of Novolog insulin, 21 units, to be given three times a day with meals. She also had an order dated 08/31/18 for Novolog insulin (a short acting insulin) to be given at different doses based on the resident's blood sugar, which was to be checked before meals. The order indicated the physician or nurse practitioner should be notified if the blood sugars were less than 70 or greater than 301. Another physician order dated 11/08/18 indicated the resident's physician or nurse practitioner should be notified if the resident's blood sugar was less than 60 or greater than 350.
Review of physician orders dated 07/16/19 revealed the resident's Lantus was increased from a dose of 58 units in the morning and 60 units at night to 65 units morning and at night.
A nursing note dated 07/19/19 at 4:34 P.M. revealed earlier at 3:30 P.M. that day, Resident #33's blood sugar was low at 57 and she complained she was feeling sweaty and shaky, symptoms of low blood sugar. Her blood sugar increased to 84 after she was given a snack. There was no evidence the nurse notified the physician of the low blood sugar and it was only documented in the nursing notes.
A nursing note on 07/21/19 at 12:04 A.M. revealed Resident #33's blood sugar had been 62 earlier, but went up to 124 after she had some orange juice. There was no evidence the physician was notified of the low blood sugar and the level was only documented in the nursing notes.
Review of the medication administration record revealed on 07/21/19 at 7:52 A.M., the residents scheduled morning Lantus dose and routine Novolog dose was held due to the resident having a blood sugar of 89 and feeling symptomatic and not feeling hungry.
Review of the medication administration record revealed Resident #33's blood sugar was 340 on 07/23/19 at 1200 P.M. There was no documentation in the medical record to indicate the physician was notified of the elevated blood sugar.
Review of the medication administration record revealed Resident 33's routine Novolog dose was not given at supper on 07/28/19. A note indicated her blood sugar was 85, but the note did not indicate if she was symptomatic. Her routine Novolog dose was also held on 07/29/19 at 12:00 P.M. for a blood sugar of 68, however, the note did not indicate any symptoms of low blood sugar.
Review of the medication administration record for August 2019 revealed Resident #33's blood sugar was 61 on 08/09/19 at 8:00 A.M. , 307 on 08/10/19 at 8:00 A.M. and 318 on 08/10/19 at 5:30 P.M. These blood sugar levels were all within the ranges of the physician's orders that required them to be called to the physician or nurse practitioner. However, there was no documentation these blood sugars were reported to the physician or nurse practitioner.
Review of the facility policy for physician notification of changes in condition or status, updated on 10/07/10, revealed the nurse would notify the physician when there were instructions to notify the physician. The policy also indicated the nurse would record this information in the resident's medical record.
Interview with Resident #33's physician, MD #500, on 08/13/19 at 4:20 P.M. revealed he did not recall specific notification from the nursing staff regarding the blood sugars as listed above. He verified the parameters for notification were conflicting, but that the resident's blood sugars were within the parameters for notification. He stated he did look at the medication administration record to check the blood sugar levels but he did not generally review the nursing notes. Thus, he did not see the nurses' notes related to the hypoglycemic episodes on 07/19/19 and 07/21/19. He also verified there was no order specifically to hold the resident's routine insulin doses, although he stated the nurses could hold the medication if the resident was symptomatic of a low blood sugar.
An interview with the Director of Nursing (DON) on 08/15/19 at 1:00 P.M. revealed she spoke to the nurse practitioner, who stated she was aware the resident's blood sugars were up and down, but confirmed there was no documentation in the medical record to verify the physician or nurse practitioner were notified of the blood sugar variances for Resident #33 in the event treatment changes were needed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
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 provide treatment to Resident #52's pressure ulcer per...
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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 provide treatment to Resident #52's pressure ulcer per the physician orders. This affected one of one resident reviewed for pressure ulcers.
Findings include:
Review of Resident #52's medical record revealed the resident was re-admitted to the facility on [DATE] with diagnoses including osteomyelitis (infection in the bone) of the vertebra, sacral and sacrococcygeal region, dementia without behavioral disturbance, hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following a cerebral infarction (stroke) affecting the right dominant side.
Review of Resident #52's physician orders revealed an order dated 07/22/19 for nursing staff to gently cleanse the wound and wound bed with normal saline, pat dry, lightly pack wound with Dakin's solution soaked gauze, and cover with an adhesive foam dressing twice daily and as needed.
Review of Resident #52's pressure ulcer wound grid dated 08/08/19 revealed he had a Stage IV pressure ulcer (a full-thickness skin and tissue loss exposing the fascia, tendon, muscle, ligaments, cartilage and/or bone which may contain slough or eschar, which is dead or devitalized tissue) measuring 7.0 cm (centimeters) in length by 4.0 cm wide by 2.0 cm in depth. The form indicated nursing staff were to cleanse the pressure ulcer wound with normal saline, apply a Dakin's solution soaked gauze dressing and cover with a foam pad twice daily.
Observation on 08/13/19 at 1:27 P.M. with Licensed Practical Nurse (LPN) #610 revealed she washed her hands, applied gloves, removed Resident #52's old pressure ulcer wound dressing on his coccyx, cleansed the wound using wound wash and gauze, removed her gloves, washed her hands, put on new gloves, applied Dakin's solution to gauze, packed the Dakin's soaked gauze into the wound and covered the wound with a foam dressing.
Interview on 08/13/19 at 2:36 PM. with LPN #610 confirmed she did not use normal saline to cleanse Resident #52's coccyx pressure wound as indicated in the physician orders.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure Resident #52's medical record contained a physi...
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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 #52's medical record contained a physician order for oxygen therapy. This affected one of two residents reviewed for respiratory care.
Findings include:
Review of Resident #52's medical record revealed the resident was re-admitted to the facility on [DATE] with diagnoses including muscle weakness, dementia without behavioral disturbance, hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following a cerebral infarction (stroke) affecting the right dominant side. Review of Resident #52's Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited severe cognitive impairment.
Review of Resident #52's current respiratory care plan revealed an intervention dated 06/13/19 for oxygen settings via nasal cannula as ordered by the physician.
Review of Resident #52's medical record did not reveal a physician order for oxygen therapy.
Observations at 08/12/19 at 9:00 A.M. and 08/14/19 at 8:42 A.M. revealed Resident #52 was lying in bed with oxygen infusing at two liters per nasal cannula via an oxygen concentrator.
Interview on 08/14/19 at 9:05 A.M. with the Director of Nursing confirmed Resident #52's medical record did not contain a physician order for oxygen therapy.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0698
(Tag F0698)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure Resident #50's medications and renal diet were p...
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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 Resident #50's medications and renal diet were provided as ordered by the physician. This affected one resident of one resident reviewed for dialysis services.
Findings include:
Review of Resident #50's medical record revealed an admission date of 05/07/18 with diagnoses including obesity, anemia, end stage renal (kidney) disease with dependence on dialysis, diabetes, and hypotension (low blood pressure).
Review of a quarterly Minimum Data Set assessment dated [DATE] revealed Resident #50 was alert and oriented with intact cognition and rejected care one to three days in the seven day review period.
Review of a care plan dated 05/16/18 revealed Resident #50 received dialysis treatments on Tuesdays, Thursdays and Saturdays.
Review of Resident #50's current physician orders revealed an order dated 08/08/19 directing staff to send all morning and afternoon medications to dialysis with the resident every Tuesday, Thursday and Saturday; an order dated 07/01/19 for dialysis treatments at 7:15 A.M. on Tuesdays, Thursdays and Saturdays; an order dated 06/30/19 for midodrine hydrochloride five milligrams (mg) one tablet by mouth three times per day for hypotension, hold medication if blood pressure was over 120/80 millimeters Mercury (mm Hg); an order dated 06/30/19 for sevelamer carbonate (renvela) 800 mg, give two tablets by mouth with meals for end-stage renal disease; an order dated 07/02/19 for aspirin 81 mg, give one tablet by mouth in the morning for heart failure; an order dated 07/02/19 for clopidogrel bisulfate 75 mg, give one tablet by mouth in the morning for heart failure; an order dated 07/02/19 for multiple vitamins-minerals tablet, give one tablet by mouth in the morning for supplement; an order dated 07/02/19 for pantoprazole sodium tablet delayed release 20 mg, give one tablet by mouth in the morning related for gastro-esophageal reflux disease without esophagitis; an order dated 07/02/19 for spironolactone tablet 25, mg give one tablet by mouth in the morning related to end-stage renal disease; and an order dated 07/16/19 for velphoro tablet chewable 500 mg, give by mouth with meals to prevent low calcium levels. A diet order dated 06/30/19 indicated Resident #50 received a liberal renal diet.
Review of pre-dialysis and post-dialysis documentation for August 2019 verified Resident #50 received dialysis on 08/08/19 (Thursday), and 08/10/19 (Saturday).
Review of Resident #50's August 2019 Medication Administration Record (MAR) indicated a 9 was recorded 08/08/19 for the 9:00 A.M. doses of sevelamer carbonate, aspirin, clopidogrel bisulfate, multiple vitamins-minerals, pantoprazole sodium, spironolactone and velphoro tablets. A 9 indicated there would be a nurses' note written regarding the medication. A 4 was recorded on 08/08/19 for the midodrine hydrochloride doses scheduled at 2:00 P.M. and 10:00 P.M. indicating the medication was outside the parameters for administration. A 9 was recorded for the midodrine hydrochloride dose scheduled for 6:00 A.M. on 08/08/19.
Review of Resident #50's nurses' notes on 08/08/19 indicated the sevelamer carbonate, aspirin, clopidogrel bisulfate, multiple vitamins-minerals, pantoprazole sodium, spironolactone and velphoro tablets were given to the resident to take at dialysis. Review of a single nurses' note dated 08/10/19 did not reveal any information to indicate the medications were given to the resident to take at dialysis.
Interview with Resident #50 on 08/14/19 at 8:34 A.M. revealed the facility recently started sending his medications with him to dialysis. Resident #50 stated he received his medications when he returned to the facility after his dialysis treatments and stated the dialysis center did not administer medications. Resident #50 stated last Thursday (08/08/19) and last Saturday (08/10/19) he was provided with the whole day's worth of medications and the medications were still present in his room.
Interview on 08/14/19 at 9:00 A.M. with Dialysis Technician #605 verified they were familiar with Resident #50 and stated the resident arrived to the dialysis center with medications from the facility and this had been happening for about two weeks. Dialysis Technician #605 said if Resident #50 took any medication at the dialysis center, the dialysis nurse was required to observe the administration.
Interview on 08/14/19 at 9:05 A.M. with Dialysis Registered Nurse (DRN) #606 revealed Resident #50 did not typically come to the dialysis center with medications. DRN #606 denied Resident #50 taking any medications during his treatment on 08/08/19.
Interview on 08/14/19 at 9:44 A.M. with Physician #607 revealed he oversaw Resident #50's medical care at the facility. Physician #607 did not think Resident #50 would be able to self-administer his own medication but it would depend as the resident was alert and oriented, but seemed a little off. Physician #607 was not aware Resident #50 had not received his medications at the facility or at the dialysis center on 08/08/19.
An interview was conducted on 08/14/19 at 9:52 A.M. with the Director of Nursing (DON) and Resident #50. Resident #50 stated he had not taken medication given to him when he went to the dialysis center as they were labeled 11:00 A.M. and he did not have food at that time. Resident #50 pointed to his lunch box during the interview. The DON retrieved three white envelopes containing pills from Resident #50's lunch box, which goes with him to dialysis. Observation of the three medication envelopes revealed one with a notation, 11 A.M. (no date) midodrine five mg; one marked 11 A.M. (no date) with renvela 800 mg (2 tabs) and one marked 5 P.M. (no date) with renvela 800 mg (2 tabs). The DON confirmed Resident #50 did not receive his medications as ordered on 08/08/19 and 08/10/19.
In addition, review of Resident #50's meal ticket revealed he was on a liberal renal diet. Dislikes listed included milk, potatoes, tomato products, dairy products and scrambled eggs.
Observation of Resident #50's breakfast meal on 08/14/19 in his room starting at 8:34 A.M. revealed two bowls of Cheerios cereal, one of which had been consumed, and a banana on his over-bed table. Bananas are high in potassium and people with kidney disease have difficulty filtering out excess potassium, thus foods low in potassium are recommended.
An interview was conducted on 08/14/19 at 8:44 A.M. with Licensed Practical Nurse (LPN) #604 and Registered Dietitian (RD) #601 upon entry into Resident #50's room. RD #601 was asked if a banana was appropriate for a resident on a renal diet and she indicated Resident #50's labs were good.
A follow-up interview on 08/14/19 with RD #601 at 9:24 A.M. verified the banana was not appropriate for Resident #50 since he was on a renal diet and should be added to the dislike list on his meal ticket so he would not receive them.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
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 medication error rate of less than 5%. The fa...
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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 medication error rate of less than 5%. The facility error rate was 18.51%, with 5 errors in 27 opportunities. This affected two of four residents observed for medication pass (Resident #'s 2 and 52).
Findings include:
1. Review of the record of Resident #2 revealed he was admitted to the facility on [DATE] with diagnoses including myasthenia gravis, gastroesophageal reflux disease and iron deficiency.
An observation of medication pass for Resident #2 was made on [DATE] at 8:25 A.M. with Licensed Practical Nurse LPN #613. LPN #613 could not find the correct dose of Ferrous Gluconate (an iron supplement, ordered [DATE]), so LPN # 611, who was nearby, found a box of the medication for LPN #613. LPN #613 popped a tablet into the cup for the resident from a blister sealed package that was in a box. The package and the blister package all were marked with an expiration date of 02/19, (February 2019). LPN #613 then individually put all pill in clear plastic envelopes to crush them in preparation for administration to the resident. The surveyor asked LPN #613 to pause, she verified she was ready to crush the medication but verified after reviewing the box and blister package that the Ferrous Gluconate was expired. She discarded the medication and LPN #611 obtained a new box of the medication which was not expired.
LPN #613 also prepared doses of Omeprazole Delayed Release 20 milligrams (a medication to treat stomach upset, ordered [DATE]) and Potassium Chloride extended release 10 milliequivalents (a potassium supplement, ordered [DATE]) with other medications for Resident #2. The Omeprazole was in a capsule form, but when LPN #613 opened the capsule into a cup, part of the capsule contents were in a more solid form, so she crushed them mechanically, as she did the potassium, stating he took them better if they were crushed.
LPN #613 verified after the medication was given that all of the medications for Resident #2 had been crushed.
Review of a list provided by the facility of medications that should not be crushed prior to administration revealed the Omeprazole and Potassium should not be crushed prior to administration due to the extended release properties of the medications.
The Director of Nursing verified on [DATE] at 4:30 P.M. the medications should not have been crushed and that the nurse should have not have attempted to administer an expired medication.
2. Review of the record of Resident # 52 revealed he was admitted to the facility on [DATE] with diagnoses including history of stroke, vitamin deficiency and hypertension. The resident had a gastrostomy tube, a flexible tube inserted into the stomach through the abdominal wall, through which he received his medications.
Observation of medication pass was conducted for Resident #52 on [DATE] with Licensed Practical Nurse LPN # 612 at 9:32 A.M. LPN #612 prepared multiple medications for Resident #52, including three liquid medications, and five pills or tablets. The medications included Vitamin C two tablets and a dose of Metoprolol (to treat high blood pressure). She prepared the tablets and capsules by either emptying them or crushing them mechanically, putting them into small plastic medication cups.
LPN #612 took all the medications into the room and set them in a line on the nightstand. She began the administration of the medication through the gastrostomy tube, after having mixed a small amount of water into each cup of the crushed medications. She flushed the tube, and then poured the first medication down the tube, flushed again and then poured the second medication down the tube. The two cups with the first two medications contained a significant amount of medication still in the cup that had not mixed in the water and was not administered. LPN #612 continued the medication pass, with all other medications administered in their entirety. After completing the medication pass, LPN #612 began to stack all the medication cups to throw them away. She was stopped by the surveyor and observed the contents remaining in the first two cups. The first cup contained a yellowish medication, which LPN #612 indicated was the Vitamin C. The second cup contained a large amount of pill residual, which was the Metoprolol, the blood pressure medication. LPN #612 verified the amount of medication in the cups was significant and verified the resident had not received the full dose of these medications and would not have if she would have continued to discard the cups. She then did administer the rest of the medications to the resident after the intervention by the surveyor.
Review of the facility policy on Administration of Medications through an Enteral Tube (gastrostomy tube), revised [DATE], revealed the medications should be diluted before administration.
An interview with the Director of Nursing on [DATE] at 4:30 P.M. confirmed the full dose of medication should be administered as ordered.
The medication error rate was 18.51%, with 5 errors in 27 opportunities.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure Resident #50's medications were appropriately st...
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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 Resident #50's medications were appropriately stored and labeled. This affected one resident of one resident reviewed for dialysis.
Findings include:
Review of Resident #50's medical record revealed an admission date of 05/07/18 with diagnoses including obesity, anemia, end stage renal (kidney) disease with dependence on dialysis, diabetes, and hypotension (low blood pressure).
Review of a quarterly Minimum Data Set assessment dated [DATE] revealed Resident #50 was alert and oriented with intact cognition.
Review of a care plan dated 05/16/18 revealed Resident #50 received dialysis treatments on Tuesdays, Thursdays and Saturdays.
Interview with Resident #50 on 08/14/19 at 8:34 A.M. revealed the facility recently started sending medications with him to dialysis. Resident #50 stated he received medications when he returned to the facility after dialysis treatments and stated the dialysis center did not administer medications. Resident #50 stated last Thursday (08/08/19) and last Saturday (08/10/19) he was provided with the whole day's worth of medications and the medications were still present in his room.
An interview was conducted on 08/14/19 at 9:52 A.M. with the Director of Nursing (DON) and Resident #50. Resident #50 stated he had not taken medication given to him when he went to the dialysis center as they were labeled 11:00 A.M. and he did not have food at that time. Resident #50 pointed to his lunch box during the interview. The DON retrieved three white envelopes containing pills from Resident #50's lunch box, which goes with him to dialysis. Observation of the three medication envelopes revealed one with a notation, 11 A.M. (no date) midodrine five mg; one marked 11 A.M. (no date) with renvela 800 mg (2 tabs) and one marked 5 P.M. (no date) with renvela 800 mg (2 tabs).
A follow-up interview with the DON on 08/14/19 at 10:23 A.M. verified the medications in the undated envelopes found in Resident #50's room were not labeled and stored properly.
Review of the policy, Storage of Medications, dated 06/23/19 revealed drugs and biologicals shall be stored in the packaging, containers or other dispensing systems in which they are received. Only the issuing pharmacy was authorized to transfer medications between containers. Drug containers that had missing, incomplete, improper or incorrect labels were to be returned to the pharmacy for proper labeling before storing.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Menu Adequacy
(Tag F0803)
Could have caused harm · This affected multiple residents
Based on observation, interview and menu spreadsheet review the facility failed to ensure meals were provided as planned on the menus. This affected three residents (Resident #43, Resident #62 and Res...
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Based on observation, interview and menu spreadsheet review the facility failed to ensure meals were provided as planned on the menus. This affected three residents (Resident #43, Resident #62 and Resident #85) of three residents on a pureed diet and one resident (Resident #6) of one resident on a level-II mechanically altered diet. The facility census was 81 residents.
Findings include:
Review of the spreadsheet titled, Week 4, Day 3 corresponding to 08/13/19 revealed residents receiving a pureed diet were to receive a #12-scoop of pureed pork, a #8-scoop of pureed potatoes, a #16-scoop of pureed cauliflower, a #16-scoop of pureed bread and a #10-scoop of pureed peanut butter brownie. The spreadsheet indicated residents receiving a level-II mechanically altered diet were to receive ground garlic pork, soft mashed potatoes, soft mashed cauliflower, a #16-scoop of pureed bread and a #10-scoop of pureed peanut butter brownie. The level-II mechanically altered diet consisted of moist and soft foods; meats were to be minced and moistened with sauces or gravies.
Observation of lunch tray service on 08/13/19 starting at 11:37 A.M. revealed Dietary Manager (DM) #600 setting up the tray line. Tray service started at 11:49 A.M. At 11:52 A.M., a puree meal was plated and noted to not receive pureed bread. No other meals were noted to receive pureed bread throughout the observation and pureed bread was not observed on the steam table.
Interview on 08/13/19 at 12:30 P.M. with Registered Dietitian (RD) #601 and Corporate Registered Dietitian (CRD) #602 verified the pureed bread had not been prepared nor provided for the lunch meal.
A follow-up interview on 08/13/19 at 1:45 P.M. with RD #601 and CRD #602 identified Resident #6, Resident #43, Resident #62 and Resident #85 as residents who should have received pureed bread during the lunch meal on 08/13/19.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0921)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the facility failed to maintain clean, functional and sanitary shower rooms. This affected Re...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview the facility failed to maintain clean, functional and sanitary shower rooms. This affected Resident #41, Resident #56 and Resident #61 and affected four of four facility shower rooms, which had the potential to affect all residents residing in the facility, except for 13 residents receiving only bed baths (Residents #8, 9, 15, 29, 35, 40, 43, 48, 50, 52, 62, 70 and 80).
Findings include:
On 08/12/19 at 10:10 A.M. interview with Resident #41 revealed the 200 hall shower room fan was not functioning and had not been since their admission [DATE]). Resident #41 indicated the shower room gets so hot it is difficult to breath and the nurse aides almost pass out from the heat.
Observation on 08/12/19 at 10:20 A.M. in the room of Resident #56 and Resident #61 revealed significant chipped paint, scrapes and scuff marks on the walls by both resident's beds. A large unpainted patched hole was noted on the wall next to the window. An interview with Housekeeper #615 at the time of the observation verified the condition of the walls in this room.
On 08/14/19 a tour of the facility's shower rooms was conducted from 11:34 A.M. until 11:59 A.M. with Maintenance Director (MD) #614. A non-functional ventilation fan was noted in the 100 hall shower room with a missing fan cover which exposed a fan filter covered with dirt and debris. The fan cover was observed on the floor leaning against the wall adjacent to the wall housing the fan. The 200 hall shower room was noted to have a covered ventilation fan with matted debris protruding through the fan cover. MD #614 removed the fan cover and discovered a matted filter tangled around the fan, covered with dirt and debris, and a large clump of matter and debris, described by MD #614 as a bird's nest behind the matted filter. MD #614 declined to turn the fan on and check for functioning due to the condition of the fan. The 300 hall shower room was noted to have a fan which did operate when turned on but made a continuous loud clunking noise until turned off by MD #614. The 500/600 hall shower room was noted to have no fan installed, only one functioning air conditioning unit on the wall adjacent to the bathtub. Each of the four shower rooms were noted to have a hole in the ceiling without a vent cover. Interview with MD #614 during the tour verified the observations and confirmed that the ceiling holes in the four shower rooms were access to the heating, air conditioning and ventilation system of the building. MD #614 further explained the ceiling holes were not equipped with mechanical ventilation, and the fans in the shower rooms were on the schedule to be checked annually.
Interview on 08/14/19 at 12:00 P.M. with State Tested Nursing Assistant (STNA) #609 confirmed the fan in the 200 hall shower room was not functioning, and indicated it had been that way for at least two months.
Interview on 08/14/19 at 12:19 P.M. with STNA #617 verified the fan in the 100 hall shower room had no cover, and stated the fan was not used during showers because it was broken.
Interview on 08/14/19 at 12:25 P.M. with STNA #616 verified there were loud clunking noises made when the 300 hall shower room fan was operated, and stated the fan was not used unless the residents complained that it got too hot.
Interview on 08/14/19 at 2:04 P.M. with MD #614 revealed the shower room fans were not on a list for regular checks and maintenance.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observation, interview, and record review, the facility failed to prepare, store and distribute food in a sanitary kitchen environment. This affected 80 of 81 residents receiving meals from t...
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Based on observation, interview, and record review, the facility failed to prepare, store and distribute food in a sanitary kitchen environment. This affected 80 of 81 residents receiving meals from the kitchen. The facility identified Resident #52 as not receiving food by mouth.
Findings include:
1. Observation of the kitchen on 08/12/19 from 8:30 A.M. to 8:53 A.M. with Dietary Manager (DM) #600 revealed in the walk-in cooler, three of the five blower fans were coated in dust. In the dry storage room, one box of cornbread was noted to be dated 09/24/18. Observation of the hood over the flat-top grill revealed a sticker indicating the hood had last been cleaned on 02/28/19 and a cobweb was noted on the right-most light over the hood. In the dish room, the log to left of the high-temperature dish machine to record dishwasher temperatures was incomplete.
Observation of a dishmachine temperature log for August 2019 revealed there were spaces for staff to document temperatures three times daily. There were only breakfast temperatures recorded on 08/01/19, 08/02/19, 08/03/19, 08/04/19, 08/06/19, 08/07/19, 08/08/19 and 08/09/19 and one lunch temperature recorded on 08/05/19. No temperatures were recorded since 08/09/19. Interview with DM #600 verified these findings at the time of observation.
DM #600 did not know how often cooler fans were cleaned since they had been employed by the facility only since June 2019. DM #600 acknowledged there was a training deficit regarding staff recording dish machine temperatures and said the dietary department had lost five staff members in the last month.
Review of the facility policy for use of the dishwashing machine dated 10/21/13 revealed temperatures would be checked with each machine cycle and staff would record the results in a facility approved log, three times a daily.
Review of the facility policy on kitchen sanitation dated 06/23/16 revealed kitchen surfaces not in contact with food shall be cleaned on a regular schedule and frequently enough to prevent accumulation.
Review of requested cleaning documentation for the last three months revealed the last time any kitchen cleaning was documented as completed was the first week of June, 2019.
2. Observation of nursing unit refrigerators with Registered Dietitian (RD) #601 on 08/12/19 from 8:53 A.M. to 9:08 A.M. revealed on the [NAME] unit, the refrigerator had spilled juice on the bottom surface. Two take-out food containers were unlabeled and undated in this refrigerator.
Observation of the sign (no date) posted on the [NAME] nursing unit refrigerator revealed all items placed in the refrigerator were to be labeled and dated. The sign directed staff to wipe up spills and keep the refrigerator clean.
Interview with RD #601 verified these findings at the time of observation. RD #601 stated staff were to wipe up spills in the refrigerator as they occurred. RD #601 stated food in the nursing unit refrigerators would be safe to eat for three days before needing to be discarded.
Review of the facility policy on Foods Brought by Facility/Visitors dated 04/23/18 revealed perishable foods were to be stored in re-sealable containers with tightly fitting lids in the refrigerator. Containers were to be labeled with the resident's name, the item and the use by date.
Review of the facility policy on food receiving and storage revised 06/23/16 revealed food and snack items on the nursing units were to be labeled with the resident's name, the item and the use by date. Partially eaten food was not to be kept in the refrigerator.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "What changes have you made since the serious inspection findings?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • Licensed and certified facility. Meets minimum state requirements.
Concerns
- • Multiple safety concerns identified: 1 life-threatening violation(s), 4 harm violation(s), $63,642 in fines. Review inspection reports carefully.
- • 45 deficiencies on record, including 1 critical (life-threatening) violation. These warrant careful review before choosing this facility.
- • $63,642 in fines. Extremely high, among the most fined facilities in Ohio. Major compliance failures.
- • Grade F (8/100). Below average facility with significant concerns.
Bottom line: Trust Score of 8/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Arbors At Fairlawn The's CMS Rating?
CMS assigns ARBORS AT FAIRLAWN THE an overall rating of 2 out of 5 stars, which is considered below average nationally. Within Ohio, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is Arbors At Fairlawn The Staffed?
CMS rates ARBORS AT FAIRLAWN THE's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 54%, compared to the Ohio average of 46%.
What Have Inspectors Found at Arbors At Fairlawn The?
State health inspectors documented 45 deficiencies at ARBORS AT FAIRLAWN THE during 2019 to 2025. These included: 1 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 4 that caused actual resident harm, and 40 with potential for harm. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates Arbors At Fairlawn The?
ARBORS AT FAIRLAWN THE 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 ARBORS AT OHIO, a chain that manages multiple nursing homes. With 88 certified beds and approximately 74 residents (about 84% occupancy), it is a smaller facility located in FAIRLAWN, Ohio.
How Does Arbors At Fairlawn The Compare to Other Ohio Nursing Homes?
Compared to the 100 nursing homes in Ohio, ARBORS AT FAIRLAWN THE's overall rating (2 stars) is below the state average of 3.2, staff turnover (54%) is near the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.
What Should Families Ask When Visiting Arbors At Fairlawn The?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the facility's Immediate Jeopardy citations.
Is Arbors At Fairlawn The Safe?
Based on CMS inspection data, ARBORS AT FAIRLAWN THE has documented safety concerns. Inspectors have issued 1 Immediate Jeopardy citation (the most serious violation level indicating risk of serious injury or death). The facility has a 2-star overall rating and ranks #100 of 100 nursing homes in Ohio. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at Arbors At Fairlawn The Stick Around?
ARBORS AT FAIRLAWN THE has a staff turnover rate of 54%, which is 8 percentage points above the Ohio average of 46%. Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was Arbors At Fairlawn The Ever Fined?
ARBORS AT FAIRLAWN THE has been fined $63,642 across 1 penalty action. This is above the Ohio average of $33,715. Fines in this range indicate compliance issues significant enough for CMS to impose meaningful financial consequences. Common causes include delayed correction of deficiencies, repeat violations, or care failures affecting resident safety. Families should ask facility leadership what changes have been made since these penalties.
Is Arbors At Fairlawn The on Any Federal Watch List?
ARBORS AT FAIRLAWN THE is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.