FOX RUN MANOR
For profit - Corporation
120 Beds
HCF MANAGEMENT
Data: November 2025
Trust Grade
45/100
#679 of 913 in OH
Photo by Fox Run Manor
Photo by Fox Run Manor
Photo by Fox Run Manor
1 / 5 photos
Last Inspection: April 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Fox Run Manor has a Trust Grade of D, indicating below-average performance and some concerning issues. It ranks #679 out of 913 facilities in Ohio, placing it in the bottom half, and #5 out of 6 in Hancock County, meaning only one local option is better. However, the facility is showing improvement, reducing issues from 18 in 2024 to just 3 in 2025. Staffing is a strength here, with a 4/5 star rating and 52% turnover, which is average but shows that some staff remain. While there have been no fines, which is positive, there are serious concerns, such as a resident being hospitalized due to dehydration and delays in responding to call lights, sometimes taking up to two hours. Additionally, staff failed to check food temperatures before serving, raising potential health risks. Overall, while there are strengths, families should weigh these serious concerns when considering this facility.
- Trust Score
- D
- In Ohio
- #679/913
- Safety Record
- Moderate
- Inspections
- Getting Better
- Staff Stability ⚠ Watch
- 52% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most Ohio facilities.
- Skilled Nurses ✓ Good
- Each resident gets 49 minutes of Registered Nurse (RN) attention daily — more than average for Ohio. RNs are trained to catch health problems early.
- Violations ⚠ Watch
- 33 deficiencies on record. Higher than average. Multiple issues found across inspections.
45/100
Bottom 26%
Needs review
18 → 3 violations
★★☆☆☆
2.0
Overall Rating
★★★★☆
4.0
Staff Levels
★★★☆☆
3.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2024: 18 issues
2025: 3 issues
The Good
-
4-Star Staffing Rating · Above-average nurse staffing levels
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in staffing levels, fire safety.
The Bad
2-Star Overall Rating
Below Ohio average (3.2)
Below average - review inspection findings carefully
Staff Turnover: 52%
Near Ohio avg (46%)
Higher turnover may affect care consistency
Chain: HCF MANAGEMENT
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 33 deficiencies on record
1 actual harm
May 2025
3 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0604
(Tag F0604)
Could have caused harm · This affected 1 resident
Based on medical record review, staff interview, review of a investigation, and review of the facility policy, the facility failed to ensure residents were not physically restrained in a wheelchair. T...
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Based on medical record review, staff interview, review of a investigation, and review of the facility policy, the facility failed to ensure residents were not physically restrained in a wheelchair. This affected one (Resident #39) of three residents reviewed for restraints. The facility census was 72.
Findings include:
Review of the medical record for Resident #39 revealed an admission date of 07/11/22. Diagnoses included dementia with agitation, anxiety, and psychotic disorder with hallucination.
Review of the Minimum Data Set (MDS) assessment 02/13/25 revealed Resident #39 had moderate impaired cognition, did not exhibit behaviors during the review period, dependent on staff for toileting, and required substantial to maximal assistance from staff for mobility. Resident #39 had a restraint and it was a wander or elopement alarm and it indicated used less than daily.
Review of the plan of care dated 04/02/25 revealed Resident #39 was at risk for wandering or elopement with interventions including the resident will not leave facility unattended, the resident's safety will be maintained, engage the resident in purposeful activity, and identify if there is a certain time of day wandering or elopement attempts occur.
Review of the investigation for Resident #49 revealed on 04/16/25, the situation was during shift report, night shift reported that Resident #49 was restless, hallucinating and combative. The resident was crawling out of bed and attempting to stand or walk. Night shift staff reported the resident was brought to the nursing station for increased monitoring. After the night shift change report, and first shift began working with residents, it was noted that the resident was in the wheelchair with a gait belt wrapped around the wheelchair arms to prevent the resident from falling or standing up again. A CNA immediately removed the gait belt. Unit Manager and or designee notified the resident's family and Medical Director. Medical Director gave orders for labs if no labs have been drawn in the past six weeks. Licensed Social Worker or designee assessed residents' psychosocial well-being with no concerns.
Interview on 05/01/25 at 5:45 A.M. with Certified Nursing Assistant (CNA) #122 stated there was an incident involving Resident #39 which occurred one night (04/16/25) when Resident #49 almost fell out of the wheelchair. CNA #122 verified after Resident #49 stood up from the wheelchair, a gait belt was placed on the front arms of the wheelchair to keep Resident #49 safe from getting hurt when trying to stand up. CNA #122 verified at the time this occurring, it was not meant to be harmful but helpful and did not know it was wrong to do this.
Interview with the Administrator on 05/01/25 at 4:15 P.M. verified there was an investigation completed when informed CNA #122 placed the gait belt on the wheelchair of Resident #49 to keep the resident safe from falling when getting up from the wheelchair. Resident #49 was not harmed, and CNA #122 was suspended until the investigation was concluded.
Review of the employee file for CNA #122 revealed the date of hire of 08/23/24. There was a disciplinary action due to performance and or conduct. The discipline dated 04/16/25 was for carelessness in performance of job duties, observance to safety rules or disregard of common safety practices or failure to use Personal Protective Equipment. The employee was suspended pending investigation.
Review of the facility's policy titled Restraint Policy dated 2016 revealed the resident has the right to be free from any physical or chemical restraint imposed for the purpose of discipline or convenience and not required to treat the resident's medical symptoms. Residents shall not be restrained unless restraints are authorized by a physician in writing, used in an emergency, or requested by an alert oriented resident or representative of the risks and benefits associated with restraint use so that the choice is an informed one. The definition of a restraint are physical restraints are defined as any manual method or physical or mechanical device, material, or equipment attached to the resident's body that the individual cannot move easily, which restricts freedom of movement or normal access to one's body. Physical restraints are not defined by the device used, but rather by the impact the device had on the resident's freedom of movement, functional status and quality of life.
This deficiency represents non-compliance investigated under Complaint Number OH00165184.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
Based on medical record review, review of the facilities Self-Reported Incidents (SRI), staff interview, and review of the facility policy, the facility failed to report an allegation of abuse when a ...
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Based on medical record review, review of the facilities Self-Reported Incidents (SRI), staff interview, and review of the facility policy, the facility failed to report an allegation of abuse when a resident was found to be physically restrained by a gait belt in her wheelchair to the State Survey Agency, the Ohio Department of Health. This affected one (Resident #39) of three residents reviewed for restraints. The facility census was 72.
Findings include:
Review of the medical record for Resident #39 revealed an admission date of 07/11/22. Diagnoses included dementia with agitation, anxiety, and psychotic disorder with hallucination.
Review of the facilities investigation for Resident #49 revealed on 04/16/25, the situation was during shift report, night shift reported that Resident #49 was restless, hallucinating and combative. The resident was crawling out of bed and attempting to stand or walk. Night shift staff reported the resident was brought to the nursing station for increased monitoring. After the night shift change report, and first shift began working with residents, it was noted that the resident was in the wheelchair with a gait belt wrapped around the wheelchair arms to prevent the resident from falling or standing up again. A CNA immediately removed the gait belt. Unit Manager and or designee notified the resident's family and Medical Director. Medical Director gave orders for labs if no labs have been drawn in the past six weeks. Licensed Social Worker or designee assessed residents' psychosocial well-being with no concerns.
Review of the SRIs revealed there was no allegation of abuse reported to the State Survey Agency involving Resident #39 being found physically restrained by a gait belt to her wheelchair.
Interview on 05/01/25 at 5:45 A.M. with Certified Nursing Assistant (CNA) #122 stated there was an incident involving Resident #39 which occurred one night (04/16/25) when Resident #49 almost fell out of the wheelchair. CNA #122 verified after Resident #49 stood up from the wheelchair, a gait belt was placed on the front arms of the wheelchair to keep Resident #49 safe from getting hurt when trying to stand up. CNA #122 verified at the time this occurring, it was not meant to be harmful but helpful and did not know it was wrong to do this.
Interview with the Administrator on 05/01/25 at 4:15 P.M. verified there was an investigation completed when they were informed that CNA #122 placed the gait belt on the wheelchair of Resident #49 to keep the resident safe from falling when getting up from the wheelchair. The Administrator verified this allegation of abuse was not reported to the Ohio Department of Health. The Administrator explained he did not feel this was done to be abusive. Resident #49 was not harmed, and the staff member was suspended until investigation was concluded.
Review of the policy titled Abuse, Neglect, Injuries of Unknown Origin and or Misappropriation of Resident Property revealed the definition which included as the willful act of of unreasonable confinement resulting in mental anguish. The administrator or designee will notify Ohio Department of Health of all alleged violations as soon as possible, but in no event later then twenty-four hours from the time of incident was made known to the staff member.
This deficiency represents non-compliance investigated under Complaint Number OH00165184.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, staff interview, and review of the facility policy, the facility failed to ensure u...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, staff interview, and review of the facility policy, the facility failed to ensure urinary catheter care was performed with proper infection control procedures. This affected one (Resident # 42) of three residents reviewed for catheter care. The facility census was 72.
Findings include:
Review of the medical record for Resident #42 revealed admission date of 11/05/24. Diagnoses included malignant neoplasm of bladder obstructive and reflux uropathy, urinary tract infection, infection and inflammatory reaction to catheter and methicillin resistant staphylococcus aureus.
Review of the physician's orders dated 04/05/25 revealed an order for an indwelling catheter care every shift.
Review of the significant change Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #42 had intact cognition, had impaired bilaterally lower extremities, dependent on staff for toileting, and had an indwelling catheter.
Review of the plan of care dated 04/11/25 revealed the indwelling catheter was due to uropathy with interventions including provide catheter care per order and as needed.
Observation of catheter care on 05/01/25 at 11:40 A.M. revealed Certified Nurse Assistant (CNA) #136 was providing catheter care to Resident #42. CNA #136 gathered a basin of warm water, three washcloths, one towel and liquid wash solution. CNA #136 placed the washcloths in the basin, took one washcloth out of the basin, and placed the liquid wash solution on the washcloth. CNA #136 cleaned the tube of the catheter which had a moderate amount of yellow film. CNA #136 then placed the used washcloth back into the basin and took out another washcloth from the now contaminated water basin and rinsed the soap off from the catheter. This second used washcloth also was placed back into the contaminated basin. CNA #136 took out the washcloth previously used to clean the tubing out of the contaminated water basin, placed liquid wash solution on it, and cleaned around the end of the penis. The used washcloth was placed back into the basin and the washcloth used to rinse the tubing was taken out of the contaminated water basin and used it to rinse around the penis. CNA #136 dried of the penis and tubing with the towel.
Interview with CNA #136 on 05/01/25 at 11:58 A.M. verified they placed the washcloths back into the basin which contaminated the water, continued to use and reuse two of the washcloths from the contaminated basin, and only used two of three washcloths that were originally placed into the basin.
Interview on 05/01/25 at 12:15 P.M. with the Regional Nurse #200 verified the facility had some issues with the CNAs using washcloths in the basin and placing them back into the basin which contaminated the water. The CNAs have been redirected several times to bring in a bag to place the dirty washcloth in and to not place it back into the basin.
Review of the facility's policy titled Indwelling Catheter dated 11/13/17 revealed a resident who enters the facility without an indwelling catheter is not catheterized unless the resident's clinical condition demonstrates that catheterization was necessary. Residents who are incontinent of bowel or bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible.
This deficiency represents non-compliance investigated under Complaint Number OH00165263.
Nov 2024
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, resident interview, and staff interview, the facility failed to clarify and impleme...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, resident interview, and staff interview, the facility failed to clarify and implement a physician order. This affected one (#70) of three residents reviewed for wound care. The facility census was 76.
Findings include:
Review of the medical record review revealed Resident #70 was admitted on [DATE]. Diagnoses included fracture of unspecified part of neck of right femur, hypertensive chronic kidney disease with stage 5 chronic kidney disease or end stage renal disease, unspecified osteoarthritis, essential hypertension, and polymyalgia.
Review of the Minimum Data Set (MDS) assessment, dated 10/29/24, revealed the resident was cognitively intact and required substantial assistance with toileting, showers, and upper/lower body dressing. Resident #70 was occasionally incontinent of bladder and frequently incontinent with bowel. Resident #70 had a surgical wound.
Review of the most recent care plan revealed Resident #70 had a deep tissue injury to the left heel and wound on the right hip. Interventions included to provide wound care treatment per physician order.
Review of physician order, dated 11/12/24 and 11/13/24, revealed an order for the right hip wound. The order read: Keep clean and dry. Apply non prescriber adherent dressing daily. Monitor for warmth, redness, increased swelling or pain. Notify medical doctor if signs or symptoms of infection occur. Every 24 hours as needed for drainage.
Review of the hand-written physician order, dated 11/12/24, revealed the right hip wound was slow to heal. Non-adherent bandage as needed for drainage, may leave open to air.
Review of the Treatment Administration Review (TAR), dated November 2024, revealed the order was categorized as a as needed (PRN) order. Review of the TAR verified Resident #70 had a right hip wound dressing changed one time on 11/24/24.
Interview on 11/26/24 at 9:00 A.M. with Resident #70 revealed the wound dressing for the surgical wound on her right hip does not always get changed like it should.
Observation on 11/26/24 at 9:07 A.M. of Resident #70's right hip wound dressing revealed the dressing was dated 11/23/24.
Interview on 11/26/24 at 9:07 A.M. with Licensed Practical Nurse (LPN) #134 verified the dressing was dated 11/23/24.
Interview on 11/26/24 at 9:52 A.M. with the Director of Nursing (DON) verified Resident #70's right hip wound physician order was unclear. The DON reported the order should have allowed the wound to be open to air and to apply non-adherent bandage for drainage. The DON verified if a dressing was applied it should be changed daily.
This deficiency represents non-compliance investigated under Complaint Number OH00159369.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, staff interview, and review of facility policy the facility failed to ensure adequa...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, staff interview, and review of facility policy the facility failed to ensure adequate infection control measures for indwelling catheters. This affected one (#22) of three residents reviewed for infection control. The facility census was 76.
Findings include:
Review of the medical record for Resident #22 revealed the resident was admitted on [DATE]. Diagnoses included chronic multifocal osteomyelitis right femur, pressure ulcer of right hip stage 4, quadriplegia, chronic kidney disease stage I, essential hypertension, major depressive disorder, and neuromuscular dysfunction of bladder.
Review of the Minimum Data Set (MDS) assessment, dated 10/18/24, revealed the resident interview was not successful. Resident #22 required substantial assistance with eating, oral hygiene, and upper and lower body dressing. The resident had an indwelling catheter.
Review of the most recent care plan revealed Resident #22 had a suprapubic catheter. The resident insists the catheter bag be placed on the floor without a cover as he wants to see it when lying in bed. Staff to place bag in basin when on the floor and the bag to be on the floor without a cover due to resident insistence.
Observation on 11/25/24 at 9:10 A.M. revealed Resident #22's catheter bag was laying on the floor with no basin in place.
Interview on 11/25/24 at 9:29 A.M. with Certified Nursing Assistant (CNA) #100 verified Resident #22's catheter bag was laying on the floor with no basin or barrier in place.
Observation on 11/25/24 at 1:20 P.M. revealed Resident #22 in the common area and resident hallway in his electric wheelchair. Approximately eight inches of Resident #22's catheter tubing was dragging along the floor.
Interview on 11/25/24 at 1:32 P.M. with the Director of Nursing (DON) verified the catheter tubing was dragging on the ground.
Review of policy, Indwelling Catheter, dated 11/13/17, verified residents who are incontinent of bowel/bladder receive appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible.
Oct 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to ensure a resident was provided dignity during meal service. Thi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to ensure a resident was provided dignity during meal service. This affected one resident (#12) of one resident reviewed for meal assistance. The facility census was 78.
Findings include:
Review of medical record for Resident #12 revealed an admission date of 03/30/23 with diagnoses including but not limited to Alzheimer' disease, abnormal posture, depression, anxiety, dysphagia, and pseudobulbar affect.
Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #12 had severe cognitive impairment. Resident #12 was dependent on staff for eating.
Observation on 10/15/24 at 12:10 P.M. of meal time revealed State Tested Nursing Assistant (STNA) #302 placed Resident #12 at the table to feed the resident lunch. STNA #12 stood on the residents left side and began to feed Resident #12 applesauce. STNA #302 stopped feeding the resident to take another resident from the dining room. STNA #302 returned to the resident and resumed feeding the resident after taking the other resident from the dining room. STNA #302 continued to stand while feeding. STNA #302 stopped feeding the resident to get a cup of ice for another resident then returned to Resident #12 to continue feeding. STNA #302 was observed talking to other residents across the dining room while assisting Resident #12.
Interview on 10/15/24 at 12:24 P.M. with Licensed Practical Nurse (LPN) #164 verified STNA #302 stood while feeding Resident #12 and stopped feeding the resident twice to assist two other residents.
Interview on 10/15/24 at 12:26 P.M. with STNA #302 verified she stood while feeding Resident #12. STNA #302 verified she stopped feeding Resident #12 twice to assist other residents. STNA #302 verified she talked to other residents across the dining room while feeding Resident #12.
Apr 2024
15 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, resident interview, and staff interview, the facility failed to timely respond to t...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, resident interview, and staff interview, the facility failed to timely respond to the resident's call light. This affected one (#70) of 18 residents observed for call lights. The facility census was 77.
Findings include:
Review of the medical record revealed Resident #70 was initially admitted on [DATE] and readmitted on [DATE]. Diagnoses included muscle weakness, difficulty in walking, pressure ulcer of left heel, right buttock, and left buttock, and osteoarthritis.
Review of the Minimum Data Set (MDS) assessment, dated 03/06/24, revealed Resident #70 was cognitively intact. Resident #70 was dependent on staff for toileting, shower/bathing, upper and lower body dressing, and personal hygiene. The resident as frequently incontinent of urinary continence and bowel incontinence.
Review of the most recent care plan revealed Resident #70 had an activities of daily living (ADL) self-care performance due to decreased mobility and incontinence. Resident #70 required one staff participation for transfers and to use the toilet.
Observation on 04/02/24 at 3:28 P.M. revealed Resident #70's call light was on for an unknown amount of time. Continuous observation revealed Resident #70's call light remain unanswered through 4:29 P.M. This was one hour and one minute later.
Interview on 04/02/24 at 3:57 P.M. with Resident #70 verified she was waiting for assistance with turning off overhead light and needed to use the bathroom.
Interview on 04/02/24 at 4:28 P.M. with Registered Nurse (RN) #257 verified the state tested nursing aides were unavailable assisting other residents and RN #257 was providing medication administration. RN #257 was notified of Resident #70's call light alerting for at minimum one hour. RN #257 answered Resident #70's call light at 4:29 P.M.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
Based on record review, staff interview, and policy review, the facility failed to ensure the physician was notified of the resident's significant weight change. This affected one (Resident #27) of tw...
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Based on record review, staff interview, and policy review, the facility failed to ensure the physician was notified of the resident's significant weight change. This affected one (Resident #27) of two residents reviewed for nutrition. The facility census was 77.
Findings include:
Review of the medical record for Resident #27 revealed a readmission date of 02/19/24. Diagnoses included acute on chronic combined systolic (congestive) and diastolic (congestive) heart failure. Review of the Minimum Data Set (MDS) assessment, dated 02/23/24, revealed the resident was cognitively intact.
Review of Resident #27's weights revealed the following weights were obtained: 192.0 pounds on 02/19/24 and 179.4 pounds on 03/20/24. This was a 6.56 percent (%) significant weight loss in less than one month. There was no documentation indicating the physician was notified of Resident #27's significant weight loss from 03/20/24 to 04/03/24.
Interview on 04/04/24 at 12:03 P.M. with Dietary Tech #346 confirmed she reviews weight changes weekly and reports significant changes to the physician. Dietary Tech #346 verified the physician was not notified of Resident #27's significant weight loss.
Review of the Weight Policy Scales, dated 03/2017 revealed the clinical technician/Registered Dietitian will notify the physician of the resident's weight gain or loss and nursing will notify the family.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0655
(Tag F0655)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to develop a baseline care plan with the minimum necessary infor...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to develop a baseline care plan with the minimum necessary information to include activities of daily living (ADL) information for two residents (Resident #57 and #332), skins concerns, psychotropic medications and anticoagulation medication information for one resident (Resident #332). This affected two residents (Resident #57 and #332) of two residents reviewed for baseline care plan. The facility census was 77.
Findings include:
1. Record review of Resident #57 revealed she admitted to the facility on [DATE]. Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, pain in right hip bursitis, and cerebral infarction due to unspecified occlusion or stenosis of unspecified middle cerebral artery.
Review of the physician orders dated 01/12/24 revealed a pressure reducing cushion to chair when out of bed for prevention, monitor for signs and symptoms of bruising / bleeding-anticoagulant therapy every shift for prophylactic , monitor for signs and symptoms of dehydration: unquenchable thirst, dry/sticky mouth, decreased urine output, dark-colored urine, unexplained tiredness, dizziness, confusion, notify physician if yes.
Review of the baseline care plan dated 01/13/24 revealed Resident #57 was to discharge home or to another facility, had skin concerns, has increased nutrition needs, and was on anticoagulant therapy. There was no information found in the baseline care plan related to Resident #57's required activities of daily living needs (ADLs).
Interview on 04/02/24 at 12:59 P.M. with Licensed Practical Nurse (LPN) #247 indicated pertinent diagnoses, physician orders, ADL information, skin concerns, anticoagulant and psychotropic use information should be included in baseline care plans and confirmed Resident #57's baseline care plan did not include information related to ADLs.
Interview on 04/03/24 at 2:42 P.M. with the Director of Nursing confirmed the baseline care plan was not complete and did not contain information for ADLs on Resident #57.
2. Record review of Resident #332 revealed he admitted to the facility on [DATE]. Diagnoses included sepsis, urinary tract infection, extended spectrum beta lactamase (ESBL) resistance, infection and inflammatory reaction due to indwelling urethral catheter, disorientation, congestive heart failure, weakness, atrial flutter, and diabetes mellitus.
Review of the physician orders dated 03/27/24 revealed the resident was to be monitored for signs and symptoms of bruising/bleeding due to anticoagulant therapy, was to receive apixaban (anticoagulant) 2.5 milligrams (gm) daily for atrial flutter and atherosclerotic heart disease, amitriptyline (tricyclic antidepressant) 10 milligrams (mg) daily at bedtime for depression, trazodone 50 mg daily for insomnia / depression.
Review of the baseline care plan dated 03/27/24 revealed Resident #332 was to discharge home or to another facility, was on antibiotics, and was using oxygen. There was no information found in the baseline care plan related to Resident #332's required activities of daily living needs (ADLs), skins concerns, psychotropic medications usage and anticoagulation medication usage.
Interview on 04/02/24 at 12:59 P.M. with Licensed Practical Nurse (LPN) #247 indicated pertinent diagnoses, physician orders, ADL information, skin concerns, anticoagulant and psychotropic use information should be included in baseline care plans and confirmed Resident #332's baseline care plan did not include information related to ADLs, skin concerns, anticoagulant use or psychotropic use.
Interview on 04/03/24 at 2:42 P.M. with the Director of Nursing (DON) confirmed the baseline care plan was not complete and did not contain information for ADLs on Resident #332. The DON confirmed the baseline care plan did not include anticoagulant use, psychotropic use or skin concerns for Resident #332.
Interview on 04/09/24 at 12:35 P.M. with the Administrator stated the facility does not have a policy for baseline care plans.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, staff interview, and policy review, the facility failed to ensure Resident #57 had a comple...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, staff interview, and policy review, the facility failed to ensure Resident #57 had a complete comprehensive care plan. This affected one (Resident #57) of 18 residents reviewed for comprehensive care plans. The facility census was 77.
Findings include:
Record review of Resident #57 revealed an admission date to the facility of 01/12/24. Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, pain in right hip bursitis, and cerebral infarction due to unspecified occlusion or stenosis of the middle cerebral artery.
Review of the significant change Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #57 was cognitively intact and had functional limitation impairment in range of motion to bilateral upper and lower extremities, required substantial assistance from staff with toileting hygiene, bathing, dressing, personal hygiene and was dependent on staff for bed mobility and transfers.
Review of the current care plan was silent for activities of daily living (ADLs).
Observation on 04/02/24 at 12:58 P.M. revealed Resident #57 transferred to a wheelchair by use of a Hoyer lift by State Tested Nursing Assistants (STNA) #306 and #308.
Interview on 04/02/24 at 12:59 P.M. with Licensed Practical Nurse (LPN) #247 indicated activities of daily living (ADL) information should be included in the comprehensive care plan and confirmed Resident #57's care plan did not include information related to ADLs.
Interview on 04/03/24 at 2:42 P.M. with the Director of Nursing (DON) confirmed Resident #57's current care plan did not address ADLs.
Review of the facility's Comprehensive Care Plan policy, dated 11/02/16, revealed the facility will develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, mental and psychosocial needs that were identified in the comprehensive assessment. The care plan must include the following: The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. A comprehensive care plan must be developed within seven days after the completion of the comprehensive assessment.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the medical record for Resident #67 revealed an admission date of 11/22/22 with diagnoses of dementia and hypertens...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the medical record for Resident #67 revealed an admission date of 11/22/22 with diagnoses of dementia and hypertension. Review of the quarterly Minimum data set (MDS) assessment dated [DATE] revealed Resident #67 had impaired cognition. Resident #67 had no falls since the previous assessment completed 11/30/23.
Review of the progress notes dated 03/16/24 revealed Resident #67 was found on the floor in her bedroom with feces on her hands, clothing, and on the floor at 3:12 P.M A large bump was noted on her forehead. Resident #67 was assessed, was alert and interactive, and was sent to the hospital via emergency transport for assessment. Resident #67 returned to the facility on [DATE] at 11:16 P.M. with no new orders.
Review of the interdisciplinary team (IDT) progress note dated 04/02/24 revealed Resident #67's fall was reviewed and a new intervention was developed for staff to assist Resident #67 with toileting.
Review of the current care plan for Resident #67 revealed she was at risk for falls and fall related injuries. An intervention was added 04/02/24 for assistance by one person with toileting.
Interview on 04/02/24 at approximately 2:00 P.M. with State Tested Nursing Aide (STNA) #319 revealed she was familiar with Resident #67 and said she rarely fell. STNA #319 was aware of Resident #67's recent fall with facial bruising and stated the new intervention was to monitor Resident #67 more frequently.
Interview on 04/09/24 at 4:06 P.M. with the Director of Nursing (DON) verified the IDT team developed a fall intervention for Resident #67 after her fall on 03/16/24, but did not add it to the care plan until 04/02/24. The DON stated she was responsible for updating care plans with fall interventions.
Review of the facility policy titled Fall Reduction Policy, dated 04/29/16, revealed if a resident experiences a fall, follow-up investigations will be done to ascertain the cause of the incident to reduce the risk of further occurrences. The policy provided no guidance regarding updating the care plan with interventions to address the identified cause of the incident.
Review of the facility policy titled Comprehensive Care Plan, dated 11/2016, revealed the facility would develop a comprehensive person-centered care plan for to meet each resident's medical and nursing needs, and the care plan would be periodically reviewed and revised after each assessment. The policy provided no guidance regarding the revision of a care plan after an accident or event.
Based on resident and staff interview, record review, and review of the facility policies, the facility failed to ensure comprehensive care plans were updated timely. This affected two (#56 and #67) of 18 residents reviewed for comprehensive care plans. The facility census was 77.
Findings included :
1. Review of the medical record for Resident #56 revealed an admission date of 11/17/22. The resident was admitted with diagnoses including urinary tract infection (UTI) and muscle weakness. The resident was discharged on 03/23/24 to hospital and readmitted on [DATE].
Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #56 had moderately impaired cognition. The resident required substantial or maximum assistance from staff for toileting and was always incontinent of bowel and bladder.
Review of the physician's orders revealed an order dated 03/31/24 for check and change brief every two hours and as needed.
Review of the care plan relative to bowel and bladder incontinence revealed interventions which included to assist with incontinence care as needed and monitor for signs or symptoms of urinary tract infection. The care plan was not updated with the new intervention which included every two hour check and change.
Interview on 04/02/24 at 10:30 A.M. with Resident #56 revealed the staff had gotten her up at 7:00 A.M, and had changed her depends. Resident #56 was concerned with staff not getting her changed every two hours like they should be. Resident #56 stated she was anxious due to being in the hospital with a urinary tract infection which caused sepsis. She does not want to get this sick again. Resident #56 believes she got the infection because they would let her set for hours in urine and feces.
Interview with the Director of Nursing on 04/09/24 at 9:31 A.M. verified Resident #56's care plan had not been updated with the new orders she received when coming back from the hospital of check and change every two hours.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the medical record for Resident #64 revealed an admission date of 06/06/22 with diagnoses of ataxia and dysphagia.
...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the medical record for Resident #64 revealed an admission date of 06/06/22 with diagnoses of ataxia and dysphagia.
Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #64 had intact cognition and was dependent on staff for personal hygiene.
Review of the current care plan for Resident #64 revealed she had an activities of daily life self care performance deficit related to weakness and would demonstrate use of adaptive devices to increase her ability with personal hygiene.
Review of the care provided by staff to Resident #64 revealed she received extensive assistance or was totally dependent on staff for personal hygiene at least twice daily between 03/13/24 and 04/09/24.
Observation on 04/01/24 at 10:42 A.M. with Resident #64 revealed she had several long chin hairs. Interview at that time with Resident #64 revealed she was aware she had long chin hairs and would like them shaved. Resident #64 stated staff did not offer to shave her on a regular basis.
Interview and observation on 04/02/24 at 2:06 P.M. revealed Resident #64 lying in bed. Resident #64 continued to have long chin hairs. Resident #64 stated she did not ask staff to shave her because she felt staff would not be willing to provide the care. Resident #64 stated she was supposed to shower the next day (04/03/24).
Observation on 04/03/24 at 9:34 A.M. revealed Resident #64 sitting in a chair in her room. Long chin hairs remained present on her chin.
Interview and observation on 04/04/24 at 7:56 A.M. revealed Resident #64 sitting in dining room with long hairs present on her chin. Resident #64 stated she was offered a shower the previous day but refused it because it was offered too late in the day.
Interview and observation on 04/04/24 at 9:05 A.M. with State Tested Nurse Aide (STNA) #319 confirmed she assisted Resident #64 out of bed that morning and worked with her on Monday and Tuesday this week. STNA #319 stated shaving normally occurs during showers and knew Resident #64 was scheduled for a second shift shower. STNA #319 confirmed Resident #64's chin hair appeared like it had not been shaved in over a week.
Based on medical record review, observation, resident and resident representative interview, and staff interview, the facility failed to ensure residents who were dependent on staff for activities of daily living (ADL) had their personal care needs met. This affected two (#10 and #64) of seven residents reviewed for ADL. The facility census was 77.
Findings include:
1. Review of the medical record revealed Resident #10 was admitted on [DATE]. Diagnoses included muscle weakness, major depressive disorder, and psychotic disorder with hallucinations due to known physiological conditions.
Review of the Minimum Data Set (MDS) assessment, dated 01/26/24, revealed the resident was severely cognitively impaired and required substantial/maximum assistance from staff with personal hygiene.
Review of the most recent care plan revealed Resident #70 had ADL self care performance due to weakness and had impaired cognitive function/dementia or impaired though processes due to advanced age.
Review of the shower task documentation, dated the last 14 days, revealed Resident #10 received a shower or bath on 03/23/24, 03/27/24, 03/30/24, and 04/03/24.
Observation on 04/01/24 at 3:25 P.M. revealed Resident #10 to have numerous (approximately 20 or more) grown out white stubble chin hairs.
Interview on 04/01/24 at 3:28 P.M. with Resident #10's representative revealed Resident #10's chin hairs were too long and the family always ends up trimming/shaving them. Resident #10's representative stated it would be preferable if the facility would meet the resident's personal hygiene requirements.
Observation on 04/04/24 at 3:27 P.M. revealed Resident #10 continued to have numerous outgrown stubble chin hairs.
Interview on 04/04/24 at 3:29 P.M. with State Tested Nursing Assistant (STNA) #280 verified residents were shaved on their shower days. STNA #280 verified Resident #10's chin hairs were outgrown and in need of trimming.
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 staff interview, record review, and review of the facility policies, the facility failed to ensure the interdisciplinar...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, record review, and review of the facility policies, the facility failed to ensure the interdisciplinary team reviewed falls timely, and interventions were developed and implemented timely. This affected one (#67) of two residents reviewed for falls. The facility census was 76.
Findings include:
Review of the medical record for Resident #67 revealed an admission date of 11/22/22 with diagnoses of dementia and hypertension.
Review of the Nursing Fall Review assessment dated [DATE] revealed Resident #67 was at moderate risk for falls.
Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #67 had impaired cognition. Resident #67 had no falls since the previous assessment completed 11/30/23.
Review of the current care plan for Resident #67 revealed she was at risk for falls and fall related injuries. An intervention was added 04/02/24 for assistance of one staff with toileting.
Review of the progress notes dated 03/16/24 revealed Resident #67 was found on the floor in her bedroom with feces on her hands, clothing, and on the floor at 3:12 P.M. A large bump was noted on her forehead. Resident #67 was assessed, was alert and interactive, and was sent to the hospital via emergency transport for assessment. Resident #67 returned to the facility on [DATE] at 11:16 P.M. with no new orders.
Review of the hospital records dated 03/16/24 revealed Resident #67 had no fractures or intracranial (inside the skull) abnormality.
Review of a physician progress note dated 03/18/24 revealed Resident #67 was sent to the emergency room after a fall on 03/16/24. Resident #67 suffered a contusion and hematoma to the left forehead. Bruising was noted down her face. Resident #67 was verbal and at baseline, not oriented but her responses to questions were appropriate. The right eye was clear and the left eye was completely closed by the upper and lower eyelid hematoma. There was a hematoma and swelling of the forehead above the eye. Resident #67 had bruising extending down the upper part of her left cheek.
Review of the interdisciplinary team (IDT) progress note dated 04/02/24 revealed Resident #67's fall was reviewed and a new intervention was developed for staff to assist Resident #67 with toileting.
Observation and interview on 04/01/24 at 10:38 A.M. with Resident #67 revealed she had purple/green bruising down the left side of her face. Resident #67 stated was aware of the bruising, but could not recall the cause.
Interview on 04/02/24 at approximately 2:00 P.M. with STNA #319 revealed she was familiar with Resident #67 and said she rarely fell. STNA #319 was aware of Resident #67's recent fall with facial bruising and stated the new intervention was to monitor Resident #67 more frequently.
Interview on 04/09/24 at 4:06 P.M. with the Director of Nursing (DON) verified the IDT team developed a fall intervention for Resident #67 after her fall on 03/16/24, but did not implement it by adding it to the care plan until 04/02/24. Additionally, the DON could provide no evidence the facility investigated the fall prior to 04/02/24 when the IDT progress note was entered in Resident #67's record.
Review of the facility policy titled Accidents and Incidents Policy, revised 04/2016, revealed the facility must conduct an investigation of the accident or incident ASAP (as soon as possible).
Review of the facility policy titled Fall Reduction Policy, dated 04/29/16, revealed if a resident experiences a fall, follow-up investigations will be done to ascertain the cause of the incident to reduce the risk of further occurrences. The policy provided no guidance regarding updating the care plan with interventions to address the identified cause of the incident.
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 medical record review, observation, resident interview and staff interview, the facility failed to ensure the residents...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, resident interview and staff interview, the facility failed to ensure the residents were provided incontinence care timely. This affected two (#56 and #72) of three residents reviewed for incontinence care. The facility census was 77.
Findings include:
1. Review of the medical record for Resident #56 revealed admission date of 11/17/22. The resident was admitted with diagnoses including urinary tract infection (UTI) and muscle weakness. The resident was discharged on 03/23/24 to hospital and readmitted on [DATE].
Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #56 had moderately impaired cognition. The resident required substantial or maximum assistance from staff for toileting and was always incontinent of bowel and bladder.
Review of the physician's orders revealed an order dated 03/31/24 to check and change brief every two hours and as needed.
Review of the care plan relative to bowel and bladder incontinence revealed interventions which included to assist with incontinence care as needed and monitor for signs or symptoms of urinary tract infection. The care plan was not updated with the new intervention which included every two hour check and change.
Interview on 04/02/24 at 10:30 A.M. with Resident #56 revealed the staff had gotten her up at 7:00 A.M, and had changed her depends. Resident #56 was concerned with staff not getting her changed every two hours like they should be. Resident #56 stated she was anxious due to being in the hospital with an urinary tract infection which caused sepsis. She does not want to get this sick again. Resident #56 believes she got the infection because they would let her set for hours in urine and feces.
Observation on 04/02/24 at 12:40 P.M. revealed Resident #56 was taken from the dining room to her room for incontinence care. State Tested Nurse Aide (STNA) #272 and STNA #271 returned the resident to bed via Hoyer lift. Resident #56 was saturated through to her pants in front and back. The resident's brief was saturated with urine and feces.
Interview with STNA #272 on 04/02/24 at 12:40 P.M. verified Resident #56 was last checked and changed at 7:00 A.M. upon getting her up this morning. STNA #272 verified she usually tried to get her changed before lunch but her assignment had quite a few check and changes, and they were not able to get all residents changed every two hours.
Interview with STNA# 325 on 04/04/24 at 5:20 A.M. revealed her assignment included Resident #56. STNA #325 stated on third shift, there were times when you work alone on the hall, there was no way to get check and changes completed every two hours due to having 18 residents to check and change. Third shift also had 13 residents to get up each night with 11 of them being a Hoyer or sit-to-stand which required two persons.
2. Review of the medical record of Resident #72 had an admission date of 10/04/23 with diagnoses of schizoaffective disorder, periprosthetic fracture of right knee, and difficulty in walking.
Review of the physician orders revealed an order for non-weight bearing to right lower extremities and wear all times.
Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #72 was cognitively intact. He required maximum assistance from staff with toileting and activities of daily living (ADL).
Review of the plan of care revealed the resident required assistance with ADLs related to fracture of right knee prothesis and leg brace. Interventions included the resident was dependent on one or two staff assistance. The plan of care for bladder incontinence included interventions to check him frequently as tolerated for incontinence. Wash, rinse and dry perineum. Change clothing as needed after incontinence episodes.
Continuous observation and interview with Resident #72 on 04/01/24 from 10:10 A.M. to 10:40 A.M. revealed staff did not enter Resident #72's room during these 30 minutes. Resident #72 stated he had his call light on prior to 10:10 A.M. and staff came into the room and turned off his call light. The resident informed the staff that he wet his pants and the staff responded to him that they needed to help someone else first. Resident #72's room smelled of urine and his shorts were noticeably wet.
Interview and observation on 04/01/24 at 10:40 A.M. revealed STNA #271 and STNA #272 entered Resident #72's room to provide incontinence care. STNAs #271 and #272 verified they had answered the call light prior and saw his pants were wet with urine, and explained they would have to come back later to clean him up. They had to get up another resident who was paraplegic. STNAs #271 and #272 stated they do not have enough staff for the resident's acuity levels at the facility.
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 record review, observation, staff interviews, and policy review, the facility failed to ensure staff used appropriate p...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, staff interviews, and policy review, the facility failed to ensure staff used appropriate personal protective equipment (PPE) while in Resident #332's room who was positive for extended spectrum beta lactamase (ESBL) resistance. Additionally, the facility failed to ensure a resident's catheter bag was not on the floor. The affected two residents (Resident #34 and #332) observed during the annual survey. The facility census was 77.
Findings include:
1. Review of the medical record for Resident #332 revealed an admission date of 03/27/24. Diagnoses included sepsis, urinary tract infection, extended spectrum beta lactamase (ESBL) resistance, infection and inflammatory reaction due to indwelling urethral catheter.
Review of Resident #332's physician orders dated 03/27/24 revealed an order for Ertapenem (antibiotic) 1,000 milligrams intravenously daily related to sepsis, organism unspecified.
Review of the Brief Interview for Mental Status (BIMS) dated 03/29/24 revealed Resident #332 has moderately impaired cognition.
Review of Resident #332's care plan dated 03/27/24 revealed the resident has an active infection of ESBL and will be on contact precautions until resolved.
Observation on 04/01/24 at 11:03 A.M. revealed a Contact Isolation sign on the door of Resident #332's room. Observation also revealed Physical Therapy Assistant (PTA) #347 and Certified Occupational Therapy Assistant (COTA) #348 were in Resident #332's room without a gown or gloves on.
Interview on 04/01/24 at 11:04 A.M. with PTA #347 and COTA #348 confirmed they know they should have had the proper personal protective equipment (PPE) on which was gown and gloves. Both voiced they just seen the resident's friend in the room and went on in without putting any PPE on.
Interview on 04/01/24 at 11:06 A.M. with Licensed Practical Nurse (LPN) #236 confirmed Resident #332 was in contact isolation and all staff who enter the room needs to wear a gown and gloves when entering the room and must wash their hands prior to exiting the room. LPN #236 confirmed there was not a physician's order for contact isolation, but there should be and she will take care of that now.
Observation on 04/01/24 at 4:24 P.M. revealed State Tested Nursing Assistant (STNA) #282 was in Resident #332's room with Resident #332 without PPE of gown or gloves. STNA #282 was touching the bedside table and talking to the resident and resident's friend. STNA #282 exited the room without washing his hands or using hand sanitizer.
Interview on 04/01/24 at 4:24 P.M. with STNA #282 confirmed PPE was not worn while in the room with Resident #332 and that he did not wash his hands or use hand sanitizer prior to exiting the room.
Review of the facility's Standard Precautions Policy, dated 08/2022, revealed it is the policy of this facility to use Transmission Based Precautions in addition to Standard Precautions for a resident with documented or suspected infection or colonization with highly transmissible epidemiologically important pathogens for which additional precautions are necessary. Personal protective equipment: Gloves are indicated for all staff and visitors entering the room. Gloves should be changed after having contact with infective material. Hand hygiene is performed before and after removing gloves; after touching potentially contaminated environmental surfaces or items and before caring for another resident. Impervious gowns are worn when entering the room; during procedures and activities likely to generate splashes and sprays of blood, body fluids, secretions or exudates; removed when leaving the room and placed in a plastic bag, tied and labeled with a biohazard label and taken to the laundry room. Hand hygiene is observed after proper disposal of the gown.
2. Review of the medical record for Resident #34 revealed an admission date of 01/18/20 with diagnoses of quadriplegia, neuromuscular dysfunction of bladder, and colostomy.
Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #34 had intact cognition and had an indwelling catheter.
Review of the physician order dated 04/09/23 revealed Resident #34 had an indwelling catheter.
Observation on 04/01/24 at 11:05 A.M. revealed Resident #34's catheter bag was lying on the floor next to her bed. An empty basin was nearby on the floor.
Interview on 04/01/24 at 11:05 A.M. with Resident #34 stated her catheter bag was usually kept in the basin on the floor. Resident #34 stated staff were preparing to get her out of bed and must have placed the catheter bag on the floor to prepare Resident #34 to transfer using a mechanical lift.
Interview and observation on 04/01/24 at 11:05 A.M. with Licensed Practical Nurse (LPN) #248 confirmed Resident #34's catheter bag was lying on the floor. LPN #248 put on gloves and moved the catheter bag into the basin.
Review of the facility policy titled Bowel/Bladder Incontinence Policy/Indwelling Catheter, dated 11/13/17, revealed residents who are incontinent of bowel/bladder receives appropriate treatment and services to prevent urinary tract infections.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected multiple residents
Based on observations, resident interview and staff interview, the facility failed to serve residents in the dining room in a dignified manner. This affected five residents (#6, #8, #18, #39, and #66)...
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Based on observations, resident interview and staff interview, the facility failed to serve residents in the dining room in a dignified manner. This affected five residents (#6, #8, #18, #39, and #66) of 23 residents in the dining room. The facility census was 76.
Findings include:
Observation in the A-hall dining room on 04/01/24 at approximately 11:50 A.M. revealed Resident #58, Resident #66, and Resident #8 were seated together at a table, Resident #39, Resident #37, and Resident #6 were seated together at a table,, and Resident #54, Resident #67, and Resident #18 were seated together at a table. Additional observation at that time revealed State Tested Nurse Aide (STNA) #319 handed a stack of meal order tickets to Dietary Aide #210 and stated the meal order tickets were in order by table.
Observation and interview n 04/01/24 at 12:06 P.M. revealed Resident #58 was seated at a table with Resident #66 and Resident #8. Resident #58 received his meal. 12 minutes later on 04/01/24 at 12:18 P.M., an interview with STNA #272 confirmed Resident #58 had his meal and Resident #66 and Resident #8 still did not have a meal.
Observation and interviews on 04/01/24 at 12:11 P.M. revealed Resident #37, Resident #39, and Resident #6 sitting together at a table. Resident #37 received her meal at 12:11 P.M. and six minutes later on 04/01/24 at 12:17 P.M. revealed Resident #39 received her meal while Resident #6 continued without a meal. 22 minutes later on 04/01/24 at 12:39 P.M. revealed STNA #271 served Resident #6 her meal. Interview with STNA #271 on 04/01/24 at 12:39 P.M. confirmed Resident #37 finished her meal and left the table and Resident #39 remained at the table with a finished meal when Resident #6 was served her meal.
Observation on 04/01/24 at 12:13 P.M. revealed Resident #54, Resident #67, and Resident #18 sitting at a table. Continued observation revealed Resident #54 received her meal at 12:13 P.M. Eight minutes later on 04/01/24 at 12:21 P.M. with Resident #18 revealed she did not have her meal and was hungry. Interview on 04/01/24 at 12:21 P.M. with STNA #271 confirmed Resident #18 did not have a meal. Eight minutes later on 04/01/24 at 12:29 P.M. revealed Resident #18 was served a meal of grilled cheese and soup.
Interview on 04/10/24 at 8:23 A.M. with STNA #272 confirmed residents should be served at the same time when seated at the same table.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0565
(Tag F0565)
Could have caused harm · This affected multiple residents
Based on review of resident council minutes and staff and resident interviews, the facility failed to ensure resident concerns were resolved timely. This affected four residents (#12, #15, #21, and #6...
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Based on review of resident council minutes and staff and resident interviews, the facility failed to ensure resident concerns were resolved timely. This affected four residents (#12, #15, #21, and #62) who regularly attended the resident council meetings. The facility census was 77.
Findings include:
Review of the resident council meeting minutes dated 01/25/24, 02/29/24, and 03/28/24, revealed concerns every month regarding nurses and state tested nursing aides (STNAs) turning off call lights, telling residents they will be back and do not come back and with call lights not being answered timely. There was no evidence the facility responded to the resident's concerns regarding call lights.
Interview on 04/01/24 at 10:37 A.M. with Resident #65 confirmed having to really wait to have call lights answered. Resident #65 stated she takes herself to the bathroom because no staff were available, even though she knows she shouldn't.
Interviews on 04/03/24 at 1:26 P.M. during the Resident Council meeting, Residents #12 and #62 stated staff turns call lights off and say they will return but they don't. The Resident Council President, Resident #15, confirmed call lights not being responded to timely. Residents #12, #15, #21, and #62 confirmed call lights not being answered timely was a concern.
Interview on 04/10/24 at 8:22 A.M. with Activities Director #299 confirmed Resident Council members have brought up concerns with call lights not being answered timely on multiple occasions. Interview also confirmed all Resident Council member concerns, brought up in the meetings, were given to the Administrator after each resident council meeting.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0919
(Tag F0919)
Could have caused harm · This affected multiple residents
Based on observation and staff interview, the facility failed to ensure call lights were installed in every stall in a common restroom. This had the potential to affect 13 ambulatory residents (#5, #9...
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Based on observation and staff interview, the facility failed to ensure call lights were installed in every stall in a common restroom. This had the potential to affect 13 ambulatory residents (#5, #9, #15, #17, #21, #37, #47, #48, #59, #66, #67, #75 and #232) who could self-transfer. The facility census was 76.
Findings include:
Observation on 04/09/24 at approximately 7:30 A.M. revealed two accessible restrooms in the common area of the facility. One was designated for males and one for females. No other signage was posted around the restrooms. The access doors were unable to be locked. Further observation revealed the women's restroom had three stalls. A pull-cord was installed in the largest stall. No pull cord was accessible from the two smaller stalls. No pull cord was in the common bathroom area.
Interview on 04/09/24 at 1:48 P.M. with Resident #21 revealed he used the common bathroom during Bingo.
Interview on 04/09/24 at 2:00 P.M. with Resident #66 revealed she used the public restroom during group activities and would use whichever stall was available.
Interview and observation on 04/09/24 at 2:35 P.M. with Administrator in Training #205 verified the male restroom had no pull light in two of three stalls.
Interview and observation on 04/09/24 at 2:53 P.M. with the Administrator and Administrator in Training #205 confirmed no signage was posted outside the public restrooms indicating it was not for resident use. Continued observation and interview inside the women's restroom with the Administrator confirmed the only pull cord installed in the bathroom was in the largest of the three stalls.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0725
(Tag F0725)
Could have caused harm · This affected most or all residents
Based on observations, resident and staff interviews, and review of the facility assessment, the facility failed to ensure there was sufficient staff to timely meet the resident's needs. This affected...
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Based on observations, resident and staff interviews, and review of the facility assessment, the facility failed to ensure there was sufficient staff to timely meet the resident's needs. This affected 13 residents (#1, #12, #15, #21, #31, #38, #56, #62, #65, #70, #72, #73, and #82) and had the potential to affect all 77 residents residing in the facility.
Findings include:
1. Review of the resident council meeting minutes dated 01/25/24, 02/29/24, and 03/28/24, revealed concerns every month regarding nurses and state tested nursing aides (STNAs) turning off call lights, telling residents they will be back and do not come back, and with call lights not being answered timely.
Interviews on 04/01/24 from 8:00 A.M. to 5:15 P.M. with Residents #1, #31, #38, #65, #73, and #82 revealed the residents had concerns related to long call light times with some reports stating call lights were up to two hours long. Resident #65 stated she really had to wait to have her call light answered. Resident #65 stated she takes herself to the bathroom because no staff were available, even though she knows she shouldn't.
Interviews on 04/03/24 at 1:26 P.M. with Residents #12 and #62 stated staff turn off their call lights and say they will return but don't actually return. Resident #15 confirmed call lights were not being responded to timely. Residents #12, #15, #21, and #62 confirmed call lights not being answered timely was a concern.
2. Observation on 04/02/24 at 3:28 P.M. revealed Resident #70's call light was on for an unknown amount of time. Continuous observation revealed Resident #70's call light remain unanswered through 4:29 P.M. (one hour and one minute).
Interview on 04/02/24 at 3:57 P.M. with Resident #70 verified she was waiting for assistance with turning off overhead light and needed to use the bathroom.
Interview on 04/02/24 at 4:28 P.M. with Registered Nurse (RN) #257 verified one state tested nursing aide (STNA) was giving a shower, two other STNAs were assisting another resident, and RN #257 was providing medication administration. RN #257 was notified of Resident #70's call light was alerting for at minimum one hour. RN #257 answered Resident #70's call light at 4:29 P.M.
3. Interview on 04/02/24 at 10:30 A.M. with Resident #56 revealed the staff had gotten her up at 7:00 A.M, and had changed her depends. Resident #56 was concerned with staff not getting her changed every two hours like they should be. Resident #56 stated she was anxious due to being in the hospital with an urinary tract infection which caused sepsis. She does not want to get this sick again. Resident #56 believes she got the infection because they would let her set for hours in urine and feces.
Observation on 04/02/24 at 12:40 P.M. revealed Resident #56 was taken from the dining room to her room for incontinence care. State Tested Nurse Aide (STNA) #272 and STNA #271 returned the resident to bed via Hoyer lift. Resident #56 was saturated through to her pants in front and back. The resident's brief was saturated with urine and feces.
Interview with STNA #272 on 04/02/24 at 12:40 P.M. verified Resident #56 was last checked and changed was at 7:00 A.M. upon getting her up this morning. STNA #272 verified she usually tries to get her changed before lunch but her assignment had quite a few check and changes, and they were not able to get all residents changed every two hours.
Interview with STNA #325 on 04/04/24 at 5:20 A.M. revealed her assignment included Resident #56. STNA #325 stated on third shift, there were times when you work alone on the hall, there was no way to get check and changes completed every two hours due to having 18 residents to check and change. Third shift also had 13 residents to get up each night with 11 of them being a Hoyer or sit-to-stand which required two persons.
4. Continuous observation and interview with Resident #72 on 04/01/24 from 10:10 A.M. to 10:40 A.M. revealed staff did not enter Resident #72's room during these 30 minutes. Resident #72 stated he had his call light on prior to 10:10 A.M. and staff came into the room and turned off his call light. The resident informed the staff that he wet his pants and the staff responded to him that they needed to help someone else first. Resident #72's room smelled of urine and his shorts were noticeably wet.
Interview and observation on 04/01/24 at 10:40 A.M. revealed State Tested Nursing Aide (STNA) #271 and STNA #272 entered Resident #72's room to provide incontinence care. STNAs #271 and #272 verified they had answered the call light prior and saw his pants were wet with urine, and explained they would have to come back later to clean him up. They had to get up another resident who was paraplegic. STNAs #271 and #272 stated they do not have enough staff for the resident's acuity levels at the facility.
Interview on 04/04/24 with STNA #312 revealed they have one STNA (#300) who they keep putting on the schedule. STNA #300 does not show up to work at least once a week. This leaves the staff short and they cannot complete all the get up and check and changes every two hours. STNA #312 works on C-Hall where they had eight residents to get up and four of them were Hoyer lifts which required two people.
Interview with Licensed Practical Nurse (LPN) #248 on 04/04/24 at 9:40 A.M. revealed the STNAs have to prioritize which resident care they complete first due to call offs and acuity of residents on the hall.
Interview with Registered Nurse (RN) #258 on 04/02/24 at 8:05 A.M. revealed the STNAs have a very hard time getting all the residents checked and changed completed every two hours. The facility has a lot of resident who require Hoyer lifts, incontinence care, feeding and behaviors which causes the staff to be unable to complete all the check and changes timely. The weekends were the worst with staffing.
Interview with LPN #241 on 04/04/24 at 5:45 A.M. revealed she worked on the C-Hall. C-Hall has two STNAs which were pretty good at getting their check and changes done. The problem was they usually only have one STNA which then they have a problem getting their assigned tasks done every two hours.
Review of the Facility Assessment, dated 03/26/24, revealed the facility had an average daily census of 80 with 13 short term care residents and 67 long term care residents. The facility identified seven residents who required injections, two residents who required intravenous medication, five residents were under the care of hospice, one resident required hemodialysis, and one resident required oxygen therapy.
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
4. Observation on 04/01/24 at 12:30 P.M. of Cook-Dietary Aides #208 and #209 revealed barbeque pulled pork and tater tots pulled from the steam table in the kitchenette on Dogwood Hall. Hot food was p...
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4. Observation on 04/01/24 at 12:30 P.M. of Cook-Dietary Aides #208 and #209 revealed barbeque pulled pork and tater tots pulled from the steam table in the kitchenette on Dogwood Hall. Hot food was pulled prior to verifying the temperatures of the food. Chicken noodle soup pulled from a plastic container, ladled into a glass bowl and microwaved. Both Cook-Dietary Aides #208 and #209 started to serve food to the residents and were stopped.
Interview and observation on 04/01/24 at 12:32 P.M. with Cook-Dietary Aides #208 and #209 confirmed they did not check the temperatures of any of the food prior to starting service. Cook-Dietary Aides #208 and #209 confirmed temperatures should be done prior to serving food from the kitchenette. Both confirmed they were not aware of what the actual temperatures should be. Cook-Dietary Aide #208 confirmed she has never obtained the temperatures of any food she serves from the kitchenette. Temperatures of the food were checked and revealed the chicken noodle soup was 120 degrees Fahrenheit (F), the barbeque pulled pork was 131 degrees F, and tater tots were 127 degrees F. Cook-Dietary Aides #208 and #209 confirmed with their direct supervisor what the temperatures should be and heated the barbeque pulled pork, tater tots and chicken noodle soap to an acceptable temperatures of 140 F.
Review of the facility policy titled Food Temperature, revised February 2018, revealed at the point of service in the kitchen, all hot foods are served at 135 degrees F or higher. In addition, temperatures are taken and record for each meal for all hot and cold foods.
Based on observations, staff interview, and review of facility policy, the facility failed to ensure adequate hand hygiene was performed during food service and failed to monitor food temperatures before serving meals. This had the potential to affect all residents in the facility except Resident #40 identified to receive no food from the kitchen.
Findings include:
1. Observation on 04/01/24 at 11:52 A.M. revealed lunch meal service being served in the C hall kitchenette. Dietary Aide #212 was observed wearing disposable gloves while handling sandwich buns. While wearing disposable gloves, Dietary Aide #212 was observed leaving the kitchenette and using the gloved hand to use the door keypad and enter the storage/dish room. Dietary Aide #212 reentered the kitchenette and changed gloves without hand washing. After applying new disposable gloves, Dietary Aide #212 was observed touching drawer handles, microwave handles and keypad while wearing the gloves then picked up sandwich buns to continue serving lunch
Interview on 04/01/24 at 12:52 P.M. with Dietary Aide #212 verified the lack of handwashing and applying new gloves prior to touching the resident's food.
2. Observation on 04/03/24 at 11:43 A.M. revealed Dietary Aide #206 wearing disposable gloves and making a peanut butter and jelly sandwich. Dietary Aide #206 was observed touching the bread with the disposable gloves, putting the bread on the counter, touching non food items including drawer handles, peanut butter and jelly containers, then touching the bread again with no handwashing or glove change.
Interview on 04/03/24 at 11:44 A.M. with Dietary Manager #212 verified Dietary Aide #206 did not wash her hands and change gloves between touching resident food and nonfood items. It was noted there was no handwashing sink available in the kitchenette and the closest handwashing sink was behind the locked storage/dish room door. Dietary Manager #212 stated no one had identified it was a problem and there was no solution identified.
3. Observation on 04/01/24 12:28 P.M. of the lunch meal service revealed Dietary Aide #212 placed a bowl of tomato soup in the microwave, set the cook time and after removed the soup, and provide it to Resident #28 without obtaining a temperature of it.
Observation on 04/01/24 at 12:45 P.M. of the lunch meal service revealed Dietary Aide #212 place a bowl of chicken noodle soup in the microwave, set the cook time and after remove the soup and provide it to an unknown resident. Dietary Aide #212 did not obtain the temperature of the soup prior to serving it to the resident.
Interview on 04/01/24 at 12:52 P.M. with Dietary Aide #212 verified she did not obtain the temperatures of the soup prior to serving it to the residents. Dietary Aide #212 stated she always warms soup for one minute thirty seconds. Dietary Aide #212 stated she was unaware she had to obtain the temperature of the soup prior to serving i to the resident.
Interview on 04/01/24 at 12:56 P.M. with Dietary Aide #209 stated to know if soup was hot enough, she places a plastic lid on the bowl of soup and when the soup reaches a certain temperature, the lid will melt in. Dietary #209 did not know what the certain temperature was and questioned if the soup needed to be a certain temperature.
MINOR
(C)
Minor Issue - procedural, no safety impact
Staffing Information
(Tag F0732)
Minor procedural issue · This affected most or all residents
Based on observation and interview, the facility failed to ensure nurse staffing data was posted on a daily basis and failed to maintain historical staffing data. This had the potential to affect all ...
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Based on observation and interview, the facility failed to ensure nurse staffing data was posted on a daily basis and failed to maintain historical staffing data. This had the potential to affect all 76 residents residing in the facility.
Findings include:
Observation on 04/01/24 at 10:00 A.M. on D Hall revealed the posted daily staffing data was dated 03/24/24.
Interview on 04/02/24 at 9:00 A.M. with Medical Records #250 on A Hall confirmed she was placing a notice of daily staffing data in the display case. Medical Records #250 confirmed the most recently posted staffing data was from November 2023.
Interview on 04/10/24 at 10:25 A.M. with Medical Records #250 stated she only had daily staffing data beginning 04/03/24 and could not produce any records prior to that. Medical Records #250 stated she did not know who was responsible for posting it before she was assigned on 04/03/24.
The facility was unable to provide any historical daily staffing data reports.
Oct 2023
1 deficiency
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Deficiency F0692
(Tag F0692)
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 resident fluid intakes, review of physician orders, staff interview, review of physici...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of resident fluid intakes, review of physician orders, staff interview, review of physician communication sheets, review of a hospital history and physical, review of hospital consultation notes, and review of facility policy, the facility failed to ensure a resident's hydration status was maintained to decrease the risk of dehydration. This resulted in actual harm when Resident #58 had a decrease in oral fluid intake for three days and was subsequently hospitalized with acute kidney injury, severe dehydration, and severe sepsis. This affected one (#58) of three residents reviewed for hydration status. The facility census was 71.
Findings include:
Review of Resident #58's medical record revealed an admission date of 09/09/23 and a readmission date of 10/07/23. Diagnoses included cerebral infarction, hemiplegia and hemiparesis, dysarthria, aphasia, chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), chronic kidney disease, heart disease, anxiety disorder, bipolar disorder, hypertension, and atrial fibrillation.
Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #58 was severely cognitively impaired and required extensive assistance with activities of daily living, including eating.
Review of a plan of care focus area initiated 09/11/23 and revised 10/12/23, revealed Resident #58 was at increased nutrition/hydration risk related to stroke, dysphagia with need for mechanically altered diet, and takes medication which can affect appetite or weight. Additionally, Resident #58 had decreased food and fluid intake, avoidable weight loss over past 30 days due to decline in condition, refusal of meals and poor oral intakes. Interventions included encourage honey thickened liquids between meals, monitor for signs and symptoms of dehydration/fluid volume deficit, monitor labs as available, monitor for decline in eating ability and assist as needed, monitor weight, and diet as ordered.
Review of physician orders revealed Resident #58 was on a regular, pureed diet with honey thickened liquids and was ordered furomeside (diuretic - used to remove water and electrolytes from the body by increasing urination) oral tablet 10 milligrams (mg) two times daily.
Review of the Medication Administration Record (MAR) from 09/15/23 through 09/22/23 revealed Resident #58 was administered furomeside 10 mg as ordered on each of the days reviewed.
Review of a Nutritional assessment dated [DATE] revealed Resident #58 received honey thickened liquids, required limited assist/supervision with feeding, had inadequate fluid intake, and swallowing difficulty. Inadequate fluid intakes were related to resident doesn't know to drink fluids as will just hold cups. Additionally, fluid intakes do not meet 100% estimated fluid needs. Continue with regular pureed diet with honey thickened liquids. Will add magic cup three times daily and honey thickened facility nourishment three times daily. Goals are for no signs or symptoms of dehydration, no difficulty with chewing or swallowing, and no significant weight change.
Review of a nursing alert progress note dated 09/18/23 revealed Resident #58 ate less than 50% over the last three shifts. Inadequate fluid intake, swallowing difficulty related to recent CVA (stroke) as evidenced by need for mechanically altered diet. Inadequate fluid intakes related to resident doesn't know to drink fluids and will just hold cups as evidenced by fluid intakes do not meet 100% estimated fluid needs. Continue with a regular pureed diet with honey thickened liquids.
Review of e-mail correspondence dated 09/18/23 revealed Case Manager (CM) #250 communicated to Registered Dietitian (RD) #200 and therapy that Resident #58 had consumed less than 50% of her meals for several days. RD #200 responded Resident #58 was on multiple supplements and weight was stable since admission.
Review of a physician communication form dated 09/19/23 revealed nursing notified Physician Assistant (PA) #300 Resident #58's oral intake was inadequate. Gags with pureed food but ok with magic cup and pudding. PA #300 responded on 09/20/23 and indicated resident was followed by speech therapy and have dietitian see for further recommendations.
Review of State Tested Nurse Aide (STNA) documentation revealed on 09/20/23 and 09/22/23, fluid intakes were documented as either resident refused or not applicable. There was no documentation Resident #58 received any fluids on those dates. Review of STNA documentation dated 09/21/23 revealed Resident #58 had consumed 480 ml (approximately 16 ounces) of fluids. Review indicates the resident did not have adequate fluid intake for three days.
Review of a physician communication form dated 09/21/23 revealed RD #200 notified PA #300 Resident #58 disliked the facility nourishment and threw it at the nurse. The nurse tried Boost Breeze with the resident and the resident drank that. RD #200 recommended Boost Breeze, eight ounces two times daily. PA #300 responded on 09/22/23 and ordered Boost Breeze as recommended.
Review of a nursing alert note dated 09/21/23 revealed Resident #58 ate less than 50% over the last three shifts. Speech therapist and dietitian are working with patient. Has appropriate supplementation ordered. No weight loss noted since admission. Further review of a nursing progress note dated 09/21/23 revealed Resident #58 was alert to self, post CVA. Right side has no movement. Medications crushed. Refusing meals, drinking some juice. Incontinent of bladder and bowel.
Additional review of a nursing progress note dated 09/23/23 at 9:45 A.M. revealed Resident #58 had noted increased drowsiness and weakness, aggressive when writer tried to give her medicine. Vital signs taken and blood pressure (BP) was 90/30, temperature 97.8, Pulse 96, and oxygen saturation (SpO2) 95%. Resident does not answer appropriately due to previous CVA. Notified physician (MD) and order received to send to the hospital. Attempted to call daughter, number cannot be reached. Resident picked up at 9:40 A.M. Report given to emergency room (ER) nurse.
Review of a hospital History and Physical, dated 09/23/23, revealed emergency medical services (EMS) reported the resident had altered mental status and failure to thrive at the facility. Resident was lethargic on arrival and hypotensive. EMS stated the resident had no food or water in a couple of days. Additionally, Resident #58 now had altered mentally so they decided to send her to the Emergency Department (ED). Resident #58 had acute encephalopathy (alteration of mental status), severe sepsis with hypotension (likely due to significant dehydration), severe dehydration due to no oral intake of food/water for the last three days (reported), significant hypernatremia (likely due to dehydration and leading to altered mental status), acute kidney injury on top of chronic kidney disease, mild acute respiratory failure with hypoxemia due to COPD exacerbation, and mild COPD exacerbation with unknown trigger at this time. Physical examination revealed the resident had a very dry tongue and oral mucosa (the mucus membrane or skin inside the mouth, including cheeks and lips). Resident #58 was admitted to the intensive care unit for closer monitoring of oxygen levels, regular diet started, daily weight and strict input and output, ED given boluses, continue Intravenous (IV) one-half normal saline (NS) at 75 milliliters/hour (ml/hr.), doing no antibiotics now as there is no evidence of infection. Lastly, furomeside (diuretic) was discontinued.
Review of hospital consultation notes dated 09/23/23 revealed Resident #58 was admitted to the hospital due to acute kidney injury, hypernatremia (high concentration of sodium in the blood), acute encephalopathy (alteration of mental status), hypotension (low blood pressure), severe sepsis, hyperkalemia (high potassium), and dehydration. Additional review revealed resident admitted with report of more than two days of poor oral intake of food and water. Treatment included dextrose 5 percent in water IV solution 1,500 milliliters (ml) 150 milliliters/hour (ml/hr) and sodium chloride 10 ml IV push two times daily.
Further review of the medical record revealed no evidence Resident #58 was assessed for dehydration signs and symptoms prior to hospitalization.
Interview on 10/16/23 at 2:07 P.M. with PA #300 revealed she recalled a conversation with someone at the facility about supplements for Resident #58. She did not specifically recall a conversation about fluid intakes. PA #300 stated she knew the resident's intakes were poor, but she was unaware the resident had not consumed any fluids on 09/20/23 and 09/22/23 and had only had 420 ml (16 ounces) on 09/21/23. PA #300 stated she saw Resident #58 on 09/20/23, but the resident was on transmission-based precautions, so she only saw her from the door and did not physically examine her. PA #300 stated she did not recall any specific concerns related to Resident #58's fluid intakes, noting the facility wanted her to back them but she did not remember notification of fluid concerns. PA #300 stated she probably would have discontinued Resident #58's furomeside if she had known the resident's fluid intakes were that low.
Interview on 10/16/23 at 2:24 P.M. with CM #250 revealed she had a conversation with PA #300 about a supplement for Resident #58 due to poor meal intakes. No changes were made because the dietitian stated the resident's weight was stable. CM #250 confirmed the communication with PA #300 was related to poor meal intakes and not inadequate fluid intakes.
Interview on 10/17/23 9:41 A.M. with Corporate Nurse (CN) #275 revealed Resident #58's vital signs had been monitored two times daily and had been stable up to the day the resident was sent out to the hospital. CN #275 stated Resident #58 had stable pulses and BP and there were no outwardly signs of obvious dehydration. The facility had been trialing some different things to increase the resident's intakes. CN #275 stated Resident #58 refused meals, fluids, care, and would become aggressive toward staff. CN #275 stated based on Resident #58's presentation, the staff were doing whatever they could and did what they needed to do. Additionally, CN #275 stated Resident #58 was on a pureed diet, and while she could not measure the amount of fluid in pureed diets, Resident #58 was receiving fluids through meals.
Interview on 10/17/23 at 10:19 A.M. of Registered Dietitian (RD) #200 revealed Resident #58 had been discussed at the facility's weekly nutrition at risk meetings. RD #200 stated Resident #58 refused meals and fluids and would hit staff. RD #200 stated all foods contain a certain percent of water, based on the food, and it was possible Resident #58 received enough fluids to sustain her through a pureed diet. RD #200 stated she would review the meals and Resident #58's intakes to calculate an estimate of fluids the resident would have received from eating a pureed diet.
Follow up interview on 10/17/23 at 12:03 P.M. with PA #300 revealed she may have been remembering the wrong resident when she spoke with this surveyor on 10/16/23. PA #300 stated she was now retired, working off of memory, and could not recall all of the details. PA #300 stated she had the resident confused with another resident and she did actually evaluate Resident #58 on 09/20/23 and had no concerns related to dehydration. While PA #300 stated she was notified by the facility on 09/19/23, Resident #58 had poor oral intakes, she believed that to mean the resident was drinking low liquids, not no liquids, which was why she deferred to the dietitian. Additionally, on 09/21/23, PA #300 stated she ordered Boost Breeze, and that was a fluid. PA #300 confirmed she was unaware Resident #58 had only consumed one - eight ounce Boost Breeze on 09/21/23 and none on 09/22/23. While some fluids could be obtained through foods, she was uncertain if it would be a sufficient amount to prevent dehydration. PA #300 verified furomeside would increase the risk of dehydration, especially in someone who was not consuming sufficient fluids, and she did not know why that was not addressed for Resident #58.
Follow-up interview on 10/17/23 at 2:45 P.M. with CN #275 confirmed while Resident #58's vital signs were stable in the days leading up to her hospitalization, there was no evidence of nursing assessment for other indicators of dehydration, including sunken eyes, skin turgor, or oral mucosa.
Interview on 10/18/23 at 9:24 A.M. with RD #200 verified she was not in the kitchen when Resident #58's meals were prepared and was unable to verify if the proper amounts of fluid was added to the resident's pureed meals and/or served to the resident.
Review of facility policy titled, Hydration Policy, approved 03/17/16, revealed the facility will provide each resident with sufficient fluid intake to maintain proper hydration status. Sufficient fluid means the amount of fluid needed to prevent dehydration and maintain health. The amount needed is specific for each resident, and fluctuates as the resident's condition fluctuates.
This deficiency represents non-compliance investigated under Complaint Number OH00146850.
Sept 2023
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, call light response log review, and resident and staff interview, the facility failed to ensure ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, call light response log review, and resident and staff interview, the facility failed to ensure call lights were answered in a timely manner. This affected two (#8 and #14) of three residents reviewed for call light response times. The facility census was 75.
Findings include:
1. Review of Resident #8's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included diabetes, urinary tract infections, anemia, and sepsis.
Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #8 was cognitively intact and able to make all needs known.
Interview with Resident #8 on 09/12/23 at 6:59 A.M. stated her call light can take up to one hour for staff to respond to and was too long to wait for help. Resident #8 stated she recently moved rooms, and call light response times were a bit better in her current location, but still took a long time for staff to answer.
Review of facility call light response logs between 09/02/23 and 09/11/23 revealed Resident #8's call light response times were monitored during this time frame. On 09/02/23, it took staff 25 minutes to answer the call light. On 09/03/23, three call lights were observed and took 26 minutes, 34 minutes, and 26 minutes, respectively, to answer. On 09/04/23, it took staff 25 minutes to answer a call light. On 09/05/23, six call lights were observed and took 27 minutes, 58 minutes, 40 minutes, one hour and two minutes, 50 minutes, and 29 minutes, respectively to answer. On 09/06/23, five call lights were observed and took 33 minutes, 53 minutes, 25 minutes, 23 minutes, and 46 minutes, respectively, for staff to answer. On 09/07/23, two call lights were observed and took one hour and three minutes and 23 minutes, respectively, to answer. On 09/09/23, a call light was observed to take 33 minutes for a staff member to answer. On 09/10/23, two call lights were observed and took staff 38 minutes and 43 minutes, respectively, to answer. On 09/11/23, to call lights were observed and took staff 59 minutes and 41 minutes, respectively, to answer.
2. Review of Resident #14's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included quadriplegia and pressure ulcers. Further review of Resident #14's medical record revealed the resident was assessed as cognitively intact and able to verbalize all needs.
Interview with Resident #14 on 09/12/23 at 11:40 A.M., confirmed it took staff in the facility forever to answer his call light. Resident #14 stated he had used his phone multiple times to call the facility number because no one would answer his call light.
Review of facility call light response logs between 09/05/23 and 09/11/23 revealed Resident #14's call light response times were monitored during this time frame. On 09/05/23, three call lights were activated and took staff 26 minutes, 24 minutes, and 24 minutes, respectively, to answer the lights. On 09/06/23, two call lights were activated and took staff 37 minutes and 33 minutes, respectively, to answer. On 09/07/23, it took staff 44 minutes to answer a call light. On 09/08/23, it took staff 41 minutes to answer a call light. On 09/09/23, it took staff 33 minutes to answer a call light. On 09/10/23, three call lights were observed and took staff 23 minutes, 48 minutes, and 25 minutes, respectively, to answer.
Interview with State Tested Nurse Aide (STNA) #107 on 09/12/23 at 6:54 A.M. verified call lights do take longer to answer than they should.
Interview with the Administrator on 09/13/23 at 1:02 P.M. confirmed the call light response times on the call light response logs for Resident #8 and Resident #14 were too long. The Administrator stated the facility did not have any policies for call lights or monitoring the length of time to answer lights appropriately to ensure resident needs are met.
This deficiency represents non-compliance investigated under Master Complaint OH00146194.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, review of infection control signage, and review of a facility policy, the facility ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, review of infection control signage, and review of a facility policy, the facility failed to follow infection control precautions for a resident placed on enhanced barrier precautions. This affected one (#8) of three residents reviewed for infection control measures. The facility census was 75.
Findings include:
Review of Resident #8's medical record revealed the resident was re-admitted to the facility on [DATE]. Diagnoses included diabetes, sepsis, urinary tract infection, and anemia.
Observation of Resident #8's room on 09/12/23 at 6:59 A.M. and 7:54 A.M. revealed the room did not have infection control signage posted on the door or near the room. Further observation of Resident #8 revealed the resident had a urinary catheter and the collection bag was located on the left side of the bed.
Observation of Resident #8's room on 09/12/23 at 9:33 A.M. with Licensed Practical Nurse (LPN) #104 revealed there was a newly added sign which read, Enhanced Barrier Precautions, posted on the outside the room. There was also a cart next to the door with personal protective equipment (PPE) inside. Interview with LPN #104 at the time of the observation confirmed Resident #8 should have had the enhanced barrier precautions sign posted on the door. LPN #104 explained Physician #105 was in the facility, and identified there was no sign posted on Resident #8's door and there should have been. LPN #104 confirmed Resident #8 moved rooms on 09/07/23, and the infection control precaution sign and cart were not moved with her.
Observation on 09/12/23 at 9:40 A.M. revealed Physician #105 was in Resident #8's room with a gown covering his scrubs. Interview with Physician #105 at the time of the observation stated because Resident #8 had open wounds on her skin and a urinary catheter, the resident was placed enhanced precautions as an infection control measure to attempt to prevent cross contamination. Physician #105 verified he reminded the staff when he arrived at the facility on 09/12/23 that Resident #8's room did not have enhanced barrier precautions in place.
Observation on 09/12/23 at 10:36 A.M. revealed State Tested Nurse Aide (STNA) #100 and STNA #101 entered Resident #8's room to provide care to the resident's urinary catheter. Both STNA #100 and STNA #101 were observed to not be wearing a gown and started to provide care to the resident. Interview with STNA #100 and STNA #101 at the time of the observation verified they saw the enhanced barrier precaution sign posted outside Resident #8's room, and verified they forgot to put a gown on over their uniforms before providing Resident #8 urinary catheter care.
Review of a facility sign titled Enhanced Barrier Precautions, revealed notice that everyone should clean their hands before entering and upon leaving the room. The sign revealed everyone should wear gloves and a gown when completing the following activities; dressing, bathing, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting; device care or use (central line, urinary catheter, tracheostomy, feeding tube), and wound care including any skin opening which required a dressing.
Review of a facility policy titled, Enhance Barrier Precautions, last revised August 2022, revealed the facility was to use enhanced barrier precautions (EBP) to prevent transmission of multi-drug resistant organisms (MDROs) from an infected or colonized resident through an infection control intervention designed to reduced transmission or resistant organisms that employs targeted gown and glove use during high contact resident care activities. EBP may be considered for the following situations: infection or colonization with a MDRO when contact precautions do not apply and with wounds and/or indwelling medical devices (e.g. central line, urinary catheter, feeding tube, tracheostomy/ventilator) regardless of MDRO colonization status.
This deficiency represents non-compliance investigated under Master Complaint Number OH00146194.
Jun 2023
2 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
Based on observations, medical record review, resident and staff interviews, and policy review, the facility failed to assist residents who required assistance with activities of daily living (ADL) wi...
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Based on observations, medical record review, resident and staff interviews, and policy review, the facility failed to assist residents who required assistance with activities of daily living (ADL) with showers and personal hygiene needs. This affected two (#19 and #39) of three residents reviewed for ADLs. The facility identified 70 residents who required assistance with bathing. The facility census was 73.
Findings include:
1. Review of the medical record for Resident #19 revealed an admission date of 11/11/19. Diagnoses included atrial fibrillation, chronic obstructive pulmonary disease (COPD), anxiety, chronic kidney disease, and hypertension (HTN).
Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 04/07/23, revealed Resident #19 had moderate cognitive impairment and required extensive staff assistance with personal hygiene and was dependent upon staff for bathing.
Review of the ADL care plan revealed Resident #19 required extensive staff assistance for bathing and personal hygiene.
Review of the bathing records from 05/01/23 to 06/06/23 revealed Resident #19 received a shower/bath three times on 05/23/23, 05/26/23, and 06/06/23. There was no documentation to support Resident #19 received any other showers/baths during this time period from 05/01/23 to 06/06/23.
Review of the unit shower/bath schedule revealed Resident #19 was scheduled for showers/bathes on Tuesdays and Fridays.
Interview on 06/05/23 at 10:22 A.M. with Resident #19 stated she doesn't get showers or baths as scheduled.
Interview on 06/07/23 at 11:15 A.M. with Regional Registered Nurse (RN) #508 confirmed the medical record for Resident #19 revealed Resident #19 received a shower/bath on 05/23/23, 05/26/23, and 06/06/23. Regional RN #508 confirmed the medical record did not contain documentation to support Resident #19 received showers/bathes as scheduled from 05/01/23 to 06/06/23.
2. Review of the medical record for Resident #39 revealed an admission date of 10/25/22. Diagnoses included chronic obstructive pulmonary disease (COPD), atrial fibrillation, and hypertension (HTN).
Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 04/14/23, revealed Resident #39 had moderate cognitive impairment and required extensive staff assistance with personal hygiene, and was dependent upon staff for bathing.
Review of the care plan, dated 12/26/22, revealed Resident #39 had a self-care deficit related to poor health management. The goal of the care plan stated Resident #39 would be clean and well groomed. The interventions included Resident #39 required one person assist with grooming and hygiene.
Review of the bathing records from 06/01/23 to 06/07/23 revealed Resident #39 received a shower/bath on 06/03/23 and 06/07/23.
Observation and interview on 06/05/23 at 2:40 P.M. revealed Resident #39 with gray facial hair noted above Resident #39's upper lip. Resident #39 stated staff do not assist her with removing her facial hair.
Subsequent observation on 06/06/23 at 3:20 P.M. revealed Resident #39's gray facial hair was noted above Resident #39's upper lip.
Observation and interview on 06/07/23 at 8:16 A.M. revealed Resident #39 exiting the shower room with wet hair. Resident #39 still had gray facial hair above her upper lip. Resident #39 stated she just received a shower and staff did not offer to provide grooming needs for facial hair.
Interview on 06/07/23 at 8:17 A.M. with State Tested Nursing Assistant (STNA) #435 confirmed she assisted Resident #39 with her shower that morning and that she did not provide Resident #39 with grooming care for her facial hair. STNA #435 stated staff were to provide grooming needs for residents on shower days. STNA #435 confirmed Resident #39 had gray facial hair above her upper lip.
Review of the policy titled Quality of Policy/Activities of Daily Living, revised April 2016, revealed each resident will receive, and the facility will provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and plan of care. The policy stated a resident who is unable to carry out ADLs will receive the necessary services to maintain good grooming, personal care, and oral hygiene.
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 medical record review, observation, staff interview, review of facility policy, and review of Centers for Disease Contr...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, staff interview, review of facility policy, and review of Centers for Disease Control and Prevention (CDC) guidance the facility failed to implement transmission based precautions for a resident when positive for a multi-drug resistant organism (MDRO) and receiving wound care. This affected Resident #4 of seven reviewed for transmission based precautions. The census was 73.
Findings include:
Review of Resident #4's medical record revealed an admission date of 12/31/18. Diagnoses included methicillin resistant staphylococcus aureus (MRSA) infection.
Review of the physician orders revealed there was an order for culture drainage from left stump wound. Review of wound culture results dated 04/13/23 revealed light growth of MRSA.
Further review of physician orders revealed no order for any transmission based precautions to be implemented on 04/13/23.
Further review of the medical record revealed Resident #4 was discharged from the facility to a local hospital on [DATE] and returned to the facility on [DATE].
Review of the hospital records dated 05/19/23 revealed Resident #4 was treated by infectious disease consult and completed antibiotic treatment. No recrudescence (reoccurrence) of infection was noted.
Review of the physician orders revealed an order dated 05/25/23 to cleanse open area on left stump (amputated leg), pack with iodoform, gauze, cover with army battle dressing (ABD), and secure with tape. Change daily and as needed (PRN). There were no orders for enhanced barrier precautions (EBP) upon return form the hospital on [DATE].
Review of a quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #4 was cognitively intact, required extensive assistance with personal hygiene, and total dependence with bathing. Resident #4 had a multi-drug resistant organism (MDRO) infection.
Observation of Resident #4's room on 06/05/23 at 2:23 P.M. and 06/07/23 at 1:05 P.M. revealed no signs for any transmission based precautions/EBP or any personal protective equipment (PPE) at the entrance.
Interview with Registered Nurse (RN) #508 on 06/07/23 at 2:02 P.M. confirmed transmission based precautions had not been implemented for Resident #4 who had a positive wound culture for MRSA on 04/13/23.
Interview with the Director of Nursing (DON) on 06/08/23 at 8:18 A.M. revealed the hospital records stated Resident #4 had completed a course of antibiotics and no reoccurrence of MRSA was noted by infectious disease. The DON confirmed Resident #4 should have been place in EBP because he was receiving wound care and had a history of MRSA.
Interview with Licensed Practical Nurse (LPN) #498 on 06/08/23 at 9:00 A.M. confirmed contact precautions were not implemented for Resident #4 on 04/13/23 when a wound culture was positive for MRSA. EBP were also not implemented when Resident #4 returned from the hospital on [DATE] and continued with wound care.
Review of the facility's policy titled MDRO Management, last revised August 2022, revealed it is the policy of the facility to follow established guidelines when caring for residents identified with specific MDROs. Contact precautions should be used for all residents infected or colonized with a MDRO.
Review of the facility's policy titled Enhance Barrier Precautions, last revised August 2022, revealed it is the policy of the facility to use EBP to prevent transmission of MDROs from an infected or colonized resident through an infection control intervention designed to reduced transmission or resistant organisms that employs targeted gown and glove use during high contact resident care activities. EBP may be considered for the following situations: infection or colonization with a MDRO when contact precautions do not apply and with wounds and/or indwelling medical devices (e.g. central line, urinary catheter, feeding tube, tracheostomy/ventilator) regardless of MDRO colonization status.
Review of the CDC website based on the current evidence, CDC continues to recommend the use of contact precautions for MRSA-colonized or infected patients. CDC will continue to evaluate the evidence on contact precautions as it becomes available. In addition, CDC continues to work with partners to identify and evaluate other measures to decrease transmission of MDROs in healthcare settings. MDRO transmission is common in skilled nursing facilities, contributing to substantial resident morbidity and mortality and increased healthcare costs. Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities. EBP may be indicated (when Contact Precautions do not otherwise apply) for residents with wounds or indwelling medical devices, regardless of MDRO colonization status and infection or colonization with an MDRO.
EBP expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDROs to staff hands, and clothing. MDROs may be indirectly transferred from resident-to-resident during these high-contact care activities. Nursing home residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs. The use of gown and gloves for high-contact resident care activities is indicated, when contact precautions do not otherwise apply, for nursing home residents with wounds and/or indwelling medical devices regardless of MDRO colonization as well as for residents with MDRO infection or colonization. Examples of high-contact resident care activities requiring gown and glove use for EBP include dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator, and wound care: any skin opening requiring a dressing.
Feb 2020
7 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of the facility's policy and staff and resident interview, the facility failed to follow ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of the facility's policy and staff and resident interview, the facility failed to follow their policy when resident's personal items were missing. This affected one resident (#90) of three residents reviewed for personal property. The facility identified seven residents with missing personal items in the last 60 days. The facility census was 104.
Findings include:
Review of the medical record for Resident #90 revealed the resident was admitted to the facility on [DATE]. Diagnoses included cellulitis of the right lower leg, chronic kidney disease, difficulty walking, spinal stenosis, pain and muscle weakness.
Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 01/07/20, revealed the resident had no cognitive deficits, abnormal behaviors or rejection of care. The resident required extensive assistance with bed mobility, locomotion, dressing and personal hygiene and limited assistance with transfers, walking and toileting.
Interview with Resident #90 on 02/03/20 at 10:23 A.M. revealed she had been missing a pair of black shorts for about two months. The resident stated the shorts accidentally got put in the facility laundry. She stated she had told the nursing staff as well as the laundry staff but no one had been able to find them.
Interview with State Tested Nursing Assistant #306, Registered Nurses #226 and #207 between 02/04/20 at 1:40 P.M. and 02/05/20 at 2:00 P.M. revealed they cared for Resident #90 and was unaware she was missing any clothing.
Interview with Laundry Staff Member #304 on 02/05/20 at 3:00 P.M. revealed she was aware the resident was missing a pair of black silky shorts for a few months. She stated she looked but was unable to find them and it had been long enough the resident should be reimbursed. She stated she had spoken with the resident's family who did the resident's laundry and the family verified the shorts had not made it back to their home.
Interview with Environmental Service Director #303 on 02/05/20 at 3:30 P.M. verified he was unaware Resident #90 had been missing any clothing and verified the laundry staff did not follow the policy for missing items. He further verified the laundry staff was aware of the resident missing clothing and did not inform him or Licensed Social Worker (LSW) #301 of the missing items, which should have been done. He stated if items were missing a note was hung so staff could be on the look out for the item and this had not been done.
Interview with Licensed Social Worker (LSW) #301 on 02/05/20 at 3:45 P.M. verified she had not been notified of any missing items for Resident #90. She stated once she was notified, a concern form was to be filled out, given to the appropriate department and also forwarded to the Administrator with follow up information, but this had not been initiated since she was not aware of the missing shorts.
Review of the facility's policy Resident/Family concerns and Missing Property, dated 02/17/16, revealed the facility would assist residents and their representatives with any concerns they have regarding care or missing property. Any concern brought to the attention of a facility employee was to be directed to the department head or unit nurse. A Resident/Family concern form was to be filled out by staff and passed onto Administrative staff. The concern was to be discussed in the morning meeting and a plan of action was to be implemented. the concern was to be logged on the Resident/concern log and was to be followed up on.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, staff interview and review of facility policy, the facility failed to ensure the Mi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, staff interview and review of facility policy, the facility failed to ensure the Minimum Data Set (MDS) assessments were accurately completed regarding residents care needs. This affected two residents (#2 and #10) of 22 residents reviewed for accurate MDS assessments. The facility census was 104.
Findings Include:
1. Review of Resident #2's medical record revealed an admission date of 06/30/17. Diagnoses included hemiplegia right side, aphasia, and cognitive communication deficit.
Review of the MDS assessment, dated 01/13/20, revealed the resident as having clear speech.
Review of Resident #2's current care plan revealed the resident has a communication problem related to expressive aphasia. Interventions included communication completed by lip reading, writing, communication board, and gestures.
Observation on 02/04/20 at 1:41 P.M. of Resident #2 revealed the resident was unable to verbally express her needs. The resident had a communication picture book in her room.
Interview on 02/05/20 at 3:39 P.M. with Registered Nurse (RN) #211 verified Resident #2's MDS assessment that listed the resident as having clear speech was not accurate. The resident did not have clear speech.
2. Record review for Resident #10 revealed the resident was admitted to the facility on 01/03/ 19 with diagnoses including end stage renal disease with dialysis, Parkinson's disease, vascular dementia, seizure disorder, and diabetes.
Review of the annual minimum data set (MDS) assessment dated [DATE] revealed the resident scored an 11 on the 'Brief Interview for Mental Status (BIMS) indicating he has moderate cognitive impairment. The assessment indicated he had no behaviors or rejection of care. The assessment stated he required extensive assistance of two staff members for eating.
Review of the Speech Therapy Evaluation and Treatment Plan, dated 01/15/20, stated Resident #10 fed himself with supervision.
Observation of the resident on 02/04/20 at 5:15 P.M. revealed the resident was in a wheelchair seated at the dining room table. He fed himself with the use of a fork. He opened a carton and Boost (a nutritional supplement) placed a straw in it and drank the supplement independently. He removed a slice of wheat bread and butter from a sealed bag by his plate. State Tested Nursing Assistant (STNA) #310 came to the table and assisted him with buttering his bread.
During an interview with STNA #310 on 02/04/20 at 5:30 P.M., she verified the resident can feed himself with set up assistance and supervision.
During an interview with Dietician #320 on 02/05/20 at 11:00 A.M., she stated she had observed the resident feeding himself breakfast earlier this morning.
During an interview with Registered Nurse, MDS Coordinator, #211 on 02/05/20 at 1:00 P.M., she verified the annual MDS was coded incorrectly for Resident #10's eating ability. She stated the resident was fed by one person or his wife.
Review of the facility's policy titled Resident Assessment Policy, dated 11/19/15, revealed the assessment will accurately reflect the resident's status.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of the facility's policy and staff and resident interview, the facility failed to ensure ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of the facility's policy and staff and resident interview, the facility failed to ensure a resident's plan of care had been updated to reflect the resident's non-compliance. This affected one (#12) of 22 residents reviewed for care plan accuracy. The facility census was 104.
Findings include:
Review of the medical record for Resident #12 revealed the resident was admitted to the facility on [DATE]. Diagnoses included hypertension, hydronephrosis with kidney and urethral stone obstruction and end stage renal disease, dependence on renal dialysis.
Review of the physician orders, dated 04/12/18, revealed the resident was to be provided a renal diabetic diet. It further revealed the resident received dialysis services on Tuesdays, Thursdays and Saturdays.
Review of a quarterly Minimum Data Set (MDS) 3.0 assessment, dated 10/21/19, revealed the resident had no cognitive deficits, required supervision with eating with set up assistance, and received dialysis.
Review of the plan of care for Resident #12, last updated 10/2019, revealed the resident was to receive a renal diet and could be offered something different if there was something he did not like. The plan of care did not include information the resident was frequently non-compliant with his renal diet or instructions for staff of what to do if the resident was non-compliant.
Review of the resident's meal ticket for 02/05/20 revealed the resident was to receive a renal diet, which included a pork cutlet, fluffy rice, wax beans, margarine, wheat bread, parsley garnish, chilled peaches, two percent milk.
Review of the regular diet menu for 02/05/20 revealed bratwurst, sauerkraut, mashed potatoes, wheat bread and cranberry velvet dessert.
Interview with Resident #12 on 02/03/20 at 3:00 P.M. revealed he was supposed to be on a renal diet but he did not follow the diet and ate what he wanted. Further interview with Resident #12 on 02/05/20 at 12:10 P.M. revealed he had eaten an early lunch and had mashed potatoes, sauerkraut and peaches.
Interview with [NAME] #305 on 02/05/20 at 12:12 P.M. revealed the resident was taken his meal slip with the renal diet listed but the resident did not want that diet and he chose the mashed potatoes and sauerkraut. She stated the resident frequently did not eat the prescribed diet.
Interview with Registered Dietician #300 on 02/05/20 at 1:15 P.M. revealed she was unaware the resident was not following his prescribed renal diet. She stated if she would have known she would have been in touch with the resident and the dialysis dietician. She further verified the resident's plan of care did not address the resident's non-compliance with his renal diet, or what interventions staff should follow when this happens, but if she would have known, she would have updated this.
Review of the facility's policy Comprehensive care plans, dated 11/02/16, revealed the facility was to develop a comprehensive person centered care plan for each resident that included measurable objectives and timetables to meet a resident's medical, nursing, mental and mental and psychosocial needs that were identified the care plan was to be periodically reviewed and revised by a team of qualified persons after each assessment. The care plan was to include any services that would otherwise be required but were not provided due to the resident's exercise of rights including the right to refuse treatment.
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 medical record review, observation, resident and staff interview, and facility policy review, the facility failed to im...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, resident and staff interview, and facility policy review, the facility failed to implement a pressure relief device to prevent the development pressure sores for one resident (#10) and failed to accurately monitor a pressure ulcer for one resident (#47). This affected two (#10 and #47) of five residents reviewed for pressure ulcers. The facility identified eight residents who have pressure ulcers. The facility census was 104.
Findings include:
1. Record review for Resident #10 revealed the resident was admitted to the facility on 01/03/ 19 with diagnoses including end stage renal disease with dialysis, Parkinson's disease, vascular dementia, seizure disorder and diabetes mellitus.
Review of the annual Minimum Data Set (MDS) assessment, dated 01/09/20, revealed the resident had moderate cognitive impairment and he had no behaviors or rejection of care. The assessment stated he was at risk for skin breakdown with no current skin breakdown.
Review of the plan of care, dated 01/23/20, stated the resident was at risk for pressure ulcers. Interventions included a cushion to the resident's chair when he was in the chair.
Review of the nursing progress notes, dated 02/03/20, stated the resident had a small open area to buttocks.
Observation on 02/04/20 12:31 P.M. revealed Certified Nurse Practitioner (CNP) #330 was checking the resident's buttocks for reported skin breakdown. She asked Resident #10 to rate the pain he was having in his buttock area. He stated his pain was a six out of ten with ten being the most excruciating pain. When he asked when the pain started he stated it has never stopped. Observation to the area revealed fragile scar tissue from a previous healed pressure ulcer. Currently there was no open areas observed. The coccyx area and buttocks was red and blanchable. CNP #330 stated she wished the resident could have pressure relief to the buttocks during the four hours he received dialysis three times a week. An inflatable waffle cushion was observed to be in the resident's wheelchair located at the end of the resident bed. The waffle cushion was observed to be flat.
During an interview with CNP #330 on 02/04/20 at 12:40 P.M. she verified the waffle cushion was not properly inflated. At this time, the resident asked where his Roho (specialized pressure relief cushion) cushion was that he had in the past. CNP #330 stated she would order a 'Roho like pressure relieving cushion.
Review of the physician order, dated 02/05/20 written by CNP #330, stated the resident was to have a Roho cushion or similar in his chair at all times and even during dialysis.
Observation of Resident #10 on 02/05/20 at 10:50 A.M. revealed he was in his room in a tilt in space wheelchair without a cushion in the seat. When asked how he was, he stated his bottom hurt rating his pain a six on a scale of one to ten. He stated he used to have a thicker Roho cushion for his chair and it came up missing.
During an interview with Licensed Practical Nurse #331 on 02/05/20 at 11:00 A.M,. she stated she was unaware of where the cushion to Resident #10's chair was. She stated she would check with therapy concerning getting a cushion for his chair.
2. Record review for Resident #47 revealed the resident was admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease, anxiety, hypertension, diabetes, major depression disorder and Vitamin B-12 anemia.
Review of the admission MDS, assessment, dated 02/11/19, revealed the resident had short and long term memory loss. She was non-ambulatory and was totally dependent on staff for all activities of daily living.
Review of the plan of care, updated 12/04/19, stated Resident #47 has actual impairment to skin integrity with an open area to her left lateral foot. The goal was for the open area on the resident's left lateral foot to be healed without complications by the next review. Interventions included working cooperatively with hospice team to ensure maximum comfort for the resident by monitoring,documenting and location, size, signs and symptoms of infection, and treatment of the open area to the resident's left lateral foot.
Review of the facility's pressure ulcer documentation for Resident #47's left lateral foot ulcer revealed a measurement of 12/02/19 stated the ulcer was acquired in the facility . The stage of the ulcer stated to be a scab, progress was stable and to see treatment administration record for treatment and to see hospice notes. The area measured three centimeter (cm.) by three cm. scab. There was no unit of measure documented . The documentation stated the area had improved with a notation to see the hospice notes. Review of the hospice notes revealed no mention of the pressure ulcer to the resident's left lateral foot on any date close to 12/02/19 .
Review of the facility's wound evaluation, completed on 12/09/20, revealed a scab to the left lateral foot scab measuring 3.0 cm. by 3.0 cm. The documentation stated the had area improved with a notation to see the hospice notes. The hospice notes, dated 12/11/19, stated there was an unstageable wound (slough and/or eschar: Known but not stageable due to coverage of wound bed by slough and/or eschar) to the resident's left outer ankle with an onset date of 10/17/19 measuring 5.2 cm. by 3.9 cm. with hard black eschar (thick scab covering an open wound) with a scant amount of serous drainage with redness to the surrounding tissues.
Review of the facility's wound assessment, dated 12/16/19, revealed a Stage III pressure ulcer (full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed.) to the left lateral foot. The progress of the wound was said to be stable measuring 2.5 cm. by 3.0 cm. with eschar. A notation was made to see the hospice notes. The hospice notes, dated 12/16/19, stated there was an unstageable wound to left lateral foot measuring 6.0 cm. by 6.0 cm. covered with hard black eschar.
Review of the facility's wound assessment, dated 12/2319, stated there was a Stage III pressure ulcer to the left lateral foot measuring 4.0 cm. by 3.5 cm. with a scab. There was a notation to see the hospice notes. The hospice notes revealed no wound assessment for 12/23/19 through 12/26/19.
Review of the facility's wound assessment dated [DATE], revealed a Stage II pressure sore (partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough) to the left lateral foot measuring 0.3 cm. by 0.3 cm. with a scab. There was a notation to see the hospice note . There was no hospice note found for this date. The hospice note, dated 01/02/20, stated there was a Stage II ulcer to the left lateral foot measuring 4.2 cm. by 4 cm. with hard black eschar .
Review of the facility's wound assessment, dated 01/06/20, revealed a Stage II left lateral foot ulcer that had worsened with increased maceration of wound measuring 2.5 cm. by 2.5 cm. by 0.3 cm. in depth. The hospice wound assessment, dated 01/06/20, stated the resident had a Stage II pressure ulcer. There were no measurement or description of the wound.
Review of the facility's wound wound assessment, dated 01/13/20, stated the resident has a Stage III left lateral foot pressure ulcer measuring 2.5 cm. by 2.5 cm. by 0.3 cm. with a half an inch scab. There was a notation to see the hospice notes. The hospice notes revealed no mention of the pressure ulcer to the resident left lateral foot on any date close to 01/13/20.
Review of the facility's wound assessment, dated 01/20/20, stated left lateral foot pressure wound was stable measuring 2.0 by 2.5 with a scab. The hospice wound assessment, dated 1/20/20, revealed a left lateral outer foot measuring 4.7 cm. by 4.2 cm. with a beefy red granulation and loose/tan slough, and a scant amount of seropurulent (yellow tan) drainage.
Review of the facility's wound assessment for the left lateral foot, dated 01/27/20, stated the pressure ulcer to the left lateral foot was an improving Stage III, measuring 2.0 cm. by 2.0 cm. by 0.5 cm. with a scab. The hospice wound note, dated 1/28/20, stated the left outer foot ulcer measured 4.7 cm. by 4.2 cm. with hard black eschar.
Observation of the left lateral ulcer on 02/06/20 at 11:30 A.M. revealed a gauge dressing on left lateral foot had a moderate amount of bright red drainage on the gauze. Registered Nurse (RN) #206 began removing the dressing which was stuck to the wound. RN #206 used saline to moisten dressing for removal. Observation revealed three separate open areas, one with thick eschar measuring 2.5 cm. by 2.0 cm. A second area to top right of the first area covered with slough measuring 2.0 cm. by 2.0 cm. and a third open area measured 1.5 cm. by 1.5 cm. with bright red drainage.
During an interview with Registered Nurse (RN) #206 on 02/06/20 at 11:45 A.M., she verified the measurement of the left lateral foot wound were inconsistent and not accurate. She verified the wound had changed and two additional wounds had open on the left lateral foot since the last wound assessment.
Review of the facility's policy titled Pressure Ulcer Policy, dated 04/29/16, stated a pressure ulcer will be monitored at least weekly and should have documentation including location and staging, size, drainage including amount and characteristics, pain if present, and wound bed and surrounding tissue. In addition the policy stated all residents will be assessed for pressure ulcer risk and appropriate interventions will be implemented. The interventions included wheelchair cushions.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0760
(Tag F0760)
Could have caused harm · This affected 1 resident
Based on record review, observation, staff interview, and review of the manufactures instructions for Flex Pen use, the facility failed ensure needles were primed prior to administration of insulin wh...
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Based on record review, observation, staff interview, and review of the manufactures instructions for Flex Pen use, the facility failed ensure needles were primed prior to administration of insulin when using an insulin pen resulting in a significant medication error for one resident ( #11) of seven residents (#1, #11, #46, #65, #66, #88 and #90) identified as having insulin Flex Pens on the Aspen Hall. The facility census was 104.
Findings include:
During an observation of medication administration for Resident #11 on 02/04/20 at 5:00 P.M. revealed Registered Nurse (RN) # 224 placed a new needle on the Novolog Insulin flex pen. She dialed the amount to be injected to four units and injected the insulin into the residents left lower abdomen. She obtained a new needle for a Humulin 70/30 flex pen, dialed the the amount to 18 units, and injected the insulin into the resident's left lowered abdomen.
During an interview with RN #224 at 5:10 P.M., she verified she did not prime the flex pen needles before administration of the Novolog and Humulin Insulin. She stated she did not know she was suppose to. Licensed Practical Nurse (LPN) #106 was standing at the medication cart while RN # 224 was preparing the insulin pens and verified the needles were not primed.
Review of the resident's residing on the Aspen hall who had physician orders for insulin Flex Pens revealed Resident #1, #11, #46, #65, #66, #88 and #90 had insulin Flex pens on the Aspen hall.
Review of the manufacture's instructions, How to Use the Flex Pen, revealed after placing a needle on the Flex Pen turn the dose selector to select two units, press the push-button all the way in. The dose selector will return to zero and a drop of insulin should appear at the needle tip. After establishing the insulin flow, turn the dose selector to the amount of insulin needed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0849
(Tag F0849)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed communicate with the hospice provider to provide continu...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed communicate with the hospice provider to provide continuity of care for a resident. This affected one (#47) of one resident reviewed for hospice services. The facility identified four residents receiving hospice services. The facility census was 104.
Findings include:
Record review for Resident #47 revealed the resident was admitted to the facility on [DATE] with diagnoses including Alzheimer's Disease, anxiety, hypertension, diabetes, major depression disorder and Vitamin B12 anemia.
Review of the admission Minimum Data Set (MDS) assessment, dated 02/11/19, revealed the resident had short and long term memory loss. She was nonambulatory and was totally dependent on staff for all activities of daily living, She was assessed as receiving hospice services prior to admission to the facility and continues to receive services.
Review of the plan of care, updated 12/04/19, stated Resident #47 has a terminal prognosis due to advanced Alzheimer's disease for which she was receiving hospice services. The goals were to maintain the resident's dignity, comfort, and autonomy will be maintained at the highest level through the next review date. Interventions included working cooperatively with the hospice team to ensure the resident's spiritual, emotional, intellectual, physical and social needs were met. Additional interventions were to communicate change in resident status to the hospice nurse, communicate with hospice any needs regarding specialty equipment or services, hospice aid to visit weekly for activities of daily living and bathing unless otherwise communicated, hospice nurse to visit weekly unless otherwise communicated, hospice to monitor medications during visits, and hospice to monitor wounds during visits.
Review of the electronic nursing progress notes revealed no mention of hospice coming to the facility or communication with hospice.
Review of the medical record located on the nursing unit revealed there were no hospice notes.
Interview with Registered Nurse (RN) #206 on 02/06/20 at 9:25 A.M. verified there were no hospice notes kept in the facility, in the electronic record or in the paper chart for the resident. She verified the communication with hospice was verbal . She stated the hospice nurse always talks to staff when they come into the facility and they call hospice with with all new concerns.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on observation, resident and staff interviews, and facility policy review, the facility failed to clean a glucometer between use on two residents (#11 and #88). The facility identified seven res...
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Based on observation, resident and staff interviews, and facility policy review, the facility failed to clean a glucometer between use on two residents (#11 and #88). The facility identified seven residents as using the glucometer for finger stick blood sugars on the Aspen Unit. In addition, the facility failed to ensure infection control protocol was implemented for one resident (#16) observed to have a dinner tray served next to an urinal. The facility census was 104.
Findings include:
1. Observation on 02/04/20 at 5:00 P.M. on the Aspen unit revealed Registered Nurse (RN) #224 lanced Resident #11's right thumb and obtained a drop of blood placing it on a glucometer strip. She disposed of the lancet and placed the glucometer on top of the medication cart. She did not clean the glucometer. After administering the resident's medication, she used the same glucometer to obtain a finger stick blood sugar on Resident #88. After obtaining a drop of blood on the glucometer strip from Resident #88, she placed the glucometer back on the medication cart. She administered medication to Resident #88.
During an interview with RN #224 on 02/04/20 at 5:15 P.M., she verified she had not cleansed the glucometer between Resident #11 and Resident #88.
During an interview with the Director of Nursing on 02/05/20 at 10:00 A.M., he stated the facility did not have a policy for cleaning the glucometers. He stated they use the Skills Documentation Evaluation - Blood Glucose Testing which states to disinfect the glucometer after use.
Review of the Skills Documentation Evaluation - Blood Glucose Testing, dated 01/2017, stated in step #12 to disinfect the glucometer per manufactures guideline.
2. Observation on 02/03/20 at 6:00 P.M. revealed a urinal containing approximately 200 milliliters (ml.) of clear yellow urine sitting on Resident #16's over the bed table. State Tested Nursing Assistant (STNA) #309 placed the dinner tray on Resident #16's over the bed table, next to the urinal, and uncovered the main entree, and left the room. When outside the room, STNA #309 verified she did not empty his urinal and she stated he tells them when he wants it emptied. She verified the urinal with urine was right beside his food.
During an interview with Resident #16 on 02/03/20 at 6:05 P.M., he stated they never empty his urinal until it was over flowing. He verified he does not want to eat with the urinal with urine in it beside of his meal tray.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • No fines on record. Clean compliance history, better than most Ohio facilities.
Concerns
- • 33 deficiencies on record, including 1 serious (caused harm) violation. Ask about corrective actions taken.
- • Grade D (45/100). Below average facility with significant concerns.
Bottom line: Trust Score of 45/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Fox Run Manor's CMS Rating?
CMS assigns FOX RUN MANOR 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 Fox Run Manor Staffed?
CMS rates FOX RUN MANOR's staffing level at 4 out of 5 stars, which is above average compared to other nursing homes. Staff turnover is 52%, compared to the Ohio average of 46%.
What Have Inspectors Found at Fox Run Manor?
State health inspectors documented 33 deficiencies at FOX RUN MANOR during 2020 to 2025. These included: 1 that caused actual resident harm, 31 with potential for harm, and 1 minor or isolated issues. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.
Who Owns and Operates Fox Run Manor?
FOX RUN MANOR 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 HCF MANAGEMENT, a chain that manages multiple nursing homes. With 120 certified beds and approximately 71 residents (about 59% occupancy), it is a mid-sized facility located in FINDLAY, Ohio.
How Does Fox Run Manor Compare to Other Ohio Nursing Homes?
Compared to the 100 nursing homes in Ohio, FOX RUN MANOR's overall rating (2 stars) is below the state average of 3.2, staff turnover (52%) is near the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.
What Should Families Ask When Visiting Fox Run Manor?
Based on this facility's data, families visiting should ask: "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?"
Is Fox Run Manor Safe?
Based on CMS inspection data, FOX RUN MANOR has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 2-star overall rating and ranks #100 of 100 nursing homes in Ohio. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Fox Run Manor Stick Around?
FOX RUN MANOR has a staff turnover rate of 52%, which is 6 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 Fox Run Manor Ever Fined?
FOX RUN MANOR has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.
Is Fox Run Manor on Any Federal Watch List?
FOX RUN MANOR 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.