JAMESTOWN PLACE HEALTH AND REHAB
For profit - Corporation
50 Beds
SIMCHA HYMAN & NAFTALI ZANZIPER
Data: November 2025
Trust Grade
75/100
#86 of 913 in OH
Last Inspection: October 2022
Over 2 years since last inspection. Current conditions may differ from available data.
Overview
Jamestown Place Health and Rehab has a Trust Grade of B, indicating it is a good choice for families, performing well overall. It ranks #86 out of 913 facilities in Ohio, placing it in the top half, and #2 out of 10 in Greene County, meaning only one nearby option is better. However, the facility is experiencing a worsening trend, with issues increasing from 5 in 2019 to 7 in 2022. Staffing is a mixed bag; it has a 3/5 rating, with a turnover rate of 48%, which is slightly below Ohio's average. Notably, there have been no fines, reflecting compliance with regulations. On the downside, there have been some concerning incidents. For example, a resident suffered an avoidable fall while using a merry walker due to lack of supervision, resulting in hospitalization for a serious injury. Additionally, the Infection Preventionist has not received proper training, raising potential health risks for all residents. Lastly, the facility failed to adhere to a prepared menu, leading to complaints about the quality of the food served. Overall, while Jamestown Place has strengths in its ratings and no fines, families should be aware of the serious incidents and staff training issues.
- Trust Score
- B
- In Ohio
- #86/913
- Safety Record
- Moderate
- Inspections
- Getting Worse
- Staff Stability ⚠ Watch
- 48% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most Ohio facilities.
- Skilled Nurses ○ Average
- Each resident gets 41 minutes of Registered Nurse (RN) attention daily — about average for Ohio. RNs are the most trained staff who monitor for health changes.
- Violations ⚠ Watch
- 26 deficiencies on record. Higher than average. Multiple issues found across inspections.
75/100
Top 9%
Needs review
5 → 7 violations
★★★★★
5.0
Overall Rating
★★★☆☆
3.0
Staff Levels
★★★★★
5.0
Care Quality
★★★★☆
4.0
Inspection Score
↔
Stable
2019: 5 issues
2022: 7 issues
The Good
-
5-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in quality measures, fire safety.
The Bad
Staff Turnover: 48%
Near Ohio avg (46%)
Higher turnover may affect care consistency
Chain: SIMCHA HYMAN & NAFTALI ZANZIPER
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 26 deficiencies on record
1 actual harm
Oct 2022
7 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, the facility failed to ensure advance directives were dated when signed. This affected one (Resident #32) out of four residents reviewed for advance directi...
Read full inspector narrative →
Based on record review and staff interview, the facility failed to ensure advance directives were dated when signed. This affected one (Resident #32) out of four residents reviewed for advance directives. The facility census was 40.
Findings include:
Review of the medical record for Resident #32 revealed an admission date of 02/14/15. Diagnoses included cellulitis of right lower limb, peripheral vascular disease, type two diabetes mellitus with other circulatory complications, major depressive disorder, chronic obstructive pulmonary disease, atrial fibrillation, iron deficiency anemia, hyperlipidemia, hypertension, and angina pectoris.
Review of the annual Minimum Data Set (MDS) 3.0 assessment, dated 08/14/22, revealed this resident had intact cognition. This resident was assessed to require extensive assistance for bed mobility, transfer, dressing, toileting, and personal hygiene. The resident was able to eat independently.
Review of the current physician orders revealed an order dated 07/17/18 for Do Not Resuscitate (DNR) Comfort Care.
Review of the completed DNR form revealed the physician had not dated the form when it was signed.
Interview on 09/28/22 at 11:29 A.M. with the Director of Nursing (DON) confirmed the DNR form was not dated and should have been dated by the physician when completed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0582
(Tag F0582)
Could have caused harm · This affected 1 resident
Based on record review and staff interview, the facility failed to ensure an advanced beneficiary notice of non-coverage was completed. This affected one resident (Resident #36) out of three residents...
Read full inspector narrative →
Based on record review and staff interview, the facility failed to ensure an advanced beneficiary notice of non-coverage was completed. This affected one resident (Resident #36) out of three residents reviewed for beneficiary notice. The facility census was 40.
Findings include:
Review of the medical record for Resident #36 revealed an admission date of 02/25/22. Diagnoses included major depressive disorder, dementia, squamous cell carcinoma, pressure ulcer of sacral region, stage four, and protein calorie malnutrition.
Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 09/01/22, revealed this resident had moderately impaired cognition. This resident was assessed to require extensive assistance with transfers, dressing, and toileting as well as supervision for eating.
Review of form titled CRI Notification for Discharge of Therapy Services, dated 04/19/22, revealed Resident #36 was discharged from therapy services effective 04/21/22 because the resident achieved all goals and was not expected to make further progress.
Interview on 09/29/22 at 2:50 P.M. with Regional Clinical Director #150 confirmed the advanced beneficiary notice was not completed and provided to Resident #36 but should have been when she was discharged from therapy by the facility.
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 staff interviews and medical record review, the facility failed to complete comprehensive person-centered care plans fo...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews and medical record review, the facility failed to complete comprehensive person-centered care plans for two (Resident #14 and Resident #19) out of the four residents sampled. The facility census was 40.
Findings include:
1. Review of medical record for Resident #14 revealed an admission date of 05/28/21. Review of the medical record revealed medical diagnoses of protein calorie malnutrition, major Depression, syncope and collapse, atrial fibrillation, anemia, hypertension and unspecified injury of head.
Review of the medical record revealed the Minimum Data Set (MDS) dated [DATE] which stated Resident #14's Brief Interview for Mental Status (BIMS) score was three indicating Resident #14 had severely impaired cognition. The MDS revealed the resident required extensive staff assistance of two staff members for bed mobility and transfers and extensive assist of one staff member for toileting. The MDS revealed Resident #14 was dependent upon staff for personal cares.
Further review of the medical record for Resident #14 revealed Hospice services were initiated on 03/23/22 with a primary terminal diagnosis of senile degeneration of the brain. The medical record did not support documentation that the facility collaborated with the Hospice provider to develop a comprehensive person-centered care plan that included measurable objectives and timeframes to meet Resident #14's psychosocial needs.
Interview on 09/28/22 at 11:02 A.M. with Regional Nurse #150 confirmed Resident #14 did not have a comprehensive person-center care plan to support the services and cares provided by the Hospice provider.
2. Review of the medical record for Resident #19 revealed an admission date of 07/16/22. The medical record revealed medical diagnoses of protein calorie malnutrition, Adult Failure to Thrive (AFTT), pneumonia, Depression, and chronic obstructive pulmonary disease (COPD).
Review of the medical record for Resident #19 revealed the MDS dated [DATE] which stated Resident #19's Brief Interview for Mental Status (BIMS) for was nine, indicating the resident had moderate cognitive impairment. Further review of the MDS revealed Resident #19 required extensive assistance of two staff members for bed mobility and transfers, and extensive assist of one staff member for toileting and locomotion on and off the unit. The MDS revealed the resident did not ambulate and was dependent for bathing.
Further review of the medical record for Resident #19 revealed lack of documentation to support the facility had developed comprehensive person-centered care plans for Resident #19 Activities of Daily Living (ADLs) or activities and preferences.
Interview on 09/27/22 at 2:48 P.M. with Regional Nurse #150 revealed the State Tested Nursing Assistance (STNAs) determined the amount of assistance Resident #19 required for ADLs from the ADL comprehensive person-centered care plan. Regional Nurse #150 confirmed the facility did not complete comprehensive person-centered ADL or Activity/preference care plan for Resident #14 in the medical record.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and policy review, the facility failed to complete quarterly care conferences for residents ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and policy review, the facility failed to complete quarterly care conferences for residents and family. This affected one (#39) of two residents reviewed for care plans. The facility census was 40.
Findings include:
Review of the medical record for Resident #39 revealed an admission date of 03/01/19. Diagnoses included dementia, Alzheimer's disease, fracture of right wrist and hand, and hypertension.
Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #39 had severe cognitive impairment. This resident was assessed to require two-person extensive assistance with transfers, dressing, and toileting, supervision with eating, and two-person total dependence with bathing.
Review of the care conferences for the last 12 months revealed Resident #39 had a care conference on 08/30/21, 06/28/22 and 09/06/22.
Interview on 09/28/22 at 11:46 A.M. with social services director #350 revealed care conferences were to be completed quarterly. Social services director #350 reported Resident #39 only had three care conferences completed in the last 12 months.
Review of the facility policy titled, Family Involvement in Resident Care, dated 11/2020 revealed residents and their representatives will be provided with an opportunity to participate in the care planning process and be included in decisions, changes of care, treatment, and/or interventions. Care plan meetings will be held to accommodate residents. Family members will be invited to quarterly care plan meetings or care plan meetings that occur due to a change in resident condition.
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** Based on observation, staff interview, and medical record review, the facility failed to provide fingernail care to one (Residen...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and medical record review, the facility failed to provide fingernail care to one (Resident #14) out of the four residents sampled. This had the potential to affect all the residents in the facility. The facility census was 40.
Findings include:
Review of medical record for Resident #14 revealed an admission date of 05/28/21. Review of the medical record revealed medical diagnoses of protein calorie malnutrition, major Depression, syncope and collapse, atrial fibrillation, anemia, HTN and unspecified injury of head.
Review of the medical record revealed the Minimum Data Set (MDS) dated [DATE] which stated Resident #14's Brief Interview for Mental Status (BIMS) score was three indicating Resident #14 had severely impaired cognition. The MDS revealed the resident required extensive staff assistance of two staff members for bed mobility and transfers and extensive assist of one staff member for toileting. The MDS revealed Resident #14 was dependent upon staff for personal care.
Review of the medical record revealed Resident #14 enrolled into Hospice services on 03/23/22. Per the medical record, Resident #14 was ordered a Hospice Home Health Aide (HHA) one day per week to assist Resident #14 with bathing and personal care. Further review of the medical record revealed a Hospice HHA visited Resident #14 weekly. The medical record did not have documentation to support the Hospice HHA or facility staff offered or completed fingernail care for Resident #14.
Observation on 09/26/22 at 10:59 A.M. revealed Resident #14 to be laying in bed covered with blankets with her hands on top of the blankets. Resident #14's fingernails were noted to be long, chipped with sharp edges and there was visible dirt under all the fingernails.
Observation and interview with Director of Nursing (DON) on 09/28/22 at 9:08 A.M. confirmed Resident #14's fingernails to be long, chipped with sharp jagged edges, and had visible dirt under the fingernails. DON was unable to provide documentation to support Resident #14 was offered or had nail care completed by the facility staff or Hospice HHA. DON stated the facility staff are to complete fingernail care on residents as needed even if the resident received Hospice services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and policy review, the facility failed to accurately monitor weights per nutritional paramet...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and policy review, the facility failed to accurately monitor weights per nutritional parameters. This affected three (#8, #20, and #28) out of three residents reviewed for nutrition. The facility census was 40.
Findings include:
1. Review of the medical record for Resident #8 revealed an admission date of 01/25/22. Diagnoses included Parkinson's disease, Alzheimer's disease, major depressive disorder, pneumonia, COVID-19, and dysphagia.
Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #8 had severe cognitive impairment. This resident was assessed to require two-person extensive assistance with transfers, dressing, and toileting, supervision with eating, and two-person total dependence with bathing.
Review of the care plan dated 06/20/22 revealed Resident #8 had potential for inadequate food/beverage intake due to depression and parkinson's. Interventions included assist feed as tolerated and indicated. Staff to give diet as ordered. Staff to invite to food related activities. Staff to monitor meal consumption daily. Staff to obtain and update food/beverage preferences. Staff to offer fluids between meals and when rendering care. Staff to provide food substitutes.
Review of the physician order dated 01/25/22 revealed Resident #8 was ordered a magic cup with lunch for supplement.
Review of the physician order dated 01/25/22 revealed Resident #8 was ordered a multivitamin tablet, give one tablet by mouth one time a day for supplement.
Review of the physician order dated 04/01/22 revealed Resident #8 was ordered a regular diet with regular texture.
Review of the physician order dated 05/09/22 revealed Resident #8 was ordered weekly weights every Sunday during dayshift.
Review of the physician order dated 07/15/22 revealed Resident #8 was ordered a house supplement two times a day.
Review of the progress note dated 07/15/22 at 11:29 A.M. revealed Resident #8 had unintended weight loss related to pneumonia with antibiotic treatment as evidenced by significant weight loss. Meal intake was 25-100% and received magic cup at lunch. Staff to monitor weights as ordered.
Review of the progress note dated 07/27/22 at 3:02 P.M. revealed Resident #8 was receiving house supplement twice a day and magic cups once a day. Resident #8 had a deep tissue injury on her coccyx per wound care. Recommended adding Pro-stat 30 milliliters (ml) twice a day and will continue to monitor.
Review of the weekly weights dated July 2022 through September 2022 revealed the facility obtained five out of 13 weights for Resident #8.
Review of the weekly weights for Resident #8 revealed inconsistent weight fluctuations up to 30 pounds without a re-weight completed for accuracy. For example, on 06/27/22, Resident #8 weighed 148 pounds. On 07/04/22, Resident #8 weighed 167 pounds. On 07/10/22, Resident #8 weighed 132 pounds.
Interview on 09/28/22 at 11:32 A.M. with the Director of Nursing (DON) revealed Resident #8 had fluctuations in her weight but no change in intake. The DON reported staff had not been completed weekly weights as ordered and were currently working to correct this concern with weights being completed every Sunday.
Interview on 09/28/22 at 3:40 P.M. with Registered Dietician (RD) #250 revealed weekly weights were not getting completed per orders. RD #250 reported weights were not obtained accurately related to weight fluctuations with no change in intake from Resident #8. RD #250 stated Resident #8 was receiving med pass supplement twice a day and a magic cup at lunch to maintain weight.
2. Review of the medical record for Resident #20 revealed an admission date of 01/06/22. Diagnoses included congestive heart failure, atherosclerotic heart disease of native coronary artery without angina pectoris, anxiety disorder, hypothyroidism, major depressive disorder, atrial fibrillation, other disorder of lung, nonrheumatic aortic (valve) stenosis, anemia, vitamin b12 deficiency anemia, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, chronic obstructive pulmonary disease, mixed hyperlipidemia, and hypertension.
Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 07/20/22, revealed this resident had moderately impaired cognition. This resident was assessed to require extensive assistance for bed mobility, transfer, dressing, toileting, and personal hygiene. The resident was able to eat independently.
Review of the plan of care dated 01/06/22 revealed the resident was at risk for malnutrition related to hypothyroidism and depression. Interventions included diet as ordered, medication as ordered, monitor meal consumption daily, and monthly weights.
Review of the current physician orders revealed an order dated 05/09/22 to obtain monthly weight every day shift starting on the 2nd and ending on the 2nd every month for weight.
Review of the Treatment Administration Record (TAR) from 08/01/22 through 09/28/22 revealed no monthly weights were documented.
Review of the weights documented in the electronic health record revealed no weights were documented for August or September 2022.
Interview on 09/28/22 at 2:15 P.M. with the Director of Nursing (DON) confirmed the facility had no documented weights for Resident #20 for the months of August or September 2022. The DON reported the monthly weights should have been obtained within the first several days of the month and acknowledged that obtaining weights had been an issue.
3. Review of the medical record for Resident #28 revealed an admission date of 08/02/22. Diagnoses included displaced spiral fracture of shaft of humerus, left arm, subsequent encounter for fracture with routine healing, hypertension, rhabdomyolysis, congestive heart failure, acute kidney failure, and atherosclerotic heart disease of native coronary artery without angina pectoris.
Review of the admission Minimum Data Set (MDS) 3.0 assessment, dated 08/06/22, revealed resident had moderately impaired cognition. This resident was assessed to require extensive assistance for bed mobility, transfer, dressing, and toileting, limited assistance for personal hygiene, and was able to eat independently.
Review of the plan of care dated 08/05/22 revealed the resident was at risk for malnutrition related to hypertension, rhabdomyolysis, congestive heart failure, acute kidney failure, and atherosclerotic heart disease. Interventions included monitor intake of meals and weights as ordered.
Review of the current physician orders revealed no orders for weight monitoring.
Review of the weights documented in the electronic health record revealed the last weight documented was dated 08/21/22.
Review of the weight note dated 08/26/22 revealed the weight obtained on 08/21/22 was thought to be inaccurate due to a weight loss of 6.1% in ten days with no changes in intakes. The recommendations were to continue regular diet and a reweigh was requested.
Interview on 09/28/22 at 2:25 P.M. with the Director of Nursing (DON) confirmed there was no documentation that Resident #28 had been reweighed. The DON also confirmed the resident did not have an order in place to obtain weights.
Review of the facility policy titled Weighing the Resident, revised 11/2019, revealed when there is a significant variance from the previous recorded weight the scale should be re-balanced and the resident re-weighed. It also revealed at a minimum, all residents of the facility shall be weighed upon admission and monthly unless ordered otherwise by the physician or as directed by the weight committee.
Review of the facility policy titled, Weight Loss Prevention Program, revealed weights were obtained by the fifth of each month and ensure accurate weights and reweighs were timely. Consistent staff were to weigh residents weekly and monthly at consistent times. Weigh wheelchairs each time. Staff were to report weights to the DON and dietary manager for calculation of significant weight loss and input into tracking system. In-service staff on appropriate use of scales.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0882
(Tag F0882)
Could have caused harm · This affected most or all residents
Based on record review and staff interviews, the facility failed to ensure the appointed Infection Preventionist had proper infection prevention and control training and certification. This had the po...
Read full inspector narrative →
Based on record review and staff interviews, the facility failed to ensure the appointed Infection Preventionist had proper infection prevention and control training and certification. This had the potential to affect all the residents in the facility. The facility census was 40.
Finding include:
Record review revealed the Director of Nursing (DON) was the Infection Preventionist for the facility. Further record review revealed the DON had not completed specialized training in infection prevention and control.
Interview on 09/29/22 at 9:33 A.M. with DON confirmed she was the appointed Infection Preventionist in the facility to manage the Infection Prevention Control Program (IPCP). The DON confirmed she had not completed specialized training in infection prevention and control.
Interview on 09/29/22 at 10:02 A.M. with Regional Nurse #150 confirmed DON was the appointed Infection Preventionist for the facility and DON had not completed specialized training for infection prevention and control.
Sept 2019
5 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observation and staff interview, the facility failed to provide to dignity during dining for a ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observation and staff interview, the facility failed to provide to dignity during dining for a resident. This affected one (#11) of 10 residents observed who required assistance/dependence with eating. The facility census was 39.
Findings include:
Clinical record review revealed Resident #11 was admitted to the facility on [DATE] with diagnoses including Alzheimer's dementia. Review of the Minimum Data Set (MDS) assessment revealed the resident had severely impaired cognition and required the extensive assist of one staff for feeding at meals.
Observation on 09/03/19 at 5:27 P.M. revealed State Tested Nursing Assistant (STNA) #53 standing while feeding Resident #11 her meal. There were five resident who received feeding assistance from the staff. Interview at that time of observation with the Director of Nursing (DON) verified STNA #53 was standing and should be sitting in a chair next to the resident when assisting a resident with her meal.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0569
(Tag F0569)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the resident fund accounts, staff interview and policy review, the facility failed to provide the resident's ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the resident fund accounts, staff interview and policy review, the facility failed to provide the resident's funds within 30 days from discharge from the facility. This affected one (Resident #194) of two residents reviewed for a closed fund account. The facility identified eight residents who had a fund accounts with the facility. The facility census was 39.
Findings include:
Review of the resident's fund account information revealed Resident #194 was admitted to the facility on [DATE]. The resident discharged to a different facility on [DATE]. A check for a balance of $516.74 was sent to the resident on [DATE].
Interview with Business Office Manager (BOM) #51 on [DATE] at 11:45 A.M. verified that Resident #194 discharged to a different facility on [DATE]. BOM #51 verified a check for a balance of 516.74 dollars was sent to the resident/responsible party on [DATE] which was 66 days after discharge.
Review of the facility's undated policy titled Patient Resident Trust Fund Policy revealed the BOM reviewed the accounts for discharged or deceased residents and closed the account within 30 days.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0655
(Tag F0655)
Could have caused harm · This affected 1 resident
Based on medical record review, staff and family interview and review of the facility policy, the facility failed to ensure a 48-hour baseline care plan was reviewed with the resident and their repres...
Read full inspector narrative →
Based on medical record review, staff and family interview and review of the facility policy, the facility failed to ensure a 48-hour baseline care plan was reviewed with the resident and their representative, and a copy of the care plan given to the resident or their representative. This affected one (Resident #15) out of 12 residents reviewed for baseline care plans. The facility census was 39.
Findings include:
Review of the medical record for Resident #15 revealed an admission date of 07/03/19. Diagnoses included malignant neoplasm of the hard palate, dysarthria and anarthria, dysphagia, blindness left eye, chronic hepatitis, benign prostatic hyperplasia, obstructive and reflux uropathy weakness and severe calorie malnutrition.
Review of the 48-hour baseline care plan for Resident #15, dated 07/03/19, revealed the care plan was completed and signed by the Registered Nurse (RN). Further review of the care plan revealed no documentation that the plan had been reviewed with the resident or his representative.
Review of the nursing progress notes dated 07/03/19 through 07/10/19, revealed no documentation that the 48-hour care plan for Resident #15 had been reviewed with the resident or his representative.
Review of the 30-day Medicare Minimum Data Set (MDS) assessment, dated 07/31/19, revealed Resident #15 to have moderate cognitive impairment. He was also assessed to be totally dependent upon staff for his eating and nutrition and his weight loss was assessed as unknown.
Interview on 09/04/19 at 4:05 P.M. with Resident #15's representative stated she had never received an initial care plan when they first arrived at the facility. She stated no one had reviewed the care plan with either her husband, Resident #15, or herself.
Interview on 09/04/19 at 4:25 P.M. with the Director of Nursing (DON) confirmed 48-hour baseline care plans were to be completed within 48 hours and reviewed with the resident and their representative. The DON confirmed after the care plan was reviewed, the care plan was signed by either the resident or their representative, a copy was made, and the facility keeps a copy and a copy one was given to the resident and their representative.
Interview on 09/04/19 at 4:33 P.M. with Social Service Designee (SSD) #68, confirmed she conducted a care conference with Resident #15 and his representative on 07/08/19, but denied reviewing the 48-hour baseline care plan with the his representative or giving her a copy of the plan.
Review of the facility policy titled Baseline Care Plan and Summary, dated 01/01/18, revealed the facility's interdisciplinary team (IDT) would review, in person or via the phone, the summary of the baseline care plan, a copy would be given to the resident, family or responsible party and a note made in the resident's medical record regarding which method the summary was reviewed. It should also contain the time, date and with whom the baseline care plan summary was shared with. Within 48 hours, the base line care plan should be reviewed with the resident, family and or responsible party, and should receive a copy of the base line care plan.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0687
(Tag F0687)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, family and staff interviews and facility procedure review, the facility failed to provide ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, family and staff interviews and facility procedure review, the facility failed to provide timely and appropriate foot care a resident. This affected one (Resident #22) of one resident reviewed for activities of daily living care. The facility census was 39.
Findings include:
Record review for Resident #22 revealed the resident was admitted to the facility on [DATE] with diagnoses including a stroke resulting in left sided hemiplegia and Parkinson's disease. Review of the Minimum Data Set (MDS) assessment, dated 07/04/19, revealed the resident was non-verbal with moderately impaired cognition. S he required the extensive assistance of one staff for hygiene. The resident's daughter was the responsible party.
Review of a Health Care Services Consent Form, dated 08/12/19, revealed the resident's daughter signed a consent for audiology, optometry and podiatry services with a visiting mobile care group.
Observation on 09/03/19 at 3:47 P.M. revealed Resident #22 was in bed with very long brown toenails and dry/flaky toes. At that time, a family interview with the resident's Daughter #251 was conducted and the daughter stated she was upset with condition of the resident's toenails/feet, and the resident needed podiatry care.
Interview on 09/03/19 at 4:01 P.M. with Social Service Designee (SSD) #97 revealed the resident was not currently scheduled for podiatry services. SSD #97 revealed the resident's daughter approached her on 08/12/19 and signed a consent for podiatry care. SSD #97 verified the consent was not completed at the time of the resident's admission on [DATE]. Interview with the Administrator at that time verified the Health Care Services Consent Form should be completed at admission and resident receive appropriate care including podiatry in a timely manner.
Observation with the Director of Nursing (DON) on 09/03/19 at 4:45 P.M. verified the resident's toenails needed to be trimmed and dry/flaky feet needed care.
Review of the facility's procedure provided from the DON revealed the procedure was from the nursing care manual by [NAME], eighth edition 2019, page 51 under bed bath. The procedure stated, if possible place a basin on the resident's bed, flex the leg and place the foot in the basin and add warm water. Soak the resident's foot, wash and rinse it thoroughly. Remove the foot from the basin, dry it, and clean the toenails. Apply a hypoallergenic moisturizer as needed to areas of dry skin to prevent skin breakdown.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Tube Feeding
(Tag F0693)
Could have caused harm · This affected 1 resident
Based on observation, medical record review and staff and family interview, the facility failed to ensure Resident #15 received the prescribed amount of enteral nutrition. This affected one (Resident ...
Read full inspector narrative →
Based on observation, medical record review and staff and family interview, the facility failed to ensure Resident #15 received the prescribed amount of enteral nutrition. This affected one (Resident #15) out of one resident reviewed for enteral feeding. The facility identified four residents received tube feedings. The facility census was 39.
Findings include:
Review of the medical record for Resident #15 revealed an admission date of 07/03/19. Diagnoses included dysarthria and anarthria, dysphagia and severe calorie malnutrition. Review of the 30-day Medicare Minimum Data Set (MDS) assessment, dated 07/31/19, revealed Resident #15 to have moderate cognitive impairment. He was also assessed to be totally dependent upon staff for his eating and nutrition and his weight loss was assessed as unknown.
Review of Resident #15's nutritional assessment, dated 07/11/19, revealed Resident #15 was currently receiving Jevity one point two calories at 55 ml/hr., with 30 ml. of water flush every hour. Nutritional summary documented by Licensed Dietitian (LD) #97, revealed the current rate of enteral nutrition did not provide the recommended nutrition. She recommended the tube feeding (TF) be increased to a rate of 65 ml/hr. She also assessed the resident as having no significant weight change and that he had good tolerance for tube feeding.
Review of Resident #15's plan of care, dated 07/22/19, revealed he was totally dependent upon TF, due to inadequate food and beverage intake related to cancer, for his nutritional needs. His goals were documented to maintain nutritional status and body weight. Interventions included enteral formula and feedings as ordered, monitor lab data as available and weekly weights.
Review of the results for Resident #15's comprehensive metabolic panel blood test, dated 07/26/19, revealed the resident's BUN (urea nitrogen) to be 32, and BUN/Creatinine ratio was 46. Both results were elevated. The normal lab value for BUN was seven through 25 milligram (mg) per deciliter (dL), (mg/dL). The normal lab value for a BUN/Creatinine ratio was six through 25. Resident #15's BUN and BUN/Creatinine ratio results were elevated which indicated possible dehydration.
Review of the current physician's orders for Resident #15, identified Jevity (a tube formula) one point two calories, enteral feed (TF), every day and night shift, related to weakness and severe protein/calorie malnutrition, at continuous rate of 65 milliliters per hour (ml/hr) via gastric tube (g-tube) for 24 hours per day. Also identified was an order for water flush per gastrostomy tube at 40 ml. every hour per pump.
Observation on 09/03/19 at 11:22 A.M. revealed Resident #15 sitting in his wheelchair with his wife and not connected to his TF pump. Interview on 09/03/19 at 11:30 A.M. with the resident's wife revealed she had arrived at the facility at 10:30 A.M. and Resident #15 was already disconnected from his TF pump.
Interview on 09/03/19 at 12:07 P.M. with State Tested Nursing Assistant (STNA) #100 confirmed Resident #15 was not connected to his TF pump.
Observation on 09/04/19 at 9:57 A.M. of Resident #15, revealed he was asleep in his bed. His TF was connected and running per pump at 65 ml/hr. A bag of water was observed hanging on the pump and connected. The container of TF was labeled, Jevity one point two. A label on the container documented the TF was started at 1:30 A.M. on 09/04/19.
Observation on 09/04/19 at 3:52 P.M. revealed Resident #15 and his wife were entering his room and Resident #15 was observed in his wheelchair, not connected to his tube feeding pump.
Interview on 09/04/19 at 4:58 P.M. with the resident's wife confirmed Resident #15 remained unconnected from his tube feeding pump and had been unconnected since they had gone outside at 3:30 P.M.
Observation on 09/04/19 at 6:20 P.M. of Resident #15 revealed Jevity one point two connected to the resident's gastrostomy tube and running at 65 ml/hr. per pump. Observation of the Jevity container revealed it to be the same one as observed at 9:57 A.M. The label of the Jevity container revealed it was started on 09/04/19 at 1:30 A.M. The container was observed with 210 ml remaining in the container. The resident was ordered enteral feed at 65 ml/hr. The length of time from 1:30 A.M. (start of the TF) to 6:30 P.M. (observation) equaled 17 hours. Calculation for 17 hours times 65 ml of TF per hour revealed the resident should have received 1105 ml. of TF.
Interview on 09/04/19 at 6:27 P.M. with the Director of Nursing (DON) confirmed only 210 ml., was observed remaining in Resident #15's TF container. She also confirmed the resident had only received 790 ml. of Jevity for the period from 1:30 A.M. to 6:30 P.M. She confirmed the resident should have received a total of 1105 ml. in that time period.
Observation on 09/05/19 at 10:01 A.M. revealed Resident #15's TF was observed connected to the resident. The container of Jevity one point two was observed running per pump at 65 ml/hr. The label on the container documented the start time of the TF as 1:45 A.M. on 09/05/19. Calculation for nine point five hours, at 65 ml/hr., of TF would equal 617.5 ml. the resident should have received during this time. Observation of the container revealed 600 ml. left in the container.
Interview on 09/05/19 at 10:23 A.M. with the DON confirmed the enteral feeding for Resident #15 was started at 1:45 A.M. and the remaining amount in the container was 600 ml. She confirmed the resident should have received 617.5 ml of TF running at 65 ml/hr. She confirmed with 600 ml .remaining in the container and the resident only received 400 ml. of TF.
Sept 2018
14 deficiencies
1 Harm
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Accident Prevention
(Tag F0689)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observations, and staff interview, the facility failed to ensure a resident was supervised accor...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observations, and staff interview, the facility failed to ensure a resident was supervised according to a fall risk care plan while utilizing a merry walker (enclosed rolling walker/ambulation device). This resulted in Actual Harm when Resident #30 was utilizing a merry walker in an unsupervised area, the resident experienced an avoidable fall and was subsequently hospitalized for the treatment of a traumatic subdural hematoma. This affected one (#30) out of two residents reviewed for falls. Facility census was 37.
Findings include:
Review of Resident #30's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses include dementia without behavioral disturbances, heart failure, hypertension, peripheral vascular disease, muscle weakness, atrial fibrillation, anxiety, lack of coordination, cognitive communication deficit, hyperlipidemia, depression, atherosclerotic heart disease, gastroesophageal reflux disease, acute kidney failure, cardiac pacemaker, and difficult ambulation.
Review of Resident #30's most recent Minimum Data Set, dated [DATE] revealed a brief interview for mental status (BIMS) was not able to be assessed as the resident is alert, but is rarely/never understood, indicating severe cognitive impairment. Further review of the MDS revealed the resident requires extensive assistance of one staff member for transfers and limited assistance of one staff member for walking in room and corridor.
Review of Resident #30's care plan revealed a care plan dated 06/20/18 regarding the resident being at risk for falls and accidents. The care plan included measurable goals and included an intervention that instructed staff that the resident utilized a merry walker and the resident is to be in a common area at all times.
Further record review revealed the care plan regarding the use of the merry walker; however, there was no assessments in the medical record regarding the use of a merry walker. Review of the physician orders revealed an order was obtained on 07/10/18 to use of the merry walker for ambulation.
Review of Fall Risk assessment dated [DATE] revealed Resident #30 scored an eight on the assessment, indicating the resident is at risk for falls.
Further review of fall investigation dated 06/22/18, revealed Resident #30 was ambulating per self with a merry walker to the dining room. As the resident was ambulating herself, the wheels to her walker became stuck on a raised floor strip at the entrance of the dining room. This caused the walker to tip over, as the resident continued pushing the walker. The resident sustained a laceration to her left eyebrow area, and she was transported to the hospital for evaluation and treatment.
Review of hospital medical records dated 06/22/18 revealed this resident was admitted to the hospital on [DATE]. The resident was diagnosed with a subdural hematoma and was then transported to a higher level trauma hospital. The resident was discharged and returned to the facility on [DATE]. No further falls were noted on her record.
On 08/28/18 at 1:18 P.M., observation of Resident #30 revealed that she ambulates throughout the facility with the use of a merry walker. The resident was observed attempting to open several closed doors on this observation with no success. Resident #30 was observed to have staff oversight at the time of this observation and no falls were noted. Care plan interventions were in place.
On 08/29/18 at 1:44 P.M., observation of Resident #30 revealed that this resident is ambulating with the use of her merry walker at this time. No obstacles were observed. No observations of the resident attempting to open closed doors. Resident is ambulating in the hallways of the facility, and is not currently in the commons area of the building.
On 08/30/18 12:18 P.M., interview with the Director of Nursing (DON) revealed that the doors to the dining room were closed on the evening of 06/22/18 at 7:00 P.M. She stated Resident #30 was pushing her merry walker while trying to push the doors to the dining room open. A floor strip was pulled up in one place at that time, and the resident got caught on that strip and fell forward. She stated that no one was with the resident at the time of the fall, and the nurse was at the nursing station when she heard the fall happen. The nurse responded to the resident fall, and assessed the resident for injuries, at which time the resident was found with a laceration to her left eyebrow. The DON stated the resident was send to the hospital and diagnosed with a traumatic subdural hematoma. The resident returned to the facility on [DATE]. The DON stated the resident has not had any falls prior to, or after this incident. The DON stated that the resident was unattended at the time of the fall. The DON verified that this resident is care planned to be in the commons area of the building at all times while in her merry walker.
On 08/30/18 at 12:20 P.M., observation of Resident #30 revealed this resident is currently ambulating with the use of her merry walker in the hallway leading to her room. Facility staff were present for oversight.
On 08/30/18 at 12:28 P.M. interview with Maintenance Director #130 revealed that all flooring and threshold strips are inspected daily for any problem areas including raised areas of the strips. Maintenance Director #130 stated that the Resident #30 was attempting to open the doors to the dining room, as she had pulled the door open towards her as this door is a one-way door. She stated that the resident had gotten the door open and was attempting to move through the doorway when the wheels on her merry walker got stuck on the floor strip. She stated that as far as she knew, the resident was by herself at the time of this fall.
On 08/30/18 at 1:31 P.M. an interview with Licensed Practical Nurse (LPN) #526 confirmed Resident #30 required increased supervision while using the merry walker. She stated she would go through doors while in the merry walker. She stated the resident was up around the nurses station the last time she saw her. The resident is constantly bumping into things such as medication carts and other items. She said usually the dining room door remains open unless there is an activity. She verified that she did not witness the fall. The resident had a history of walking in the direction of the dining room. LPN #526 confirmed the strip did not lift up but stated it was thicker than the one that is there now. LPN #526 described it as a silver strip and they replaced it with gold. She explained the resident would not be aware due to her cognition that her pushing through and over the strip was an unsafe act, she would not know to turn around. LPN #526 stated she feels the wheel on the merry walker separated the the device when she fell. She broke the merry walker going over the strip and lost her balance and fell.
On 08/30/18 at 2:41 P.M., an interview with Maintenance Director #130 revealed the metal strip was replaced on 06/22/18, and it was the same type as was previously installed there. She also verified the merry walker was broken at the time of the fall, and was repaired with a screw to hold the piping together.
On 08/30/18 at 3:13 P.M. an interview with the DON verified Resident #30 does not have a completed assessment for the use of the merry walker. The DON also verified that the facility does not have an active policy on the use of a merry walker. The DON stated that she placed a call to the Corporate Nurse and they do not have a policy on the use of a merry walker, as it is being used as an enabler and not a restraint. The DON stated Resident #30 has utilized a merry walker for a long time now, and when asked if the resident can open it on her own, the DON stated that sometimes she can. The DON stated that she cannot remember when the resident started utilizing a merry walker originally. The DON confirmed they should be assessing the resident for the use of the merry walker. The DON further verified Resident #30 was not supervised by facility staff on 06/22/18, which contributed to her fall and subsequent injury.
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 medical record review and resident, family and staff interview, the facility failed to ensure a Sit to Stand lift was i...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and resident, family and staff interview, the facility failed to ensure a Sit to Stand lift was in proper working order, for a resident to use during therapy. This affected one (#31) of two reviewed for limited range of motion. Facility census was 37.
Findings included:
Review of the medical record revealed Resident #31 was admitted on [DATE] with diagnosis that included major depression, diabetes, chronic kidney disease, and unspecified psychosis.
Review of Minimum Data Set (MDS) dated [DATE] included the resident was moderately cognitively impaired and required extensive assistant or was dependent for staff assistance for all activities of daily living (except eating).
Review of Physical Therapy discharge summary noted start of care 06/19/18 and ended 08/13/18 included the resident required maximum assistance with standing tolerance of 1:15-1:30 at this time. Client does not transition to enable a pivot transfer and as such remains on a lift and has reached a plateau. Under Impact on Burden of Care/Daily life included possible re-attempt of Physical Therapy once sit to stand lift is functioning.
Interview with Resident #31 and family member #1 on 08/27/18 at 2:09 P.M. explained the facility does not provide restorative, and they were not sure what was going on with Resident #31's therapy. They also expressed concerns they had heard regarding the mechanical lifts used to get Resident #31 in/out of bed.
Interview on 08/30/18 at 8:50 A.M. with Occupational Therapist Assistant (OTA) #602 (acting therapy manager) explained Resident #31 was on caseload and he was able to tolerate standing for about a minute. She thought towards the end of therapy for Resident #31 they figured out the cord was missing to the sit to stand, because they wanted him to work on tolerating it more. OTA #602 thought the cord has been ordered the previous week by Maintenance Director (MD) #130. OTA #602 thought MD #130 was working on permission to get the battery.
Interview on 08/30/18 at 8:57 A.M. with MD #130 stated she was notified the cord was missing on 08/27/18 for the sit to stand lift. She stated her corporate office had asked her what was needed and to create an inventory list. When she talked with therapy they explained they needed a cord. No one had previously notified MD #130 that the cord was needed it for a resident and that the therapy could possibly be resumed when the sit to stand was functional.
Telephone interview on 08/30/18 at 9:38 A.M. with Physical Therapist (PT) #607 explained it was normal progression for someone that can stand well, but not pivot to use the sit to stand to build up the tolerance (like Resident #31). He stated the resident can stand well from a static (sitting) position. He stated about two weeks PT #607 wanted to use the stand (for Resident #31) and the cord was missing, and it was not functional. He explained the resident could be picked back up for therapy if the lift was functional.
Interview on 08/30/18 at 9:46 A.M. with the Administrator stated she was not aware that a cord for the sit to stand lift had not been ordered, and a resident was waiting on that to re-attempt therapy.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0569
(Tag F0569)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of resident accounts, staff interviews and reviews of facility policy and procedures, the facility failed to dis...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of resident accounts, staff interviews and reviews of facility policy and procedures, the facility failed to disburse Resident #41's personal fund account balance to the probate jurisdiction administering Resident #41's estate within 30 days of her death. This affected one (#41) out of six resident accounts reviewed. Facilty census was 37.
Findings include:
Review of the resident's personal funds account on [DATE] at 10:51 A.M. with the Business Office Manager #14 revealed Resident #41 expired on [DATE]. Resident #41's personal account balance was $9.07 and as per regulatory guidelines has not been sent to the resident's estate. The Business Office Manager #14 explained the administrator had not issued a check in the amount of $9.07 to release the funds to the funeral home and close the expired resident's account.
On [DATE] at 10:58 A.M. interview with the Administrator confirmed a check in the amount of $9.07 has not been issued to close the personal funds account of Resident #41.
Review of the Patient Trust Fund Estate Refund Notices policy and procedure revealed: If there is no Will to be probated, but an estate is to be opened with an Administrator appointed, the Business Office Manager will process and print a copy of the resident's Personal Trust Account within ten (10) days of the date of death . The copy of the ledger will be mailed to the Administrator of the deceased estate. The refund will be made payable to the Estate of the deceased c/o the Administrator within 30 days of the date of death .
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, observation and resident, family, and staff interview, the facility failed to ensure a window th...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation and resident, family, and staff interview, the facility failed to ensure a window that was boarded up was timely fixed. This affected one (#31) of all resident rooms observed during initial tour. Facility census was 37.
Findings included:
Review of the medical record revealed Resident #31 was admitted on [DATE] with diagnosis that included major depression, diabetes, chronic kidney disease, and unspecified psychosis.
Review of Minimum Data Set (MDS) dated [DATE] included the resident was moderately cognitively impaired and required extensive assistant or was dependent for staff assistance for all activities of daily living (except eating).
Interview and observation on 08/27/18 at 1:54 P.M. with Resident #31 and family member #1 explained when the air conditioner was installed, the facility did not replace plexi-glass above it. Family member #1 stated, I think it is an eye sore and makes it dark. Resident #31 stated, I would like to be able to see out the Window.
Observations on 08/28/18 at 10:52 A.M. and at 1:57 P.M. Res # 31's room remains with wood up in the window.
Interview on 08/28/18 at 2:46 P.M. with Maintenance Director (MD) #130 confirmed there was wood in Resident #31's right window. MD #130 explained that the resident, still has one window (on the left). She explained the resident wanted an air conditioner, but no one makes air conditioners for roll out windows. There are no air conditioning units in the resident rooms, only the halls are air conditioned, she explained. The Air Conditioning unit with the wood piece to secure, and the boarded window would have been installed in May 2018. Observed directly after, with DM #130 revealed empty resident room [ROOM NUMBER] which had two windows, on the right window there was a piece of wood right above the air conditioner, and then a clear plexi-glass above it. DM #130 stated at this time there was no plan to replace the wood in Resident #31's boarded window, but the facility could discuss it. She confirmed other residents have the Air Conditioner units, but none of them have the second window boarded up above the unit (like Resident #31). MD #130 confirmed she would not leave a window at her house boarded up.
Observation on 08/28/18 at 2:56 P.M. revealed unoccupied resident room [ROOM NUMBER] wood was measured at approximately four inches by 19 inches (above air conditioner to secure), and plexi-glass was three foot three inches by 19 inches (above the smaller wood piece).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0604
(Tag F0604)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observations, and staff interviews, the facility failed to ensure a resident was free from a phy...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observations, and staff interviews, the facility failed to ensure a resident was free from a physically restraining device when the facility utilized a merry walker (enclosed rolling walker/ambulation device) without an assessment and adequate indication of use. This affected one (#30) out of one reviewed for restraints. The facility identified they had no residents who were physically restrained. The facility census was 37.
Findings include:
Review of Resident #30's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses include dementia without behavioral disturbances, heart failure, hypertension, peripheral vascular disease, muscle weakness, atrial fibrillation, anxiety, lack of coordination, cognitive communication deficit, hyperlipidemia, depression, atherosclerotic heart disease, gastroesophageal reflux disease, acute kidney failure, cardiac pacemaker, and difficult ambulation.
Review of Resident #30's most recent Minimum Data Set, dated [DATE] revealed a brief interview for mental status (BIMS) was not able to be assessed as the resident is alert, but is rarely/never understood, indicating severe cognitive impairment. Further review of the MDS revealed the resident requires extensive assistance of one staff member for transfers and limited assistance of one staff member for walking in room and corridor. The MDS identified no restraints were being used.
Review of Resident #30's care plan revealed a care plan dated 06/20/18 regarding the resident being at risk for falls and accidents. The care plan included measurable goals and included an intervention that instructed staff that the resident utilized a merry walker and the resident is to be in a common area at all times.
Further record review revealed the care plan regarding the use of the merry walker; however, there was no assessments in the medical record regarding the use of a merry walker. Review of the physician orders revealed an order was obtained on 07/10/18 to use of the merry walker for ambulation.
Review of Fall Risk assessment dated [DATE] revealed Resident #30 scored an eight on the assessment, indicating the resident is at risk for falls.
On 08/28/18 at 1:18 P.M., observation of Resident #30 revealed that she ambulates throughout the facility with the use of a merry walker. The resident observed attempting to open several closed doors on this observation with no success. Resident observed to have staff oversight at the time of this observation and no falls were noted. This resident is unable to release the latch to open this walker on observation.
On 08/30/18 at 12:18 P.M., an interview with the Director of Nursing (DON) verified Resident #30 had not been assessed for the use of restraints, and that this device was considered an enabler. The DON stated that the resident can sometimes open the latch for the walker, but not all the time.
On 08/30/18 at 3:13 PM an interview with the DON verified Resident #30 does not have a completed assessment for the use of the merry walker. The DON also verified that the facility does not have an active policy on the use of a merry walker. The DON stated that she placed a call to the Corporate Nurse and they do not have a policy on the use of a merry walker, as it is being used as an enabler and not a restraint. The DON stated that the resident has been in the merry walker for a long time now, and when asked if the resident can open it on her own, the DON stated that sometimes she can. The DON stated that she cannot remember when the resident was placed in the merry walker originally. The DON verified that the resident had been using the merry walker prior to the physician order on 07/10/18.
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 maintenance log, observations, resident, staff, and family interview, and review o...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of the maintenance log, observations, resident, staff, and family interview, and review of the care planning policy, the facility failed to ensure a resident had a timely care planning meeting and the resident was included in decisions regarding the use/non-use of his side rails. This affected one (#31) of one reviewed for care planning. Facility census was 37.
Findings included:
1. Review of the medical record revealed Resident #31 was admitted on [DATE] with diagnosis that included major depression, diabetes, chronic kidney disease, and unspecified psychosis.
Review of Minimum Data Set (MDS) dated [DATE] included the resident was moderately cognitively impaired and required extensive assistant or was dependent for staff assistance for all activities of daily living (except eating).
Interview on 08/27/18 at 2:04 P.M. with Resident #31 and family member #1 both indicated they had not been invited to nor participated in a care planning meeting for Resident #31.
Interview on 08/29/18 at 3:34 P.M. Social Service Designee (SSD) #142 was unable to find care planning meeting information in the binder. SSD #142 stated she did not have any further documentation in the facility or in the resident's medical record that was indicate the resident had a meeting. SSD#142 could not recall a meeting for Resident #31.
2. Review of current falls care plan dated 04/12/17 for Resident #31 interventions included top ½ (half) side rails up to assist with bed mobility and involved resident and/or responsible party in treatment plan. Update as needed regarding changes in treatment/condition.
Review of Maintenance log included on 04/16/18 included bed side rails were tied strapped bed railing down on all units.
Review of Maintenance log on 06/04/18 included bed rails were removed in multiple resident rooms.
Interview and observation on 08/27/18 at 1:54 P.M. with Resident #31 and family member #1, they explained the resident's side rails on the bed were tied down. They pointed to the ties and the area was observed. Resident #31 stated he would feel safer if he has the side rails up on his bed during patient care. Family member #1 indicated Resident #31 felt scared without them. Both explained there were no discussion regarding the removal of the use of the side rails.
Interview with the Director of Nursing (DON) on 08/29/18 at 5:17 P.M. confirmed Resident #31 was alright with trialing the side rails removal. She stated Resident #31 did not like the trial though. She confirmed the facility rushed through the documentation and confirmed there was no indication the resident was involved with the decision or there was any follow up to determine if the resident should/should not have use of the side rail. She explained Resident #31 cannot physically move himself, but he can put his hand on the side rails if staff were turning him. The DON explained Resident #31 required two-person assist.
Interview on 08/28/18 at 2:30 P.M. with State Tested Nursing Assistant (STNA) #136 confirmed the side rails were tied down on Resident #31's bed. STNA #136 stated Resident #31 would not be able to put the side rails up and down. She explained Resident #31 was completely dependent for care. She stated Resident #31 is able to put his hands on the rails (during care), but he is not able to help The staff have to push him with their full body weight. STNA #136 stated if Resident #31 had a fear of falling the staff were on both sides of him. When asked STNA #136 was if Resident #31 is fearful while they give care, she stated he gets jerky and the staff reassure him. She explained when the rails were up, it was more of a leverage to get him over. STNA #136 stated, I know Resident #31 does not like the rails being tied down. STNA #136 confirmed that the resident may feel reassured if there was a grab bar there.
Review of Care Plan Review policy dated 02/2016 included all residents will receive a review of the Plan of Care by the Interdisciplinary team at least quarterly.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0676
(Tag F0676)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to ensure proper supervision during meals. This af...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to ensure proper supervision during meals. This affected one (#30) of five residents the facility identified as needing assistance during meals who also ate in the dining room. Facility census was 37.
Findings Included:
Record Review of Resident #30 revealed that the resident was admitted to the facility on [DATE] with diagnoses that included dementia without behavioral disturbances, heart failure, muscle weakness, atrial fibrillation, anxiety, lack of coordination, cognitive communication deficit, depression, and gastroesophageal reflux disease. This resident was alert but was rarely/never understood on the most recent MDS assessment completed on 07/24/18, indicating severe cognitive impairments. It was also noted the resident required limited assistance for meals.
Review of care plan dated 05/25/18 indicated the resident typically consumes less than the required amount. Impaired Neurological care plan dated 06/14/18 indicated it was due to Resident #30 diagnosis of dementia and subdural hematoma. Interventions included to monitor activities of daily living and render care as needed. Impaired cognitive care plan dated 06/14/18 included intervention to promote Resident #30's dignity. Impaired vision care plan dated 07/04/18 included the resident had a diagnosis of glaucoma.
Dining observation began on 08/27/18 at 11:01 A.M. by 11:20 A.M. side items and/or meals were being served. At 11:21 A.M. Resident #30 was using her fingers to eat salad with a white dressing, and continues and she starts using appropriate silverware at 11:23 A.M. By 11:26 A.M. Resident #30 resumed eating her salad with her hands. At 11:29 A.M. Spaghetti was served, and Resident #30 used her fingers to eat spaghetti for a few pieces and then began using her silverware. At 11:30 A.M. Resident #30 was using her hand to eat salad with white dressing, then picks up butter knife and was licking it. The white dressing dripped down her face. At 11:31 A.M. Resident #30 was using her hands to eat spaghetti then wipes mouth. At 11:35 A.M. Resident #30 was using knife like it was a fork trying to eat the salad continues until 11:37 A.M. when Resident #30 was using the knife to scoop/eat salad then used knife to eat spaghetti. By 11:38 A.M. the resident was using her fingers to eat spaghetti. By 11:39 A.M. Activities Director (AD) #450 (who was the only staff member in the dining room providing assistance) asked Resident #30 if she was ok, and prompts the resident to eat and moves the plate of spaghetti closer and gives her fork. The resident continued to use the fork thereafter as he salad bowl and knife were pushed out of sight. Resident #30 was eating at a faster rate once she was given her fork. At 11:48 A.M. Resident #30 was offered a peanut butter and jelly sandwich and had no trouble eating.
Additional observation on 08/30/18 at 11:25 A.M. Resident #30 had a slice of buttered bread (butter side up) lying directing on the table. She is using a spoon to cut the bread and eat it. At 11:29 A.M. AD #450 asks Resident #30 if she is ok and Resident #30 says no. At 11:30 A.M. Resident #30 was trying to drink cranberry sauce out of the dessert bowl two times. At 11:34 A.M. Resident #30 was trying to use her hands to pick up cranberry sauce and unsuccessful drops on clothing protector and she starts eating it off the clothing protector. At 11:38 Resident #30 was using her fingers to eat chunked pineapple. At 11:39 A.M. Resident #30 was eating cranberry sauce off of the table with her hands, and tried to eat more off of the clothing protector. At 11:40 A.M. continued to eat cranberry sauce off of the table. At 11:46 A.M. Resident #30 attempts three times with her spoon to get chunked pineapple out of the dessert bowl. Each time putting the spoon in the bowl getting nothing and putting it to her mouth and taking a bite.
Interview with observation at 11:50 A.M. with AD #450 confirmed Resident #30 was using her hands to eat. She explained she will be redirected and use silverware most of the time depending on the day. At 11:50 A.M. AD #450 asks Resident #30 if she wants some help and starts to feed Resident #30. By 11:55 A.M. Resident #30 had finished the entire bowl of pineapples with staff assistance. There were 14 residents, one family member, and one staff (AD #450).
Interview on 08/30/18 at 12:57 P.M. with AD #450 explained she was the only person in the dining room at lunch, and also for dinner, however sometimes the nurses come in. She explained it was hard to effectively help and assist all of the residents. She confirmed at least four residents needed prompted and/or assisted. AD #450 confirmed Resident #30 will use a knife inappropriately and eats inappropriate items using her fingers. AD #450 explained typically there are fourteen up to sixteen residents eating in the dining room depending on which residents come to the dining room.
Interview on 08/30/18 at 2:16 P.M. with the Director of Nursing (DON) confirmed Resident #22, #8, #30, #26, and #11, all need prompting and the last four need to be fed at times. The DON stated she was not aware that Resident #30 needed the additional assistance with eating. When asked if the DON thought one staff was enough to care for all of the residents who need assistance, the DON stated she did not think they all needed assistance at one time. The DON confirmed Resident #30 should be prompted to use silverware appropriately while eating to promote dignity.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0679
(Tag F0679)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident and staff interview, and review of the Activity Director job description, the faci...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident and staff interview, and review of the Activity Director job description, the facility failed to ensure a resident (#28) was thoroughly assessed for activities and was provided an increased amount of activities as recommended. This affected one resident (#28) of one reviewed for activities. Facility census was 37.
Findings Included:
Review of the medical record revealed Resident #28 was admitted to the facility on [DATE] with diagnosis that included intellectual disability, obsessive compulsive disorder, depression and dementia.
Review of all care plans provided did not include a specific activity care plan. A care plan (not dated) indicated the resident had behaviors which include shouting, name calling, calling people on the phone repeatedly, insists on having meetings and ordering things, getting angry with staff, going in other resident rooms when they don't want him to. Intervention included attempt interventions before the behaviors begin. Encourage the resident to participate in activities he likes games, crafts, and drawing.
Review of provider progress notes included 03/08/18 and 06/07/18 Psychiatric Certified Nurse Practitioner (CNP) progress note which included the resident appears to be stable. Pleasant and talkable. Intrusive at times. Plan included would benefit from more activities and structure.
Review of Activity Participation from 06/2018 to 08/2018 included the resident went out of the facility on one occasion, there no indications of physical games played in the last three months, and no indication of when a game of cards (like Uno) was offered or played.
Review of quarterly activity assessment dated 07/2018 included the resident's mood and behavior patterns, memory, and communication needs. It listed the resident likes BINGO, socials, newspaper, church, and cleaning. The resident is an active participant in activities. There was no further indication of a comprehensive list of items the resident was asked regarding his preferences. It was noted, frequently bothers others, shuts the facility's curtains every night, frequently makes plans for things that cannot happen.
Interview on 08/30/18 at 8:17 A.M. with Social Service Designee (SSD) #142 explained a few years ago the facility tried to get Resident #28 enrolled in a workshop, however $41 a day would have to be released daily from the facility from the resident's patient liability. The facility declined the offer.
Telephone interview on 08/30/18 at 8:26 A.M. with local county board of intellectual disability representative #1 stated for Resident #28 as long as he has Medicaid funding it would be duplication of services for the resident to received skilled services at the nursing home, and receive services at workshop. Our understanding is the resident is living at a facility who is supplying him with care and act that he is having his day fulfilled. We don't typically provide services for folks in the nursing home because they have an activity director and social services.
Interview with the Resident #28 on 08/30/18 at 10:40 A.M. revealed he likes to go out of the facility to eat (specifically a privately-owned restaurant in a neighboring town), he likes to play Uno (cards), likes to play soccer and likes to play with balloons (resident was seen juggling three balloons on 08/29/18).
On 08/30/18 at 11:13 A.M. Resident #28 came into the conference room and asked to go to the Flea Market. At 11:34 A.M. Resident #28 requested snacks from the surveyors. At 1:15 P.M. Resident #28 wanted a raise for one of the staff. At 2:40 P.M. the resident interrupts surveyor and Administrative staff completing paperwork. At 2:48 P.M. Resident #28 notified surveyors about concerns he has regarding an unknown person.
Interview on 08/30/18 at 1:10 P.M. with Activity Director (AD) #450 confirmed Resident #28's activity schedule does not indicate refusals or when he is invited and does not attend. Confirmed the activity assessment was not comprehensive and does not have the original. AD #450 explained the resident likes to set up BINGO, shut curtains and the resident is always asking for jobs. AD #450 confirmed Resident #28 has not been out of the facility for the past few months, except in August a family member who came in from Texas and took him out. AD #450 confirmed Resident #28 likes to leave the facility. AD #450 explained the last time we went out was in April and he did go on that trip, we took him to Walmart shopping. AD #450 was aware Certified Nurse Practitioner noted for involvement in more activities. AD #450 explained more items Resident #28 liked to do and confirmed the assessment available was not a comprehensive list. She confirmed she is unable to indicate how she has attempted to increase activities since the recommendation was made.
Review of Activity Director's job description dated 02/05/18 included the AD is responsible to develop organize and implement a program of activities to meet the social, emotional, physical and other therapeutic needs of residents as identified on the residents' plan of care. Initiate and promote activities both within the facility and outside the facility. Consistently maintain standards for activity scheduling and documentation established by polices and regulatory requirements. Solicit the involvement of the community. Maintain detailed records of activity programs and participation of individual residents. Participate in resident care planning by identifying the activity needs of residents in accordance with the medical assessment. Maintain all activity related records required by regulations and Medical records including activity assessments and progress notes.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0685
(Tag F0685)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff, resident and family interview, the facility failed to ensure a prescription for new eyeglasses...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff, resident and family interview, the facility failed to ensure a prescription for new eyeglasses was filled timely. This affected one resident (#31) of one reviewed for vision. Facility census was 37.
Findings included:
Review of the medical record revealed Resident #31 was admitted on [DATE] with diagnosis that included major depression, diabetes, chronic kidney disease, and unspecified psychosis.
Review of impaired vision care plan dated 07/03/18 included the resident has impaired vision related to degenerative changes. Inability to see small print. Interventions included vision exam as needed.
Review of Minimum Data Set (MDS) dated [DATE] included the resident was moderately cognitively impaired and required extensive assistant or was dependent for staff assistance for all activities of daily living (except eating).
Review of nursing note dated 10/27/17 01:20 P.M. included Resident #31 was out to eye doctor by stretcher via transportation services escorted by spouse.
Review of nursing note dated 04/17/18 at 10:01 A.M. included Social Services Designee (SSD) #142 was trying to get Resident #31 new glasses, the resident was seen by the eye doctor, but his insurance would not cover and that was resolved. He was to be fitted recently and the physician had a car accident & that has been postponed, will get that rescheduled soon.
Review of nursing note dated 07/03/18 at 2:07 P.M. included SSD #142 has been working on getting his new glasses. Optical was to be here to fit him for new glasses but had a car accident on the way here and had to reschedule. SSD #142 to follow up on when they will be here again.
On 08/27/18 at 2:06 P.M. an interview with Resident #31 and family member #1 was conducted. Family member #1 stated, They sent him to get his eyes tested. When I went to get his prescription filled they did not take his insurance. Family member #1 explained this was a year ago in November/December (2017). He has to be retested for his glasses now and I am not happy. Resident #31 stated, I would wear glasses if I got them. I am about blind, and I have glasses that are not effective.
Interview on 08/29/18 at 3:28 P.M. with SSD #142 revealed our contracted eye physician saw Resident #31 and there was a problem with the script and insurance was not covering the glasses. Now they want to get another eye exam and Resident #31 was not eligible to be seen again until August 2018, they think the prescription was too old. SSD #142 was trying to find an optical place to take his insurance. He would have to go by stretcher and SSD #142 could not find anyone to take him and the family would not. The contracted physician promised they would fill his prescription, but it was too old. SSD #142 stated it was last seen in August of last year (2017), and contracted eye physician won't come see any residents until they have several to see. SSD #142 was not able to indicate when the eye physician would be in to visit Resident #31 and/or the new prescription could be filled.
Review of Ophthalmic Services care plan dated 02/2016 included ophthalmic services will be provided to all residents as needed and it is the charge nurse and social services responsibility. After the resident returns from the appointment review the recommendations and communicate as needed with the attending physician.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure an order to apply oxygen as needed was monitored and/o...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure an order to apply oxygen as needed was monitored and/or implemented as needed. This affected one (#22) of one resident reviewed for respiratory care. Facility census was 37.
Findings Included:
Review of the medical record revealed Resident #22 was admitted on [DATE] with diagnosis that included persistent atrial fibrillation, and hydrocephalus.
Review of physician order dated 04/18/17 included to apply oxygen as needed for oxygen saturation levels less than 90%. Also noted on monthly orders dated 08/2018.
Review of care plan dated 04/03/18 included the resident was at risk for altered cardiac output and has the potential for impaired gas exchanged related to high blood pressure, shortness of breath and persistent atrial fibrillation. Interventions included to monitor vital signs as ordered.
Review of Minimum Data Set, dated [DATE] included the resident was severely cognitively impaired and requested extensive assistance or was dependent for all activities of daily living.
Review of Medication Administration Record for August 2018 revealed the order as written, however there was no indication that the resident's oxygen saturation level was checked to determine if administration was needed.
Interview on 08/28/18 at 11:58 A.M. with Registered Nurse (RN) #238 and review of the MAR revealed RN #238 confirmed the facility does not take the resident's oxygen saturation level on a routine basis. RN # 238 explained that they would take it if she is symptomatic. RN #238 confirmed that it was not always possible to tell a person's oxygen saturation level by looking at them. She was unable to explain how they were implementing the order as written. She confirmed they should be taking Resident #22's oxygen saturation level on a routine basis.
Interview on 08/28/18 at 12:05 P.M. with the Director of Nursing (DON) confirmed the order to check Resident #22's oxygen level and apply oxygen as needed should be implemented. The DON explained when the last company took over, they had the ancillary orders removed to clean up the MAR.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0825
(Tag F0825)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff, resident, and family interviews, the facility failed to ensure therapy was continued as indicated...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff, resident, and family interviews, the facility failed to ensure therapy was continued as indicated when a lift needed was non-functional. This affected one (#31) of two residents reviewed for limited range of motion. Facility census was 37.
Findings included:
Review of the medical record revealed Resident #31 was admitted on [DATE] with diagnosis that included major depression, diabetes, chronic kidney disease, and unspecified psychosis.
Review of Minimum Data Set (MDS) dated [DATE] included the resident was moderately cognitively impaired and required extensive assistant or was dependent for staff assistance for all activities of daily living (except eating).
Review of Physical Therapy discharge summary noted start of care 06/19/18 and ended 08/13/18 included the resident required maximum assistance with standing tolerance of 1:15-1:30 at this time. Client does not transition to enable a pivot transfer and as such remains on a lift and has reached a plateau. Under Impact on Burden of Care/Daily life included possible re-attempt of Physical Therapy once sit to stand lift is functioning.
Interview with Resident #31 and family member #1 on 08/27/18 at 2:09 P.M. explained the facility does not provide restorative, and they were not sure what was going on with Resident #31's therapy. They also expressed concerns they had heard regarding the mechanical lifts used to get Resident #31 in/out of bed.
Interview on 08/30/18 at 8:50 A.M. with Occupational Therapist Assistant (OTA) #602 (acting therapy manager) explained Resident #31 was on caseload and he was able to tolerate standing for about a minute. She thought towards the end of therapy for Resident #31 they figured out the cord was missing to the sit to stand, because they wanted him to work on tolerating it more. OTA #602 thought the cord has been ordered the previous week by Maintenance Director (MD) #130. OTA #602 thought MD #130 was working on permission to get the battery.
Interview on 08/30/18 at 8:57 A.M. with MD #130 stated she was notified the cord was missing on 08/27/18 for the sit to stand lift. She stated her corporate office had asked her what was needed and to create an inventory list. When she talked with therapy they explained they needed a cord. No one had previously notified MD #130 that the cord was needed it for a resident and that the therapy could possibly be resumed when the sit to stand was functional.
Telephone Interview on 08/30/18 at 9:38 A.M. with Physical Therapist (PT) #607 explained it was normal progression for someone that can stand well, but not pivot to use the sit to stand to build up the tolerance (like Resident #31). He stated the resident can stand well from a static (sitting) position. He stated about two weeks PT #607 wanted to use the stand (for Resident #31) and the cord was missing, and it was not functional. He explained the resident could be picked back up for therapy if the lift was functional.
Interview on 08/30/18 at 9:46 A.M. with the Administrator stated she was not aware that a cord for the sit to stand lift had not been ordered, and a resident was waiting on that to re-attempt therapy.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Room Equipment
(Tag F0908)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure a Sit to Stand lift was in proper working order. This ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure a Sit to Stand lift was in proper working order. This affected one (#31) of two reviewed for limited range of motion. Facility census was 37.
Findings included:
Review of the medical record revealed Resident #31 was admitted on [DATE] with diagnosis that included major depression, diabetes, chronic kidney disease, and unspecified psychosis.
Review of Minimum Data Set (MDS) dated [DATE] included the resident was moderately cognitively impaired and required extensive assistant or was dependent for staff assistance for all activities of daily living (except eating).
Review of Physical Therapy discharge summary noted start of care 06/19/18 and ended 08/13/18 included the resident required maximum assistance with standing tolerance of 1:15-1:30 at this time. Client does not transition to enable a pivot transfer and as such remains on a lift and has reached a plateau. Under Impact on Burden of Care/Daily life included possible re-attempt of Physical Therapy once sit to stand lift is functioning.
Interview with Resident #31 and family member #1 on 08/27/18 at 2:09 P.M. explained the facility does not provide restorative, and they were not sure what was going on with Resident #31's therapy. They also expressed concerns they had heard regarding the mechanical lifts used to get Resident #31 in/out of bed.
Interview on 08/30/18 at 8:50 A.M. with Occupational Therapist Assistant (OTA) #602 (acting therapy manager) explained Resident #31 was on caseload and he was able to tolerate standing for about a minute. She thought towards the end of therapy for Resident #31 they figured out the cord was missing to the sit to stand, because they wanted him to work on tolerating it more. OTA #602 thought the cord has been ordered the previous week by Maintenance Director (MD) #130. OTA #602 thought MD #130 was working on permission to get the battery.
Interview on 08/30/18 at 8:57 A.M. with MD #130 stated she was notified the cord was missing on 08/27/18 for the sit to stand lift. She stated her corporate office had asked her what was needed and to create an inventory list. When she talked with therapy they explained they needed a cord. No one had previously notified MD #130 that the cord was needed it for a resident and that the therapy could possibly be resumed when the sit to stand was functional.
Telephone Interview on 08/30/18 at 9:38 A.M. with Physical Therapist (PT) #607 explained it was normal progression for someone that can stand well, but not pivot to use the sit to stand to build up the tolerance (like Resident #31). He stated the resident can stand well from a static (sitting) position. He stated about two weeks PT #607 wanted to use the stand (for Resident #31) and the cord was missing, and it was not functional. He explained the resident could be picked back up for therapy if the lift was functional.
Interview on 08/30/18 at 9:46 A.M. with the Administrator stated she was not aware that a cord for the sit to stand lift had not been ordered, and a resident was waiting on that to re-attempt therapy.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Menu Adequacy
(Tag F0803)
Could have caused harm · This affected most or all residents
Based on review of the facility menu, observation and staff and confidential resident interview, the facility failed to ensure staff followed a prepared menu. This had the potential to affect all 37 r...
Read full inspector narrative →
Based on review of the facility menu, observation and staff and confidential resident interview, the facility failed to ensure staff followed a prepared menu. This had the potential to affect all 37 residents residing in the facility. Facility census was 37.
Findings included:
Review of the menu for the week included Spaghetti and meat sauce for 08/29/18 with broccoli.
Confidential interviews on 08/27/18 with two residents indicated they had concerns regarding the quality of the food.
Observation on 08/29/18 at 9:57 A.M. revealed the Goulash appeared dry and the temperature was taken, and it was above the appropriate temperature. An interview with conducted right after with [NAME] #241. [NAME] #241 was asked if she used a recipe for the goulash and she stated, DM (Dietary Manager) #340 just tells us what to put in. At 10:36 A.M. DM #240 explained she had no recipe for the goulash, as the vegetable lasagna had not come in. She explained on 08/27/18 she served spaghetti with meat sauce because the lasagna was not in, but she was going to serve it on 08/29/18 . However, the lasagna never came in. [NAME] #241 began plating meals for staff, then residents thereafter.
At 11:25 A.M. [NAME] #241 put the first pan of goulash (previously being used to serve the dining room and some resident rooms) and switched it for another pan that had been in the oven.
At 11:43 A.M. DM #340 was interviewed about residents having concerns with the meals. She explained it was hard to please everyone. She stated they had a lot of trouble with the a certain resident. She stated the resident demanded to use specific items (specific store) honey peanut butter for example. She stated the resident had strawberry bread but the facility could never toast it quite right.
At 11:45 A.M. the test tray was plated and by 11:48 A.M. had left the kitchen. By 11:57 A.M. the cart was delivered to the last hallway and at 12:25 P.M. the test tray was delivered. The temperature of the items was appropriate. However, the goulash was mushy and bland, and the breadstick was doughy confirmed with DM #340. Dietician #706 joined the observation/interview. She stated she was not aware of the goulash recipe and her and DM #340 had not discussed it prior to meal service. DM #340 explained she made the meal like spaghetti but substituted V8 juice for the sauce. Two confidential Resident interviews directly after included one resident stated he could tell the goulash was made without sauce as it had not much flavor and another resident explained the goulash was bland without taste.
Observation with interview on 08/29/18 at 4:05 P.M. with Dietary Manager (DM) #340 confirmed she had no recipe available for Goulash, she had just pulled (prior to the interview) two off of internet American she said that was like Spaghetti, and Cincinnati Goulash which calls for Catsup. She stated DM #340 and the Dietician are going to come up with a recipe.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0804
(Tag F0804)
Could have caused harm · This affected most or all residents
Based on review of the facility menu, observation and staff and confidential resident interview, the the facility failed to ensure food served was palatable. This had the potential to affect all 37 re...
Read full inspector narrative →
Based on review of the facility menu, observation and staff and confidential resident interview, the the facility failed to ensure food served was palatable. This had the potential to affect all 37 residents residing in the facility. Facility census was 37.
Findings included:
Review of the menu for the week included Spaghetti and meat sauce for 08/29/18 with broccoli.
Confidential interviews on 08/27/18 with two residents indicated they had concerns regarding the quality of the food.
Observation on 08/29/18 at 9:57 A.M. revealed the Goulash appeared dry and the temperature was taken, and it was above the appropriate temperature. An interview with conducted right after with [NAME] #241. [NAME] #241 was asked if she used a recipe for the goulash and she stated, DM (Dietary Manager) #340 just tells us what to put in. At 10:36 A.M. DM #240 explained she had no recipe for the goulash, as the vegetable lasagna had not come in. She explained on 08/27/18 she served spaghetti with meat sauce because the lasagna was not in, but she was going to serve it on 08/29/18 . However, the lasagna never came in. [NAME] #241 began plating meals for staff, then residents thereafter.
At 11:25 A.M. [NAME] #241 put the first pan of goulash (previously being used to serve the dining room and some resident rooms) and switched it for another pan that had been in the oven.
At 11:43 A.M. DM #340 was interviewed about residents having concerns with the meals. She explained it was hard to please everyone. She stated they had a lot of trouble with the a certain resident. She stated the resident demanded to use specific items (specific store) honey peanut butter for example. She stated the resident had strawberry bread but the facility could never toast it quite right.
At 11:45 A.M. the test tray was plated and by 11:48 A.M. had left the kitchen. By 11:57 A.M. the cart was delivered to the last hallway and at 12:25 P.M. the test tray was delivered. The temperature of the items was appropriate. However, the goulash was mushy and bland, and the breadstick was doughy confirmed with DM #340. Dietician #706 joined the observation/interview. She stated she was not aware of the goulash recipe and her and DM #340 had not discussed it prior to meal service. DM #340 explained she made the meal like spaghetti but substituted V8 juice for the sauce. Two confidential Resident interviews directly after included one resident stated he could tell the goulash was made without sauce as it had not much flavor and another resident explained the goulash was bland without taste.
Observation with interview on 08/29/18 at 4:05 P.M. with Dietary Manager (DM) #340 confirmed she had no recipe available for Goulash, she had just pulled (prior to the interview) two off of internet American she said that was like Spaghetti, and Cincinnati Goulash which calls for Catsup. She stated DM #340 and the Dietician are going to come up with a recipe.
This deficiency substantiates Complaint Number OH00099554.
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
- • 26 deficiencies on record, including 1 serious (caused harm) violation. Ask about corrective actions taken.
Bottom line: Generally positive indicators. Standard due diligence and a personal visit recommended.
✓ Report will be sent to your email
About This Facility
What is Jamestown Place Health And Rehab's CMS Rating?
CMS assigns JAMESTOWN PLACE HEALTH AND REHAB an overall rating of 5 out of 5 stars, which is considered much above average nationally. Within Ohio, this rating places the facility higher than 99% of the state's 100 nursing homes. This rating reflects solid performance across the metrics CMS uses to evaluate nursing home quality.
How is Jamestown Place Health And Rehab Staffed?
CMS rates JAMESTOWN PLACE HEALTH AND REHAB's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 48%, compared to the Ohio average of 46%.
What Have Inspectors Found at Jamestown Place Health And Rehab?
State health inspectors documented 26 deficiencies at JAMESTOWN PLACE HEALTH AND REHAB during 2018 to 2022. These included: 1 that caused actual resident harm and 25 with potential for harm. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.
Who Owns and Operates Jamestown Place Health And Rehab?
JAMESTOWN PLACE HEALTH AND REHAB 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 SIMCHA HYMAN & NAFTALI ZANZIPER, a chain that manages multiple nursing homes. With 50 certified beds and approximately 27 residents (about 54% occupancy), it is a smaller facility located in JAMESTOWN, Ohio.
How Does Jamestown Place Health And Rehab Compare to Other Ohio Nursing Homes?
Compared to the 100 nursing homes in Ohio, JAMESTOWN PLACE HEALTH AND REHAB's overall rating (5 stars) is above the state average of 3.2, staff turnover (48%) is near the state average of 46%, and health inspection rating (4 stars) is above the national benchmark.
What Should Families Ask When Visiting Jamestown Place Health And Rehab?
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 Jamestown Place Health And Rehab Safe?
Based on CMS inspection data, JAMESTOWN PLACE HEALTH AND REHAB 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 5-star overall rating and ranks #1 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 Jamestown Place Health And Rehab Stick Around?
JAMESTOWN PLACE HEALTH AND REHAB has a staff turnover rate of 48%, which is about average for Ohio nursing homes (state average: 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 Jamestown Place Health And Rehab Ever Fined?
JAMESTOWN PLACE HEALTH AND REHAB 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 Jamestown Place Health And Rehab on Any Federal Watch List?
JAMESTOWN PLACE HEALTH AND REHAB 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.