ASHTABULA COUNTY NURSING HOME
Non profit - Other
133 Beds
Independent
Data: November 2025
1 Immediate Jeopardy citation
Trust Grade
48/100
#213 of 913 in OH
Photo by Ashtabula County Nursing & Rehabilitation Center
Photo by Ashtabula County Nursing & Rehabilitation Center
Photo by Ashtabula County Nursing & Rehabilitation Center
1 / 10 photos
Last Inspection: August 2023
Over 2 years since last inspection. Current conditions may differ from available data.
Overview
Ashtabula County Nursing Home has a Trust Grade of D, which indicates below-average quality and raises some concerns about the facility. It ranks #213 out of 913 nursing homes in Ohio, placing it in the top half, but its county rank of #6 out of 12 means there are better local options available. The facility's trend is stable, with the same number of issues reported in both 2023 and 2024. Staffing is a relative strength with a turnover rate of 34%, lower than the Ohio average, but it has concerning RN coverage that is less than 99% of other facilities, which could impact the quality of care. Notable incidents included a resident suffering a traumatic brain injury from a fall due to inadequate intervention and another resident developing a serious pressure ulcer due to a lack of timely assessments, highlighting both critical and serious concerns that families should consider.
- Trust Score
- D
- In Ohio
- #213/913
- Safety Record
- High Risk
- Inspections
- Holding Steady
- Staff Stability ○ Average
- 34% turnover. Near Ohio's 48% average. Typical for the industry.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most Ohio facilities.
- Skilled Nurses ⚠ Watch
- Each resident gets only 16 minutes of Registered Nurse (RN) attention daily — below average for Ohio. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 20 deficiencies on record. Higher than average. Multiple issues found across inspections.
48/100
Top 23%
Review needed
1 → 1 violations
★★★★☆
4.0
Overall Rating
★★★☆☆
3.0
Staff Levels
★★★☆☆
3.0
Care Quality
★★★★☆
4.0
Inspection Score
↔
Stable
2023: 1 issues
2024: 1 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover below average (34%)
14 points below Ohio average of 48%
Facility shows strength in fire safety.
The Bad
Staff Turnover: 34%
12pts below Ohio avg (46%)
Typical for the industry
The Ugly 20 deficiencies on record
1 life-threatening 3 actual harm
Nov 2024
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0624
(Tag F0624)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure Resident #115's guardian was informed and gave consent for R...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure Resident #115's guardian was informed and gave consent for Resident #115 to be discharged from the facility. This affected one resident ( Resident # 115) of the three residents reviewed for discharge. The facility census was 114.
Findings include:
Review of the medical record revealed Resident #115 was admitted to the facility on [DATE] and discharged from the facility on 08/12/24. Guardian #392 was listed as the responsible party guardian and emergency contact #1. Resident #115's mother was the emergency contact #2. Medical diagnoses included pulmonary edema, Asperger's syndrome, diabetes, bipolar, hypertension, glaucoma, dependence on renal dialysis, depression, and anemia.
Review of the Minimum Data Set ( MDS) 3.0 Discharge Return Not Anticipated assessment dated [DATE] revealed discharge was unplanned to home. Resident #115 had moderate impairment for decision making. Resident #115 displayed physical behaviors. Resident #115 needed set up for eating. Maximum assistance was needed for oral hygiene. Moderate assistance was needed for toilet hygiene, bathing and dressing. Resident #115 needed moderate assistance to roll left and right in bed, sit on the side of the bed, lie back in bed , stand and transfer from bed. Moderate assistance was needed to walk ten feet. Resident #115 received hemodialysis.
Review of the Health Status Note dated 08/12/24 at 2:41 P.M. written by Licensed Practical Nurse (LPN) #344 , revealed Resident #115's mother stated she wanted to take Resident #115 home. The physician was notified. This note stated Residents guardian [NAME] was also notified of residents discharge from the facility.
Review of the document titled Probate Court of Ashtabula County Letters of Guardianship, dated 08/07/23, revealed Catholic Charities of Ashtabula County shall be appointed Guardian of Resident #115, an incompetent and the duties of the Guardian shall be discharged by the appointed agent Guardian #392. As Guardian, powers were person only for an indefinite time period. The document was signed by the Probate Judge.
Review of medical record Discharge summary dated [DATE] revealed Resident #115 was discharged from the facility to home and Resident #115's mother signed the Discharge Summary along with LPN #344.
Interview with Healthcare Compliance Investigator( HCI) #391 on 11/04/24 at 8:34 A.M. revealed the facility allowed Resident #115 and his mother to sign themselves out because of behaviors Resident #115 was displaying. The legal guardian was not notified until after Resident #115 was discharged from the facility. This was not a planned discharge. The guardian wanted Resident #115 to remain in the facility. HCI #391 also stated the mother missed some health appointments while Resident #115 was home.
Interview on 11/04/24 at 12:20 P.M. with Social Service Director ( SSD) #375 revealed Resident #115's discharge was considered an impromptu discharge. SSD #375 verified the facility did not have the legal guardianship paperwork in the medical record so they were not aware of it. SSD #375 stated during the next care conference social work would bring up no guardianship paperwork was in the chart. SSD #375 also stated the social worker did not set up skilled care for home because Resident #115's mom was to be the caregiver.
Interview on 11/04/24 at 12:30 P.M. with Unit Manager Licensed Practical Nurse ( LPN) #344 revealed she called the physician to notify the physician of Resident #115's request to leave the facility. LPN #344 stated she did not call the guardian because there was no paperwork in the chart during Resident #115's discharge. LPN #344 stated she called the guardian when Resident #115 left. LPN #344 stated Resident #115 did not make safe decisions. LPN #344 stated the facility still discharged the resident despite the guardian not approving of the discharge.
Interview on 11/04/24 at 12:40 P.M. with the Director of Nursing ( DON) revealed a text message was sent on 08/12/24 at 12:05 P.M. to physician regarding Resident #115 wanting a discharge home. The DON was unable to provide a text message to the guardian and could not verifying the guardian was notified by text or phone call on 08/12/24. The DON stated Resident #115 created an uproar with staff in the facility.
Interview with Guardian #392 on 11/04/24 at 1:22 P.M. revealed she did speak with the nurse staff on Saturday 08/10/24 regarding Resident #115's behaviors and Resident #115 wanted to be discharged . Guardian #392 told the facility she did not agree with Resident #115's discharge to home. Guardian #392 stated she was notified on 08/12/24 during an unannounced visit at 2:00 P.M. to the facility to check on Resident #115. Guardian #392 stated she did not sign in because this was an unannounced visit. Guardian #392 stated the facility did not notify her prior to Resident #115's discharge and the guardian paper work should have been sent in with the hospital paperwork on admission. The Guardian #392 stated the facility did not call her on 08/12/24 prior to Resident #115 discharge because she had no missed calls or voice messages from the facility. Guardian #392 stated the facility did not prepare Resident #115 for a safe discharge. The Guardian stated Resident #115 had been placed at another facility and passed away in October 2024 due to complications from COVID-19 related pneumonia.
Review of the facility policy titled, Notice of Transfer and/or Discharge, dated April 2011, revealed a resident or representative sponsor would be given 30 days notice of impending transfer or discharge from a facility except if the transfer was necessary for the resident welfare and the resident needs could not be met in the facility. Consent of Notice: the resident or representative sponsor would be provided the following information, the reason for discharge, the effective date, the location.
This deficiency represents non-compliance investigated under Complaint Number OH00159196
Aug 2023
1 deficiency
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 observation and interview the facility failed to ensure all meals were served at an appetizing temperature. This had the potential to affect 108 residents at the facility. The facility identi...
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Based on observation and interview the facility failed to ensure all meals were served at an appetizing temperature. This had the potential to affect 108 residents at the facility. The facility identified one resident (#30) as receiving no food from the kitchen. The facility census was 109.
Findings include:
On 08/30/23 at 11:34 A.M. observation of temperatures taken on the tray line revealed the roast turkey measured an internal temperature of 170 degrees Fahrenheit (F). The Brussel sprouts measured an internal temperature of 148 degrees F, and the scalloped corn measured an internal temperature of 160 degrees F.
On 08/30/23 at 12:04 P.M. the food cart with the test tray left the kitchen.
On 08/30/23 at 12:06 P.M. the cart was on the unit.
On 08/30/23 at 12:07 P.M. two staff members started passing the food trays.
On 08/30/23 at 12:26 P.M. all resident trays had been passed and the food on the test tray was evaluated. Review of the test tray with Assistant Dietary Manager (ADM) #759 revealed the tray consisted of roast turkey, Brussel sprouts, and scalloped corn. The turkey measured an internal temperature of 118 degrees F. The Brussel sprouts measured an internal temperature of 118 degrees F, and the scalloped corn measured an internal temperature of 112 degrees F.
Interview on 08/30/23 at 12:29 P.M. ADM #759 verified the temperature findings of the test tray.
Dec 2022
1 deficiency
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Accident Prevention
(Tag F0689)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, closed record review, facility policy and procedure review and interview the facility failed to provide ad...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, closed record review, facility policy and procedure review and interview the facility failed to provide adequate interventions to prevent a fall with injury for Resident #114.
Actual Harm occurred on 10/14/22 when Resident #114, who was severely cognitively impaired and at high risk for falls sustained an unwitnessed fall from an electronic lift recliner chair in his room. The resident was found face down on the ground with his electronic lift recliner chair in the forward position with a large amount of blood coming from a laceration to his left eyebrow and a loss of consciousness. Resident #114 was subsequently transferred to the hospital and then to another long-term acute care hospital after being diagnosed with a traumatic brain injury. This affected one resident (#114) of three residents reviewed for falls. The facility census was 108.
Findings include:
Review of the closed medical record for Resident #114 revealed an admission date of 01/28/22 and a discharge date of 11/28/22. Resident #114 had diagnoses including urinary tract infection, pressure ulcer of right buttocks, and psychosis not due a substance or known physiological condition.
Review of fall risk assessments dated 01/28/22, 02/09/22, 03/19/22, 07/20/22, 09/24/22, and 09/30/22 revealed Resident #114 was at a high risk for falling.
Review of care plan dated 01/31/22 and updated 07/28/22 for Resident #114 revealed he was at a high risk for falls due to impaired mobility and cognition. Interventions included to keep his call light within reach and have him nonslip socks while out of bed.
Review of quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #114 had severe cognitive impairment. The assessment revealed Resident #114 required extensive two-person physical assistance for bed mobility and toileting; total dependence of two-persons for transfers; extensive one-person physical assistance for dressing and personal hygiene; and limited one-person physical assistance for eating. Resident #114 was always incontinent of urine and bowel.
Review of physician's progress note, dated 10/13/22 for Resident #114 revealed the resident was alert and oriented times person and place. The note revealed the resident was mildly anxious, dysphoric, and somatic.
Review of nursing progress note, dated 10/14/22 for Resident #114 revealed the nurse was in the hallway and she hear a loud noise. She went to the room and found Resident #114's electronic lift recliner chair all the way forward and Resident #114 on the floor face first. Resident #114 was unconscious for about one minute. The resident had to be turned on his back due to the amount of blood due to a laceration to his left eyebrow. The resident was alert and oriented times person and place and did not recall falling. Resident #114 was transferred to the hospital.
Review of a nursing progress note, dated 11/28/22 revealed Resident #114 was not returning to the facility from the long-term acute care hospital he had been in and was going to another facility.
On 12/07/22 an initial tour was conducted which noted electronic lift recliner chairs were observed in each room for resident's on the rehabilitation unit.
Interviews on 12/07/22 from 9:21 A.M. to 1:35 P.M. with Licensed Practical Nurse (LPN) #551 and #593 and State Tested Nursing Assistants (STNA) #524, #547, and #572 revealed most of the rooms on the rehabilitation unit have electronic left recliner chairs in their rooms. They reported residents were educated on admission about safe usage. The staff also reported if a resident was confused, they would not put the resident in the chairs or they would tuck the remote in the pouch on the side of the chair out of the residents' reach. They also confirmed if they moved the remote, the resident would have their call buttons in reach.
Interview on 12/07/22 at 2:29 P.M. with the Director of Nursing (DON) and Registered Nurse (RN) #500 revealed after investigating Resident #114's fall they were not sure how the resident hit the remote on the electronic lift chair to move his chair into the forward position and fall out of it. They reported he could have sat on it or was pushing the buttons thinking it was the call light. The also confirmed Resident #114 was confused and had good and bad days. The staff verified there were no interventions in place for safe electronic lift recliner chair use.
Review of facility policy falls - clinical protocol, revised October 2010 revealed as part of the initial assessment, the physician would help identify individuals with a history of falls and risk factors for subsequent falling. Each resident would have a fall risk indicator; it would be located in the plan of care. The resident specific tasks would include safety checks.
This deficiency represents non-compliance investigated under Complaint Number OH00137601.
Dec 2019
6 deficiencies
1 Harm
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Pressure Ulcer Prevention
(Tag F0686)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to ensure timely assessments were completed and adequate i...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to ensure timely assessments were completed and adequate interventions were implemented to prevent the development of a pressure ulcer for Resident #94.
Actual Harm occurred on 10/29/19 when Resident #94, who was quadriplegic and required extensive assistance to total dependence on staff for activity of daily living care, including bed mobility and transfers developed an unstageable/Stage IV (full thickness tissue loss with exposed bone, tendon or muscle, slough or eschar may be present on some parts of the wound bed, often include undermining and tunneling) pressure ulcer to the coccyx. This affected one resident (#94) of two residents reviewed for pressure ulcers. The facility identified eight current residents with pressure ulcers.
Findings include:
Record review revealed Resident #94 was admitted to the facility on [DATE] with diagnoses including quadriplegia, neurogenic bowel, neuromuscular dysfunction of bladder and diabetes mellitus type 1.
Review of Resident #94's care plan initiated 04/10/19 revealed a care focus for total assistance with bed mobility, bowel stimulation for bowel movement daily and risk of impaired skin integrity due to impaired mobility, neuropathy, and quadriplegia. Interventions noted the resident required skin inspection with hands on care and observation for redness and open areas, barrier cream per physician order, pressure reducing cushion in wheelchair, air mattress in bed, and to turn and reposition every two hours and as needed.
Review of Resident #94's physician's orders, revealed an order dated 04/09/19 to perform neurogenic bowel management as per orders/instruction sheet every night, a pressure reducing cushion, an air mattress, to turn and reposition with pillows every two hours when in bed to prevent skin breakdown, and on 07/22/19 an order to apply a thin layer of barrier cream to buttocks with morning care one time a day to prevent skin breakdown.
Review of the Neurogenic Bowel Management instruction sheet indicated to perform a mini enema along the side of the wall of the rectum/bowel while resident was in bed, then after ten minutes and using one lubricated finger digitally stimulate using a circle along the wall of the bowel for 30 seconds until stool appeared, and repeat the process up to four times.
Review of the Minimum Data Set (MDS) 3.0 assessment, dated 10/16/19 revealed Resident #94 had no pressure ulcers.
Review of Resident #94's shower sheets for October 2019 indicated no skin changes to the coccyx area were identified during the shower that occurred on 10/26/19.
Review of Resident #94's progress notes revealed an entry dated 10/24/19 which indicated the resident had no significant weight changes, he was eating meals well and his estimated nutritional needs were being met. On 10/29/2019 at 6:12 A.M. a nursing progress note revealed a new Stage IV pressure area was found on the resident's coccyx during bowel care.
Review of the wound assessment, dated 10/29/19 revealed Resident #94 had an unstageable pressure ulcer to the coccyx that measured 3.1 centimeter (cm) in length by 1.2 cm width with 70 percent (%) slough. The assessment revealed the resident had no sensation to the area.
Review of quarterly Braden Scale, dated 11/02/19 revealed Resident #94 was at moderate risk for developing pressure ulcers due to the resident being chair fast, having impaired sensory, limited mobility, adequate protein and requiring moderate to maximum assistance in moving.
Review of the MDS 3.0 assessment, dated 11/08/19 revealed Resident #94 had no cognitive impairment, required extensive assistance from two staff for bed mobility and was totally dependent on staff for personal hygiene, transfers, dressing, toileting and bathing. The assessment revealed the resident was always incontinent of bowel and had one unstageable wound not coded as present upon entry into the facility.
Observation on 12/03/19 at 10:17 A.M. revealed Resident #94 was seated in a specialized wheelchair and was reclined at 46 degrees. Interview with the resident at the time of the observation confirmed the degree of the wheelchair and confirmed the resident currently had a pressure ulcer to the coccyx area. The resident revealed he had little if any feeling in the area and staff changed the dressing daily on night shift after he received bowel stimulation by the nurse and was cleaned up afterward by the state tested nursing assistant (STNA) staff.
Observation on 12/04/19 at 12:50 P.M. revealed Resident #94 was fully reclined in a specialized wheelchair at this time. Additional observations on 12/04/19 at 2:20 P.M., 12/04/19 at 4:45 P.M., 12/05/19 at 8:41 A.M. and 12/05/19 at 10:45 A.M. revealed Resident #94 was sitting in up in the specialized wheelchair.
Interview on 12/04/19 at 9:56 A.M. with Licensed Practical Nurse (LPN) #612 verified Resident #94's wound was initially discovered while in the facility on 10/29/19 as a Stage IV pressure ulcer.
Interview on 12/04/19 at 2:29 P.M. with LPN #613 verified the resident was assessed to have a Stage IV pressure ulcer the morning of 10/29/19 and then it was changed to an unstageable pressure ulcer because the wound bed was covered in slough. She verified Resident #94 received neurogenic stimulation of bowel from the night shift nurses and bowel incontinence care thereafter since admission. She further indicated Resident #94 preferred to stay in the chair and indicated the resident could tilt himself. However, there was no evidence the facility had implemented any interventions to assess the effectiveness of the resident's tilting ability/frequency or included any information in the plan of care related to the resident or staff responsibility for position changes.
Interview on 12/04/19 at 3:15 P.M. with STNA #615 revealed Resident #94 stayed up in the chair most of the time.
Interview on 12/04/19 at 5:57 P.M. with Registered Nurse (RN) #606 and review of the resident's plan of care revealed Resident #94 received neurogenic stimulation of the bowel which should include a skin inspection. She further indicated if neurogenic stimulation of the bowel was conducted then the entire area would need checked for skin breakdown with the incontinence care thereafter. RN #606 further verified Resident #94's preference to stay up in the wheelchair which was not reflected in the care plan as well as a lack of evidence of monitoring or assessing the effectiveness of tilting frequency in the chair.
Interview on 12/04/19 at 6:12 P.M. with LPN #616 verified Resident #94 stayed up in his chair most of the day unless he asked to lay down, he received bowel protocol every night, and the pressure reducing cushion he had was built into his wheelchair. She further indicated she believed Resident #94 tilted himself in the wheelchair and was not monitored by staff related to position changes in the wheelchair.
Interview on 12/04/19 at 6:27 P.M. with LPN #613 revealed staff did not monitor the resident for position changes in the wheelchair but staff would lay him down if he asked.
Interview on 12/05/19 at 2:19 P.M. with STNA #614 revealed Resident #94 spent most of the day up in his chair. The STNA revealed she did not assist with repositioning in the chair, tilting the chair or reminding the resident to change the tilt of the chair.
Interview on 12/05/19 at 12:29 P.M. with the Director of Nursing verified Resident #94's pressure ulcer was facility acquired and discovered on 10/29/19 as a Stage IV until reassessed later that same day as unstageable due to the presence of slough tissue. She further verified neurogenic bowel stimulation was provided to Resident #94 every night and was a lengthy procedure, the resident was not able to feel in that area, and he was compliant with nutritional interventions. She also confirmed with these factors staff should be more hypervigilant to ensure skin checks were thorough and completed to find early signs of skin breakdown.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0602
(Tag F0602)
Could have caused harm · This affected 1 resident
Based on record review and interview the facility failed to ensure Resident #49 was free from misappropriation of money. This affected one resident (#49) of three residents reviewed for misappropriati...
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Based on record review and interview the facility failed to ensure Resident #49 was free from misappropriation of money. This affected one resident (#49) of three residents reviewed for misappropriation.
Findings include:
Review of the medical record for Resident #49 revealed an admission date of 03/01/17 with diagnoses that included Parkinson's disease, congestive heart failure, chronic kidney disease and major depression.
Review of the form titled, Resident Personal Funds revealed Resident #49 signed on 03/22/17 that she authorized the facility to manage her personal money while she was a resident at the facility.
Review of a facility self-reported incident (SRI), tracking number 180181 revealed an incident involving misappropriation for Resident #49 was discovered on 09/08/19. The SRI revealed on 09/02/19 State Tested Nursing Assistant (STNA) #600 asked Resident #49 if she would like to have her coin purse locked up rather than leave her money in her room. Resident #49 agreed and STNA #600 took Resident #49's coin purse that contained $38.00 to Licensed Practical Nurse (LPN) #601. STNA #600 and LPN #601 verified the coin purse contained $38.00 and LPN #601 locked the coin purse inside the B wing medication cart inside the narcotic drawer. On 09/08/19 Resident #49 had asked for her money back and the coin purse was returned with $2.00 inside. Resident #49 reported she had money missing.
A witness statement per LPN #602 dated 09/08/19 revealed Resident #49 came to her and requested her change purse from the medication cart. LPN #602 opened the narcotic drawer and retrieved the change purse. LPN #602 revealed Resident #49 stated she had $52.00 dollars in the change purse. LPN #602 opened the change purse and there were two one-dollar bills and some change wrappers in the purse. Resident #49 was given her change purse and the incident was reported to Registered Nurse (RN) #603.
Review of police report dated 09/10/19 at 10:50 A.M. for theft revealed Police Officer #604 responded to the facility. Assistant Director of Nursing (ADON) #605 revealed Resident #49 stated she was missing approximately $50.00. The police report stated the money was in Resident #49's possession until LPN #601 took the money for safekeeping and locked the money inside the medication cart. He revealed the cart was only assessable by the nurses at the facility. He was advised this was sometimes done to keep resident's money safe. He revealed the exact date when the money went missing was unknown and was advised almost a dozen nurses had access to the medication cart from the time the money was put into the cart and the time the money was located missing; therefore, was unable to investigate.
A witness statement per Resident #49 dated 09/10/19 revealed STNA #600 found the coin purse and asked Resident #49 if she wanted her coin purse with her money locked up with the nurse. Resident #49 agreed and then checked on 09/08/19 to see if she had enough money to get lunch and the nurse gave her the coin purse and there was money missing.
A witness statement per STNA #600 dated 09/10/19 revealed she gave LPN #601 Resident #49's coin purse that contained $38.00 dollars. She revealed she counted the money in front of LPN #601 and LPN #601 put the purse and money inside the medication cart.
A witness statement per LPN #601 dated 09/15/19 revealed STNA #600 brought her Resident #49's coin purse and LPN #601 and STNA #600 counted the money inside the coin purse and there was $38.00 dollars. LPN #601 wrote on a piece of tape the resident's name and $38.00 dollars and placed the tape on the coin purse. LPN #601 placed the coin purse inside the B wing medication cart inside the narcotic drawer.
Interview on 12/03/19 at 2:49 P.M. with LPN #602 verified Resident #49 had asked for her change purse with money out of the narcotic drawer on 09/08/19. She verified the change purse contained $2.00 dollars inside. She verified they did not have accounting records of Resident #49's money as they did not count her money in the narcotic drawer shift to shift.
Interview on 12/03/19 at 3:06 P.M. STNA #600 verified on 09/02/19 Resident #49 agreed to not keep her change purse with money in her room. She verified she gave LPN #601 the change purse and they counted the money together and Resident #49 had $38.00 dollars inside the change purse. She verified LPN #601 placed the change purse with the money in the medication cart inside the narcotic drawer.
Interview on 12/04/19 at 1:48 P.M. with the Administrator verified Resident #49 had personal money missing from the medication cart inside the narcotic drawer. She verified she had a personal funds account at the facility and revealed Resident #49's personal money should not have been maintained in the narcotic drawer instead should have been put into her personal account.
Review of facility policy titled Abuse, Neglect, Misappropriation of Resident's Property and Injury of Unknown Source, dated 10/17/17 revealed misappropriation was defined as deliberate, depriving, defrauding, or otherwise obtaining the real or personal property of a resident.
Review of facility policy titled Protection and Management of Resident Funds, dated 03/01/19 revealed if a resident presented written authorization, the facility shall hold, safeguard and manage and account for the resident's personal funds deposited with the facility.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
Based on observation, record review and interview the facility failed to ensure Resident #62, who had a diagnosis of diabetes mellitus received insulin injections in accordance with the physician's or...
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Based on observation, record review and interview the facility failed to ensure Resident #62, who had a diagnosis of diabetes mellitus received insulin injections in accordance with the physician's order for administration and to meet the resident's needs. This affected one resident (#62) of six residents observed for medication administration.
Findings include:
Review of the medical record for Resident #62 revealed an admission date of 03/02/18 with diagnoses including diabetes mellitus type 2, dementia and chronic kidney disease.
Record review revealed the resident had a physician's order, dated 09/18/19 for NovoFine Lantus Solostar KwikPen Insulin Needles, inject one applicator subcutaneously every morning and at bedtime. The order included to rotate sites, use arms not abdomen for injection.
During medication administration observation on 12/03/19 at 7:42 A.M., Licensed Practical Nurse (LPN) #610 entered Resident #62's room with the prepared Lantus Solostar Kwikpen and exposed the resident's abdomen which revealed two small blue, red, and purple colored bruises to the right upper quadrant. Resident #62 inquired of LPN #610 why she was getting bruises and LPN #610 responded she believed it was from her insulin shots but she would check. LPN #610 then wiped an area of Resident #62's abdomen in the left upper quadrant of the abdomen and proceeded to inject six units of Lantus insulin using the Kwikpen.
Interview on 12/03/19 at 3:27 P.M. with Resident #62 and LPN #610 confirmed Resident #62 had three bruises on the abdomen. LPN #610 verified two bruises coincided with previous insulin injections on the abdominal right upper quadrant and the third was new from the insulin injection she gave that morning.
Interview on 12/03/19 at 3:49 P.M. with the Director of Nursing verified Resident #62 had a physician's order, dated 09/18/19 to use her arms and not the abdomen for insulin injections. She further confirmed Resident #62 received insulin injections in the abdomen on multiple occasions from 09/19/19 to 12/03/19.
Review of Medication Administration Records for September through December 2019 revealed Resident #62 received the Lantus Solostar insulin injection in the abdomen on 09/19/19 at 9:15 P.M., 09/20/10 at 7:23 A.M. and at 8:23 P.M., on 09/21/19 at 7:46 A.M. and at 8:08 P.M., on 09/22/19 at 7:56 A.M. and at 8:06 P.M., on 09/23/19 at 7:14 A.M. and at 9:15 P.M., on 09/24/19 at 7:12 A.M. and at 8:01 P.M., on 09/25/19 at 7:47 A.M. and at 8:33 P.M., on 09/26/10 at 7:19 A.M. and at 8:25 P.M., on 09/27/10 at 7:34 A.M. and at 8:51 P.M., on 09/28/19 at 8:41 P.M., on 09/29/19 at 7:33 A.M. and at 8:07 P.M., on 09/30/19 at 6:49 A.M. and at 8:07 P.M., on 10/01/19 at 7:13 A.M. and at 8:55 P.M., on 10/02/19 at 7:06 A.M. and at 08:18 P.M., on 10/03/19 at 7:25 A.M. and at 8:08 P.M., on 10/04/19 at 9:21 A.M. and at 8:09 P.M., on 10/05/19 at 7:04 A.M. and at 8:09 P.M., on 10/06/19 at 7:11 A.M. and at 8:35 P.M., on 10/07/19 at 7:35 A.M. and at 8:43 P.M., on 10/08/19 at 7:08 A.M. and at 8:35 P.M., on 10/09/19 at 7:20 A.M. and at 8:58 P.M., on 10/10/19 at 7:11 A.M. and at 8:08 P.M., on 10/11/19 at 7:27 A.M. and at 8:11 P.M., on 10/12/19 at 8:45 A.M. and at 8:04 P.M., on 10/13/19 at 7:25 A.M. and at 8:03 P.M., on 10/14/19 at 8:49 A.M. and at 8:31 P.M., on 10/15/19 at 7:59 A.M. and at 8:05 P.M., on 10/16/19 at 11:19 A.M. and at 8:42 P.M., on 10/17/19 at 7:20 A.M. and at 8:04 P.M., on 10/18/19 at 8:02 A.M. and at 8:29 P.M., on 10/19/19 at 9:02 A.M. and at 8:54 P.M., on 10/20/19 at 9:27 A.M. and at 8:07 P.M., on 10/21/19 at 8:51 A.M., on 10/22/19 at 8:55 A.M. and at 9:04 P.M., on 10/23/19 at 7:22 A.M. and at 8:17 P.M., on 10/24/19 at 8:52 A.M. and at 8:19 P.M., on 10/25/19 at 7:36 A.M. and at 10:45 P.M., on 10/26/19 at 7:48 A.M. and at 8:05 P.M., on 10/27/19 at 7:04 A.M. and at 10:31 P.M., on 10/28/19 at 9:59 A.M. and at 8:26 P.M., on 10/29/19 at 10:25 A.M. and at 8:13 P.M., on 10/30/19 at 7:31 A.M. and at 10:44 P.M., on 10/31/19 at 8:46 A.M and at 8:04 P.M., on 11/01/19 at 7:46 A.M. and at 8:07 P.M., on 11/02/19 at 9:33 A.M. and at 8:20 P.M., on 11/03/19 at 7:58 A.M. and at 8:27 P.M., on 11/04/19 at 8:44 A.M. and at 8:38 P.M., on 11/05/19 at 8:52 A.M. and at 9:24 P.M., on 11/06/19 at 7:40 A.M. and at 8:11 P.M., on 11/07/19 at 9:39 A.M. and at 8:30 P.M., on 11/08/19 at 10:33 A.M. and at 9:12 P.M., on 11/09/19 at 7:12 A.M. and at 8:50 P.M., on 11/10/19 at 7:29 A.M., on 11/11/19 at 7:37 A.M. and at 8:28 P.M., on 11/12/19 at 9:42 A.M. and at 9:22 P.M., on 11/13/19 at 7:00 A.M. and at 8:41 P.M., on 11/14/19 at 7:19 A.M. and at 8:11 P.M., on 11/15/19 at 7:39 A.M. and at 8:52 P.M., on 11/16/19 at 7:27 A.M. and at 8:28 P.M., on 11/17/19 at 9:38 A.M. and at 8:06 P.M., on 11/18/19 at 9:00 A.M. and at 9:06 P.M., on 11/19/19 at 7:39 A.M. and at 9:36 P.M., on 11/20/19 at 10:50 A.M. and at 8:12 P.M., on 11/21/19 at 9:29 A.M. and at 8:00 P.M., on 11/22/19 at 7:03 A.M. and at 8:14 P.M., on 11/23/19 at 8:50 A.M. and at 9:00 P.M., on 11/24/19 at 9:27 A.M. and at 8:34 P.M., on 11/25/19 at 7:10 A.M. and at 8:15 P.M., on 11/26/19 at 9:48 A.M. and at 8:17 P.M., on 11/27/19 at 7:16 A.M and at 9:02 P.M., on 11/28/19 at 7:29 P.M. and at 8:18 P.M., on 11/29/19 at 7:20 A.M. and at 8:04 P.M., on 11/30/19 at 7:57 A.M. and at 8:33 P.M., on 12/01/19 at 7:41 A.M. and 8:12 P.M., and on 12/02/19 at 7:31 A.M and 8:09 P.M.
Review of facility undated policy titled Medication Administration revealed medications must be administered in accordance with the orders.
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, record review and interview the facility failed to ensure medications were administered to Resident #59 via gastrostomy tube to decrease the risk of stomach upset/gastrointestina...
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Based on observation, record review and interview the facility failed to ensure medications were administered to Resident #59 via gastrostomy tube to decrease the risk of stomach upset/gastrointestinal disturbance. This affected one resident (#59) six residents observed for medication administration.
Findings include:
Review of the medical record for Resident #59 revealed an admission date of 06/23/04 with diagnoses including heart failure, gastro-esophageal reflux disease, gastrostomy status and chronic bronchitis.
Review of the physician's orders, dated 06/27/19 revealed the resident had an order for Potassium chloride solution 20 milliequivalents (meq) per 15 milliliters (ml) 10 percent (%) solution, give 7.5 ml via gastrostomy tube once daily for heart failure.
During medication administration observation on 12/03/19 at 9:38 A.M., Licensed Practical Nurse (LPN) #610 prepared the Potassium chloride solution 10% 7.5 ml into a medication administration cup. Observation of the Potassium Chloride medication label revealed a note that stated, must dilute before using.
Interview at the time of the observation with LPN #610 revealed she would dilute the medication prior to administering in the gastrostomy tube. LPN #610 prepared five additional medications for administration, entered Resident #59's room, washed hands, applied gloves, disconnected the resident's tube feeding, removed gloves, washed hands, applied new gloves, checked gastrostomy tube placement, then added 15 to 30 ml water to each medication for dilution except for the Potassium chloride.
Interview with LPN #610 at the time of the observation confirmed no additional water was added to the Potassium chloride liquid for dilution prior to the administration. LPN #610 then used gravity technique and a piston syringe barrel dated 12/03/19, flushed the gastrostomy tube with 200 ml water, followed by each medication with 30 ml of water flush in between and once for a final flush. Upon completion, LPN #610 disposed of the supplies in the appropriate containers, removed gloves and washed hands.
Interview on 12/04/19 at 9:07 A.M. with Pharmacy Consultant #611 revealed liquid potassium was recommended to be diluted with four to six ounces of water when a dilution amount was not specified in the order. He further indicated if administered with less than four ounces of water dilute, a risk existed for stomach upset or gastrointestinal disturbance.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Record review revealed Resident #63 was admitted to the facility on [DATE] with diagnoses including dementia, major depressiv...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Record review revealed Resident #63 was admitted to the facility on [DATE] with diagnoses including dementia, major depressive disorder, and chronic kidney disease stage 3.
Review of the care plan dated 06/09/19 included a care area of high risk for falls related to risks including immobility and dementia. The care plan was revised on 08/20/19 to initiate a chair tender alarm and again on 09/24/19 to initiate an alarming floor mat per doctor's order.
Physician's orders included an alarming floor mat to left side of bed dated 09/03/19 and a chair tender while up to alert staff of unassisted transfers dated 09/13/19.
Review of the MDS 3.0 assessment dated [DATE] indicated chair and bed alarms were coded as not used for the resident.
Observations of Resident #63 on 12/03/19 at 11:58 A.M. and 12/04/19 at 2:14 P.M. revealed the resident was seated in her wheelchair with the chair tender in place.
Observations of Resident #63 on 12/03/19 at 1:48 P.M., 12/04/19 at 8:48 A.M. and 12/04/19 at 12:41 P.M. revealed an alarm floor mat in place under the left side of the bed while resident was sitting in a nearby reclining chair.
Interview on 12/04/19 at 2:30 P.M. with Licensed Practical Nurse #613 verified Resident #63 used a chair alarm when in the wheelchair and bed alarm when in bed.
Interview on 12/04/19 at 2:31 P.M. with the Director of Nursing verified if a resident had active orders for an alarm, that alarm should be reflected on the MDS.
Interview on 12/04/19 at 3:15 P.M. with State Tested Nursing Assistant (STNA) #615 verified Resident #63 used a chair alarm when in the wheelchair and bed alarm when in bed.
Interview on 12/05/19 at 11:22 A.M. with STNA #614 verified Resident #63 used a chair alarm when in the wheelchair and bed alarm when in bed.
Based on observation, record review and interview the facility failed to accurately code alarms on the Minimum Data Set (MDS) 3.0 assessment for Resident #29, Resident #63, Resident #96 and Resident #99. This affected four residents (#29, #63, #96 and #99) of four residents reviewed for alarms.
Findings include:
1. Record review for Resident #99 revealed an admission to the facility on [DATE]. Resident #99's current diagnoses included unspecified dementia with behavioral disturbance, major depressive disorder, generalized osteoarthritis, and primary hypertension.
A fall risk assessment dated [DATE] revealed that Resident #99 was a high risk of falls.
Review of the physician's orders for Resident #99 revealed an order, dated 10/30/19 for motion [NAME] alarm for bathroom, an order dated 09/22/19 for self releasing alarm belt to wheelchair, a motion [NAME] to the residents bed, and an order for bed tender alarm dated 06/05/18.
A care plan relative to fall risk revealed individualized interventions for falls including: motion sensor beside bed, a motion sensor to bathroom door, and a self release alarmed seatbelt to wheelchair.
The MDS 3.0 assessment, dated 11/08/19 revealed Resident #99 had a with a brief interview mental status (BIMS) score of of 99 indicating resident was unable to complete the assessment due to severe cognitive impairment. There was no reference to the use of alarms.
Review of Resident #99's MDS 3.0 assessments, dated 10/11/19 and 11/08/19 under Section P-0200 Alarms, revealed the MDS indicated that (A) a bed alarm was not used, (B) a chair alarm was not used, (C ) a floor mat alarm was not used and (D) motion [NAME] alarm were not used.
Interview with MDS Coordinator RN #606 at 3:36 P.M. revealed the MDS section verified Section P indicated that a bed alarm (marked 0) was not used, a chair Alarm (marked 0) was not used, a floor mat alarm (marked 0) not used, and a motion [NAME] alarm (marked 0) was not used.
2. Record review revealed Resident #29 was admitted to the facility on [DATE] with diagnoses including Parkinson's disease, unspecified dementia without behavioral disturbance and a history of falling.
Review of the physician's orders revealed an order dated, 03/15/16 for bilateral half side-rails up when in bed, an order, dated 04/11/19 for a chair alarm to wheelchair and recliner for safety and an order dated 04/24/19 for a personal body alarm (PBA) at all times.
Review of the MDS 3.0 dated 09/20/19 revealed the resident was moderately cognitively impaired, required extensive assist of two staff for transfers and toileting, used a wheelchair for mobility, had no falls, and had no use of physical restraints or alarms.
Review of the care plan, dated 10/01/19 included a care area for falls with interventions including a chair alarm (01/07/19) and a PBA (04/12/19).
Observations of Resident #29 on 12/03/19 at 10:56 A.M. and 12/05/19 at 9:44 A.M. revealed the resident was seated in a wheelchair with the PBA and chair alarms in place.
Interview on 12/04/19 at 2:31 P.M. with the Director of Nursing verified if a resident had active orders for an alarm, the alarm use should be reflected on the MDS assessment.
Interview on 12/04/19 at 3:34 P.M. with Registered Nurse (RN) #606 verified Resident #29 had a chair alarm and PBA in place but the alarm section of the MDS for Resident #29 was not accurate to reflect the use of the alarming devices. RN #606 revealed this may have been overlooked.
Review of the Alarm policy, dated 01/11/13 revealed alarms were utilized for the purpose of safety, providing an audible notification to the staff of a resident's need for assistance or an audible reminder to the resident of their need receive or request assistance from staff. Need for alarm intervention and type of alarm was determined by or through the Fall Risk Assessment, the admission assessment, a post fall assessment, the interdisciplinary team and/or the interdisciplinary team and/or the resident's physician.
3. Record review revealed Resident #96 was admitted to the facility on [DATE] with diagnoses including unspecified dementia without behavioral disturbance, aphasia (loss of ability to understand or express speech) after a stroke.
Physician orders included an order, dated 07/02/18 for bilateral half side-rails up when in bed, an order,dated 05/07/19 for a motion sensor to the left side of the bed to alert staff on unassisted transfers and an order for chair alarm on at all times to alert staff of unassisted ambulation.
Review of the MDS 3.0 assessment, dated 11/08/19 revealed the MDS did not reflect the use of alarms.
Review of the care plan, dated 11/18/19 included a care area for risk of falls with interventions including a chair alarm and motion sensor to bedside.
Observation and interview on 12/02/19 at 9:10 A.M. with State Tested Nursing Assistant (STNA) #608 verified Resident #96 had a motion sensor and chair alarm to help prevent falls.
Interview on 12/04/19 at 2:31 P.M. with the Director of Nursing verified if a resident had active orders for an alarm, the alarm(s) should be reflected on the MDS assessment.
Interview on 12/04/19 at 03:34 P.M. with Registered Nurse (RN) #606 verified the alarm section of the MDS for Resident #96 was not complete and the use of alarms might have been overlooked.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
Based on observation, record review and interview the facility failed to maintain adequate infection control practices during the administration of medication for Resident #62 and during meal services...
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Based on observation, record review and interview the facility failed to maintain adequate infection control practices during the administration of medication for Resident #62 and during meal services to prevent the spread of infection. This affected one resident (#62) of six residents observed during medication administration and six residents (#10, #27, #63, #73, #85 and #87) of ten residents observed for meal service.
Findings include:
1. During medication observation on 12/03/19 at 7:19 A.M. Licensed Practical Nurse LPN #610 entered Resident #62's room to obtain a glucometer reading. LPN #610 entered the resident's room, washed her hands, applied gloves and then completed the blood sugar testing. After completing the test, the LPN discarded the items in the appropriate container, removed her gloves and then returned to the medication cart without first performing any hand washing or hand hygiene. The LPN then cleaned the glucometer with a sanitizing wipe and obtained the resident's Lantus Solostar KwikPen from the medication drawer and prepared it for administration. LPN #610 then entered Resident #62's room, applied gloves, administered the insulin, discarded the needle into the designated container, removed her gloves and returned to the medication cart without performing any hand hygiene/washing.
Interview with LPN #610 on 12/03/19 at 7:38 A.M. verified she did not perform handwashing after removing her gloves.
Review of facility policy titled Handwashing/Hand Hygiene, revised April 2010 revealed employees must wash their hands or use an alcohol-based hand rub after removing gloves.
2. Observation on 12/02/19 at 12:08 P.M. of meal tray service with State Tested Nursing Assistant (STNA) #609 revealed STNA #609 obtained a meal tray and a clean clothing protector, then delivered it to Resident #10. STNA #609 adjusted Resident #10's bed position using the bed remote, then adjusted the overbed tray table, set-up the resident's meal tray by opening containers and lids, cut the resident's food using a fork and knife, and then re-adjusted the overbed tray table before leaving Resident #10's room. STNA #609 then entered Resident #63's room to assist the resident with another staff member without washing her hands.
Interview on 12/02/19 at 12:28 P.M. with STNA #609 verified the above observation.
Observation on 12/03/19 at 12:04 P.M. of meal tray service with STNA #609 revealed STNA #609 obtained a meal tray and a clean clothing protector from the meal cart and delivered the tray to Resident #85. STNA #609 adjusted the overbed tray table, pushed it toward Resident #85, applied the clothing protector onto Resident #85, cut the resident ' s food and opened condiments before returning to the meal cart. STNA #609 returned and opened the meal cart without first washing her hands, obtained another tray and delivered the tray to Resident #73. STNA #609 returned to the meal cart, obtained a meal tray and a clean clothing protector and delivered it to Resident #27. STNA #609 adjusted the overbed tray table, pushed it toward Resident #27, applied the clothing protector onto Resident #27, removed lids and opened condiments, then turned on the overbed light before leaving the room. STNA #609 then returned to the meal cart and picked up a used clothing protector and placed it into the soiled barrel in the soiled utility room. Without washing her hands, STNA #609 then provided assistance to Resident #87.
Interview on 12/03/19 at 12:25 P.M. with STNA #609 verified the above observation.
On 12/04/19 at 12:25 P.M. with Director of Nursing revealed the facility policy was to wash hands or use hand sanitizer after touching resident's personal effects which included resident furniture.
Review of facility policy titled Assisting the Resident with In-Room Meals, revised April 2011, revealed it was not necessary to wash hands between each resident tray; however, if there was contact with soiled dishes, clothing or the residents' personal effects, the employee must wash their hands before serving food to the next resident.
Oct 2018
11 deficiencies
1 IJ
CRITICAL
(J)
Immediate Jeopardy (IJ) - the most serious Medicare violation
Deficiency F0757
(Tag F0757)
Someone could have died · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of hospital records, interview with facility staff, review of laboratory testing results,...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of hospital records, interview with facility staff, review of laboratory testing results, review of the facility policy titled Anticoagulation Clinical Protocol and review of the Nursing Drug Handbook, 38th Edition, the facility failed to ensure adequate monitoring was completed for one resident (Resident #6) who received the oral anticoagulant (blood thinning) medication, Coumadin. This resulted in Immediate Jeopardy when the blood clotting time was not monitored. Actual Harm occurred to Resident #6 on 08/28/18 when the resident was transported to the local emergency room with upper extremity bruising and bleeding evidenced by blood in the urine (indicators of possible increased bleeding due to the Coumadin medication) and was admitted to the hospital with retroperitoneal bleed and perinephric bleed. The resident's International Normalized Ratio (INR) level (blood testing used to monitor therapeutic levels of the medication Coumadin) was significantly elevated with a level over 9 on that date. This affected one of eleven residents reviewed the facility identified as receiving anticoagulant medication. The facility census was 116.
On 10/17/18 at 4:12 P.M., the Administrator, Regional Consultant #40, Assistant Director of Nursing (ADON) and Director of Nursing (DON) were notified Immediate Jeopardy began on 08/20/18 when the facility failed to obtain laboratory (INR) testing to monitor Resident #6's Coumadin level. The lack of monitoring resulted in the resident being transferred to the emergency room and admitted to the hospital on [DATE] with bruising and hematuria (blood in urine) with hospital diagnoses of retroperitoneal bleed and perinephric bleed. Resident #6 subsequently received fresh frozen plasma (FFP) and Vitamin K in an attempt to reverse the effects of the Coumadin medication.
The Immediate Jeopardy was removed on 10/19/18 when the facility implemented the following corrective actions:
•
On 08/27/18 at 3:01 P.M. Registered Nurse (RN) #10 identified bruises on Resident #6's arms and notified the physician who ordered an INR and complete blood count lab work to be drawn on 08/27/18.
•
Laboratory testing results, dated 08/28/18 at 8:30 A.M. revealed Resident #6's INR level was over 9. The physician was notified, and an order was obtained to administer five milligrams (mg) of Vitamin K intramuscularly. Blood was subsequently identified in Resident #6's urine at 9:15 A.M. The facility reported the bloody urine symptom to the physician at 9:15 A.M. who ordered Resident #6 to the hospital for evaluation. At 9:30 A.M. emergency medical services (EMS) was called and at 9:56 A.M. Resident #6 was taken to the hospital emergency room.
•
A review of a facility investigation revealed Licensed Practical Nurse (LPN) #14 failed to document on the Coumadin log that PT/INR testing for Resident #6 was due on 08/20/18. Review of employee disciplinary action, dated 09/15/18 revealed LPN #14 was issued a three-day working suspension on 09/21/18, 09/22/18 and 09/23/18 for not ordering the PT/INR for Resident #6 on 08/20/18.
•
An emergency meeting of the Quality Assurance committee consisting of the administrator, DON, ADON and management consultants was held on 08/28/18 to direct the following corrective action related to the incident with Resident #6: Ongoing and frequent communication with the hospital and family regarding resident condition. Completion of preliminary audits on all units regarding Coumadin logs and the completion of those logs.
•
On 08/29/18 Coumadin log audits were completed for the eleven residents receiving Coumadin (Resident #6, #11, #19, #23, #27, #58, #65, #74, #83, #85, and #99) and were set for weekly audit through 12/31/18. The audits were completed by the unit managers, RN #620, RN #621 and RN #622.
•
On 08/29/18 body audits were completed/reviewed for the remaining ten residents, Resident #11, #19, #23, #27, #58, #65, #74, #83, #85, and #99 receiving Coumadin and found no negative for bleeding or bruising. The body audits were completed by the DON.
•
On 08/29/18 a plan was implemented for Coumadin log audits to be checked by the DON bi-weekly through 06/30/19.
•
Staff education regarding the use of anticoagulants, the Coumadin monitoring log and entering lab orders into Point Click Care electronic records was conducted on 09/15/18 for LPN and RN staff by the ADON. There were six LPNs and three RNs as of 09/15/18 who had not received the education. Those six LPNs and three RNs received the education on 10/18/18 by the ADON. Staff education was provided on 10/19/18 by the ADON for eight agency LPNs and any agency nurses who did not receive the education on 10/19/18 were put onto a Do Not Return list.
•
On 10/19/18 at 12:30 P.M. the DON provided a plan for all new agency staff to receive mandatory training on the same topic (related to the use of anticoagulants) from the ADON before working in the facility. A plan for any newly hired nurses to receive the training as part of the orientation program by the ADON was also implemented.
•
Nursing staff interviews were conducted on 10/19/18 from 9:06 A.M. to 9:24 A.M. with LPN #615, LPN #617, LPN #618 and LPN #619 who were employed by the facility. All LPN's interviewed verified recent education on anticoagulants including Coumadin, using the monitoring tool to track PT/INR levels, Coumadin orders and lab orders and how to input lab orders into the electronic records system.
Although the Immediate Jeopardy was removed on 10/19/18 the facility remained out of compliance at Severity Level 2 (no actual harm with potential for minimal harm that is not Immediate Jeopardy) as the facility remained in the process of implementing their corrective action plan.
Findings include:
Review of Resident #6's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including atherosclerotic heart disease, major depressive disorder, oropharyngeal dysphagia, poly neuropathy, generalized osteoarthritis, pain in left shoulder, muscle wasting, dementia and cognitive communication deficit.
Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #6 was cognitively intact and required extensive assistance from staff for bed mobility, transfers, toileting and hygiene. Record review revealed Resident #6 was unable to make her own financial and health care decisions without input from her son who was identified to be her responsible party.
Record review revealed a plan of care, initiated on 07/03/18 and revised on 07/30/18 indicating the resident was on anticoagulant therapy. The goal developed was for the resident to be free from discomfort and adverse reactions related to anticoagulant use. Interventions included to monitor for side effects and effectiveness once a shift and labs as ordered, report abnormal lab results to physician.
Review of the physician's orders revealed an order, dated 07/02/18 for the anticoagulant (blood thinning) medication, Coumadin (Warfarin Sodium) two milligrams (mg) once a day every Sunday, Tuesday, Thursday and Saturday for atrial fibrillation. On 07/02/18 an additional Coumadin order was written for a four mg Coumadin once a day every Monday, Wednesday and Friday for atrial fibrillation. The orders were discontinued on 07/16/18 and new orders were obtained.
Review of the physician's orders revealed a new order, dated 07/16/18 for Coumadin four mg once a day on Sunday, Monday, Wednesday, Thursday and Saturday. On 07/16/18 a second order for Coumadin was noted for two mg once a day on Tuesday and Friday. Both of those orders were discontinued on 07/30/18 and a new order was written for Coumadin five mg by mouth one time a day for anticoagulant therapy.
Review of the laboratory testing results revealed the resident's Coumadin was monitored by checking a Prothrombin Time (PT) and International Normalized Ratio (INR) value. The resident's PT/INR were obtained on 07/06/18, 07/09/18, 07/16/18, 07/23/18, 07/30/18, 08/06/18 and 08/13/18 with changes made to the Coumadin dosage as noted above. The 08/13/18 laboratory testing revealed the resident's PT was 29.6 and INR was 2.9 (within normal limits for the resident) with an order to maintain the same dose and recheck values in one week.
However, there was no evidence of any subsequent PT/INR lab values obtained by the facility until 08/28/18 after the resident was assessed with bruising. The results were called to the facility by the lab to report critically high levels of PT at 88.8 and INR over 9.0.
Review of the PT/INR Tracking Form for Resident #6 revealed that on 08/13/18 the facility was to draw another PT/INR in one week, however the next draw was not done until 08/28/18 after the resident had shown symptoms of bruising.
Review of the nursing progress notes written by RN #10 on 08/27/18 at 3:01 P.M. revealed Resident #6 had three dark bruises on her right and left arm. RN #10 notified the physician and the physician ordered laboratory testing for an INR and complete blood count (CBC) lab work to be done on 08/27/18.
The nursing progress notes written by LPN #11 on 08/28/18 at 2:47 A.M. revealed Resident #6 had bruises to the underside of both upper arms and the bruising was dark purple/red in color.
Review of the nursing progress notes written by LPN #12 on 08/28/18 at 9:58 A.M. revealed that lab called the facility at 8:30 A.M. to report an elevated PT 88.8 and INR over 9. The physician was notified with new orders to give Vitamin K five mg intramuscular, hold the Coumadin, recheck on Thursday. Vitamin K was given at 9:00 A.M. and at 9:15 A.M. Resident #6 urinated a large amount of hematuria (blood in urine). The physician then gave a new order to send Resident #6 to the emergency room. EMS (911) was called at 9:30 A.M. and arrived at 9:56 A.M. to transport Resident #6 to the hospital.
Review of the Medication Administration Record (MAR) from August 2018 for Resident #6 revealed the resident received Coumadin as ordered until it was held beginning on 08/28/18.
Review of the nursing progress notes dated 08/28/18 at 3:24 P.M. by LPN #12 revealed Resident #6 was admitted to the hospital due to an elevated INR. The nursing progress notes written by RN #13 on 08/30/18 at 8:00 P.M. revealed Resident #6 returned to the facility on [DATE] at approximately 8:00 P.M. A nursing progress note written by LPN #14 on 08/31/18 at 1:37 P.M. revealed Resident #6 was not to be on Coumadin for four to six weeks upon re-admission.
Review of the hospital discharge summary indicated Resident #6 was admitted on [DATE] due to significant, elevated INR over 9, and spontaneous bleeding with hematoma to arms and hematuria. Resident #6 was given several units of fresh frozen plasma and Vitamin K. Resident #6 had a computed tomography (CT) scan that showed a retroperitoneal bleed with a perinephric bleed. The discharge summary also recommended that before any Coumadin could be resumed for Resident #6 there would need to be a repeat CT scan.
An interview was conducted on 10/17/18 at 7:36 P.M. with RN #10 who verified Resident #6 had dark bruises on both arms on 08/27/18 with no other signs of bleeding. RN #10 indicated she reported the findings to the physician who ordered a PT/INR and CBC to be done on 08/27/18.
An interview was conducted on 10/17/18 at 7:48 P.M. with LPN #11 who verified Resident #6 had dark bruises on both arms on 08/28/18 with no other signs of bleeding.
An interview was conducted on 10/18/18 at 8:24 P.M. with the DON who revealed the follow-up CT scan on Resident #6 was performed per hospital recommendations on 10/03/18 and found to be improved.
Review of the CT scan report of the abdomen and pelvis with intravenous contrast completed on 10/03/18 for Resident #6 revealed bleeding was resolved.
A review of physician orders, dated 10/17/18 and 10/18/18 revealed a PT/INR was drawn on 10/17/18 with result of 13.7 and 1.1, the doctor was notified and gave an order to begin Coumadin 2.5 mg once a day to start on 10/18/18. Per review of the MAR, the first dose was scheduled to begin on 10/18/18 at 5:00 P.M.
An interview was conducted on 10/18/18 at 10:01 A.M. with the DON and ADON. The DON identified LPN #14 as the LPN who failed to enter the order for the PT/INR check to be done on 08/20/18. The DON and ADON explained that discipline was carried out per the progressive discipline policy of the facility.
Review of the facility policy titled, Anticoagulation Clinical Protocol, dated 10/2010, revealed the physician would order appropriate laboratory testing to monitor anticoagulant therapy and potential complications and the staff should use a monitoring tool to follow trends in anticoagulant dosage and response.
Review of the Nursing Drug Handbook, 38th Edition revealed Coumadin was an anticoagulant and used as treatment of deep vein thrombosis, myocardial infarction, pulmonary embolism, rheumatic heart disease with heart valve damage, prosthetic heart valves and chronic atrial fibrillation. The handbook indicated the medication should be used with caution and the most serious risk of therapy was hemorrhage. The dosage was adjusted according to the INR results and elderly tended to require lower dosages to produce a therapeutic level of anticoagulation. Under black box warning it indicated to regularly inspect patient for bleeding gums, bruises on arms or legs, nosebleeds, melena (dark and sticky stools), tarry stool, hematuria and hematemesis.
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 observation, record review and interview the facility failed to ensure adequate assistance was provided to Resident #64...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to ensure adequate assistance was provided to Resident #64 and Resident #74 to prevent falls.
Actual harm occurred on 05/03/18 at 11:15 A.M. when Resident #64, assessed as requiring supervision with bathing, was left unattended by State Tested Nurse Aide (STNA) #626 in the shower room and fell to the floor while reaching for his clothing. The resident sustained an injury to his arm which subsequently became infected, requiring hospitalization and surgical intervention. The resident also reported difficulty with using his arm following the incident.
Actual harm occurred on 06/11/18 when Resident #74, assessed as requiring two staff for bed mobility and toileting, rolled out of bed sustaining a facial contusion and emergent hospital visit, while being provided care by only one STNA.
This affected two residents (Resident #64 and #74) of four residents reviewed for falls.
Findings include:
1. Record review revealed Resident #64 was admitted to the facility on [DATE] with diagnoses that included unsteadiness on feet, generalized osteoarthritis, chronic obstructive pulmonary disease and anxiety. A diagnoses of infective bursitis of the left elbow was added to the list of diagnoses after Resident #64 was hospitalized on [DATE].
A plan of care was initiated on 01/26/15 and revised on 02/21/18 and identified Resident #64 was at risk for falls. A fall risk assessment completed on 02/08/18 revealed Resident #64 was at risk for falls. The fall interventions included bed locked and in low position during transfers, fall risk assessment and safety checks per policy, and nonskid strips to the floor on the right side of the bed.
Review of the Minimum Data Assessment (MDS) 3.0 assessment, dated 02/09/18 revealed the resident was alert and oriented with no cognitive impairment and required the extensive assistance of one person for bed mobility, transfers, dressing, and toileting. Resident #64 required supervision and set up for both hygiene and bathing.
Review of the nursing progress note, dated 05/03/18 at 3:23 P.M. revealed the nurse found Resident #64 on his knees holding onto his wheelchair. Resident #64 had a skin tear on the left forearm and small cut on his right second toe. The nursing progress note indicated STNA #626 told the nurse the resident had been left alone in the shower room (prior to being found on his knees on the floor).
Review of an incident report revealed Resident #64 sustained a fall on 05/03/18. The incident report indicated Resident #64 was left alone in the shower room, fell onto his knees and hands while reaching for his clothing, was bleeding from his left arm and had cut his second toe on his right foot. As part of the investigation, STNA #626 provided a statement indicating she did leave Resident #64 alone in the shower. Following the incident, STNA #626 was in-serviced on not leaving residents alone in the shower room.
Review of the MDS 3.0 assessment, dated 05/07/18 revealed Resident #64 was cognitively intact, required one person assistance for bed mobility, transfers and dressing. For personal hygiene Resident #64 was assessed to require set up and supervision.
Review of the nursing progress notes from 05/09/18 through 06/05/18 revealed on 05/09/18 Resident #64 began complaining of pain and swelling in his left elbow region. The physician was notified and started him on the steroid medication, Prednisone 50 milligrams (mg) at bedtime. On 05/14/18 the pain and swelling increased, the physician was notified and came to see Resident #64. The physician expressed concern the arm was infected and planned for him to see an orthopedic physician the next morning. On 05/15/18 Resident #64 was started on the antibiotic Rocephin for a left elbow infection. On 05/16/18 nursing notes revealed that pain and redness was spreading in the left elbow region so his primary care physician at the facility wanted him evaluated at the hospital. Resident #64 was admitted to the hospital on [DATE] and had surgery during the stay for a diagnosis of septic olecranon bursitis of the left elbow and cellulitis. He returned to the facility on [DATE] and was placed in contact isolation for the Methicillin Resistant Staphylococcus Aureus (MRSA) in his elbow being treated with two antibiotics Ceftin and Bactrim DS. Resident #64 remained in contact isolation until 06/05/18.
An interview was conducted on 10/15/18 at 4:04 P.M. with Resident #64 who revealed STNA #626 was assisting him in the shower, finished washing his back and told him she had to step out. Resident #64 said he was left on the shower bench with no towel and his dry clothing were on his wheelchair at least two to three feet out of reach. After ten to fifteen minutes had gone by he stated he was cold and reached for his clothing. He stated he managed to get his shorts on and when he reached a second time for his shirt he fell to the floor landing on his left forearm, which was cut during the fall. Resident #64 said that he was left handed and never had problems using his left arm until the fall on 05/03/18. Resident #64 explained that he had to go to the hospital because the cut he sustained on his left forearm got infected and he had to have surgery due to an infection and pain. He said his arm has not worked the same since the accident.
An interview was conducted on 10/17/18 at 5:50 P.M. with the director of nursing who verified Resident #64 fell in the shower room and sustained an injury to his left arm as a result of STNA #626 leaving him unattended.
The facility policy titled Shower/tub bath policy, dated 10/2010, revealed employees were to stay with residents throughout the bath and never leave the resident unattended in the bath or shower.
2. Record review revealed Resident #74 was admitted to the facility on [DATE] with diagnoses including atrial fibrillation, dementia, and unspecified hemiplegia (paralysis on one side of the body).
Review of Resident #74's MDS 3.0 assessment, dated 03/18/18 revealed the resident required extensive assistance from two staff for bed mobility and toileting.
Record review revealed Resident #74 sustained a fall on 06/11/18 when STNA #705 was providing bowel incontinence care. The post-fall investigation revealed one witness statement had been made concerning the event (done by STNA #705), which revealed STNA #705 rolled the resident in bed onto their side. Resident #74 rolled over the side of the bed when STNA #705 turned away to get a washcloth from the table. The investigation contained no other witness statements. Resident #74 received a contusion (bruise) to the face and was sent to the emergency room.
On 10/17/18 at 6:51 P.M. interview with the Director of Nursing (DON) revealed she was involved in the post-fall investigation for Resident #74. The DON verified only one STNA was present in the resident's room and providing care at the time of the fall. The DON verified the resident was assessed to require two staff for bed mobility.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
Based on observation, record review and interview the facility failed to ensure care provided to residents was provided in a dignified manner related to agency staff listening to music on their phones...
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Based on observation, record review and interview the facility failed to ensure care provided to residents was provided in a dignified manner related to agency staff listening to music on their phones while responsible for resident care and failed to ensure Resident #42's urinary catheter drainage bag was properly covered to promote dignity for the resident. This affected two residents (Resident #42 and Resident #66) of 116 residents residing in the facility.
Findings include:
1. Interview with Resident #66 during a resident group meeting on 10/16/18 at 12:58 P.M. revealed concerns with agency staff entering her room to provide care while listening to music on their phones. The resident stated this concern had been shared with facility staff during previous resident council group meetings held at the facility.
Interview with Licensed Practical Nurse (LPN) #701 on 10/17/18 at 10:56 A.M. revealed she had occasionally seen agency staff listening to personal music while providing care to residents. LPN #701 indicated the last time she saw it occur was earlier that morning. She stated she had previously received reports from residents that agency staff treated them disrespectfully.
Interview with Activity Director #702 on 10/18/18 at 9:53 A.M. revealed Registered Nurse (RN) #703 (an assistant director of nursing) attended resident council meetings and handled concerns raised by the resident council about agency staff. She verified residents at the resident council meetings had expressed concerns about agency staff playing music on headphones while providing care.
Interview with Registered Nurse (RN) #703 at 10:10 A.M. on 10/18/18 revealed that in either the September or October 2018 resident council meeting (she was not sure which), residents had raised concerns that staff were listening to music on their cell phones while working.
Interview with LPN #704 on 10/18/18 at 1:48 P.M. revealed she had previously seen agency staff listening to personal music while giving report at the nursing station. She was unsure when the event occurred.
Review of resident council minutes for the last 12 months revealed no documented concerns related to agency staff listening to music, however in the section for nursing concerns the 09/05/18 meeting minutes identified the assistant director of nursing was present to handle all concerns, and the 10/03/18 minutes said nursing concerns were written on a sheet to be given to the nursing supervisor.
Review of supplemental documentation for the September and October 2018 resident council meetings furnished by the facility revealed they identified nursing concerns were raised in the meetings and what was done by the facility in response. Neither month's documentation identified any raised concerns or interventions regarding cell phone or personal music use by staff. The 09/05/18 supplemental documentation did note social media presence with no context of whether it was a resident concern or whether any corrective action was taken.
The above findings were reviewed with RN #703 on 10/19/18 at 12:25 P.M. RN #703 revealed the reference to social media presence on the supplemental documentation was not related to the concern regarding personal music.
Review of the facility undated cell phone policy revealed cell phone use was prohibited in resident care areas. Professional conduct was expected from all employees at all times.
2. Record review for Resident #42 revealed an admission date of 07/05/18 with diagnoses that included congestive heart failure, respiratory failure with hypoxia, neuromuscular dysfunction of the bladder, and diabetes. Resident #42 had a physician order with a revision date of 10/09/18 for an indwelling urinary (Foley) (a thin sterile tube inserted into the bladder to drain urine) catheter number 18 French (a measurement system used to measure the size of a catheter) to continuous drainage.
Review of Resident #42's care plan with a revision date of 07/18/18 revealed Resident #42 had a Foley catheter related to neurogenic bladder. The care plan revealed an intervention for staff to store the urine drainage bag inside a protective dignity pouch.
Review of quarterly Minimum Data Set (MDS) 3.0 assessment, dated 08/03/18 revealed Resident #42 required extensive assist with bed mobility and transfers and walking did not occur. The MDS revealed Resident #42 had an indwelling catheter in place.
Observation on 10/15/18 at 9:45 A.M. revealed Resident #42 was in bed with her catheter drainage bag hanging on the side of the bed without a protective dignity pouch. From the hallway, the urine drainage bag was observed to be three fourths full of urine.
Observation on 10/15/18 at 5:23 P.M. revealed Resident #42 was in bed with her urine drainage bag hanging on the side of the bed without protective dignity pouch and it was visible from the hallway.
Observation on 10/16/18 at 6:14 P.M. revealed Resident #42 was in bed with her urine drainage bag hanging on the side the bed facing the doorway without a protective dignity pouch and the urinary drainage tubing was lying on the floor.
Interview and observation on 10/16/18 at 6:22 P.M. with Licensed Practical Nurse #600 verified the indwelling catheter drainage bag and tubing were on the floor without a protective dignity pouch.
Interview on 10/18/18 at 9:52 A.M. with Resident #42 revealed that she used to work as a nursing assistant as her profession. She said her catheter was a personal thing and it bothered her and she thought it should be covered. She said sometimes the staff forgot to put the drainage bag inside a cover to provide privacy.
Review of facility policy dated 05/2017 labeled, Placement of the Foley Drainage Bag, revealed when a resident was in bed, the drainage bag on the bed frame should be below the level of the bladder to provide straight gravity drainage, yet not on the floor. Staff were to place the catheter bag in a cover provided by the laundry department or central supply.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Notice
(Tag F0623)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure the Ombudsman's office was notified when Resident #6 and Resi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure the Ombudsman's office was notified when Resident #6 and Resident #19 were discharged to the hospital. This affected two residents (Resident #6 and #19) of two residents reviewed for transfer/hospitalization.
Findings included:
1. Review of Resident #6's medical record revealed the resident was admitted to the facility on [DATE] and transferred to the hospital for an acute illness on 08/28/18. Resident #6 was readmitted to the facility on [DATE]. Resident #6's medical record contained no evidence the Ombudsman's office was notified of the transfer to the hospital.
An interview was conducted on 10/19/18 at 1:51 P.M. with Ombudsman #800 who revealed that neither she nor the Ombudsman's office received any notification that Resident #6 had been transferred to the hospital on [DATE].
An interview was conducted on 10/19/18 with the Administrator and Corporate Consultant #40 who verified that there was currently no system in place to notify the Ombudsman's office of any resident transfers to the hospital. Corporate Consultant #40 said he and the facility were working on a process to make a monthly compilation of all facility initiated discharges to send to the Ombudsman's office to be in compliance with the regulation.
The facility's undated policy titled, Notice of Transfer to Hospital, revealed a copy of the facility initiated discharge would be sent to the Ombudsman's office monthly.
2. Review of Resident #19's medical record revealed the resident was admitted to the facility on [DATE] and transferred to the hospital for an acute illness on 08/17/18. Resident #19 was readmitted to the facility on [DATE]. Resident #19's medical record contained no evidence that the Ombudsman's office was notified of the transfer to the hospital.
An interview was conducted on 10/19/18 with the Administrator and Corporate Consultant #40 who verified that there was currently no system in place to notify the Ombudsman's office of any resident transfers to the hospital. Corporate Consultant #40 said he and the facility were working on a process to make a monthly compilation of all facility initiated discharges to send to the Ombudsman's office to be in compliance with the regulation.
The facility undated policy titled, Notice of Transfer to Hospital, revealed a copy of the facility initiated discharge would be sent to the Ombudsman's office monthly.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure Resident #10's Minimum Data Set (MDS) 3.0 assessment was accu...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure Resident #10's Minimum Data Set (MDS) 3.0 assessment was accurate related to weight loss. This affected one resident (Resident #10) of six residents reviewed for nutrition.
Findings include:
Medical record review revealed Resident #10 was admitted to the facility on [DATE] with diagnoses that included unspecified dementia without behavioral disturbance, tremor, anxiety disorder, bipolar disorder, vitamin D deficiency, hypothroidism, major depression, unspecified fracture of left acetabulum and left ischium (hip) and left hip osteoarthritis.
A significant change Minimum Data Set (MDS) 3.0 assessment, dated 05/13/18 was completed for Resident #10 after she suffered a left hip fracture following a fall on 04/28/18. An MDS 3.0 assessment, dated 10/02/18 indicated Resident #10 had severely impaired cognition and was dependent on staff for activities of daily living including meal tray set up and supervision for eating. Section K indicated that Resident #10 was 63 inches tall, 138 pounds and had not had any significant weight loss or gain in the last one or six months.
A review of the monthly vitals section which included height and weight indicated that on 04/01/18 Resident #10's weight was 159 pounds and her height was 63 inches. On 07/04/18, Resident #10's weight was 142 pounds, on 09/02/18 Resident #10's weight was 138 pounds and on 10/02/18 Resident #10's weight was 135 pounds.
From 04/01/18 to 10/02/18 Resident #10 lost 24 pounds, a 15% weight loss, in six months. According to the MDS any weight loss of 10% or more in six months should be coded for a significant weight loss on the MDS. Section K of the 10/02/18 MDS indicated a weight of 138 pounds and no significant weight loss in one or six months. The signature section indicated that Dietary Manager #628 completed section K of that MDS on 10/04/18. The MDS section K was completed incorrectly and did not capture the six month significant weight loss.
An interview was conducted on 10/17/18 at 1:12 P.M. with Dietary Manager (DM) #628 who verified she used the 09/02/18 weight of 138 pounds for the MDS assessment date of 10/02/18 which was not an accurate representation of the 10/02/18 weight of 135 pounds, and it did not capture the 15% weight loss in six months for Resident #10. DM #628 explained that she was responsible for completing the MDS section K for Resident #10. DM #628 also said that she was responsible for completing all of the nutritional assessments except for the goals and interventions sections which are completed by Dietitian #625. DM #628 verified that she provided wrong weight information on the 10/02/18 nutrition assessment by listing a weight for 10/02/18 as 138 pounds instead of 135 pounds.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0679
(Tag F0679)
Could have caused harm · This affected 1 resident
Based on observation, record review and interview the facility failed to develop and implement a comprehensive and individualized activity program designed to meet the total care needs of Resident #79...
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Based on observation, record review and interview the facility failed to develop and implement a comprehensive and individualized activity program designed to meet the total care needs of Resident #79. This affected one resident (Resident #79) of one resident reviewed for activities.
Findings include:
Review of Resident #79's medical record revealed an admission date of 08/03/18 with diagnoses including fracture of left fibula, a pressure ulcer and major depressive disorder.
Review of the activities initial review dated 08/03/2018 revealed the resident wanted to participate in activities and was not interested in independent activities such as reading or puzzles.
Review of the 60-day Minimum Data Set (MDS) 3.0 assessment, dated 10/15/18 revealed the resident was cognitively intact. Resident #79 required extensive assistance from staff for bed mobility and dressing. The resident was totally dependent on staff for transfers and locomotion.
Record review revealed no plan of care had been developed for Resident #79 related to her activity needs or preferences. In addition, record review revealed no activity progress notes had been completed for the resident.
Review of the Activities Task Sheets for 10/2018 revealed Resident #79 was coded to have participated in the following activities from 10/01/18 to 10/18/18: one pet visit, television twice and range of motion exercise once. There were no other activity records or task sheets available to review.
Written statements, provided and done on 10/18/18 by Activities Staff #643 and Activities Staff #644 revealed one to one visits were provided to the resident on 09/03/18, 09/11/16, 09/19/18 and 10/08/18 and a visit with the bunnies (as noted on the activities task sheet) was provided on 10/05/18.
On 10/16/18 at 8:51 A.M., interview with Resident #79 revealed she would love to have a puzzle to work on in the room. No puzzles or other activities were observed in the room at that time.
On 10/19/18 at 2:10 P.M. a telephone interview with Activities Director #623 revealed she had spoken with Resident #79 on the evening of 10/18/18. The Director indicated the resident told her she enjoyed getting lotion/hand therapy, loved visiting with the bunnies and liked classical music. The resident reported she wanted to come to more activities but didn't always feel up to it because she was frequently in pain.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure pharmacy medication recommendations were completed timely for...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to ensure pharmacy medication recommendations were completed timely for Resident #57. This affected one resident (Resident #57) of ten residents reviewed for unnecessary medication use.
Findings include:
Record review revealed Resident #57 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD), generalized anxiety disorder and major depressive disorder.
Review of Resident #57's pharmacy medication record review dated 03/26/18 revealed the Center of Medicare and Medicaid Services (CMS) guidelines now limited the duration of all as needed psychoactive medication orders to no more than 14 days. The pharmacist recommended to review Resident #57's Ambien, five milligrams (mg) by mouth as needed for insomnia. Resident #57's primary care physician, Physician #801, reviewed and signed the pharmacist medication record review on 06/20/18, almost three months after the recommendation. Physician #801 recommended Ambien 5 mg by mouth as needed for insomnia to continue for six months.
Review of Resident #57's pharmacy medication record review dated 04/24/18 revealed Resident #57 received Incruse Ellipta, one puff every day for COPD as well as Ipratropium inhaler two puffs every four hours as needed for shortness of breath. The pharmacist recommendation was to consider changing the Ipratropium to a short acting beta agonist such as Albuterol or Levoalbuterol. Physician #801 reviewed and signed the pharmacy medication record review on 06/28/18, two months after the recommendation was made.
Interview with the Director of Nursing (DON) on 10/18/18 at 4:20 P.M. verified Resident #57's pharmacy medication record review for 03/26/18 was reviewed and signed by Physician #801 on 06/20/18. The Director of Nursing also verified Resident #57's pharmacy medication record review for 04/24/18 was signed and reviewed on 06/28/18 by Physician #801. The DON verified Resident#57's primary care physician comes to the facility at least monthly but often during the evening. The DON said it was difficult for the facility to review the pharmacy recommendations with the primary care physician timely.
Review of facility policy dated 2016 titled, Consulting Pharmacist Monthly Drug Review, revealed the resident's attending physician must document in the medical record the identified irregularity had been reviewed, and what, if any action had been taken to address the medication drug review recommendation. If there was to be no change in the medication, the attending physician must document his or her rationale in the resident's medical record at the physician's next visit.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
Based on record review and interview the facility failed to ensure psychotropic medications ordered as needed (PRN) were limited to fourteen days or provided with a rationale in the resident's medical...
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Based on record review and interview the facility failed to ensure psychotropic medications ordered as needed (PRN) were limited to fourteen days or provided with a rationale in the resident's medical record indicating the reason and duration for the as needed psychotropic medication if ordered longer than fourteen days. This affected two residents (Resident #16 and Resident #57) of ten residents reviewed for unnecessary medication use.
Findings include:
1. Review of Resident #16's medical record revealed an admission date of 02/16/11 with diagnoses that included anxiety disorder and major depressive disorder. Resident #16 had a physician order with a start date of 01/27/18 for Diazepam tablet, 5 milligram (mg), one tablet by mouth every 12 hours as needed for anxiety. No duration was given.
Record review of Resident #16's medication record review per the pharmacist dated 07/21/18 revealed the Center for Medicare and Medicaid Services (CMS) guidelines now limited the duration of all as needed psychotropic medication orders to no longer than 14 days. The pharmacist recommended to review the following orders and consider discontinuing therapy for Diazepam, 5 mg by mouth every 12 hours as needed for insomnia and anxiety and Zolpidem, 5 mg, every night as needed for insomnia. The pharmacy medication record review revealed Resident #16's primary care physician, Physcian #800, reviewed the recommendation on 07/30/18 and recommended to discontinue the Zolpidem but to continue Diazepam. No duration for use was given.
Review of the August 2018 medication administration record (MAR) revealed Resident #16 received Diazepam tablet, 5 mg as needed on 08/01/18, 08/06/18, 08/08/18, 08/09/18, 08/10/18, 08/11/18, 08/15/18, 08/16/18, 08/17/18, 08/20/18, 08/21/18, 08/23/18, 08/24/18, 08/25/18, 08/26/18, 08/27/18, 08/28/18, 08/29/18, and 08/31/18.
Record review of the September 2018 MAR revealed Resident #16 received Diazepam tablet, 5 mg, as needed on 09/03/18, 09/04/18, 09/05/18, 09/06/18, 09/07/18, 09/09/18, 09/10/18, 09/11/18, 09/12/18, 09/13/18, 09/18/18, 09/20/18, 09/21/18, 09/22/18, 09/23/18, 09/25/18, 09/26/18, 09/27/18, and 09/29/18.
Record review of October 2018 MAR revealed Resident #16 received Diazepam, 5 mg, as needed on 10/01/18, 10/02/18, 10/05/18, 10/06/18, 10/12/18, and 10/15/18.
Interview on 10/16/18 at 5:06 P.M. with the Director of Nursing verified Resident #16's Diazepam order did not have a duration indicated by the physician.
Review of facility policy dated 2001, titled Anti-psychotic Medication Use revealed the policy did not include information for nursing staff to ensure as needed orders for psychotropic medications were limited to fourteen days or provide rationale in the resident's medical record indicating the reason and duration for the as needed medication.
2. Review of Resident #57's medical record revealed an admission date of 06/09/16 with diagnoses that included generalized anxiety disorder and major depressive disorder. Resident #57 had a physician order, with a start date of 07/24/18 for Haloperidol tablet, give 3 milligram (mg) by mouth every two hours as needed for anxiety while on dialysis and a physician order with a start date of 06/09/18 for Ambien tablet 5 mg give one tablet by mouth every hour of sleep as needed for sleeplessness.
Record review of Resident #57's pharmacy medication record review dated 03/26/18 revealed the Center of Medicare and Medicaid Services (CMS) guidelines now limited the duration of all as needed psychoactive medication orders to no longer that 14 days. The pharmacist recommended to review Resident #57's Ambien 5 mg by mouth as needed for insomnia. Primary Care Physician #801 reviewed the pharmacist medication record review on 06/20/18 and recommended Ambien 5 mg by mouth as needed for insomnia to continue for six months.
Record review of the medication administration record for September 2018 reviewed Resident #57 received Ambien 5 mg give one tablet by mouth as needed for sleeplessness on 09/01/18, 09/03/18, 09/05/18, 09/07/18, 09/10/18, 09/11/18, 09/12/18, 09/18/18, and 09/28/18. Resident #57 did not receive Haloperidol 3 mg by mouth every two hours as needed while on dialysis.
Record review of Resident #57's pharmacy medication record review dated 09/22/18 revealed CMS guidelines now limited the duration of all as needed anti-psychotic medication orders to no longer than 14 days unless the prescriber had evaluated the resident for appropriateness of the medication. The pharmacist recommended to review Resident #57's physician order for Haldol 3 mg by mouth every two hours as needed for anxiety while on dialysis. Primary Care Physician #801 reviewed the pharmacy recommendation on 10/18/18 and discontinued the Haldol.
Record review of the medication administration record for October 2018 reviewed Resident #57 received Ambien tablet 5 five mg by mouth as needed for sleeplessness on 10/3/18, 10/15/18, and 10/17/18. Resident #57 did not receive Haloperidol 3 mg by mouth every two hours as needed for anxiety while on dialysis.
Interview with the Director of Nursing on 10/18/18 at 12:54 P.M. verified Resident #57 had a physician order with a start date of 07/24/18 for Haloperidol 3 mg by mouth every two hours as needed for anxiety while on dialysis without a stop date. The Director of Nursing revealed she would have the physician review the pharmacy medication record review today for the use of Resident #57's Haloperidol. The Director of Nursing also verified Resident #56's Primary Care Physician #801 did not review the pharmacy medication regimen review dated 03/26/18 for Resident #57 until 06/20/18.
Review of facility policy dated 2001, titled Anti-psychotic Medication Use revealed the policy did not include information for nursing staff to ensure as needed orders for psychotropic medications were limited to fourteen days or provide rationale in the resident's medical record indicating the reason and duration for the as needed medication.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected 1 resident
Based on observation, record review and interview the facility failed to maintain a medication error rate of less than five percent. The medication error rate was calculated to be 8 percent and includ...
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Based on observation, record review and interview the facility failed to maintain a medication error rate of less than five percent. The medication error rate was calculated to be 8 percent and included two medication errors of 25 medication administration opportunities. This affected one resident (Resident #70) of five residents observed during medication administration.
Findings include:
Observation of a medication pass for Resident #70 on 10/16/18 from 8:40 A.M. to 9:13 A.M. by Licensed Practical Nurse (LPN) #612 revealed Resident #70 to be on a continuous enteral feed (tube feed) infusion. The nurse prepared a 50 milligram (mg) tablet of Riluzole, a medication to treat amyotrophic lateral sclerosis, for administration. Review of the Riluzole package revealed instructions from the pharmacy to give on an empty stomach, either an hour before or two to three hours after eating.
Interview with LPN #612 at the time of the above observation revealed Resident #70's enteral feeding had not been stopped for an hour or more before the administration of the medications. She confirmed the staff had no current process for ensuring Riluzole was given to Resident #70 on an empty stomach, and that the pharmacy instructions for Riluzole called for it to be given on an empty stomach. LPN #612 also revealed Resident #70 had an order for liquid Docusate, a stool softener, to be administered at this time, which was not available. Following the interview, the LPN administered the prepared medications, including the Riluzole.
Interview with LPN #612 on 10/16/18 at 10:28 A.M. revealed Resident #70 had still not received their ordered Docusate medication.
Record review for Resident #70 revealed an order dated 09/05/18 for 10 milliliters (ml) of Docusate in a concentration of 50 mg per 5 ml to be administered twice daily at 9:00 A.M. and 9:00 P.M.
The above findings were reviewed during an interview with the Director of Nursing on 10/16/18 at 10:50 A.M.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to maintain Resident #42's indwelling urinary (Foley) cath...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility failed to maintain Resident #42's indwelling urinary (Foley) catheter tubing and drainage bag in a manner to prevent the spread of infection. This affected one resident (Resident #42) of 15 residents identified to have indwelling (Foley) catheters.
Findings include:
Record review revealed Resident #42 was admitted to the facility on [DATE] with diagnoses including congestive heart failure, respiratory failure with hypoxia, neuromuscular dysfunction of the bladder, and diabetes.
Review of Resident #42's care plan with a revision date of 07/18/18 revealed Resident #42 had a Foley catheter related to neurogenic bladder. The care plan revealed an intervention to use universal precautions (safe handling of potentially contaminated equipment or surfaces in the residents environment) and appropriate handling of Foley catheter and tubing.
Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #42 required extensive assist from staff for bed mobility and transfers and walking did not occur. The MDS 3.0 assessment revealed Resident #42 had a indwelling catheter.
Record review revealed Resident #42 had a physician order, with a revision date of 10/09/18 for a Foley (a thin sterile tube inserted into the bladder to drain urine) catheter number 18 French (measurement system to measure size of a catheter) to continuous drainage.
Observation on 10/15/18 at 03:49 P.M. of Resident #42 revealed she was up in a wheelchair in front of the nursing station and her indwelling catheter tubing was touching the floor underneath her wheelchair.
Observation on 10/16/18 at 06:14 P.M. of Resident #42 revealed she was in bed with her indwelling catheter drainage bag hanging on the side of the bed facing the doorway. The drainage bag and part of the catheter tubing were observed directly on the floor.
Interview on 10/16/18 at 06:22 P.M. with Licensed Practical Nurse #600 verified the indwelling catheter drainage bag and tubing were on the floor at that time.
Review of facility policy, dated 05/2017 titled Placement of the Foley Drainage Bag revealed when a resident was in bed the drainage bag on the bed frame should be below the level of the bladder to provide straight gravity drainage, yet not on the floor. Staff were to place the catheter bag then in a cover provided by the laundry department or central supply.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Medical record review revealed Resident #10 was admitted to the facility on [DATE] with diagnoses that included unspecified d...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Medical record review revealed Resident #10 was admitted to the facility on [DATE] with diagnoses that included unspecified dementia without behavioral disturbance, tremor, anxiety disorder, bipolar disorder, vitamin D deficiency, hypothyroidism, major depression, unspecified fracture of left acetabulum and left ischium (hip fracture) and left hip osteoarthritis.
A nutritional care plan was initiated on 02/07/18 indicating that Resident #10 was at risk for impaired nutrition, weight loss and impaired hydration. Interventions included nutritional supplements would be provided per physician orders.
A significant change Minimum Data Set (MDS) 3.0 assessment, dated 05/13/18 was completed for Resident #10 after she suffered a left hip fracture following a fall on 04/28/18. Resident #10 was on a regular diet and as of 05/24/18 and was to receive Med Pass 2.0, a nutritional supplement, twice a day, amount unspecified in the orders.
The MDS 3.0 assessment, dated 10/02/18 indicated Resident #10 was severely impaired cognitively and was dependent on staff for activities of daily living including meal tray set up and supervision for eating. Section K of this MDS indicated that Resident #10 was 63 inches tall, weighed 138 pounds and did not reflect a significant weight loss or gain in the last one or six months.
Observation conducted on 10/16/18 at 5:11 P.M., 5:17 P.M. and 5:25 P.M. revealed Resident #10 sitting upright in her bed with her dinner tray in front of her. She was able to feed herself with some difficulty due to her hand tremors. There were no staff providing supervision during the meal. She had eaten her meat but left 75% of her meal uneaten.
Review of the monthly vitals section which included height and weight indicated on 04/01/18 Resident #10's weight was 159 pounds. On 07/04/18, Resident #10's weight was 142 pounds. On 09/02/18, Resident #10's weight was 138 pounds and on 10/02/18 Resident #10's weight was 135 pounds.
From 04/01/18 to 10/02/18 Resident #10 lost 24 pounds which was a 15% weight loss in six months. According to the MDS, any weight loss of 10% or more in six months should be coded for a significant weight loss on the MDS. The 10/02/18 MDS indicated a weight of 138 pounds but was not coded as a significant weight loss in one or six months. The signature section indicated Dietary Manager (DM) #628 completed this section of the MDS on 10/04/18.
An interview was conducted on 10/17/18 at 1:12 P.M. with DM #628 who verified she used the 09/02/18 weight of 138 pounds for the MDS assessment completed on 10/02/18. DM #628 said it should have been 135 pounds, and verified it did not capture the 15% weight loss in six months for Resident #10. She explained she was responsible for completing all of the nutritional assessments except for the goals and interventions sections which are completed by Dietitian #625.
The nutritional assessments for Resident #10 completed on 02/05/18, 05/13/18, 07/03/18 and 10/02/18 contained no information related to Resident #10's calorie, protein or fluid needs. The nutritional assessment completed on 10/02/18 indicated a weight of 138 pounds and the goals and interventions section completed by Dietitian #625 also indicated there had been no significant weight loss and no new nutritional recommendations were made.
An interview was conducted on 10/17/18 at 12:08 P.M. with Dietitian #625. She verified she completed the last two parts of the nutritional assessments, the goals and interventions sections. Dietitian #625 verified these nutritional assessments did not contain an assessment of calorie, protein or fluid needs and did not indicate Resident #10 was high nutritional risk. Dietitian #625 verified Resident #10's calorie, protein and fluid needs would increase after her hip fracture. Dietitian #625 explained that on 05/24/18 she recommended Resident #10 have the Med Pass 2.0 supplement twice a day due to a decline in her meal intakes. She said she assumed the specific amount of 120 milliliters twice a day would be put onto the medication administration record (MAR). Dietitian #625 stated that if the amount was not specified she would not know if a resident's needs were being met.
An interview was conducted on 10/17/18 at 10:51 A.M. with Licensed Practical Nurse (LPN) #617. She explained that whenever a resident was ordered Med Pass 2.0 a specific amount to be given was specified in the physician order and it would be entered onto the MAR. LPN #617 verified Resident #10's MAR did not specify how much Med Pass 2.0 she was to receive. LPN #10 said nursing staff should have clarified the order to specify the amount. She said she gave Resident #10 whatever amount she would consume, which was usually four ounces but not always. She said sometimes she drank less or more. LPN #617 said there was no way to tell exactly how much Resident #10 consumed of the Med Pass supplement.
Review of the MARs from May 2018 through October 2018 revealed there was no documentation of the amount of Med Pass supplement consumed by Resident #10.
Review of the policy titled, Medical Nutritional Supplements, revised 11/05/09 indicated the facility would provide a designated amount of supplement during the routine medications passes.
Review of the policy titled Nutritional Assessment, revised December 2011 indicated the dietitian would document an estimate of calorie, protein, nutrient and fluid needs of each resident on the nutritional assessment and whether the resident's current intake was adequate to meet his or her nutritional needs. The policy also indicated the multidisciplinary team shall identify upon a change in condition the resident at increased risk for impaired nutrition and an increased need for calories and/or protein.
3. In addition, the nutrition risk assessments for four additional residents, Resident #269, Resident #46, Resident #57, and Resident #79 reviewed for weight loss revealed none had an estimate of their calorie, protein, nutrient and fluid needs.
On 10/18/18 at 2:32 P.M., Dietitian #625 confirmed the resident nutritional needs had not been calculated and placed on record for the above residents until her progress note dated 10/17/18 which was following a discussion of the need for such information to be available.
Review of the policy, Nutritional Assessment revised 12/2011, revealed the dietitian would document an estimate of calorie, protein, nutrient and fluid needs of each resident and whether the resident's current intake was adequate to meet his or her nutritional needs. The policy also indicated the multidisciplinary team shall identify upon a change in condition the resident at increased risk for impaired nutrition and an increased need for calories and/or protein.
Based on observation, record review and interview the facility failed to ensure comprehensive nutritional assessments were completed and/or timely and adequate nutritional interventions were implemented to prevent weight loss. This affected six residents (Resident #269, #46, #57, #10, #79 and #70) of six residents reviewed for weight loss.
Findings include:
1. Review of Resident #70's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including amyotrophic lateral sclerosis (ALS), cognitive communication deficit, dysphasia, acute and chronic respiratory failure with hypoxia, anxiety disorder and major depressive disorder. The resident was ventilator dependent and received nutrition/hydration via a gastrostomy tube.
Review of the admission nursing assessment identified Resident #70 was admitted with a weight of 166 pounds. The resident's height was six feet.
Review of the 14-day Minimum Data Set (MDS) 3.0 assessment, dated 09/24/18 revealed the resident had intact cognition. Rejection of care had not been exhibited. The resident was dependent for eating. The assessment indicated the resident had a weight of 145 pounds and had no or unknown weight loss on a feeding tube.
Review of the 30-day Minimum Data Set (MDS) 3.0 assessment which was in progress and dated 10/08/18 revealed the resident had intact cognition. Rejection of care had not been exhibited. The resident was dependent for eating. The assessment indicated the resident had a weight of 138 pounds and had no or unknown weight loss on a feeding tube.
Review of the nutrition risk assessments dated 09/19/18, 08/16/18 and 06/06/18 revealed the resident was at low risk for nutritional deficits. The amount of calories, protein and fluids the tube feeding was supplying was documented. However, none of the completed assessments reflected what Resident #70's calorie, protein, fluid or other nutritional needs were calculated to be to ensure his needs were being met via the enteral tube feedings.
Review of the plan of care revealed the resident was at risk for weight loss due to the multiple diagnoses and the resident's refusal of the tube feeding at times. Interventions included obtain weight per doctor's order, notify the doctor and the dietitian of significant changes, monitor intake, tolerance, residuals and record. Dietitian to evaluate and make tube feeding, flush and supplement change recommendations.
Review of nutrition notes from 06/11/18, 06/22/18 and 6/23/2018 revealed Resident #70 was complaining of feeling full and uncomfortable and frequently asked to have the tube feeding shut off. An intermittent tube feed schedule was attempted. However, the resident was not agreeable to that tube feed schedule. The resident wanted the tube feeding held during the night. A more concentrated tube feeding formula was tried. Reducing the tube feeding rate was tried. A third tube feeding formula was then started and continued. Weight loss was noted for the resident in each of the notes.
Review of the Weekly Weight Meeting Notes from 06/15/18 through 10/02/18 revealed Resident #70 was discussed weekly. However, there was no evidence of any new nutritional interventions after 08/17/18 despite Resident #70's weight loss that was identified.
Observation on 10/15/18 at 1:19 P.M. revealed the Resident #70 was receiving tube feeding at the ordered rate. The head of the bed was at elevated. The resident appeared cachectic.
Interview by phone on 10/17/18 at 10:31 A.M. with registered dietitian, licensed dietitian (RD, LD) #625 revealed Resident #70 had not tolerated several different tube feedings at different rates and schedules. The RD LD indicated the tube feeding was the most well tolerated but the resident occasionally had nursing turn it off. When the resident was in hospital his weight went up, which was possibly because the tube feeding wasn't being turned off. There was no evidence the facility determined why the resident was continuing to lose weight or why he was not tolerating the tube feedings that were being ordered.
On 10/18/18 at 2:32 P.M. RD, LD #625 confirmed the resident's nutritional needs had not been calculated to ensure the enteral feeding ordered was meeting his needs prior to 10/17/18.
Review of weights revealed on 06/06/18 Resident #70 weighed 166.0 pounds. On 10/17/2018 Resident #70 weighed 136.8 pounds which reflected a total weight loss of 29.2 pounds or 18% from 06/06/18 to 10/17/18 (a four month period of time) for a resident who received all of his nutrition/hydration via gastrostomy tube.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "What changes have you made since the serious inspection findings?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • No fines on record. Clean compliance history, better than most Ohio facilities.
- • 34% turnover. Below Ohio's 48% average. Good staff retention means consistent care.
Concerns
- • Multiple safety concerns identified: 1 life-threatening violation(s), 3 harm violation(s). Review inspection reports carefully.
- • 20 deficiencies on record, including 1 critical (life-threatening) violation. These warrant careful review before choosing this facility.
- • Grade D (48/100). Below average facility with significant concerns.
Bottom line: Trust Score of 48/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Ashtabula County's CMS Rating?
CMS assigns ASHTABULA COUNTY NURSING HOME an overall rating of 4 out of 5 stars, which is considered 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 Ashtabula County Staffed?
CMS rates ASHTABULA COUNTY NURSING HOME's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 34%, compared to the Ohio average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Ashtabula County?
State health inspectors documented 20 deficiencies at ASHTABULA COUNTY NURSING HOME during 2018 to 2024. These included: 1 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 3 that caused actual resident harm, and 16 with potential for harm. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates Ashtabula County?
ASHTABULA COUNTY NURSING HOME is owned by a non-profit organization. Non-profit facilities reinvest revenue into operations rather than distributing to shareholders. The facility operates independently rather than as part of a larger chain. With 133 certified beds and approximately 109 residents (about 82% occupancy), it is a mid-sized facility located in KINGSVILLE, Ohio.
How Does Ashtabula County Compare to Other Ohio Nursing Homes?
Compared to the 100 nursing homes in Ohio, ASHTABULA COUNTY NURSING HOME's overall rating (4 stars) is above the state average of 3.2, staff turnover (34%) is significantly lower than the state average of 46%, and health inspection rating (4 stars) is above the national benchmark.
What Should Families Ask When Visiting Ashtabula County?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the facility's Immediate Jeopardy citations.
Is Ashtabula County Safe?
Based on CMS inspection data, ASHTABULA COUNTY NURSING HOME has documented safety concerns. Inspectors have issued 1 Immediate Jeopardy citation (the most serious violation level indicating risk of serious injury or death). The facility has a 4-star overall rating and ranks #1 of 100 nursing homes in Ohio. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at Ashtabula County Stick Around?
ASHTABULA COUNTY NURSING HOME has a staff turnover rate of 34%, 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 Ashtabula County Ever Fined?
ASHTABULA COUNTY NURSING HOME 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 Ashtabula County on Any Federal Watch List?
ASHTABULA COUNTY NURSING HOME 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.