EMBASSY OF MARION
For profit - Corporation
99 Beds
GARDEN SPRINGS HEALTHCARE
Data: November 2025
1 Immediate Jeopardy citation
Trust Grade
33/100
#671 of 913 in OH
Photo by Marion Rehabilitation
Photo by Marion Rehabilitation
Photo by Marion Rehabilitation
1 / 5 photos
Last Inspection: August 2023
Over 2 years since last inspection. Current conditions may differ from available data.
Overview
Embassy of Marion has received a Trust Grade of F, indicating significant concerns about the quality of care provided. It ranks #671 out of 913 nursing homes in Ohio, placing it in the bottom half, and #4 out of 5 in Marion County, meaning only one facility nearby is rated lower. The facility is showing signs of improvement, having reduced serious issues from 4 in 2024 to 2 in 2025, but still has a high total of 28 issues, including one critical incident related to COVID-19 isolation protocols. Staffing is relatively stable, with a turnover rate of 38%, which is better than the state average, but the facility has concerning fines totaling $40,053, higher than 81% of other Ohio nursing homes. Additionally, residents faced issues such as a non-functional doorbell that could hinder emergency access and expired medical supplies in emergency carts, posing potential risks to resident safety. Overall, while there are some strengths, such as stable staffing, the facility's significant deficiencies and fines raise serious concerns for families considering care for their loved ones.
- Trust Score
- F
- In Ohio
- #671/913
- Safety Record
- High Risk
- Inspections
- Getting Better
- Staff Stability ○ Average
- 38% turnover. Near Ohio's 48% average. Typical for the industry.
- Penalties ✓ Good
- $40,053 in fines. Lower than most Ohio facilities. Relatively clean record.
- Skilled Nurses ⚠ Watch
- Each resident gets only 28 minutes of Registered Nurse (RN) attention daily — below average for Ohio. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 28 deficiencies on record. Higher than average. Multiple issues found across inspections.
33/100
Bottom 27%
Review needed
4 → 2 violations
★★☆☆☆
2.0
Overall Rating
★★☆☆☆
2.0
Staff Levels
★★★☆☆
3.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2024: 4 issues
2025: 2 issues
The Good
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover below average (38%)
10 points below Ohio average of 48%
Facility shows strength in fire safety.
The Bad
2-Star Overall Rating
Below Ohio average (3.2)
Below average - review inspection findings carefully
Staff Turnover: 38%
Near Ohio avg (46%)
Typical for the industry
Federal Fines: $40,053
Above median ($33,413)
Moderate penalties - review what triggered them
Chain: GARDEN SPRINGS HEALTHCARE
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 28 deficiencies on record
1 life-threatening
Apr 2025
2 deficiencies
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0919
(Tag F0919)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interview, review of a job description, and policy review, the facility failed to ensur...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interview, review of a job description, and policy review, the facility failed to ensure the call light system was functioning for all residents and timely repairs were made to the system. This affected 23 of 77 facility residents including nine (#1, #11, #16, #28, #40, #50, #55, #62, and #71) residents with no functioning call light and an additional 14 (#18, #22, #26, #34, #37, #47, #53, #56, #58, #60, #63, #70, #75, and #76) residents with intermittent functioning call lights. The facility census was 77.
Findings include:
Interview on 04/21/25 at 8:52 A.M., with the Administrator revealed there were a few rooms on the north end of the facility where the call lights were not working and would have to check how long they had not been working. The Administrator revealed the residents were given hand bells and revealed she had gotten a couple of quotes for repair and replacement of the call light system. The Administrator revealed the staff had increased the frequency of rounding for the rooms with hand bells, but could not say how often the rounding was done. During the interview, the Administrator was asked to provide the documentation of service provider quotes to repair or replace the call light system.
Interview on 04/21/25 at 9:17 A.M., with Licensed Practical Nurse (LPN) #206 revealed the call lights on the north unit were not working and the residents had hand bells. LPN #206 revealed if she was at the nurse's station she would leave the door open so the hand bells could be heard.
Interview on 04/21/25 at 9:29 A.M., with Resident #50 revealed her call light had not been working for months. Resident #50 stated the call light would stay on for a few minutes then would just shut off. Resident #50 revealed she called the facility via telephone when she needed assistance.
Interview on 04/21/25 at 9:33 A.M., with Resident #28 revealed her call light was not working since her admission on [DATE]. Resident #28 had a hand bell but stated her roommate would call the facility for her via telephone when she needed help.
Interview on 04/21/25 at 9:35 A.M., with Resident #58 revealed her call light had not been working for a couple of weeks. Resident #58 had a hand bell and stated it took forever for the staff to answer it.
Interview on 04/21/25 at 9:37 A.M., with Resident #62 revealed her call light and her roommate's (#71) call light had not been working for a week or two. Resident #62 and Resident #71 had hand bells.
Interview on 04/21/25 at 9:42 A.M., with Resident #75 revealed his call light had not been working for about a week and had a hand bell.
Interview on 04/21/25 at 9:43 A.M., with Resident #40 revealed his call light was not working but was unsure for how long it was not working. The resident had a hand bell.
Interview on 04/21/25 at 9:56 A.M., with LPN #210 revealed the call lights on the north end had not been working for a few weeks and thought the facility was supposed to replace the call light system.
Interview on 04/21/25 at 10:53 A.M., with Certified Nurse Aide (CNA) #230 revealed the residents had hand bells and she was rounding on the residents every 30 minutes. CNA #230 revealed the call lights had not been working for a couple of weeks.
Interview on 04/21/25 at 10:55 A.M., with CNA #242 revealed she was completing checks on the residents with hand bells about every 30 minutes. CNA #242 revealed the call lights had not been working for at least two weeks.
Interview on 04/21/25 at 11:01 A.M., with the Administrator revealed the call lights on the north end had not been working correctly since 03/31/25. The Administrator revealed she had been getting service pricing quotes, but the repair providers indicated the system could not be fixed. Further interview on 04/21/25 at 1:48 P.M., the Administrator revealed she was unable to provide documentation of service provider quotes to repair or replace the call light system. The Administrator revealed the vendors stated the call light system was an old system and would not put anything in writing.
Observations on 04/21/25 beginning at 11:13 A.M., with the Director of Nursing (DON) revealed the call lights were not working in the rooms of nine (#50, #28, #71, #62, #16, #40, #1, #11, and #55) residents. Concurrent interview with the DON revealed the call lights worked intermittently in the rooms of 14 (#56, #70, #18, #22, #76, #60, #75, #53, #63, #47, #26, #58, #34, and #37) additional residents. The DON revealed the 23 total residents all had hand bells or service bells.
Interview on 04/21/25 at 1:35 P.M., with Director of Maintenance (DOM) #400 revealed the call lights had not been working on the north end of the building for about two and a half weeks. DOM #400 revealed it was an old system and there was a power problem with the voltage. DOM #400 revealed some rooms worked intermittently.
Review of the job description titled, Plant Operations Manager, dated 08/31/20, revealed maintenance staff would maintain the facility equipment in proper working order, repair or replace any equipment not functioning properly, conduct facility rounds and repair any areas needing attention, and contact outside contractor to get quotes to complete work as required.
Review of the facility policy titled, Answering the Call Light, dated 09/2022, revealed no guidelines for maintaining the call light system. Further review of the policy revealed no guidelines for when the call lights were not functioning.
Review of an undated facility policy titled, Call Lights-Answering, revealed if the call light system was not functioning properly, residents would be provided call bells, and the assigned staff would make ongoing rounds until the call light system was working properly. There were no guidelines for maintaining and fixing the call light system when not functioning.
This deficiency represents non-compliance investigated under Master Complaint Number OH00164950 and Complaint Number OH00164825.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0921)
Could have caused harm · This affected most or all residents
Based on observation, staff interview, and review of a job description, the facility failed to ensure the doorbell to the front entrance of the facility was functional. This had the potential to affec...
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Based on observation, staff interview, and review of a job description, the facility failed to ensure the doorbell to the front entrance of the facility was functional. This had the potential to affect all 77 residents residing in the facility. The facility census was 77.
Findings include:
Observation on 04/21/25 at 8:32 A.M. revealed the doorbell to the front door of the facility was missing a cover plate. The button on the doorbell was pushed twice and the doorbell would not ring and made no sound. There was no sign posted with the facility telephone number to obtain assistance to enter the building.
Interview on 04/21/25 at 8:52 A.M., the Administrator revealed on 04/16/25 a nurse notified her the facility telephones and internet were not working and were out for a few hours until fixed. The Administrator revealed she was unaware if the doorbell to the facility was functioning. The Administrator revealed she had been at the facility for about six months and never checked to see if the doorbell was functioning.
Observation and interview on 04/21/25 at 9:02 A.M. with the Administrator and the Director of Nursing (DON) revealed the doorbell to the facility front entrance door would not ring when the buttons were pushed. The DON revealed the doorbell was used to enter the facility at night and should sound at the nurse's station. The Administrator and the DON verified the doorbell was not working.
Interview on 04/21/25 at 9:17 A.M., with Licensed Practical Nurse (LPN) #206 was unaware the facility doorbell was not working.
Interview on 04/21/25 at 10:53 A.M., with LPN #210 was unaware the facility doorbell was not working.
Interview on 04/21/25 at 1:35 P.M., with Director of Maintenance (DOM) #400 revealed he had never checked the doorbell to see if it was functioning and was not part of his routine checks. DOM #400 revealed he found out about a week ago the doorbell was not working but the staff member who reported it had never filled out a maintenance work order.
Interview on 04/21/25 at 2:17 P.M., with LPN #265 revealed an outside provider was at the facility on 04/16/25 and told her the telephones and the front entrance doorbell were not working. LPN #265 revealed she reported to the Administrator about the telephones, internet, and doorbell not working. LPN #265 revealed she had not notified maintenance staff about the doorbell not working because another nurse told her maintenance was already aware.
Interview on 04/21/25 at 3:57 P.M., with the Administrator revealed facility staff were trained during new hire orientation to enter maintenance requests in the computer system.
Interview on 04/21/25 at 4:05 P.M., with the DON revealed some staff locked the front entrance door at night and some staff did not. The DON revealed the facility had no policy requiring the door to be locked at night. The DON revealed some staff locked the front entrance between 9:00 P.M. and 10:00 P.M. and unlocked the door between 6:00 A.M. and 6:30 A.M.
Review of the job description titled, Plant Operations Manager, dated 08/31/20, revealed maintenance would maintain the facility equipment in proper working order, repair or replace any equipment not functioning properly, conduct facility rounds and repair any areas needing attention, and contact outside contractors to get quotes to complete work as required.
This deficiency represents non-compliance investigated under Master Complaint Number OH00164950.
Sept 2024
3 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and policy review, the facility failed to properly assess and treat a resident'...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and policy review, the facility failed to properly assess and treat a resident's rash. This affected one (#1) out of three residents reviewed for a change in condition. The facility census was 69.
Findings include:
Review of the medical record revealed Resident #1 was admitted to the facility on [DATE]. Diagnoses included dementia, anxiety, depression, hypertension, muscle weakness, and need for assistance with personal care.
Review of the admission Minimum Data Set assessment, dated 07/19/24, revealed Resident #1 was identified as cognitively impaired. The resident required assistance from staff for all activities of daily living.
Review of Resident #1's medical record for 09/06/24 and 09/07/24 revealed no other information, documentation, or assessment regarding a rash.
Review of the shower sheet dated 09/07/24, revealed Resident #1 had a rash on their left thigh.
Review of the nursing progress notes dated 09/08/24 and timed 10:00 A.M., revealed the nurse on duty noted a red rash on the top of Resident #1's left thigh and lower back. A State Tested Nurse Aide (STNA) reported the rash was reported to the unit managers on 09/06/24. The nurse on duty notified the on-call provider who ordered Acyclovir (anti-viral) medication. The provider on call and the family were notified via phone.
Review of the skin assessment dated [DATE] indicated Resident #1 had a rash on the front of their left thigh and on their lower back, extending from the left flank to the right flank.
Interview on 09/26/24 at approximately 10:42 A.M., with the Director of Nursing, revealed Resident #1's rash was reported to Licensed Practical Nurse (LPN) #167 on 09/06/24. LPN #167 reported the rash to LPN Supervisor #171. LPN #171 then reported the rash to the DON. The DON verified there was no documentation to support the facility had identified, assessed, or obtained treatment orders for the rash until 09/08/24.
Review of the policy titled Notification of Changes, dated February 2023, revealed the need to alter treatment significantly was defined as needing to stop a form of treatment due to adverse consequences (such as adverse drug reaction), or commence a new form of treatment to deal with a problem. The facility would inform the resident, consult with the resident's physician and/or notify the resident's family member or legal representative when there was a change requiring such notification. Circumstances requiring notification included new treatment of discontinuation of a current treatment.
Review of the policy titled Change in a Resident's Condition or Status, revised February 2021, revealed the facility would notify the resident's attending physician or physician on call when there has been including but not limited to an adverse reaction to medication or a need to alter the resident's medical treatment significantly. The policy also stated the nurse would record in the resident's medical record information relative to changes in the resident's medical/mental condition or status.
This deficiency represents non-compliance investigated under Complaint Number OH00157697.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
Based on observation, staff interview, and review of the policy, the facility failed to ensure the glucose monitor device was cleaned after use. This directly affected three residents (#26, #67 and #6...
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Based on observation, staff interview, and review of the policy, the facility failed to ensure the glucose monitor device was cleaned after use. This directly affected three residents (#26, #67 and #68) and had the potential to affect 15 residents (#16, #18, #21, #23, #32, #36, #37, #39, #44, #48, #50, #52, #56, #61, and #63), identified by the facility as having blood glucose monitored using the blood glucose device. The facility census was 69.
Findings include:
Observation on 09/27/24 at 5:35 A.M., revealed Licensed Practical Nurse (LPN) #100 used a blood glucose monitor device to obtain a blood glucose result on Resident #26. After obtaining the result, LPN #100 used an alcohol swab to cleanse the monitor device. Interview directly following, with LPN #100 provided verification the alcohol swab was not the correct substance to clean the device.
Observation on 09/27/24 at 5:53 A.M., revealed LPN #103 to obtain a blood glucose reading using a blood glucose device for Resident #67. LPN #103 did not clean the device before proceeding to use the device to obtain a blood glucose result on Resident #68. Interview immediately following the second test, with LPN #103 provided verification she had not cleaned the device between residents #67 and #68.
Review of the undated policy titled Glucometer Disinfection, revealed the glucometer is to cleaned and disinfected after each use. The glucometer is to be disinfected with a wipe pre-saturated with an Environmental Protection Agency registered healthcare disinfectant
This deficiency represents non-compliance investigated under Complaint Number OH00157697.
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Room Equipment
(Tag F0908)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and review of policy, the facility failed to ensure the crash carts (emergency use) were ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and review of policy, the facility failed to ensure the crash carts (emergency use) were stocked with non-expired medical devices. This had the potential to affect all 69 residents residing in the facility. The census was 69.
Findings include:
Observation, along with Licensed Practical Nurse (LPN) #171, on [DATE] at 9:30 A.M., revealed the crash cart(located in the nurses station on the skilled nursing side) contained four 10 milliliter syringes with expiration date of [DATE]. The cart contained three 22 gauge angiocaths with expiration date of [DATE], two 20 gauge angiocaths with expiration date of [DATE], five intravenous start kits with expiration dates of (3) [DATE] and (2) [DATE], and an unopened, sealed bottle of blood glucose test strips dated [DATE]. The cart in the locked dementia unit contained three suction catheter kits dated [DATE] and a sealed providone swab stick expired 10/23.
Interview at the time of the observation, with LPN #171 verified all of the findings at the time of the observations.
Review of the undated policy titled, Emergency Crash Cart and Automated External Defibrillators revealed expired items are replaced when applicable.
This deficiency represents non-compliance investigated under Complaint Number OH00157697.
Apr 2024
1 deficiency
CONCERN
(F)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observation, staff interview, and policy review, the facility failed to ensure food was served at safe holding food temperatures. The deficient practice had the potential to affect all 63 res...
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Based on observation, staff interview, and policy review, the facility failed to ensure food was served at safe holding food temperatures. The deficient practice had the potential to affect all 63 residents that receive food from the kitchen. The facility census was 63.
Findings include:
Observation on 04/02/24 at 12:19 P.M., with Dietary Manager #35 and District Manager #95, of the tray line revealed the lunch menu consisted of meatballs, capris vegetables, and white rice. Dietary Manager #35 gave a thermometer and santizer wipes to [NAME] #40. [NAME] #40 then temperature tested the food on tray line being served on the test tray. The meatballs were 150 degrees Fahrenheit, the capris vegetables were 127 degrees Fahrenheit, and the white rice was 130 degrees Fahrenheit coming out of hot holding to be placed on the test tray. The test tray left the kitchen at 12:21 P.M.
Observation of tray distribution in the Reflections unit started on 04/02/25 at 12:24 P.M.
Interview on 04/02/24 at 12:26 P.M., with Dietary Manager #35 revealed she was not aware what temperature the food should be during hot holding and that she was going to have to ask.
Interview on 04/02/24 at 12:29 P.M., with District Manager #95 revealed they want food to be at least 135 degrees Fahrenheit coming out of the kitchen. When asked if the facility does test trays, District Manager #95 said they haven't gotten to train Dietary Manager #35 to do test trays yet.
Observation of the test tray that left the kitchen at 12:21 P.M., was opened at 12:41 P.M., Dietary Manager #35 temperature tested the food on the tray and confirmed the food temperatures. The meatballs were 127 degrees Fahrenheit, the capris vegetables were 129 degrees Fahrenheit, and the white rice was 132 degrees Fahrenheit.
Review of the policy titled, Food Preparation Policy dated February 2023, stated all foods will be held at appropriate temperatures, greater than 135ºF (or as state regulation requires) for hot holding and less than 41ºF for cold holding.
This deficiency represents non-compliance investigated under Complaint Number OH00152371.
Dec 2023
4 deficiencies
1 IJ (1 facility-wide)
CRITICAL
(L)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Infection Control
(Tag F0880)
Someone could have died · This affected most or all residents
⚠️ Facility-wide issue
Based on Nursing Home Guidance from the Centers for Disease Control (CDC), medical record review, observation, interview with residents, interview with facility staff, and review of facility policy, t...
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Based on Nursing Home Guidance from the Centers for Disease Control (CDC), medical record review, observation, interview with residents, interview with facility staff, and review of facility policy, the facility failed to appropriately implement the isolation procedures and use of Personal Protective Equipment (PPE) to prevent the spread of the SARS-CoV-2 virus (COVID-19) among facility residents. This resulted in Immediate Jeopardy and the potential for serious life-threatening harm, negative health outcomes, and/or death when the facility staff failed to require 13 residents (#19, #21, #42, #46, #47, #51, #55, #56, #59, #61, #62, #64, and #65) who were positive for COVID-19 to remain in isolation from the onset of the outbreak on 11/25/23. As of 12/12/23, 20 residents were identified as COVID-19 positive (Residents #02, #03, #05, #06, #07, #10, #19, #21, #31, #43, #45, #46, #47, #50, #51, #57, #58, #60, #61, and #62). These 20 residents are located throughout the facility since the facility does not have a dedicated COVID-19 unit. The facility also allowed six residents (#01, #04, #08, #20, #32, and #63) who were COVID-19 negative to remain in a room with a COVID-19 positive roommate. Licensed Practical Nurse (LPN) #215 was observed not to change her mask when exiting a COVID-19 positive resident's room (#50) and State Tested Nursing Assistant (STNA) #275 failed to utilize proper PPE when coming into contact with a COVID-19 positive resident (#45) when the staff member was observed to not utilize a gown, gloves, or eye protection when in the resident's room. STNA #275 also did not change her face mask when exiting the room. No trash receptacles were placed close to the door in the COVID-19 positive rooms for staff to discard used PPE upon exit from the room. Additionally, the facility failed to implement staff COVID-19 testing strategies when the COVID-19 outbreak occurred on 11/25/23. Failure of the facility to have systems in place to prevent the transmission and spread of COVID-19 to the vulnerable population of the facility placed all 64 residents at potential risk for contracting the virus. The total facility census was 64.
On 12/13/23 at 1:11 P.M., the Administrator, Director of Nursing (DON) and Regional Director of Operations (RDO) #530 were notified Immediate Jeopardy began on 11/25/23 when the facility did not implement isolation procedures and COVID-19 positive residents were allowed to be out of their rooms if they wore source control. The facility had six residents (#01, #04, #08, #20, #32, and #63) who were COVID-19 negative but remained in a room with a COVID-19 positive roommate. LPN #215 exited a COVID-19 positive room and did not change her mask when exiting the room, STNA #275 did not use proper PPE when coming into contact with a COVID-19 positive resident, and the facility had no formal staff COVID-19 testing occurring since the COVID-19 outbreak. No trash receptacles were placed close to the door in the COVID-19 positive rooms for staff to discard used PPE upon exit from the room. As of 12/12/23, 20 residents were identified as COVID-19 positive and are located throughout the facility since the facility does not have a dedicated COVID-19 unit.
The Immediate Jeopardy was removed on 12/15/23 when the facility implemented the following corrective actions:
•
On 12/07/23 at 3:00 P.M., RDO #530 educated the Administrator on COVID policies.
•
On 12/13/23 at 2:30 P.M., the Administrator educated all department heads including the DON, Human Resource Director (HRD) #535, Maintenance #520, Receptionist #540, Dietary Manager #515, Housekeeping Manager #505, Unit Manager #550, MDS Nurse #260, Therapy Director #500, Business Office Manager #510, Activities Director #570, Admissions Director #580, and Social Service Director #230 on the COVID policies. Education of floor staff (Nurse, STNA, Dietary, Laundry, housekeeping, receptionist, Maintenance, Activities, SS, therapy) by the DON, MDS Nurse #260, Unit Manager #550, Dietary Manager #515, Housekeeping Manager #505, Therapy Director #500, and/or HRD #535 on COVID policy, proper PPE (don/doff) on 12/13/23 on Carefeed via Read & Sign, or prior to the start of their next scheduled shift completed by 12/14/23 at 4:30 P.M.
•
On 12/13/23 by 4:30 P.M., audits of rooms were completed by Housekeeping Manager #505 for proper trash bins in COVID positive rooms.
•
Scheduled staff testing for COVID-twice a week on Tuesdays and Fridays or when symptomatic by DON/Infection Preventionist (IP)/Designee. Positive staff will be removed from the schedule, removed from the facility, and will follow isolation precautions/rules for their symptoms. Employees will follow Return to Work Guidelines per Centers for Medicare & Medicaid Services (CMS), CDC, State and local guidelines, and company policy, 12/12/23 at 5:10 P.M.
•
(For healthcare personnel (HCP) who were initially suspected of having COVID-19 but, following evaluation, another diagnosis is suspected or confirmed, return-to-work decisions should be based on their other suspected or confirmed diagnoses. Either antigen test (ex, Binax Now, Quidel, BD Veritor) or NAAT (PCR) testing can be utilized. It is not recommended to test staff who are COVID-19 recovered in the past 30 days. Inform the staff member to self-monitor for fever and symptoms consistent with COVID-19 and not to report to work when ill or testing positive for COVID-19. Confer with the staff member to work restrict if: The staff member is unable to wear source control for 10 days following exposure. They are personally moderately to severely immunocompromised. They work solely on units with residents who are moderately or severely compromised and are unable to be reassigned or they are assigned to a unit that is currently in outbreak and the transmission is not controlled with initial interventions and they are unable to be re-assigned). We will either follow Table 1 Return to Work Criteria, Confirmed Infection, Conventional Staffing or Table 2 Return to work Criteria, Confirmed Infection, Contingency and Crisis Staffing.
•
Residents are educated on COVID-19 policies and in room isolation requirement on COVID -19 positive date by DON/IP/Designee, at time of event.
•
Re-testing of all negative residents-twice a week on Tuesdays and Fridays or when symptomatic by DON/IP/Designee, initiated 12/07/23. If a resident is COVID-19 positive they will be immediately provided a private room as available and will be cohorted with residents with the same pathogen as able.
•
On 12/13/23 by 5:15 P.M., the DON/IP/Designee re-located all non-COVID-19 positive residents.
•
On 12/13/23, the DON/IP/Designee ensured all residents are cohorted with like status, and documented, educated, and will monitor (signs and symptoms) those who refused room moves.
•
Starting on 12/15/23, the Administrator/DON/designee to monitor the education through completion. Any staff on paid time off (PTO) will be educated prior to working, and any new hires will be educated during orientation. This monitoring will be conducted weekly for four weeks, then monthly times two.
•
Starting on 12/15/23, the DON/designee to monitor resident testing until the outbreak has ended. This monitoring will be conducted weekly for four weeks, then monthly times two.
•
Starting on 12/15/23, the DON/Human Resources (HR)/Designee to monitor staff testing until the outbreak has ended. This monitoring will be conducted weekly for four weeks, then monthly times two.
Although the Immediate Jeopardy was removed on 12/15/23, the facility remained out of compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) as the facility was in the process of implementing their corrective action plan and monitoring to ensure on-going compliance.
Findings include:
Interview with the Administrator and the DON on 12/12/23 at 9:25 A.M. confirmed the facility is in COVID-19 outbreak status and the facility had their first COVID-19 positive resident on 11/25/23. The Administrator and DON confirmed there were currently 20 residents (Residents #02, #03, #05, #06, #07, #10, #19, #21, #31, #43, #45, #46, #47, #50, #51, #57, #58, #60, #61, and #62) who were COVID-19 positive and there was not a dedicated COVID-19 unit. The Administrator confirmed at the beginning of the COVID-19 outbreak, COVID-19 positive residents were allowed to be out of their rooms if they wore source control and maintained social distance.
Interview with LPN #200, LPN #260, Housekeeper #235 and Social Services #230 on 12/12/23 from 11:32 A.M. to 1:12 P.M. all confirmed the facility did allow COVID-19 residents to be out of their rooms and in common areas until last week.
Observation on 12/12/23 at 11:32 A.M. revealed LPN #215 took medication into a resident (#50) in an isolation room, and the LPN donned gloves and gown and had on a surgical mask and glasses. The resident was heard to refuse the medications and the nurse was observed to remove the gown and place it in a small, resident room sized trash can by the door, dump the medication in the sharp's container, remove her gloves with the medication cup in the gloves, exit the room, complete hand hygiene with hand sanitizer and discard her gloves in the medication cart trash can. The nurse continued to wear the same surgical mask she had on prior to entering the isolation room. The nurse verified the facility staff were wearing surgical masks and verified she should have removed her mask prior to exiting the isolation room but she had not.
Observation of State Tested Nursing Assistant (STNA) #275 on 12/13/23 at 10:10 A.M. revealed the STNA was observed in a COVID-19 positive resident's (#45) room, with a face mask in place as the only PPE in use. There was PPE outside the door and signage on the door indicating staff were to wear a gown, gloves, mask, and eye protection if entering the room. The STNA was observed to exit the room carrying a large Styrofoam cup and walk down the hallway.
Interview with STNA #275 on 12/13/23 at 10:12 A.M. confirmed she had exited the resident's room with a large cup. The STNA stated yea I didn't have any PPE on. I was just getting this cup. She verified she did not remove her mask and was wearing the same surgical mask she had on while she was in the room. She stated she had performed hand hygiene and then obtained more large Styrofoam cups from the kitchen.
Interview with the DON on 12/12/23 at 11:40 A.M. confirmed the staff are not being tested by the facility for COVID-19 but have been told if they feel sick, they need to test and if they are positive, they come to the facility to test and have their result verified. The DON stated the staff are allowed to test anytime they want but it is not tracked at the facility. The DON verified the residents are currently being tested on Tuesdays and Fridays.
Observation of all isolation rooms on 12/12/23 at 4:15 P.M. revealed there were no trash receptacles close to the door for staff to discard used PPE upon exit from the room.
Interviews with LPN #200, LPN #210, and LPN #215 on 12/13/23 at 7:45 A.M. confirmed there were no trash receptacles near the doors to discard their PPE and it made it difficult to properly remove their PPE and exit the isolation rooms.
The facility had six residents (#01, #04, #08, #20, #32, and #63) who were COVID-19 negative but remained in a room with a COVID-19 positive roommate.
Review of the facility policy titled, Initiating Transmission-Based Precautions (TBA)(Isolation)(contact, Enhanced, Airborne, Droplet) dated 08/2011 revised 05/2023 revealed when Transmission-Based Precautions are implemented, the following is recommended: provide a private room as available, cohort residents with the same pathogen as able, ensure that an appropriate linen barrel/hamper and waste container, with appropriate liner, are placed in or near the resident's room.
Review of the CDC guidance for transmission-based precautions regarding COVID -19 revealed: Patient Placement
•
Place a patient with suspected or confirmed SARS-CoV-2 infection in a single-person room. The door should be kept closed (if safe to do so). Ideally, the patient should have a dedicated bathroom.
•
If cohorting, only patients with the same respiratory pathogen should be housed in the same room. Multidrug-resistant organisms (MDRO) colonization status and/or presence of other communicable disease should also be taken into consideration during the cohorting process.
•
Facilities could consider designating entire units within the facility, with dedicated HCP, to care for patients with SARS-CoV-2 infection when the number of patients with SARS-CoV-2 infection is high. Dedicated means that HCP are assigned to care only for these patients during their shifts. Dedicated units and/or HCP might not be feasible due to staffing crises or a small number of patients with SARS-CoV-2 infection.
•
Limit transport and movement of the patient outside of the room to medically essential purposes.
•
Communicate information about patients with suspected or confirmed SARS-CoV-2 infection to appropriate personnel before transferring them to other departments in the facility (e.g., radiology) and to other healthcare facilities.
https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Fhcp%2Flong-term-care.html#:%7E:text=Top%20of%20Page-,2.%20Recommended%20infection%20prevention%20and%20control%20(IPC)%20practices%20when%20caring%20for%20a%20patient%20with%20suspected%20or%20confirmed%20SARS%2DCoV%2D2%20infection,-The%20IPC%20recommendations
This deficiency represents non-compliance investigated under Complaint Number OH00148969 and OH00148956.
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 F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility staff interview, and policy review, the facility failed to update care plans for three (#21, #5...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility staff interview, and policy review, the facility failed to update care plans for three (#21, #57 and #61) of four residents reviewed for being COVID-19 positive. The total facility census was 64.
Findings include:
1. Review of Resident #21's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including obstructive hydrocephalus, bradycardia, dementia, epilepsy, chronic obstructive pulmonary disease, bipolar disorder, and depression.
Review of the 10/12/23 state optional Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had mild cognitive impairment, no behaviors, required extensive assist from one for bed mobility, transfers, toileting and supervision for eating.
The resident had order for isolation and observation due to positive COVID status for 10 days dated 12/04/23.
Care plans reviewed revealed the resident is long term care at the facility. That she likes to spend most of her time outside her room in communal areas and will watch tv and will participate regularly in bingo and group discussions. The care plan included a plan that she has demonstrated a refusal or inability to wear a mask when outside her room. The care plan had no documentation regarding the resident being positive for COVID-19, or being in isolation.
2. Review of Resident #57's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including infection to skin and subcutaneous tissue, venous insufficiency, need for assistance with personal care, hypertension, chest pain, and weakness.
Review of the state other MDS 3.0 dated 10/06/23 revealed the resident is cognitively intact and had no behaviors. Resident #57 required no help from staff for bed mobility, transfers, eating and personal hygiene.
Review of Resident #57's orders revealed the resident had order for vital signs due to COVID positive results and for isolation for 10 days due to COVID positive status dated 12/11/23.
Review of facility COVID -19 tracking revealed the resident tested positive for COVID-19 on 12/10/23.
Review of care plans revealed the resident had a care plan dated 12/10/23 that stated she had the potential for or required an actual isolation related to COVID -19 if she developed a fever (2 degrees over baseline 100.4), cough, difficulty breathing or shortness of breath. The care plan did not state that she required isolation due to being COVID-19 positive.
3. Review of Resident #61's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including acute kidney failure, type two diabetes, anxiety, heart failure, asthma, chest pain, weakness, obesity, depression and need for assistance with personal cares.
Review of the 11/21/23 state other MDS 3.0 assessment revealed the resident is cognitively intact, had no behaviors, required supervision for bed mobility, transfers, eating and personal hygiene.
Review of facility COVID-19 documentation revealed the resident tested positive for COVID-19 on 12/04/23.
Review of care plans revealed the resident had a care plan dated 12/04/23 that stated he had the potential for or require an actual isolation related to COVID -19 if he developed a fever (2 degrees over baseline 100.4), cough, difficulty breathing or shortness of breath. The care plan did not state that he required isolation due to being COVID-19 positive.
Interview with the Director of Nursing on 12/13/23 at 4:00 P,M. confirmed the residents' care plans were not updated to reflect the residents' diagnosis of COVID-19 or their being in isolation.
Review of the policy titled, F656, F657, F658 Comprehensive Care Plans, dated 09/2012 last revised 09/2023 revealed the facility's care planning/Interdisciplinary team in coordination with the resident, his/her family or representative(sponsor), develops and maintains a comprehensive care plan for each resident that identified the highest level of functioning the resident may be expected to attain. The comprehensive care plan is based on a thorough assessment that includes, but is not limited to, the MDS and physician's orders. Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility staff interview, and policy review, the facility failed to notify the responsible party for two...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility staff interview, and policy review, the facility failed to notify the responsible party for two residents (#21 and #57) of four reviewed for COVID-19 that they were positive for SARS-CoV-2 virus (COVID-19), and the facility failed to notify the responsible party of six (#01, #04, #08, #20, #32, and # 63) of six residents reviewed who were COVID-19 negative that the resident remained in a room with a COVID-19 positive roommate. The total facility census was 64.
Findings include:
1. Review of Resident #21's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including obstructive hydrocephalus, bradycardia, dementia, epilepsy, chronic obstructive pulmonary disease, bipolar disorder, and depression.
Resident #21 was documented to have a guardian over her care at the facility.
Review of the state optional minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident had mild cognitive impairment, no behaviors, required extensive assist from one for bed mobility, transfers, toileting and supervision for eating.
Resident #21 had order for isolation and observation due to testing positive for COVID-19 for 10 days dated 12/04/23.
Review of the facility's COVID -19 tracking revealed Resident #21 tested positive for COVID-19 on 12/03/23.
Resident #21's record had no documentation that the responsible party was notified of the resident's change in condition, testing positive for COVID-19, or requiring isolation in the facility.
2. Review of Resident #57's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including infection to skin and subcutaneous tissue, venous insufficiency, need for assistance with personal care, hypertension, chest pain, and weakness.
Review of the state other MDS 3.0 assessment dated [DATE] revealed the resident is cognitively intact and had no behaviors. Resident #57 required no help from staff for bed mobility, transfers, eating and personal hygiene.
Review of Resident #57's orders revealed the resident had an order dated 12/11/23 for vital signs due to diagnosis of COVID-19 and to isolate the resident for 10 days.
Review of the facility's COVID -19 tracking revealed Resident #57 tested positive for COVID-19 on 12/10/23.
Resident #57's record had no documentation that the responsible party was notified of the resident's change in condition, testing positive for COVID-19, or requiring isolation in the facility.
3. Review of Resident #01's medical record revealed the resident was admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease, paranoid schizophrenia, weakness, hypertension and cardiac murmur.
Resident #01 had family listed as her responsible party over her care. The medical record did not have documented evidence that the family was notified that the resident was cohorting with a COVID-19 positive roommate.
Review of the facility's COVID -19 tracking revealed Resident #01 was negative for COVID-19.
4. Review of Resident #04's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including dementia, anxiety, pneumonia, dysphagia, pulmonary fibrosis, chronic obstructive pulmonary disease, weakness and cognitive communication deficit.
Resident #04 had a family listed as her responsible party over her care. The medical record also not have documented evidence that the family was notified that the resident was cohorting with a COVID-19 positive roommate.
Review of the facility's COVID -19 tracking revealed Resident #04 was negative for COVID-19.
5. Review of Resident #08's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease, depression, heart failure, pulmonary hypertension and type two diabetes.
Resident #08 had a family listed as responsible party over his care. The medical record did not have documented evidence that the family was notified that the resident was cohorting with a COVID-19 positive roommate.
Review of the facility's COVID -19 tracking revealed Resident #08 was negative for COVID-19.
6. Review of Resident #20's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including dissociative and conversion disorder, weakness, cognitive communication deficit, anxiety, epilepsy, hypertensive heart disease, myalgia, and obesity.
Resident #20 had a family over her care. The medical record did not have documented evidence that the family was notified that the resident was cohorting with a COVID-19 positive roommate.
Review of the facility's COVID-19 tracking revealed Resident #20 was negative for COVID-19.
7. Review of Resident #32's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including anemia, hypertension, assist for personal care, unspecified psychosis.
Resident #32 had a guardian over his care. The medical record did not have documented evidence that the guardian was notified that the resident was cohorting with a COVID-19 positive roommate.
Review of the facility's COVID -19 tracking revealed Resident #32 was negative for COVID-19.
8. Review of Resident #63's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including hypertension, depression, and weakness.
Resident #63 had a family listed as her responsible party over her care. The medical record did not have documented evidence that the family was notified that the resident was cohorting with a COVID-19 positive roommate.
Review of the facility's COVID -19 tracking revealed Resident #63 was negative for COVID-19.
Interview with the Director of Nursing on 12/13/23 at 4:00 P.M. confirmed the findings.
Review of the facility policy titled, Initiating Transmission-Based Precautions (TBA)(Isolation)(contact, Enhanced, Airborne, Droplet) dated 08/2011 revised 05/2023 revealed when Transmission-Based Precautions are implemented, the following is recommended: provide a private room as available, cohort residents with the same pathogen as able, ensure that an appropriate linen barrel/hamper and waste container, with appropriate liner, are placed in or near the resident's room.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and facility staff interview, the facility failed to monitor six (#01, #04, #08, #20, #32, and #63) of si...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and facility staff interview, the facility failed to monitor six (#01, #04, #08, #20, #32, and #63) of six residents who were COVID-19 negative and remained in a room with a COVID-19 positive roommate for signs and symptoms of COVID-19. The total facility census was 64.
Findings include:
1. Review of Resident #01's medical record revealed the resident was admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease, paranoid schizophrenia, weakness, hypertension and cardiac murmur.
Resident #01's medical record lacked evidence that the resident was having her temperature taken daily or was being observed daily for signs and symptoms of COVID-19.
Review of the facility's COVID -19 tracking revealed Resident #01 was negative for COVID-19, but remained in a room with a COVID-19 positive roommate.
2. Review of Resident #04's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including dementia, anxiety, pneumonia, dysphagia, pulmonary fibrosis, chronic obstructive pulmonary disease, weakness and cognitive communication deficit.
Resident #04's medical record lacked evidence that the resident was having her temperature taken daily or was being observed daily for signs and symptoms of COVID-19.
Review of the facility's COVID-19 tracking revealed Resident #04 was negative for COVID-19, but remained in a room with a COVID-19 positive roommate.
3. Review of Resident #08's medical record revealed the resident was admitted to 11/10/23 with diagnoses including chronic obstructive pulmonary disease, depression, heart failure, pulmonary hypertension and type two diabetes.
Resident #08's medical record lacked evidence that the resident had his temperature taken daily or was being observed daily for signs and symptoms of COVID-19.
Review of the facility's COVID -19 tracking revealed Resident #08 was negative for COVID-19, but remained in a room with a COVID-19 positive roommate.
4. Review of Resident #20's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including dissociate and conversion disorder, weakness, cognitive communication deficit, anxiety, epilepsy, hypertensive heart disease, myalgia, and obesity.
Resident #20's medical record lacked evidence that the resident was having her temperature taken daily or was being observed daily for signs and symptoms of COVID-19.
Review of the facility's COVID -19 tracking revealed Resident #20 was negative for COVID-19, but remained in a room with a COVID-19 positive roommate.
5. Review of Resident #32's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including anemia, hypertension, assist for personal care, and unspecified psychosis.
Resident #32's medical record lacked evidence the resident was having his temperature taken daily or was being observed daily for signs and symptoms of COVID-19.
Review of the facility's COVID -19 tracking revealed Resident #32 was negative for COVID-19, but remained in a room with a COVID-19 positive roommate.
6. Review of Resident #63's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including hypertension, depression and weakness.
Resident #63's medical record lacked evidence that the resident was having her temperature taken daily or was being observed daily for signs and symptoms of COVID-19.
Review of the facility's COVID -19 tracking revealed Resident #63 was negative for COVID-19, but remained in a room with a COVID-19 positive roommate.
Interview with the Director of Nursing on 12/14/23 at 4:00 P.M. confirmed Resident #01, #04, #08, #20, #32, and #63 remained in a room with a COVID-19 positive roommate and the facility was not monitoring the residents daily for signs or symptoms of COVID-19.
Aug 2023
5 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident and staff interview, review of the facility's self-reported incidents (SRIs), and revie...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident and staff interview, review of the facility's self-reported incidents (SRIs), and review of the facility policy, the facility failed to timely report an allegation of physical abuse of a resident to the State Survey Agency. This affected one (Resident #66) of two residents reviewed for abuse. The facility census was 62.
Findings include:
Review of the medical record for Resident #66 revealed an admission date of 01/26/23. Diagnoses included chronic obstruction pulmonary disease, schizophrenia, depressive disorder, pain in shoulder, cognitive communication deficit, psychotic disorder, and anxiety.
Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #66 was cognitively intact and required limited to extensive assistance of one staff member for mobility and transfers.
Interview on 08/22/23 at 9:00 A.M. with Resident #66 revealed she had an allegation of abuse with State Tested Nursing Aide (STNA) #126 smacking her during care. Resident #66 revealed she had reported the allegation of physical abuse by STNA #126 to the Director of Nursing (DON) previously. Resident #66 stated this alleged incident occurred about one month ago but could not recall the exact date.
Interview on 08/22/23 at 3:42 P.M. with the DON revealed she was not aware of Resident #66 having concerns related to abuse and revealed she did not recall Resident #66 reporting concern of STNA #126 had smacked her. The DON stated she would begin an investigation related to the abuse allegation.
Subsequent interview on 08/24/23 at 9:22 A.M. with the DON confirmed the physical abuse allegation reported by the State Survey Agency on 08/22/23 had not yet been reported as an SRI.
Review of the facility's SRI revealed there were no allegation of physical abuse of Resident #66 reported to the State Survey Agency from 07/01/23 to 08/25/23. The DON was informed on 08/22/23 at 3:42 P.M. that the allegation of physical abuse was not reported as an SRI yet.
Review of the facility policy titled Abuse Prevention Program, dated 08/2022, revealed residents had the right to be free from abuse. The policy revealed the facility had policy and procedures which included reporting and filing documents relative to abuse.
This deficiency represents non-compliance investigated under Complaint Number OH00145738.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
PASARR Coordination
(Tag F0644)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, review of the facility policy, and record review, the facility failed to ensure the resident's pre-ad...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, review of the facility policy, and record review, the facility failed to ensure the resident's pre-admission screening and resident interview (PASARR) assessment was completed accurately to include all the resident's mental health diagnoses. This affected one (Resident #66) of two residents reviewed for PASARR assessments. The facility census was 62.
Findings include:
Review of the medical record for Resident #66 revealed an admission date of 01/26/23. Diagnoses included schizophrenia and psychotic disorder. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #66 was cognitively intact.
Review of the PASARR assessment dated [DATE] revealed Resident #66 was marked to have a diagnosis of schizophrenia. Psychotic disorder was not marked as a diagnosis for Resident #66.
Interview on 08/22/23 at 2:25 P.M. with Social Services Designee (SSD) #121 revealed she completed the resident's PASARR assessments. SSD #123 denied having knowledge of a diagnosis not matching the medical record and the PASARR's documentation.
Interview on 08/22/23 at 2:48 P.M. with the Director of Nursing (DON) confirmed the PASARR diagnosis did not match the diagnosis list in the medical record for Resident #66. The DON confirmed psychotic disorder was not listed on the completed PASARR for Resident #66.
Review of the facility policy titled Pre-admission Screening and Resident Review, dated 05/2022, revealed the facility would coordinate assessments with the preadmission review program. The policy did not include any language about ensuring all mental health diagnoses are included on the PASARR assessment.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, review of the facility policy, and record review, the facility failed to ensure a resident receiving ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, review of the facility policy, and record review, the facility failed to ensure a resident receiving an as needed psychotropic medication had an end date and/or was re-evaluated by the medical provider every 14 days. This affected one (Resident #66) of five residents reviewed for unnecessary medication. The facility census was 62.
Findings include:
Review of the medical record for Resident #66 revealed an admission date of 01/26/23. Diagnoses included schizophrenia, psychotic disorder, and anxiety. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #66 was cognitively intact.
Review of Psychiatric Practitioner notes dated 06/29/23 revealed Resident #66 was having anxiety and a new medication would be started, Vistaril 25 milligrams (mg) as needed (PRN) every six hours for anxiety.
Review of Resident #66's physician orders dated 06/29/23 revealed an order for Vistaril (Hydroxyzine Pamoate) 25 mg capsule with instructions to administer one capsule by mouth every six hours PRN for anxiety. There was no stop date to the PRN psychotropic medication.
Further review of Resident #66's medical record from 06/30/23 to 08/22/23 revealed there was no documentation for the re-assessment of Vistaril and the continued rationale for the use of PRN psychotropic medication.
Review of Medication Administration Report dated 07/2023 and 08/2023 revealed Resident #66 received Vistaril PRN multiple times on the following dates: once on 07/03/23, 07/06/23, 07/08/23, 07/12/23, 07/14/23, 07/15/23, 07/16/23, 07/17/23, 07/18/23, 07/19/23, 07/20/23, 07/21/23, 07/22/23, 07/23/23, 07/24/23, 07/25/23, 07/26/23, 07/28/23, 07/29/23, 07/30/23, 07/31/23, 08/01/23, 08/02/23, 08/05/23, 08/08/23, 08/09/23, 08/11/23, 08/12/23, 08/13/23, 08/14/23, 08/15/23, 08/16/23, 08/17/23, 08/19/23, and 08/20/23 and was administered the medication twice daily on 07/07/23, 07/10/23, and 07/11/23.
Interview on 08/22/23 at 3:42 P.M. with the Director of Nursing (DON) and MDS Nurse #182 verified Resident #66 had an order for Vistaril PRN for anxiety. The DON and MDS Nurse #182 verified the facility no evidence the medical provider had reviewed the resident for appropriateness of the PRN psychotropic medication order to be continued including a stop date and medical reasoning for the continued use of the medication.
Subsequent interview on 08/22/23 at 5:00 P.M. with DON revealed the facility's system generated a reorder of Vistaril for every 14 days and confirmed there was no documentation or reasoning for the continuation.
Review of the facility policy titled Psychotropic Drug Use, dated 01/2023, revealed the resident would only receive psychotropic medications when necessary to treat specific conditions. An unnecessary drug was defines as a medication for an excessive duration or without adequate monitoring. PRN doses should be limited to 14 days or can be extended beyond 14 days through documentation in the medical record by the medical practitioner why this should occur.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the medical record for Resident #11 revealed an admission date of 10/09/21. Diagnoses included dementia, anxiety, o...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the medical record for Resident #11 revealed an admission date of 10/09/21. Diagnoses included dementia, anxiety, osteoporosis, pulmonary fibrosis, and collar bone fracture.
Review of the progress notes dated 05/30/23 revealed Resident #11's roommate was heard yelling and staff entered the room and found Resident #11 on the floor. Resident appeared agitated and was guarding her left bicep area with no visible injury.
Review of the pain assessment from the fall investigation dated 05/30/23 revealed Resident #11 had reported pain to the left shoulder and left bicep area. Resident #11 reported that it hurts a little bit and had marked vocal complaints of pain and marked protective body movements or postures including bracing, guarding, or rubbing.
Review of the hospice notes dated 05/30/23 revealed Resident #11 had complained of pain and rated the pain at a four out of 10.
Review of the fall incident investigation dated 05/30/23 revealed Resident #11 had no injuries or pain. This was marked differently that the progress notes, hospice notes, and pain assessment dated [DATE].
The progress note dated 06/01/23 revealed Resident #11 complained of left shoulder pain and was guarding and grimacing when the left shoulder was touched and moved. An X-ray was pending. A later note on 06/01/23 revealed the resident was transferred to the hospital for an arm sling.
Review of physician orders for 06/01/23 identified orders for stat x-ray of the left shoulder. Review of the x-ray result dated 06/01/23 revealed an acute non-displaced distal clavicle fracture.
The progress note dated 06/07/23 revealed the interdisciplinary (IDT) team met to discuss Resident #11's fall on 05/30/23 and revealed no injuries were noted.
Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #11 had one fall with no injury. On 08/21/23, an amendment was made to the MDS assessment dated [DATE] and revealed Resident #11 had one fall with major injury.
Interview on 08/21/23 at 3:21 P.M. with the Director of Nursing (DON) and MDS Nurse #182 revealed they were unaware of the resident's fracture not being documented as a fall with major injury on the MDS assessment dated [DATE]. MDS Nurse #182 made an amendment to the MDS assessment on 08/21/23.
Subsequent interviews on 08/24/23 at 9:40 A.M. with the DON verified the progress notes, hospice notes, and pain assessment did not match the facility's fall incident investigation. The DON verified the resident's pain and injuries sustained from the fall did not match. The DON also confirmed the resident's pain should have been documented consistently through the fall investigation forms instead of the fall investigations saying no pain and the pain assessment saying verbal and non-verbal indicators of pain were present. At 4:00 P.M., the DON acknowledged concerns related to documentation and the thoroughness and accuracy of documentation.
Based on staff interviews and medical record reviews, the facility failed to ensure the resident's medical record was accurate. This affected two (Residents #11 and #34) of 19 residents reviewed for medical record accuracy. The facility census was 62.
Findings include:
1. Review of the medical record for Resident #34 revealed an admission date of 05/04/18. Diagnoses included Alzheimer's disease, anemia, and dementia.
Review of the Resident #34's nursing progress notes dated 01/17/23 and 02/05/23 revealed she was being treated for some kind of rash.
Review of Resident #34's care conference documentation dated 03/22/23 revealed Resident #34 continued to have a rash on her entire body.
Review of the state tested nursing aide (STNA) shower sheets dated from 01/02/23 to 06/29/23 revealed Resident #34 had a rash on her body during a six-month time frame.
Review of Resident #34's Hand-Skin Observation sheets completed weekly from 01/3/23 to 07/23/23 revealed the weekly observation sheets were completed inaccurately as they indicated Resident #34 did not have a rash.
Review of the Resident #34's Dermatologist visit note dated 06/27/23 revealed Resident #34 was seen by the dermatologist and evaluated for a rash on Resident #34's body that she has been dealing with for the last six months.
Interview on 08/24/23 at 9:19 A.M. with the Director of Nursing (DON) confirmed Resident #34's Hand-Skin Observation sheets from 01/03/23 to 07/23/23 did not indicate Resident #34 had a rash. The DON confirmed the observation sheets were completed inaccurately as Resident #34 did have a rash during this time. Subsequent interview on 08/24/23 at 3:30 P. M. with the DON confirmed the facility does not have a policy or procedure how to complete the Hand-Skin observation sheets.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0921)
Could have caused harm · This affected most or all residents
Based on observations, staff and resident interviews, the facility failed to ensure a safe environment for residents, staff, and visitors. This had the potential to affect all 62 residents residing in...
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Based on observations, staff and resident interviews, the facility failed to ensure a safe environment for residents, staff, and visitors. This had the potential to affect all 62 residents residing in the facility.
Findings include:
The initial tour was conducted on 08/21/23 from 8:30 A. M. to 9:00 A.M. and revealed the entry way into the facility contained two glass doors. The first entry door (from the outside, door number one) from the bottom of the glass door closest to the floor extending up three quarters of the door and the entire width of the door, the glass was shattered. It appeared to have a shattered circle of glass in the center of the door with extending cracked glass to forming sharp lines of cracked glass extending in every direction. The area resembled a sun beam design or a spider web effect. Four feet in front of the first entry glass door was another glass door into the lobby of the facility. Door number two was shattered at the bottom right side about 24 inches wide and extended up to the middle of the door, the shattered glass was covered with a two-inch tape on both sides. There were no particles of glass in the area. The shattered glass remained inside the two door frames.
Interview with the Administrator on 08/21/23 at 2:48 P. M. revealed on 07/27/23, a resident was attempting to exit the building, and hit the glass with his wheelchair causing the door number two's glass to break. Two days later on 07/29/23, after business hours, the first entry door (door number one) was locked. An unidentified person who appeared to be intoxicated attempted to enter the locked facility. The person kicked the glass door and cracked the glass. Per the direction of the corporate office, Maintenance Director #165 was instructed to place tape over each crack on the doors. The Administrator explained they had a company come and give an estimate to replace the doors. The process continues as the facility was in the process of obtaining additional bids for replacement of the doors.
Observation on 08/24/23, at 2:00 P. M. revealed there was a sign on the entry door and door number two that stated, Close door gently to prevent slamming. Thank you.
Interview on 08/24/34 at 2:13 P.M. with the Maintenance Director #165 confirmed the outside door was covered with duct tape while the inside door has some special glass tape to prevent further breakage. The additional areas of cracked glass were covered with a generic clear tape. Observation of the doors accompanied by Maintenance Director #165 confirmed the outside glass door had a new area of cracked glass that was not covered with tape.
Interview on 08/24/23 at 2:15 P.M. with Resident #9 stated the doors have been shattered since July. The facility has many residents who go outside to sit, and they must be careful when exiting the building to prevent the shattered doors from further cracking.
Interview on 08/24/23 at 2:30 P.M. with Licensed Practical Nurse (LPN) #182 stated the facility has 40 residents who use a wheelchair to enter and exit the building. LPN #182 stated several residents liked to sit outside this time of year.
Jul 2023
1 deficiency
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, observations and interviews the facility failed to ensure a clean, safe, homelike environment. This aff...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, observations and interviews the facility failed to ensure a clean, safe, homelike environment. This affected four residents (#43, #04 #10 and #42) out of the four residents reviewed for environment. The facility census was 63.
Findings include:
1. Review of the medical record for Resident #43 revealed the resident was admitted to the facility on [DATE] with diagnosis including, osteoarthritis, acute kidney failure, epilepsy, and anxiety disorder.
Review of the [NAME] Data Set (MDS) assessment dated [DATE] for Resident #43, revealed the resident had intact cognition.
Observation of Resident #43's bathroom on 07/27/23 at 9:45 A.M. revealed an area behind the toilet that was approximately three feet wide with crumbling, grayish colored drywall consistent with the drywall previously being wet and the base board below it had separated from the wall. There were pieces of crumbled drywall along the floor. The area of drywall also contained a three-inch hole and the wallboard from the adjoining bathroom was visible through the hole.
Interview with Resident #43 on 07/27/23 at 9:46 A.M., revealed the area in the bathroom had been caused by a leaking toilet approximately two weeks ago. Resident #43 stated he did not like how the wall looked. Resident #43 further stated, the maintenance staff knew about the wall.
Interview with the Administrator on 07/27/23 at 9:58 A.M., verified Resident #43's drywall behind his toilet had been wet. The area was caused a leaking toilet discovered two weeks ago. The maintenance staff had to repair another room first before fixing Resident #43's room. Administrator stated there were no other rooms available to move Resident #43 while the facility fixed the resident's bathroom wall. Administrator stated once the other room was completed, the facility would move Resident #43 to that room while her bathroom's wall was being repaired.
2. Review of the medical record for Resident #04, revealed the resident was admitted to the facility on [DATE] with the diagnoses including paranoid schizophrenia, chronic obstructive pulmonary disease (COPD), high blood pressure, and Parkinson's Disease.
Review of the MDS dated [DATE] for Resident #04, revealed the resident had intact cognition.
Observation of Resident #04's bathroom on 07/27/23 at 1:40 P.M., revealed the bathroom sink was observed with three inches of standing, light brown colored water with an unknown sediment in the bottom of the sink. The sink appeared to be not draining.
Interview with Resident #04 on 07/27/23 at 1:45 P.M., revealed the standing water observed in the bathroom sink had been there since the previous evening. Resident #04 stated the sink would not drain and it happened frequently.
Interview with the Director of Nursing (DON) on 07/27/23 at 2:00 P.M., verified the standing water had not drained out of Resident #04's bathroom sink. The DON further verified the unknown sediment in the bottom of sink.
Interview on 07/27/23 at 2:10 P.M. with Maintenance Staff #02 verified the standing water in Resident #04's bathroom sink and indicated the water would not drain. Maintenance Staff #02 indicated the problem was believed to be in the pipes inside the wall.
3. Review of the medical record for Resident #10, revealed the resident was admitted to the facility on [DATE] with the diagnoses including dementia, anxiety disorder, dysphasia, COPD, and pulmonary fibrosis.
Review of the MDS dated [DATE] for Resident #10 revealed the resident had severely impaired cognition.
Review of the medical record for Resident #42, revealed the resident was admitted to the facility on [DATE] with diagnosis including anxiety disorder, cerebral infarction, and glaucoma.
Review of the MDS dated [DATE] for Resident #42, revealed the resident had severely impaired cognition.
Observation of the bathroom shared by Residents (#10 and #42) on 07/27/24 at 2:00 P.M. revealed approximately one inch of standing water in the bathroom sink and it appeared to not be draining. The bathroom sink was located on the adjoining wall of Resident #04's bathroom sink.
Interview with Licensed Practical Nurse (LPN) #04 on 07/27/23 at 2:05 P.M. verified Resident's (#10 and #42) bathroom sink had standing water and was not draining. LPN #04 indicated Resident #10 had a feeding tube and it was difficult caring for the resident when she could not use the sink. LPN #04 stated she had to go to the nurse's station to get water when she had to flush the resident's feeding tube.
Interview on 07/27/23 at 2:10 P.M. with Maintenance Staff #02 verified the standing water in the sink and it was not draining. Maintenance Staff #02 indicated the sink was on the adjoining wall of Resident #04's bathroom sink and believed the issue was in the pipes inside the wall.
Review of facility policy titled Supervision, Maintenance Services dated 11/2012 revealed, The day-to-day maintenance operation is under the supervision of the Maintenance Director. Maintenance work orders shall be completed to establish a priority of maintenance service.
This deficiency represents non-compliance investigated under Complaint Number OH00144585.
Apr 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0573
(Tag F0573)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of the facility medical record request log, staff interview, and facility policy review, ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of the facility medical record request log, staff interview, and facility policy review, the facility failed to provide copies of requested medical records in a timely manner. This affected one (#72) of three residents reviewed for resident rights. The census was 69.
Findings include:
Resident #72 was admitted to the facility on [DATE]. Diagnoses include type II diabetes, hypertensive heart and chronic kidney disease with heart failure, chronic obstructive pulmonary disease, difficulty walking, low back pain, other hypertrophic osteoarthropathy, rheumatoid arthritis, anxiety disorder, morbid obesity, muscle weakness, other chronic pain, spinal stenosis, chronic kidney disease (stage III), schizoaffective disorder, dementia, major depressive disorder, and anemia.
Review of Resident #72's minimum data set (MDS) assessment, dated 11/11/22, revealed she had a severe cognitive impairment.
Review of Resident #72 medical records revealed she had a severe cognitive impairment, so members of her family were deemed to be their responsible parties and could make medical decisions on her behalf.
Review of facility medical records request log revealed Resident #72 family requested medical records on 01/06/23. The facility did not provide the medical records until 02/06/23. Also, Resident #72 family requested medical records on 04/17/23. As of 04/27/23, the facility had not provided those medical records.
Interview with Director of Nursing (DON) on 04/27/23 at 9:45 A.M. and 10:30 A.M. and Administrator on 04/27/23 at 8:30 A.M. and 2:25 P.M. confirmed the dates in which Resident #72 family requested the records and the date in which they provided the records to the family. They confirmed it was more than 48 hours after the request. They confirmed they make copies of the medical records, send them to their corporate legal team to review, and then they will provide the medical records to the family.
Review of facility Request for Medical Records policy, dated August 2018, revealed it is the policy of the facility to comply with requests for medical records if the requesting party is legally authorized to request the record. Upon receipt, and prior to the release of any legal documents or requested record, the Administrator and the DON will be notified and given a copy of the request. The Administrator will notify the appropriate corporate staff and send a copy of that request. The facility staff will start immediately gathering the requested information, but no information will be released unless directed by the regional staff involved in the oversight of the request, or an attorney who is representing the facility. The facility will work with the requesting party to determine when the party wants the records and in what format, then attempt to comply with that request. If there are things that would delay meeting the timeframe, the party will be notified and the records would be obtained as soon as possible. The requesting party will be notified of the cost, if any, and payment received prior to the record being sent or given to them.
This deficiency represents non-compliance investigated under Master Complaint Number OH00142199 and Complaint Number OH00141579.
Feb 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and policy and procedure review, the facility failed to ensure wounds were init...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and policy and procedure review, the facility failed to ensure wounds were initially comprehensively assessed upon admission. This affected one resident (#72) out of three residents (#02, #68, and #72) reviewed for wounds. The census was 69.
Findings Include:
Review of the medical record for Resident #72 revealed an admission date of 08/05/22 and a discharge/death date of 12/24/22. Diagnoses included diabetes type two, difficulty walking, chronic obstructive pulmonary disease, hypertensive heart, chronic kidney disease, anxiety, schizoaffective disorder, depression, and dementia.
Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #72 had a stage two pressure ulcer and there was no Moisture Associated Skin Damage (MASD).
Review of the pressure ulcer risk assessment dated [DATE] revealed Resident #72 was a low risk.
Review of the plan of care dated 08/06/22 revealed Resident #72 had the potential for an alteration in skin integrity related to immobility, terminal diagnoses, and incontinence with interventions to educate the residents family on skin breakdown risk factors and preventative measures, encourage the resident to float heels while in bed, encourage frequent turning and positioning, pressure reduction mattress to bed, provide perineal care as needed, and use barrier cream with showers and incontinence episodes. The care plan dated 08/05/22 revealed the resident had an actual area of skin impairment with interventions to provide wound treatments as ordered and observe/document wound character weekly. Review of the care plan dated 08/06/22 revealed the resident/family had elected hospice care, the resident desired to be kept comfortable and not receive life sustaining measures with interventions to communicate changes in condition to hospice staff, coordinate care with the resident, the family and the hospice, the staff to provide comfort measures and turn and reposition as indicated.
Review of the admission skin assessment dated [DATE] revealed Resident #72 had a history of skin issues. The assessment indicated the resident had an open area to her right buttock. There was no additional information related the wound, such as size, color, drainage, odor, etc.
Review of the wound monitoring sheets dated 08/09/22 revealed Resident #72 had a stage two pressure area present on the right buttocks. The wound measured 0.5 centimeters (cm) by 0.5 cm by 0.1 cm deep. The wound was described with epithelial tissue to the wound bed with light serous drainage with no tunneling or odors present. Review of the wound monitoring sheets revealed the residents wound was assessed and monitored weekly and there were no concerns. Review of the wound monitoring sheets dated 11/01/22 revealed the residents stage two pressure area present on the right buttocks had healed.
Interview on 01/31/23 at 1:09 P.M., with the Regional Nurse/Registered Nurse #100 verified they would expect a full initial assessment to be completed of a wound and confirmed Resident #72's wound was not initially comprehensively assessed until 08/09/22. A follow-up interview on 01/31/23 at 2:30 P.M., with the Regional Nurse #100 verified the wound upon admission was MASD, but that there was no further information about it until 08/09/22.
Review of facility policy titled Wound Care, dated November 2018 revealed wounds will be evaluated when they are noted and weekly until resolved. Wounds will be monitored for location, size, undermining, tunneling, exudates, necrotic tissues, and the presence or absence of granulation tissue and epithelialization.
This deficiency represents non-compliance investigated under Complaint Number OH00139252.
Jan 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and review of facility policies, the facility failed to have medications docume...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and review of facility policies, the facility failed to have medications documented as administered per physician order for a resident. This affected one (#38) of three residents reviewed. The census was 65.
Findings include:
Review of Resident #38's medical record revealed an admission date of 04/20/22. Diagnoses listed included anxiety disorder, osteoarthritis, Alzheimer's disease, and ataxia.
Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #38 was severely cognitively impaired and required extensive assistance with activities of daily living (ADLs).
Review of physician orders revealed an order dated 11/14/22 for melatonin tablet (sleep aide) by mouth at bedtime for insomnia and an order dated 11/23/22 for Norco (narcotic pain medication) 7.5 milligrams (mg)-325 mg, give one tablet by mouth four times a day for pain.
Review of medication administration records (MAR) revealed on 12/02/22, 12/03/22, 12/04/22, 12/05/22, 12/19/22, 12/26/22, and 12/31/22 melatonin was not documented as being administered. On 12/02/22, 12/03/22, 12/04/22, 12/05/22, 12/19/22, 12/26/22, and 12/31/22 Norco was not documented as being administered at 8:00 P.M.
Review of progress notes revealed no documentation of any justification for Resident #38 not receiving melatonin and Norco on the above dates.
During an interview on 01/03/23 at 12:05 P.M. the Director of Nursing (DON) confirmed melatonin and Norco were not documented as being administered to Resident #38 on the above dates.
Review of the facility's undated policy titled Administering Medications medications must be administered in accordance with the orders, including the required timeframe. The individual administering the medication must initial the resident's MAR on the appropriate line after giving each medication and before administering the next ones.
This deficiency represents non-compliance investigated under Complaint Number OH00138808.
Jun 2021
4 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to provide fluids to a resident in a specialized cup. This affected one ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to provide fluids to a resident in a specialized cup. This affected one (Resident #70) of four residents reviewed for appropriate assistive devices. The facility identified 12 residents who required assistive devices with meals.
Findings include:
Review of Resident #70's medical record revealed she admitted [DATE]. Diagnoses included Alzheimer's disease.
Review of a physician order dated 03/31/21 revealed Resident #70 was prescribed a regular, mechanical soft diet.
Review of Resident #70's care plan dated 02/16/21 revealed she was at risk for altered nutritional status related to Alzheimer's disease. Interventions included a handled cup with a spout lid.
During observation on 06/21/21 at 11:42 A.M., Resident #70 had one regular cup and one handled cup with a spout lid, each filled with a different beverage. Resident #70 attempted to pick up her regular fluid-filled cup and inadvertently spilled it on the dining room table.
During interview on 06/21/21 at 11:48 A.M., Registered Nurse (RN) #712 confirmed Resident #70 was care planned to have handled cups with spout lids for drinking at meals. RN #712 confirmed Resident #70 was provided a regular cup without a handle or spout and she spilled her drink on the table.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0805
(Tag F0805)
Could have caused harm · This affected multiple residents
Based on record review, observation and interview, the facility failed to serve appropriately pureed potato salad to four (Residents #7,#5, #90 and #29) of five residents reviewed for puree consistenc...
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Based on record review, observation and interview, the facility failed to serve appropriately pureed potato salad to four (Residents #7,#5, #90 and #29) of five residents reviewed for puree consistency. The facility identified five residents who were ordered pureed meals.
Findings include:
Review of a facility provided list dated 06/24/21 revealed Resident #7, Resident #5, Resident #90, and Resident #29 were prescribed pureed meals and served pureed potato salad for the lunch meal 06/23/21.
1.
Review of Resident #7's medical record revealed she admitted to the facility 03/22/21. Diagnoses included Alzheimer's disease. Review of a physician order dated 03/31/21 revealed she was ordered a regular, pureed diet.
2.
Review of Resident #5's medical record revealed she admitted to the facility 03/15/21. Diagnoses included Chronic obstructive pulmonary disease. Review of a physician order dated 04/06/21 revealed she was ordered a regular, pureed diet.
3.
Review of Resident #90's medical record revealed she admitted to the facility 01/14/21. Diagnoses included cerebral infarction. Review of a physician order dated 04/19/21 revealed she was ordered a regular, pureed diet.
4.
Review of Resident #29's medical record revealed she admitted to the facility 09/21/16. Diagnoses included Alzheimer's disease. A physician order dated 03/31/21 revealed she was prescribed a regular, pureed diet.
Observation in the kitchen on 06/23/21 at 10:55 A.M. with Dietary Staff #313 revealed he pureed potato salad. Dietary Staff #313's completed product appeared lumpy and not smooth.
Observation and subsequent interview on 06/23/21 at 1:10 P.M. via test tray with Dietician #600 confirmed the pureed potato salad was not smooth and was not the correct consistency. Five nickel-sized, cubed-shaped chunks of potato were observed in one serving of pureed potato salad. Dietician #600 confirmed Resident #7, Resident #5, Resident #10, and Resident #29 received the inaccurately pureed potato salad for lunch 06/23/21.
Review of a facility policy titled, Homemade Puree, undated, revealed staff measured out the portion of food needed to puree and placed food in a blender or processor. Staff then gradually added liquid, cover, and pulse on-off until the food was course. The policy then directed staff to puree until the food was smooth.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observation, interview and policy review, the facility failed to maintain sanitary conditions during meal preparation. This affected all residents who ate from the kitchen except Resident #71...
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Based on observation, interview and policy review, the facility failed to maintain sanitary conditions during meal preparation. This affected all residents who ate from the kitchen except Resident #71, Resident #63, and Resident #12.
Findings include:
1.
Observation and subsequent interview on 06/21/21 at 10:30 A.M. with Dietician #600 revealed there were conglomerated strings and clumps of dust hanging from the light covers over the entire meal preparation area that was easily visible. Dietician #600 confirmed the presence of the dust build-up on the lighting fixtures over the meal preparation area.
2.
Observation and subsequent interview on 06/23/21 at 10:38 A.M. with Dietary Staff #313 revealed during the process of pureeing resident meals, he doffed his gloves, removed the lid of the refuse can, disposed of trash, and took soiled utensils to the three-compartment sink. Dietary Staff #313 then placed both soiled hands on the open, top rim of the thickener powder contained, and moved the container eight inches down the preparation table. Dietary Staff #313 confirmed his hands were soiled when he moved the thickener container that had no lid. He confirmed he should have completed hand hygiene prior to moving the opened thickener.
3.
Observation on 06/23/21 at 10:55 A.M. revealed Dietary Staff #313 placed a scoop on the soiled preparation counter that had various meat and meat fluid splattered intermittently across the preparation area. Observation and subsequent interview on 06/23/21 at 11:03 A.M. revealed Dietary Staff #313 picked up the soiled scoop and used it to scoop potato salad out of a large vat of potato salad and into the food processor. Immediate interview with Dietary Staff #313 confirmed the food preparation table was soiled and he used a soiled scoop and placed it into the potato salad.
Review of a facility policy titled, Sanitization, last revised October 2008, revealed the food service area would be maintained in a clean and sanitary manner. The policy revealed all kitchens, kitchen areas, and dining areas would be kept clean. All equipment, food contact surfaces, and utensils should be washed. Further review of the policy revealed the Food Services Manager was responsible for scheduling staff for regular cleaning of kitchen and dining areas. Food service staff were trained to maintain cleanliness throughout their work areas during all tasks, and to clean after each task before proceeding to the next assignment.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0730
(Tag F0730)
Could have caused harm · This affected most or all residents
Based on record review and interview, the facility failed to conduct 90-day and annual performance evaluations for two State Tested Nursing Assistants (STNA #614 and #713). This had the potential to a...
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Based on record review and interview, the facility failed to conduct 90-day and annual performance evaluations for two State Tested Nursing Assistants (STNA #614 and #713). This had the potential to affect all resident in the facility. Facility census 83.
Findings include:
1. Review of the personnel records for State Tested Nursing Assistant (STNA) #614 revealed a hire date of 07/17/19. Review of the performance evaluation history revealed the last performance evaluation was completed on 10/31/19. No annual evaluation was present in the employee's file.
2. Review of the personnel records for STNA #713 revealed a hire date of 07/16/20. Review of the performance evaluation history revealed the 90-day performance evaluation was not present in the employee's file.
During interview on 06/23/21 at 4:35 P.M., Administrative Assistant #502 revealed the personnel records were lacking the above information.
Feb 2019
5 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interviews, the facility failed to accurate assess the rejection of care on the minimum...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interviews, the facility failed to accurate assess the rejection of care on the minimum data set (MDS) assessments. This affected two residents (#43 and #56) of 19 resident MDS assessment reviewed. The facility census was 81.
Findings include;
1. Resident #43 was admitted in the facility on 06/06/14 with diagnoses including pneumonia, dysphasia type II diabetes aphasia, hypertension, and major depressive disorder.
Review of the quarterly MDS assessment dated [DATE] stated the resident was unable to complete the Brief Interview for Mental Status (BIMS) due to short and long term memory deficits. In section E0800 the assessments stated the resident does not exhibit or behaviors or rejection of care. He was totally dependent on staff for bed mobility, transfers, and bathing.
Review of the nursing progress note dated 12/15/2018 at 10:02 P.M. stated the resident refused his shower and a bed bath.
Nursing progress note dated 12/28/2018 at 2:09 P.M. stated the nurse spoke with the resident about going to the shower room for showers. He stated no. The resident's plan of care stated he preferred bed baths. The staff will continue to encourage showers but offer bed baths upon refusal.
Review of the plan of care updated on 01/10/19 stated the resident has a behavior problem refusing care of care and treatment . He is non compliance. The goal is for the resident to have fewer episodes of refusing care and showers.
Interview with State Tested Nursing Assistant (STNA) # 87 on 02/06/19 at 10:00 A.M., she stated Resident #43 resists personal care and generally refuses to get out of bed. She stated she will reapproach the resident at least three times before she reports the refusal to the nurse.
Interview with Licensed Practical Nurse (LPN) #20 on 02/6/19 at 10:25 A.M. he stated the resident refuses personal care, showers, bathing, and getting out of bed frequently.
Interview with Registered Nurse (RN) MDS #125 coordinator on 02/06/19 at 11:00 A.M. verified the resident frequently refuses care. She stated she does not complete the behavior section of the MDS. She verified she does sign and verify the information on the MDS is accurate. She verified the 12/18/18 quarterly MDS assessment section E0800 was marked stating the resident was not resistant to care which is inaccurate.
Interview with Registered Social Service Representative on 02/06/19 at 12:30 P.M. verified Resident #43 refuses care on a routine basis. She verified the MDS was coded inaccurately in section E0800.
2. Resident #56 was admitted to the facility on [DATE] with diagnoses including atherosclerotic heart disease of native coronary artery, osteoarthritis. sleep apnea, rheumatoid arthritis vitamin D deficiency, osteoporosis , major depressive disorder, Barrettes esophagus, mood disorder, anxiety disorder , and over active bladder.
Review of the quarterly MDS assessment dated [DATE] reveled the BIMS was 14 indicating the resident had no cognitive deficits. She exhibited verbal behaviors one to three days of the assessment period with no rejection of care under section E0800. She requires extensive assistance of two staff members for transfers and personal hygiene. She is non ambulatory propels wheelchair short distances. The resident is assessed as having no limitation to her upper or lower extremities.
Review of the plan of care dated 01/11/19 stated the resident is resistive to care due to anxiety. The goal is for the resident to participate in care by allowing care. The interventions include to reassure the resident and reattempt care when the resident refuses.
Interview with STNA # 87 on 02/06/19 at 10:00 A.M., stated Resident #56 resists personal care. She stated she will re approach the resident at least three times before she reports the refusal to the nurse. She stated the resident has a lot of facial hair which she will not allow the staff to shave until she wants to be shaved.
Interview with LPN #20 on 02/06/19 at 10:25 A.M. stated the resident refuses personal care, showers, and bathing frequently. He states he can usually encourage her to shower or bathe and shave when the staff reports she is refusing.
Interview with RN MDS #125 coordinator on 02/06/19 at 11:00 A.M. verified the resident frequently refuses care. She stated she does not complete the behavior section of the MDS. She verified she does sign and verify the information on the MDS is accurate. She verified the 01/07/19 quarterly MDS the section E0800 indicated the resident does not resist care which is inaccurate.
Interview with Registered Social Service Representative on 02/06/19 at 12:30 P.M. she verified Resident #56 refuses care on a routine basis. She verified the MDS was coded inaccurately in section E0800.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0645
(Tag F0645)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to follow up on a Pre-admission Screening and Resident Review (P...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to follow up on a Pre-admission Screening and Resident Review (PASARR) determination for Resident #37. This affected one (#37) out of three residents reviewed for PASARR screening. The facility census was 81.
Findings include:
Resident #37 was admitted to the facility on [DATE] with diagnoses including seizures, migraines, chronic obstructive pulmonary disease, bipolar disorder, anxiety disorder, essential hypertension borderline personality and eating disorder.
Review of quarterly minimum data set (MDS) assessment dated [DATE] revealed Brief Interview for Mental Status (BIMS) score was a 15 revealing she is alert and oriented with no cognitive deficits. She has no hallucinations or delusions. She exhibits verbal behavioral symptoms occurred four days of the assessment period. The resident required supervision and setup for all activities of daily living with no hands on assistance. She is always continent of bowel and bladder.
Review of plan of care dated [DATE] stated the resident requires long term care for 24 hour care needs. The interventions include the Guardian is looking into different options for community living. The Guardian is working with home choice to see if it is possible to get her into an apartment.
The plan of care was updated on [DATE] stated the resident needs long term care due to 24 hour care needs. The goal is for the resident to accept needing 24 hour support. Interventions include the resident will be able to make her room as home like as possible.
Review of the PASARR dated [DATE] stated the determination of the Level II PASARR was the resident was approved to stay for a specified period of 90 days for nursing home services. The determination stated it expired on [DATE] if you need an extension it must be requested by [DATE] . The first correspondence regarding an appeal was on [DATE]. Review of an e-mail from Resident #37 guardian dated [DATE] stated he would pick the resident up on [DATE] at 8:45 AM. for an appeal hearing. There is no formal documentation concerning the rescheduling of an appeal hearing and the resident remains in the nursing facility.
Interview with the Registered Social Services (RSS) #100 on [DATE] at 3:45 PM verified she the resident was in a psychiatric hospital in [DATE] and not approved for nursing home placement according to the PASSAR screen completed [DATE]. She stated the guardian has been working on an appeal since [DATE]. She verified there is no documentation when the appeal request was made. She thinks it may have been in [DATE]. She stated when the guardian took her in [DATE] for a an appeal hearing no one was there. She is unaware when another appeal is scheduled.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0646
(Tag F0646)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to refer a resident (#1) who was newly diagnosed mental illness ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to refer a resident (#1) who was newly diagnosed mental illness to the appropriate state-designated authority for a Level II Pre-admission Screening and Resident Review, (PASARR) evaluation. This affected one (#1) out of three residents reviewed for PASARR screening. The facility census was 81.
Findings include:
Review of Resident #1 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #1 include displacement of fistula, end stage renal disease, dementia, schizophrenia, heart disease, bipolar disorder, and chronic obstructive pulmonary disease.
Review of Resident #1's PASARR screening dated 08/21/17 revealed the resident was assessed as having no mental illness prior to admission to the facility.
Further review of Resident #1's record revealed the resident was discharged to the hospital on [DATE] and was re-admitted to the facility on [DATE].
Review of the comprehensive Minimum Data Set, (MDS), significant change assessment dated [DATE] revealed when Resident #1 returned to the facility he was coded in the MDS as having schizophrenia and bipolar disorder.
Review of Resident #1's progress notes reviewed from 03/2018 to 02/2019 revealed no documentation of behaviors relating to schizophrenia or bipolar disease was noted in the progress notes.
Review of Resident #1's physician history and physical dated 09/18/18 revealed Resident #1 has a history of schizophrenia and bipolar disorders.
Interview on 02/07/19 at 10:15 A.M. with Registered Social Services (RSS) #100 revealed Resident #1 went to the hospital on [DATE] and returned to the facility on [DATE]. Per RSS #100 after the resident returned there was a significant change MDS assessment completed with the new diagnoses of schizophrenia and bipolar disorder. RSS #100 verified no new PASARR Level I or Level II had been completed on Resident #1 after he returned to the facility. RSS #100 verified Resident #1 was not referred to any outside agency for an evaluation of the mental illness noted on the MDS significant change assessment.
Interview on 02/07/19 at 3:00 P.M. with the Director of Nursing, (DON), verified Resident #1 was not admitted with the diagnoses of schizophrenia and bipolar disorder on 05/30/17 when first admitted to the facility. The DON verified when the resident was admitted to the hospital on [DATE] and returned on 04/10/18 the resident had schizophrenia and bipolar disorders listed on the resident's history and physical dated 04/10/18. Per the DON the resident had not been offered any services or been evaluated by outside agencies for the mental illnesses or services to be offered.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, staff and resident interview and facility policy, the facility failed to ensure int...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, staff and resident interview and facility policy, the facility failed to ensure interventions were in place to prevent further decreased range of motion for one resident (#14). In addition, the facility failed to provide an exercise program for Resident #56 following a discharge from therapy. This affected two (#14 and #56) out of five residents review for limitations in range of motion. The facility census was 81.
Findings Include:
1. Review of Resident #14's medical record revealed an initial admission date of 09/05/12 and a re-admission date of 01/13/18. Diagnoses included gastrointestinal hemorrhage, muscular dystrophies, cerebral palsy, quadriplegia, and encephalopathy.
Review of Resident #14's Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severe cognitive impairment. In addition, the resident had impairment on both sides of upper extremities.
Review of Resident #14's current care plan revealed was at risk for contractures/impaired functional range of motion of arms and legs related to cerebral palsy. Goal was for the resident to receive restorative passive range of motion to bilateral upper extremities and lower extremities. Interventions included to apply leg ankle foot orthosis (AFO) when out of bed and provide passive range of motion (ROM) to extremities.
Review of Resident #14's physician orders dated 11/01/18 and discontinued on 01/03/18 revealed an order for AFO's to bilateral lower extremities when up every shift.
Review of Resident #14's tasks dated 01/09/19 through 02/05/19 for passive ROM to shoulders, wrist, fingers, ankles, knees and hips revealed the resident did not receive ROM for 15 times during the time period.
Review of Resident #14's Occupational Therapy (OT) evaluation dated 01/03/19 revealed the resident to have contractures of right and left upper extremities.
Review of Resident #14's OT Discharge summary dated [DATE] revealed the resident's current wheelchair did not fit the resident and the resident required AFO's before wheelchair adjustments. Caregiver training was given regarding the resident needing AFO's for lower extremities before wheelchair adjustments could be made.
Review of Resident #14's TAR's dated January 2019 revealed the resident's AFO's to bilateral lower extremities had been discontinued and not re-ordered until 02/06/19.
Review of Interdisciplinary Historical Screen/Data dated 02/06/18 revealed the resident needs a restorative program and could benefit from ROM program for contracture management/prevention.
Observation on 02/05/19 at 1:27 P.M. of Resident #14 revealed the resident to have contractures of bilateral hands with no interventions in place. The resident had bilateral AFO's in place on lower extremities. The AFO's were not listed on the physician orders or on the Treatment Administration Record (TAR). Additional observations of the resident on 02/06/19 and 02/07/19 revealed no interventions in place for the resident's hand contractures.
Interview on 02/05/19 at 2:27 P.M. with Occupational Therapist (OT) #135 stated Resident #14 had been on services to make wheelchair adjustments but the resident's AFO's for his lower extremities had been lost and the wheelchair adjustments were made after finding the AFO's. OT #135 stated the resident should have some kind of hand splints for his hand contractures. OT stated the facility no longer has a restorative program and if any recommendations were are needed upon discharge from therapy then therapy would write non-applicable.
Interview on 02/06/19 at 10:40 A.M. with Registered Nurse (RN) #120 stated Resident #14's AFO's for bilateral lower extremities had been lost for awhile and were discontinued. The resident had been referred to therapy to get new AFO's for lower extremities then the old ones were found. RN #120 stated the resident did have some palm protectors and is not sure where they are. RN #120 verified the resident did not have anything in place on the bilateral upper extremities to prevent further decline. RN #120 stated the facility does not currently have a restorative program.
Interview on 02/06/19 at 9:30 A.M. with Physical Therapist (PT) Director #130 stated usually when a resident discharges from therapy and needs additional care then therapy would recommend restorative therapy. PT #130 stated the facility does not have a restorative therapy program. A discharge communication form is completed and given to nursing with any recommendations.
Review of facility policy titled Resident Mobility and Range of Motion dated July 2017 revealed, residents with limited range of motion will receive treatment and services to increase and/or prevent a further decrease in range of motion. Residents with limited mobility will receive appropriate services, equipment and assistance to maintain or improve mobility unless reduction in mobility is unavoidable.
2. Resident #56 was admitted to the facility on [DATE] with diagnoses including atherosclerotic heart disease of native coronary artery, osteoarthritis. sleep apnea, rheumatoid arthritis vitamin D deficiency, osteoporosis , major depressive disorder, Barrettes esophagus, mood disorder, anxiety disorder , and over active bladder.
Review of the quarterly MDS assessment dated [DATE] reveled the BIMS was 14 indicating the resident had no cognitive deficits She exhibited verbal behaviors one to three days of the assessment period with no rejection of care. She requires extensive assistance of two staff members for transfers and personal hygiene. She is non ambulatory propels wheelchair short distances. The resident is assessed as having no limitation to her upper or lower extremities.
Review of the plan of care dated 01/11/19 stated the resident has osteoporosis. The goal is for the resident to remain free from or at a level of discomfort acceptable to the resident. The interventions include to encourage weight bearing exercise as tolerated to help maintain bone mass. The plan of care states the resident has an self care performance deficit due to limited mobility and strength. The goal is the resident will improve her current level of functioning.
Review of the Occupation Therapy Discharge Summary dated 01/16/19 revealed the dates the resident received occupational therapy were 12/19/18 to 01/16/19. The summary stated the short term goals included bilateral upper extremities strengthening. The resident was discharged to long term care. The discharge recommendations was to continue with home exercises.
Interview with PT #130 on 02/06/19 at 11:20 A.M. stated physical therapy has not worked with Resident #56 for several months. She stated therapy had tried a standing lift which was very unsafe due to the resident having 70 degree contracture of her knees and contractures of her shoulders with osteoporosis.
Interview with OT #135 on 02/06/19 at 12:00 P.M. she stated she gave the resident exercises for upper extremity strengthening upon discharge from occupational therapy on 01/16/19. She verified nursing was not trained to help with the exercises due to not having any restorative nursing programs.
Interview with Resident #56 on 02/07/19 at 1:30 P.M. stated she did not receive exercises for upper body strengthening after she was discharged from occupational therapy. She feels she is weaker and has less strength in her arms now. She is fearful of losing all strength. in her arms.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected most or all residents
Based on review of the facility's infection control log and staff interview, the facility failed to track and trend urinary tract infections in the facility. This affected six out of six months review...
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Based on review of the facility's infection control log and staff interview, the facility failed to track and trend urinary tract infections in the facility. This affected six out of six months reviewed and had the potential to affect all 81 residents residing in the facility. The facility census was 81.
Findings include:
Review of infection log form August 2018 through January 2019 revealed the facility was not tracking the organisms when a culture and sensitivity (C&S) was completed for urinary track infections.
Review of the August 2018 Infection Control Log revealed there were ten residents urinary tract infections in the facility during the month of August. It was documented all ten residents had a urine C&S. Four of the residents had organisms identified as escherichia (E Coli) bacteria found in the gastrointestinal tract. The remaining six residents the log did not state the organism.
Review of the September 2018 Infection Control Log revealed the facility identified four residents with urinary tract infections in the facility. All four of the residents had urine C&S testing. The facility did not identify and track the organisms.
Review of the October 2018 Infection Control Log revealed the facility identified seven residents with urinary tract infections in the facility. All seven of the residents had urine C&S testing. The facility did not identify and track the organisms.
Review of the November 2018 Infection Control Log revealed the facility identified eleven residents with urinary tract infections in the facility. All eleven of the residents had urine C&S testing. The facility did not identify and track of the organisms.
Review of the December 2018 Infection Control Log revealed the facility identified seven residents with urinary tract infections in the facility. All seven of the residents had urine C&S testing. The facility did not identify and track the organisms.
Review of the January 2019 Infection Control Log revealed the facility identified five residents with urinary tract infections in the facility. All five of the residents had urine C&S testing. The facility did not identify and track the organisms.
Interview on 02/07/19 at 11:45 A.M. with Registered Nurse #120 stated she was the facility's infection control nurse. She verified the facility was not tracking organisms and trending the infections though out the building. The facility confirmed this had the potential to affect all 81 residents residing in the facility.
This deficiency represents ongoing non-compliance from the survey dated 01/31/19.
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
- • 38% turnover. Below Ohio's 48% average. Good staff retention means consistent care.
Concerns
- • Multiple safety concerns identified: 1 life-threatening violation(s), $40,053 in fines. Review inspection reports carefully.
- • 28 deficiencies on record, including 1 critical (life-threatening) violation. These warrant careful review before choosing this facility.
- • $40,053 in fines. Higher than 94% of Ohio facilities, suggesting repeated compliance issues.
- • Grade F (33/100). Below average facility with significant concerns.
Bottom line: Trust Score of 33/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is Embassy Of Marion's CMS Rating?
CMS assigns EMBASSY OF MARION an overall rating of 2 out of 5 stars, which is considered below average nationally. Within Ohio, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is Embassy Of Marion Staffed?
CMS rates EMBASSY OF MARION's staffing level at 2 out of 5 stars, which is below average compared to other nursing homes. Staff turnover is 38%, compared to the Ohio average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Embassy Of Marion?
State health inspectors documented 28 deficiencies at EMBASSY OF MARION during 2019 to 2025. These included: 1 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death) and 27 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 Embassy Of Marion?
EMBASSY OF MARION is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by GARDEN SPRINGS HEALTHCARE, a chain that manages multiple nursing homes. With 99 certified beds and approximately 72 residents (about 73% occupancy), it is a smaller facility located in MARION, Ohio.
How Does Embassy Of Marion Compare to Other Ohio Nursing Homes?
Compared to the 100 nursing homes in Ohio, EMBASSY OF MARION's overall rating (2 stars) is below the state average of 3.2, staff turnover (38%) is near the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.
What Should Families Ask When Visiting Embassy Of Marion?
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 you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" These questions are particularly relevant given the facility's Immediate Jeopardy citations and the below-average staffing rating.
Is Embassy Of Marion Safe?
Based on CMS inspection data, EMBASSY OF MARION has documented safety concerns. Inspectors have issued 1 Immediate Jeopardy citation (the most serious violation level indicating risk of serious injury or death). The facility has a 2-star overall rating and ranks #100 of 100 nursing homes in Ohio. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at Embassy Of Marion Stick Around?
EMBASSY OF MARION has a staff turnover rate of 38%, 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 Embassy Of Marion Ever Fined?
EMBASSY OF MARION has been fined $40,053 across 1 penalty action. The Ohio average is $33,479. While any fine indicates a compliance issue, fines under $50,000 are relatively common and typically reflect isolated problems that were subsequently corrected. Families should ask what specific issues led to these fines and confirm they've been resolved.
Is Embassy Of Marion on Any Federal Watch List?
EMBASSY OF MARION 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.