O'BRIEN MEMORIAL HEALTH CARE C
For profit - Corporation
95 Beds
WINDSOR HOUSE, INC.
Data: November 2025
1 Immediate Jeopardy citation
Trust Grade
8/100
#746 of 913 in OH
Photo by Windsor House at O'Brien Memorial
Photo by Windsor House at O'Brien Memorial
Photo by Windsor House at O'Brien Memorial
1 / 5 photos
Last Inspection: June 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
O'Brien Memorial Health Care Center has received a Trust Grade of F, indicating significant concerns and a poor overall standing. Ranked #746 out of 913 facilities in Ohio, they fall in the bottom half of nursing homes, and #13 out of 17 in Trumbull County means there are only a few local options that are better. While the facility is reportedly improving, having reduced issues from 13 in 2024 to 2 in 2025, it still has substantial weaknesses, including $68,952 in fines, which is higher than 87% of Ohio facilities, suggesting ongoing compliance problems. Staffing is average with a 52% turnover rate, and the facility has concerningly low RN coverage compared to 95% of state facilities. Specific incidents include a critical failure to supervise a resident, resulting in sexual abuse, and a serious lack of timely care for another resident, leading to hospitalization for sepsis. Overall, while there are some signs of improvement, families should be cautious due to the facility's troubling past and current challenges.
- Trust Score
- F
- In Ohio
- #746/913
- Safety Record
- High Risk
- Inspections
- Getting Better
- Staff Stability ⚠ Watch
- 52% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ✓ Good
- $68,952 in fines. Lower than most Ohio facilities. Relatively clean record.
- Skilled Nurses ⚠ Watch
- Each resident gets only 19 minutes of Registered Nurse (RN) attention daily — below average for Ohio. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 23 deficiencies on record. Higher than average. Multiple issues found across inspections.
8/100
Bottom 19%
Review needed
13 → 2 violations
★★☆☆☆
2.0
Overall Rating
★★★☆☆
3.0
Staff Levels
★★★★☆
4.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2024: 13 issues
2025: 2 issues
The Good
-
4-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in quality measures, fire safety.
The Bad
2-Star Overall Rating
Below Ohio average (3.2)
Below average - review inspection findings carefully
Staff Turnover: 52%
Near Ohio avg (46%)
Higher turnover may affect care consistency
Federal Fines: $68,952
Well above median ($33,413)
Moderate penalties - review what triggered them
Chain: WINDSOR HOUSE, INC.
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 23 deficiencies on record
1 life-threatening 1 actual harm
May 2025
1 deficiency
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Quality of Care
(Tag F0684)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed medical record review, review of the acute care hospital paperwork, facility policy review and interview, the fa...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed medical record review, review of the acute care hospital paperwork, facility policy review and interview, the facility failed to provide care per physician's orders and failed to timely identify and address a change in condition for Resident #71 resulting in hospitalization.Actual Harm occurred on 03/16/25 when Resident #71 began displaying changes in his baseline mentation, eating patterns, and activity level and staff failed to document, notify the physician and/or timely address the change in condition resulting in Resident #71 continuing to decline without physician notification through 03/22/25 when Resident #71 was transferred to an acute care hospital at the insistence of his family and was diagnosed with sepsis related to aspiration pneumonia and acute metabolic encephalopathy.Findings include: Review of the closed medical record for Resident #71 revealed an admission date of 02/12/25 and a discharge date of 03/22/25. Resident #71 had diagnoses including Alzheimer's disease, chronic obstructive pulmonary disease (COPD), and hypertension.Review of the care plan dated 02/12/25 revealed Resident #71 had a nutritional problem. Interventions included providing diet as ordered and monitoring intake and weight as ordered.Review of a physician's order dated 02/13/25 revealed an order to clean Resident #71's right elbow with normal saline, apply non adherent dressing, and a dry dressing daily. Review of the treatment administration record (TAR) dated February 2025 revealed that the wound care was not provided as ordered on 02/13/25, 02/14/25, 02/18/25, 02/19/25, 02/22/25, or 02/27/25.Review of a physician's order dated 02/13/25 revealed an order to weigh Resident #71 on admission and then every week for four weeks. The order was set to expire on 03/24/25. Resident #71 weighed 119 pounds on admission [DATE]) and at his last weight on 03/10/25 was 110 pounds which was a 7.5% weight loss in less than 30 days, indicating a severe weight loss for the resident. Resident #71 was identified as a weight loss on 03/11/25 and was ordered a dietary supplement twice daily. No further weights were documented. There was no documented evidence the physician was notified of the severe weight loss.Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #71 had severe cognitive impairment with a memory problem. The assessment revealed Resident #71 required staff supervision to moderate assistance for all activities of daily living.Review of the nursing documentation from 03/16/25 to 03/22/25, until the note on 03/22/25 at 12:53 A.M., revealed no documentation, physician notification and/or interventions regarding any changes in Resident #71's baseline mentation, eating patterns, or activity level. Review of skilled nursing documentation dated 03/22/25 at 12:53 A.M. revealed the resident's blood pressure was 114/50, heart rate 81, respirations 18, his pulse oximetry was 94% on room air, and his temperature was 97.9 degrees Fahrenheit.Review of the nursing progress note dated 03/22/25 at 5:41 P.M. revealed Resident #71 was not eating or drinking much since he was sick a week prior and his family was concerned. The doctor was notified, and an order was obtained to transfer the resident to the hospital. Review of the medical record revealed Resident #71 did not return from the hospital. Review of the medical record for Resident #71's stay at the acute hospital revealed he was admitted [DATE] with sepsis protocol. The emergency room placed in an indwelling urinary catheter and the resident required intravenous antibiotics. Resident #71 was also assessed to have bilateral lower lung infiltrates suspected of pneumonia. Hospital diagnoses included sepsis related to aspiration pneumonia and acute metabolic encephalopathy.Interview on 05/20/25 at 11:14 A.M. with Clinical Director #501 confirmed Resident #71 was ordered weekly weights but did not receive one the week of 03/17/25. She also confirmed that no wound care was documented as completed for his right elbow on 02/13/25, 02/14/25, 02/18/25, 02/19/25, 02/22/25, and 02/27/25. Clinical Director #501 also confirmed staff failed to document the resident's identified decline in eating and drinking for a week based on the 03/22/25 nurse's note. In addition, there was no evidence the physician, family or dietician were notified of this change. Telephone interview on 05/20/25 at 1:27 P.M. with Resident #71's daughter reported the resident weighed 107 pounds on 03/22/25, when he went to the hospital. The resident had a raging bladder infection, and his urethra was swollen shut. She also reported that when the resident was admitted to the hospital, they found a fecal impaction and aspiration pneumonia. Resident #71's daughter reported that after going to visit him on 03/22/25, they had had enough, her father was not his normal pleasant self, so the family insisted he be sent to the hospital. The resident's daughter revealed she was glad they insisted on the transfer and indicated the resident would not be returning to the facility due to the concerns they had. Resident #71's daughter reported that her father had been pleasantly confused and loved to be up and about in the facility in his wheelchair but about a week prior to him being transferred to the hospital, he had been refusing to get up and was going to bed earlier than usual. Interview on 05/21/25 at 8:14 A.M. with Licensed Practical Nurse (LPN) Admissions Director #509 revealed she was told Resident #71 would not be returning to the facility following the hospitalization because the family was not happy with his care. Interview on 05/21/25 at 9:40 A.M. with Regional Clinical Supervisor #511 revealed she was aware (through a review of Resident #71's medical record) the facility had not provided care to Resident #71 to timely identify a change in his condition.Review of the facility policy change of condition, resided February 2024, revealed it was the policy of this facility to inform the resident, consult with the resident's physician/health care practitioner, and the resident's representative when there was an accident involving the resident which results in injury and may require physician/medical intervention, a significant change in the resident's physical, mental or psychosocial status, a need to alter treatment significantly or a decision is made to transfer or discharge the resident. Nurses were to document what, where, symptoms, assessments, physician's orders, treatments, and notifications of any change in condition. This deficiency represents noncompliance investigated under Complaint Number OH00164712.
Mar 2025
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
Deficiency F0727
(Tag F0727)
Could have caused harm · This affected most or all residents
Based on interview, documentation of Registered Nurse (RN) coverage review, Payroll Based Journal (PBJ) review and Facility Annual Assessment review, the facility failed to ensure there was adequate R...
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Based on interview, documentation of Registered Nurse (RN) coverage review, Payroll Based Journal (PBJ) review and Facility Annual Assessment review, the facility failed to ensure there was adequate RN coverage for at least eight consecutive hours a day, seven days a week as required. This had the potential to affect all 68 residents residing in the facility.
Findings include:
Review of the Facility Annual Assessment, dated 05/31/24, revealed under licensed nurses the facility would have one full-time Director of Nursing (DON), one full time Clinical Director (not specifying if this was an RN or Licensed Practical Nurse (LPN), and under the area of RN, they would have one full time Minimum Data Set (MDS) RN, one full time Restorative RN plus 100-136 hours of a RN per two weeks. The facility assessment did not reference that they would have at least eight consecutive hours a day, seven days a week as required.
Review of the PBJ Staffing Data Report Certification and Survey Provider Enhanced Reports (CASPER) Report 1705D 07/10/24 through 09/30/24 revealed the facility had four or more days within the quarter with no RN coverage and had a one-star staffing rating.
Review of the facility tracking calendars for RN coverage for July 2024, August 2024, September 2024, October 2024, November 2024, December 2024, January 2025, February 2025, and March 2025 revealed on 07/05/24, 07/06/24, 07/07/24, 07/20/24, 07/21/24, 08/03/24, 08/04/24, 08/17/24, 08/18/24, 09/01/24, 09/14/24, 09/15/24, 09/28/24, 09/29/24, 10/26/24, 10/27/24, 11/09/24, 11/10/24, 12/07/24, 12/08/24, 12/21/24, 12/22/24, 01/04/25, 01/05/25, 01/18/25, 01/19/25, 02/01/25, 02/02/25, 02/15/25, 02/22/25, 03/01/25, 03/02/25, 03/08/25, and 03/09/25, there was not an RN for eight consecutive hours.
On 03/14/25 at 12:59 P.M., an interview with Regional Administrator #610 verified the facility was without an RN on the days listed above and verified the PBJ Report was accurate. She revealed she did not realize the Administrator thought he only had to have two hours of RN coverage per day, not eight.
On 03/14/25 at 1:05 P.M. and 1:12 P.M., an interview with the Administrator revealed he thought he only needed two hours of RN coverage per day not eight hours. He also verified the facility was without an RN on the days listed above and verified the PBJ Report was accurate.
This deficiency represents non-compliance investigated under Complaint Number OH00161619.
Aug 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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and policy review the facility failed to ensure the kitchen was maintained in a clean and sanit...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and policy review the facility failed to ensure the kitchen was maintained in a clean and sanitary manner. This had the potential to effect 75 of the 77 residents who ate food prepared in the kitchen. Residents #13 and #18 did not take any nourishment by mouth.
Findings include:
Observations on 08/07/24 at 8:14 A.M., during a tour of the kitchen with the administrator, revealed multiple concerns with kitchen cleanliness. Of the two hand washing stations, both were unclean and there were water stains and soap scum on the sink and back splash and grime around the faucets and handles. The hand washing station located next to the rear exit door did not have paper towels. The [NAME] shelf located beneath a workstation near the entrance to the kitchen had dried food debris on the bottom shelf and employee personal items including keys and a beverage cup with a lid and straw were sitting on top of the workstation. The bottom shelf of the workstation located next to the two-compartment sink where baking pans and other food prep items were stored had a large amount of dried food debris underneath the baking pans. Observation of the walk-in cooler revealed dark black spots covering the two large, grated shelving units, walls, and ceiling which came off when a finger ran over the areas. The fan inside the cooler was covered in black dust. The floor and the seam where the floor and wall met the cooler had dried food and other unidentified caked on debris.
Interview on 08/07/24 at 11:40 A.M. with Regional Administrator #200 confirmed the walk-in cooler contained what looked like mold and any food that was not in a sealed box was discarded.
Review of the State of Ohio Food Inspection Report dated 07/30/24 revealed cleanliness of equipment and food contact surfaces and utensils were a repeat violation. The report also revealed no paper towels were observed at the handwashing sink during the inspection.
Review of the Kitchen Floor Cleaning and Maintenance Policy dated March 2023 revealed staff were to deep clean the kitchen floor every four to six weeks.
Review of the Walk-in Freezer and Walk-in Cooler Policy dated 10/17/23 revealed the walk-in cooler was to be cleaned, swept, and mopped once weekly.
Interview with the Assistant Director of Nursing on 08/07/24 at 2:30 P.M. revealed Residents #13 and #18 received nothing by mouth.
This deficiency represents non-compliance investigated under Complaint Number OH00155377.
Jun 2024
9 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
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, record review, review of facility self-reported incidents (SRIs), and facility policy review t...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, record review, review of facility self-reported incidents (SRIs), and facility policy review the facility failed to ensure physician's orders were followed to prevent potential resident-to-resident abuse. This affected three residents (#7, #21, and #37) of 18 residents reviewed for abuse. This had the potential to affect three other residents (#18, #19, and #67) on the 400-Unit. The facility census was 81.
Findings include:
Review of the medical record for Resident #37 revealed an admission date of 12/15/23 with diagnoses including schizoaffective disorder bipolar type, mild cognitive impairment, and anxiety.
Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #37 was able to understand staff and was able to be understood. She refused to answer questions on the cognitive assessment; however, staff stated she had impaired memory. Resident #37 knew she was in a nursing home, where her room was, staff names and faces, and the season. Staff stated Resident #37 was independent regarding decision making for tasks of daily life.
Review of the facility SRIs tracking number 247416 dated 05/12/24 revealed at 1:20 P.M. Resident #37 went into Resident #21's room and slapped her in the face. No injuries were noted, and Resident #37 was placed on 15-minute-checks. Additionally, a door alarm was placed to notify staff of wandering.
Review of the facility SRIs tracking number 247423 dated 05/12/24 revealed at 18:15 P.M. a state tested nurse aide (STNA) had just left a resident's room after providing care and observed Resident #37 stand, approach Resident #7 and slap her once on both sides of the face. The STNA immediately responded and placed Resident #37 on a couch in the lounge area. Resident #7 was taken to her room. Both residents were assessed, and no injuries were noted. Resident #37 was provided one-on-one supervision until transported to the hospital for evaluation for escalating behaviors. While at the hospital, Resident #37's labs and urinalysis were withing normal limits. When she returned to the facility, she continued on one-on-one observations at all times to monitor behaviors.
Review of the monthly physician's orders for June 2024 revealed Resident #37 had an order dated 05/13/24 for constant one-on-one supervision for prevention and safety.
Review of the medication administration record (MAR) and treatment administration record (TAR) for June 2024 for Resident #37 revealed staff were documenting she was to have one-on-one supervision.
Review of the nursing progress note dated 06/09/24 at 10:20 A.M. revealed Resident #37 had behaviors with attempting to touch and sit on other residents. Staff had separated her from other residents, and the physician was updated. A new order was obtained to send the resident to the emergency room to be evaluated. The nursing progress note on 6/10/24 at 1:49 A.M. stated Resident #37 was back at the facility and an intervention of one-on-one supervision was initiated as well as 15-minute safety checks.
Observation with Registered Nurse (RN) #1275 on 06/11/24 at 9:26 A.M. revealed Resident #37 to be in her room, awake and lying in her bed. There were no staff in her room or in the hallway on the unit. RN #1275 verified Resident #37 was to have someone with her at all times. RN #1275 was only able to find one staff member, State Tested Nurse Aide (STNA) #1223 who was in the lounge/common area out of view from Resident #37's room. STNA #1223 came to Resident #37's room and stated she was the only staff member on the unit to care for six residents. STNA #1276 went on break which left only her on the unit. On 06/11/24 at 9:30 A.M., STNA #1276 returned to the unit and stated she had been on her 15-minute break. She stated she left the floor at 9:20 A.M. and was unaware that she was supposed to update staff on other units that she would need someone to replace her so that STNA #1223 could continue to perform one-on-one supervision to Resident #37.
Interview on 06/11/24 at 9:47 A.M. with the Director of Nursing (DON) verified Resident #37 had an order for one-on-one supervision due to escalated behaviors on 06/09/24. She stated staff should stay with the resident and call staff on other units when they needed a break so they could replace her on the floor.
Review of the facility policy titled, Resident Abuse Prevention Practices, revised October 2022, revealed it was the policy of the facility to protect all residents from abuse.
This deficiency represents non-compliance investigated under Complaint Number OH00154456.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy review the facility failed to maintain a functioning alarm f...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy review the facility failed to maintain a functioning alarm for Resident #38 as ordered by the physician. This affected one resident (#38) out of four residents reviewed for alarms. The facility census was 81.
Findings include:
Review of the medical record for Resident #38 revealed an admission date of 03/16/22 with diagnosis of dementia.
Review of the physician's order dated 03/20/24 revealed Resident #38 had an order for a door alarm to the bathroom door that exited into room [ROOM NUMBER] to alert staff if he attempted to enter room [ROOM NUMBER]. Every shift was to check the function of this alarm.
Review of the medication administration record (MAR) and treatment administration record (TAR) for March 2024 through June 2024 revealed staff had not documented they had ensured the alarm was functioning on afternoons on 03/23/24, 03/24/24, 03/26/24, 03/29/24, 04/18/24, 04/20/24, 04/24/24, 05/23/24, 05/28/24, and on nights on 03/22/24 and 04/23/24.
Observation and interview on 06/06/24 at 10:22 A.M. with Resident #38 revealed there was an alarm on the bathroom door because women were in the adjacent room. He stated the alarm helped so he did not get confused going out the wrong bathroom door. Observation revealed the alarm was not on and functioning when the door was opened and entering the adjacent room out of the bathroom.
Observation and interview on 06/10/24 at 10:29 A.M. with Licensed Practical Nurse (LPN) #1216 revealed Resident #38's bathroom door alarm, which lead to the adjacent room (female resident room), did not have a functioning alarm. LPN #1216 turned on the alarm and stated staff would turn the alarm off and forget to turn it back on.
Review of the facility policy titled, Alarms: Bed, Chair, Door, Floor Alarms, Motion Detection, revised February 2024, revealed staff would check that alarms were functioning properly when assisting residents with care. Residents were not to be left unattended when alarms were removed or shut off.
This deficiency represents non-compliance investigated under Complaint Number OH00154456.
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 F0760
(Tag F0760)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and facility policy review the facility failed to ensure Resident #2 was free of significant...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and facility policy review the facility failed to ensure Resident #2 was free of significant medication errors. This affected one resident (#2) of 33 residents reviewed during the annual survey. The facility census was 81.
Findings include:
Review of medical record for Resident #2 revealed an admission date of 01/25/24 with diagnosis including leukemia (blood cancer that affects the production and function of blood cells) not having achieved remission.
Review of the discharge instructions from the hospital on [DATE] revealed Resident #2 was ordered Bosutinib (medication used to treat types of blood cancers such as leukemia) 500 milligrams (mg) one tablet a day for leukemia and Nilotinib HCl (medication used to treat leukemia) 200 mg one capsule two times a day related to leukemia. Both of these medications were considered oral chemotherapy drugs.
Review of the care plan dated 01/26/24 for Resident #2 revealed she had leukemia and was on an oral chemotherapy drug. Interventions included administering medications as ordered.
Review of the monthly physician's orders for January 2024 through April 2024 for Resident #2 revealed she had an order for Bosutinib 500 mg one tablet a day for leukemia dated 01/25/24. This medication was discontinued on 02/05/24. Resident #2 also had an order for Nilotinib HCl 200 mg one capsule two times a day for leukemia dated 01/25/24.
Review of the Medication Administration Record (MAR) for January 2024 through April 2024 for Resident #2 revealed the following:
Bosutinib 500 mg was not given on 01/26/24, 01/27/24, 01/28/24, 01/29/24, 01/30/24 and 01/31/24 due to the medication not being available.
Nioltinib 200 mg was not given in the morning on 01/26/24, 01/27/24, 01/28/24, 02/26/24, 02/27/24, 02/28/24, 02/29/24, 03/29/24, 03/30/24, 04/01/24, 04/02/24, 04/03/24, 04/06/24, 04/07/24, 04/08/24, 04/09/24, 04/10/24, 04/11/24, 04/12/24, 04/13/24, 04/16/24, 04/17/24, 04/18/24, 04/19/24, 04/21/24, 04/22/24, 04/23/24, 04/24/24, 04/25/24, 04/26/24, and at night on 01/26/24, 01/27/24, 02/26/24, 02/27/24, 02/28/24, 03/28/24, 03/29/24, 04/01/24, 04/02/24, 04/03/24, 04/04/24, 04/05/24, 04/06/24, 04/07/24, 04/08/24, 04/09/24, 04/10/24, 04/11/24, 04/12/24, 04/14/24, 04/15/24, 04/17/24, 04/18/24, 04/20/24, 04/21/24, 04/22/24, 04/23/24 and 04/24/24, due to the medication being on order, not available, or awaiting delivery from the pharmacy.
Review of the nursing progress notes dated 01/26/24 through 04/24/24 revealed Resident #2's oncologist was not notified of the oral chemotherapy medications being unavailable.
Interview on 06/12/24 at 10:25 A.M. with Pharmacist #1297 verified the pharmacy had not sent Resident #2's oral chemotherapy medication to the facility until 04/24/24. She stated prior to that time, the pharmacy was unable to provide this medication due to insurance not covering the medication and cost.
Interview on 06/12/24 at 10:32 A.M. with Registered Nurse (RN) #1232 revealed she was aware there was an issue with getting Resident #2's oral chemotherapy medications as the insurance would not cover it, so the pharmacy would not send the medication. She stated Resident #2's oncologist was aware and stated to hold the medication until the facility received it. She did verify before the facility admitted someone, the admissions office reviewed the resident's medications to ensure they could provide the care and services to the resident. She was unable to state why the medications were not available on admission if the facility had followed this process. RN #1232 stated she was also not aware Resident #2 had any further appointments with her oncologist, Physician #1296.
Interview on 06/12/24 at 11:10 A.M. with Physician #1296 revealed he saw Resident #2 on 06/12/24 in his office. He stated her previous appointment was on 02/28/24. Physician #1296 stated he only provided prescriptions for oral chemotherapy medications monthly and needed to see the resident in the office every month to assess her. At the office visit he would provide the prescription for the oral chemotherapy medication. He verified the facility had not called his office after 02/28/24 to update him that Resident #2 was not taking her medications due to unavailability. He was unable to confirm or deny if this delay in medication hindered her treatment course.
Review of the facility policy titled, Medication Administration, revised May 2024, revealed nursing staff were to review the electronic medication administration record for medication administration orders and instructions and to provide the medication within one hour prior to or after the time ordered. There was nothing in the facility procedure to advise nursing staff on what to do if the medication was unavailable except that a pharmacy policy and procedure manual was available for additional guidance.
This deficiency represents non-compliance investigated under Complaint Number OH00154456.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy review the facility failed to ensure medications were dispos...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and facility policy review the facility failed to ensure medications were disposed of when they had expired. This affected 12 residents (#15, #32, #53, #72, #78, #177, #178, #180, #226, #227, #228, and #276) who had received expired tuberculin tests (medication to test for tuberculosis) with the potential to affect all residents in the facility. The facility census was 81.
Findings include:
Observation on [DATE] at 7:44 A.M. of the medication storage room located on the 600-hall with Registered Nurse (RN) #1293 revealed a bottle of Tuberculin, Purified Protein Derivative, Diluted Aplisol five milliliters (mL) that contained 50 tests, lot #68154. The date opened on the bottle stated [DATE].
Interview with RN #1293 at the time of the observation verified the medication was expired, and she discarded the medication.
Review of the list provided by the facility of residents that were given tuberculosis (TB) tests for lot #68154 after the medication had expired on [DATE] included Residents #15, #32, #53, #72, #78, #177, #178, #180, #226, #227, #228, and #276.
Review of the facility policy titled, Medication Administration, revised [DATE], revealed the facility should follow manufacturer instructions for expiration dates of medications.
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, interview, and facility policy review the facility failed to ensure foods were stored in a manner to prevent contamination and foodborne illness. This had the potential to affect...
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Based on observation, interview, and facility policy review the facility failed to ensure foods were stored in a manner to prevent contamination and foodborne illness. This had the potential to affect all residents who received food from the kitchen. The facility identified two residents (#27 and #36) who received no food by mouth. The facility census was 81.
Findings include:
Observation on 06/10/24 at 8:04 A.M. of the kitchen revealed the following items open and undated in the dry storage area: one bag of potatoes, one bag of cornflakes, one bag of Cheerios, one box of pancake batter, three bags of pasta, and one jar of syrup. There were also three bags of hoagie buns that expired on 05/28/24. The cooler contained the following open and undated items: nine packs of strawberries, two bags of lettuce, one container of salad mix, one tomato, half of an onion, one bag of cucumbers, and 13 prepared cups of juice. The refrigerator contained the following items open and undated: three hard boiled eggs, two boxes of chicken breasts, three packs of lunch meat, two bags of shredded cheese, one-half full container identified by [NAME] #1262 as chicken noodle soup, one bag of cooked bratwurst, and one-half full container of applesauce as identified by [NAME] #1262. There was also one bucket of pickles open and undated on the floor and one three-fourths full gallon of milk with no cap. The freezer contained the following open and undated items: one box of mixed vegetables, one bag of sausage links, one bag of green beans, one bag of chicken tenders, and one frozen pizza. There was also one box of French fries, one box of chicken filets, one box of frozen pizza, and one box of beef stew directly on the freezer floor.
Interview at the time of the above observation with [NAME] #1262 confirmed food should be labeled with both an open and use by date, and no boxes should be stored on the floor. He also confirmed the expired hoagie buns and other items identified during the tour as open and undated.
Review of the facility policy titled Covering, Labeling and Dating Food, dated March 2023, revealed all food stored would be covered, labeled, and dated, fresh fruits should contain a received on date, and food would be discarded by the manufacturer's use by or sell by date.
This deficiency represents non-compliance investigated under Complaint Number OH00154456.
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of medical record for Resident #15 revealed an admission date of 05/30/24 with diagnoses including non-pressure chroni...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of medical record for Resident #15 revealed an admission date of 05/30/24 with diagnoses including non-pressure chronic ulcer of the right foot, cellulitis (skin infection) of the left lower limb, diabetes mellitus, and peripheral vascular disease.
Observation on 06/12/24 at 11:30 A.M. with RN #1275 of intravenous (IV) medication administration to Resident #15 revealed he had a central line venous catheter (a line that is inserted into a vein that leads to the heart). On Resident #15's door leading into the room there was a sign that stated he was on EBP that instructed staff to wear gown and gloves if there was device care including the use of central lines. During observation, RN #1275 performed hand hygiene, put gloves on, cleaned Resident #15's bedside table, removed her gloves, washed her hands, put gloves on, cleaned Resident #15's central line venous catheter tubing end and then flushed the central with 10 milliliters (mL) of normal saline. RN #1275 then hooked the central line venous catheter to the IV tubing that was attached to the antibiotics. At 11:45 A.M. RN #1275 verified she was aware Resident #15 was on EBP but thought it was for wound care only. She verified she had not followed the EBP for the device care.
Review of the physician's orders for Resident #15 revealed an order for contact isolation every shift dated 05/31/24. There was no order for EBP.
Review of the care plan dated 05/31/24 for Resident #15 revealed he had an infection of a wound requiring isolation. Interventions included to provide contact isolation.
Review of the medication administration record (MAR) and treatment administration record (TAR) for Resident #15 for June 2024 revealed nursing staff had been signing off on each shift that Resident #15 should be in contact isolation.
Review of the Resident #15's wound care progress note dated 06/03/24 revealed he had Methicillin-Resistant Staphylococcus Aureus (MRSA) (bacteria that is resistant to commonly used antibiotics) in the left medical lower leg wound and was on IV antibiotics for four weeks.
Interview and observation on 06/12/24 at 1:27 P.M. with RN #1232 verified there was no sign on Resident #15's room alerting staff and visitors that he was in contact isolation. RN #1232 stated Resident #15 had MRSA in his wound that was covered by a wound vac. She stated he was a picker and she believed he had disconnected his wound vac at times as he is non-compliant.
Review of the facility policy titled, Contact Precautions, revised March 2020, revealed gown and gloves should be worn when staff entered the room and removed before leaving the room when a resident was in contact isolation.
Based on observation, interview, record review, and facility policy review the facility failed to initiate and use transmission-based precautions (TBP) and enhanced barrier precautions (EBP) when appropriate for Residents #15, #56, and #179. This affected three residents (#15, #56 and #179) and had the potential to affect all 81 residents residing in the facility.
Findings include:
1. Observation and interview on 06/10/24 at 9:18 A.M. with Resident #179 revealed a tracheostomy was in place. There was no EBP posted and no PPE (personal protective equipment) available near the room entrance.
Review of the medical record for Resident #179 revealed an admission date of 05/29/24. Diagnoses included acute and chronic respiratory failure and tracheostomy status. The physician orders effective June 2024 and care plan dated 05/29/24 indicated tracheostomy care was required at least every shift and more often as needed.
Observation on 06/12/24 at 10:43 A.M. with Registered Nurse (RN) #1266 and Licensed Practical Nurse (LPN) #1268 of tracheostomy care for Resident #179 revealed both nurses entered the room. There were no EBP posted and no PPE available near the room entrance. Gloves were donned after appropriate hand washing, and tracheostomy care was provided. No gowns were worn by either nurse. Interview at the time of the observation with RN #1266 and LPN #1268 verified no EBP were in place, and gowns were not worn during tracheostomy care as required.
Review of the facility policy, Enhanced Barrier Precautions (EBP), dated March 2024, revealed EBP were used in conjunction with standard precautions and expand the use of PPE to donning of gown and gloves during high-contact resident care activities. EBP was indicated for residents with indwelling medical devices including tracheostomies.
2. Resident #56 was admitted on [DATE] with diagnoses that included Alzheimer's disease, osteomyelitis, kidney disease, frontotemporal neurocognitive disorder, anemia, anxiety, and depression.
Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #56 was alert and oriented to person, place, and time. He had an unstageable wound (full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed) on the outside of his left heel.
Observation on 06/11/24 at 1:15 P.M. of a dressing change for Resident #56 revealed he was not ordered to be under EBP due to his pressure wound.
Interview on 06/11/24 at 1:15 P.M. with LPN #1268 revealed his wound was not considered chronic, so there was no EBP needed.
MINOR
(C)
Minor Issue - procedural, no safety impact
Abuse Prevention Policies
(Tag F0607)
Minor procedural issue · This affected most or all residents
Based on record review and interview, the facility failed to ensure all employees had reference checks prior to hire. This affected seven of sixteen employees reviewed for abuse. This had the potentia...
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Based on record review and interview, the facility failed to ensure all employees had reference checks prior to hire. This affected seven of sixteen employees reviewed for abuse. This had the potential to affect all 81 residents residing in the facility.
Findings include:
Review of the employee file for [NAME] #1262 revealed a hire date of 01/12/22. There was no documented evidence reference checks were completed upon hire.
Review of the employee file for State Tested Nurse Aide (STNA) #1249 revealed a hire date of 01/31/23. There was no documented evidence reference checks were completed upon hire.
Review of the employee file for Licensed Practical Nurse (LPN) #1229 revealed a hire date of 05/14/23. There was no documented evidence reference checks were completed upon hire.
Review of the employee file for STNA #1217 revealed a hire date of 10/17/23. There was no documented evidence reference checks were completed upon hire.
Review of the employee file for LPN #1257 revealed a hire date of 03/26/24. There was no documented evidence reference checks were completed upon hire.
Review of the employee file for Housekeeper #1256 revealed a hire date of 03/26/24. There was no documented evidence reference checks were completed upon hire.
Review of the employee file for Dietary Supervisor #1243 revealed a hire date of 04/10/24. There was no documented evidence reference checks were completed upon hire.
Interview on 06/12/24 at 10:38 A.M. with the Administrator confirmed there was no documented evidence reference checks were completed for the above employees.
This deficiency represents non-compliance investigated under Complaint Number OH00154456.
MINOR
(C)
Minor Issue - procedural, no safety impact
Deficiency F0730
(Tag F0730)
Minor procedural issue · This affected most or all residents
Based on employee personnel file review and interview, the facility failed to ensure State Tested Nurse Aide (STNA) evaluations were completed within 90 days of hire and annually. This affected six ST...
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Based on employee personnel file review and interview, the facility failed to ensure State Tested Nurse Aide (STNA) evaluations were completed within 90 days of hire and annually. This affected six STNA's of six reviewed for performance. This had the potential to affect all 81 residents residing in the facility.
Findings include:
Review of the employee file for STNA #1219 revealed a hire date of 06/14/21. There was no documented evidence of an annual evaluation.
Review of the employee file for STNA #1212 revealed a hire date of 01/24/21. There was no documented evidence of an annual evaluation.
Review of the employee file for STNA #1200 revealed a hire date of 11/19/21. There was no documented evidence of an annual evaluation.
Review of the employee file for STNA #1249 revealed a hire date of 01/31/23. There was no documented evidence of an annual evaluation.
Review of the employee file for STNA #1233 revealed a hire date of 04/21/23. There was no documented evidence of an annual evaluation.
Review of the employee file for STNA #1217 revealed a hire date of 10/17/23. There was no documented evidence a 90-day evaluation was completed.
Interview on 06/12/24 at 10:38 A.M. with the Administrator confirmed there was no evidence 90-day evaluation for STNA #1217or annual evaluations for STNAs #1219, #1212, #1200, #1249, and #1233.
MINOR
(C)
Minor Issue - procedural, no safety impact
Deficiency F0839
(Tag F0839)
Minor procedural issue · This affected most or all residents
Based on personnel file review and interview, the facility failed to ensure Licensed Practical Nurse (LPN) #1229 had an active and unrestricted nursing license prior to hire. This affected one of thre...
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Based on personnel file review and interview, the facility failed to ensure Licensed Practical Nurse (LPN) #1229 had an active and unrestricted nursing license prior to hire. This affected one of three personnel files reviewed for staff qualifications. This had the potential to affect all residents residing in the facility. The facility census was 81.
Findings include:
Review of the personnel file for LPN #1229 revealed a hire date of 05/14/24. There was no documented evidence LPN #1229's license was verified prior to starting work.
Interview on 06/12/24 at 12:57 P.M. with the Administrator confirmed there was no documented evidence of licensure verification in LPN #1229's file.
Review of the document titled License Look Up dated 06/21/24 and timed 1:13 P.M. confirmed LPN #1229 had an active and unrestricted nursing license.
Apr 2024
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Free from Abuse/Neglect
(Tag F0600)
Could have caused harm · This affected 1 resident
Based on record review, review of the facility Self-Reported Incident (SRI), interview with facility staff, and review of the facility's policy on abuse, the facility failed to ensure Resident #65 and...
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Based on record review, review of the facility Self-Reported Incident (SRI), interview with facility staff, and review of the facility's policy on abuse, the facility failed to ensure Resident #65 and Resident #87 were free from sexual abuse. This affected three residents (Resident #27, Resident #65, and Resident #87) of three residents reviewed for sexual abuse. The facility census was 85.
Findings include:
Review of the medical record for Resident #27 revealed an admission date of 02/05/24 with diagnosed included but not limited to Parkinson's disease without dyskinesia, without mention of fluctuations, dementia in other diseases classified elsewhere unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety with other behavioral disturbance, major depressive disorder, and unspecified disorder of adult personality and behavior.
Review of the behavior care plan, dated 02/05/24, revealed Resident #27 had behaviors to include sitting next to female residents in the lounge and holding hands. Resident #27 has been sent out to psychiatric services for inappropriate behavior. Interventions included administer medications as ordered, monitor/document for side effects and effectiveness, anticipate resident needs, assist resident to develop more appropriate methods of coping and interaction, encourage resident to express feelings appropriately, educate resident/family/caregivers on successful coping and interaction strategies, explain all procedures, if reasonable discuss resident's behavior, intervene as necessary to protect the rights and safety of others, approach in a calm manner, divert attention, remove from situation and take to alternate location as needed, minimize potential for the resident's disruptive behaviors, monitor behavior episodes and attempt to determine underlying cause, praise any indication of progress/improvement in behavior, 15 minute safety checks, room located near nurses' station, and one on one sitter.
Review of the admission Minimum Data Set (MDS) Assessment, dated 02/14/24, revealed Resident #27 had impaired cognition. No behaviors or mood was noted.
Review of the following information revealed Resident #27 had two incidents of sexual abusive behavior towards Resident #65 and Resident #87:
a. Review of the medical record for Resident #65 revealed an admission date of 03/06/24 with diagnosis included but not limited to unspecified dementia, unspecified severity, with psychotic disturbance, with other behavioral disturbance, delirium due to known psychological condition, and hypothyroidism.
Review of the admission Minimum Data Set (MDS) Assessment, dated 03/13/24, revealed Resident #65 had severely impaired cognition. Behaviors were noted to include physical, verbal towards others and wandering.
Review of Resident #65's care plan dated 03/19/24 revealed the resident had potential to be physically aggressive related to dementia. Resident #65 hits, slaps, kicks, pinches, and attempts to bite staff. Interventions include administer medications as ordered, monitor/document for side effects and effectiveness, assess and address for contributing sensory deficits, analyze time of day, places, circumstances, triggers, and what de-escalates behavior and document.
Review of Resident #27's progress note dated 03/28/24 at 10:30 A.M. revealed State Tested Nursing Assistant (STNA) #187 observed Resident #27 in Resident #65's room. Resident #27 was observed touching Resident #65's breasts on top of her clothes. Residents were immediately separated, and notifications were done. Both resident #27 and Resident #65 were continued on 15-minute checks. Resident #27 was moved to a different unit.
Review of the facility's Self-Reported Incident (SRI) #245723 for sexual abuse, dated 03/28/24, indicated STNA #187 observed Resident #27 in Resident #65's room. Resident #27 was observed touching Resident #65's breasts on top of her clothes. Residents were immediately separated, and notifications were done. Both resident #27 and Resident #65 were continued on 15-minute checks. Resident #27 was moved to a different unit.
B, Review of the medical record for Resident #87 revealed an admission date of 03/05/24 and a discharge date of 04/06/24. Diagnosis included but were not limited to, acute kidney failure, chronic kidney disease, stage 3B, thyrotoxicosis unspecified, type 2 diabetes mellitus (DM) with hyperglycemia, heart failure, and morbid obesity.
Review of Resident #87's admission Minimum Data Set (MDS) Assessment, dated 03/12/4, revealed Resident #87 had intact cognition with no behaviors.
Review of Resident #87's progress note dated 03/29/24 at 11:23 A.M. revealed Resident #87 reported to RN #172 Resident #27 kissed her and touched her breast. Resident #87 had already separated herself from Resident #27 and came to the nurse's station. A skin assessment was completed with no abnormal findings. All notifications to physician and family were done. Resident #27 was provided one on one staff (1:1). All notifications were completed with an order to send Resident #27 out to the hospital for evaluation. Resident #27's family member agreed to transport to hospital. Resident #27's family expressed she feels his behavior is medication related.
Review of Resident #27's progress note dated 03/29/24 at 12:09 P.M. revealed Physician #194 was notified of Resident #27's behavior and gave order to send to hospital due to increased behaviors.
Review of Resident #27's progress note dated 03/29/24 at 1:53 P.M. revealed Resident #87 reported to Registered Nurse (RN) #172 that Resident #27 kissed her and touched her breast. Resident #87 had already separated herself from Resident #27 and came to the nurse's station. Resident #27 was provided one on one staff (1:1). All notifications were completed. Order to send Resident #27 out to the hospital for evaluation. Resident #27's family member agreed to transport to hospital. Resident #27's family expressed she feels his behavior is medication related.
Review of the facility's Self-Reported Incident (SRI) #245753 for sexual abuse, dated 03/29/24, indicated Resident #87 reported to RN #172 Resident #27 kissed her and touched her breast. Resident #87 had already separated herself from Resident #27 and came to the nurse's station. A skin assessment was completed with no abnormal findings. All notifications to physician and family were done. Resident #27 was provided one on one staff (1:1). All notifications were completed. Order to send Resident #27 out to the hospital for evaluation. Resident #27's family member agreed to transport to hospital. Resident #27's family expressed she feels his behavior is medication related.
Interview on 04/09/24 at 2:02 P.M. with Regional Administrator (RA) #193 revealed she found out about both SRI's on 03/28/24 and on 03/29/24 regarding sexual abuse. RA #193 reported on 03/28/24 STNA #187 observed Resident #27 on the locked dementia unit in Resident #65's room fondling her breast. RA #193 reported they were immediately separated and assessed. RA #103 reported Resident #27 was moved off the unit to another unit to be closer to the nurse's desk and on 15-minute checks. RA #193 reported all notifications were done. RA #193 reported on 03/29/24 Resident #27 had kissed and touched the breast of Resident #87. RA #193 reported Resident #87, who is alert and oriented reported the incident to RN #172. RA #193 reported all assessments and notifications were done. RA #193 reported physician ordered Resident #27 to be sent out to hospital for evaluation regarding his behaviors. Resident #27 was put on one on one (1:1) until transferred out to the psychiatric hospital. RA #193 reported Resident #27 was not to return to facility, however on 04/04/24 Resident #27 was sent back to facility. RA #193 reported Resident #27's daughter told the psychiatric hospital to take Resident #27 off all his psychiatric medications. Upon return Resident #27 was on 15 minute checks. RA #193 reported Resident #27 was seen by psychiatric physician and psychiatric nurse practitioner (NP) who put him back on psychiatric medications.
Observation on 04/10/24 at 7:35 A.M. revealed STNA #122 sitting outside of Resident #27's room. The door was closed to his room. Interview with STNA #122 reported Resident #27 was started on 1:1 due to his sexual inappropriate behavior.
Interview on 04/10/24 at 9:13 A.M. with RA #193 revealed Resident #27 was put on 1:1 with sitter last night. RA #193 reported since Resident #27 returned, medication on board, and sitter 1:1 he hasn't had any more incidents. RA #193 reported the sexual behaviors were new to him.
Interview on 04/11/24 at 7:58 A.M. with RN #172 revealed she heard Resident #27 touching Resident #65 inappropriately on the dementia locked unit. She reported the residents were separated and Resident #27 was moved off the unit to another unit to be closer to the nurses' station. Both residents were on 15-minute checks. RN #172 reported she was working the day Resident #87 reported Resident #27 had kissed her and touched her breast. RN #87 reported Resident was already separated from Resident #27. RN #172 reported Resident #27 was sent to hospital for evaluation of behaviors.
Interview on 04/11/24 at 9:25 A.M. with Psychiatric Physician (PP) #194 revealed the sexual behaviors of Resident #27 were new behaviors. PP #194 reported he was notified of the incidents on 03/28/24 and 03/29/24. PP #194 reported the facility had done everything they could to monitor Resident #27's sexual behaviors. PP #104 reported the facility is willing to take the challenging residents that no one else will take, so it only makes sense there will be challenging incidents.
Interview on 4/11/24 at 10;39 A.M. with LPN # 100 revealed on 03/28/24 he worked and was notified by STNA #187 regarding Resident #27 touching breast of Resident #65. LPN #100 reported the residents were immediately separated and once he was notified, he did assessments on both resident and notified physician and family. LPN #100 reported Resident #27 was moved off the unit and physician ordered a psychiatric consult. Both Residents on 15-minute checks.
Interview on 04/11/24 at 11:41 A.M. with STNA #187 revealed on 03/28/24 she observed Resident #27 in Resident #65's room grabbing and squeezing her breast over top of her clothes. STNA #187 immediately separated them and notified LPN #100. STNA #187 reported LPN #100 immediately assessed both residents and notified physician and family. STNA #187 reported Resident #27 was moved to another unit. STNA #187 reported both residents were on 15-minute checks.
Interview on 04/18/24 at 10:58 A.M. with Psychiatric Nurse Practitioner (PNP) #209 revealed she was notified of the two incidents regarding sexual inappropriate touching by Resident #27. PNP #209 reported she saw Resident #27 on 03/26/24 for the first time had she didn't have any sexual behavior concerns. PNP #209 reported he was confused and thought he was in the hospital. PNP #209 reported she made some adjustments to his medications at that time. PNP #209 reported the facility did everything possible to prevent this from happening. PNP #209 reported the facility takes challenging behaviors and you would expect behaviors like this. PNP #209 reported the facility is quite phenomenal monitoring the behaviors.
Review of facility policy titled, Resident Abuse Prevention Practices, dated 10/2022, revealed all residents would be protected from verbal, mental, emotional, or financial abuse by staff, families, residents, visitors or outside ancillary service employees or in any situation that would be harmful to the resident. The facility's policy defines sexual abuse as Non-consensual sexual contact of any type with a resident. Includes but is not limited to sexual harassment, sexual coercion, or physical sexual assault. Sexual contact in non-consensual if either the resident appears to want the contact to occur but lacks the cognitive ability to consent or does not want the contact to occur.
This deficiency represents non-compliance investigated under Complaint Number OH00152730, Complaint Number OH00152066, and is an example of continued non-compliance from the survey dated 02/29/24.
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 F0760
(Tag F0760)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to ensure residents were free from significant medication errors. Thi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews the facility failed to ensure residents were free from significant medication errors. This affected two residents (#47 and #86) out of six residents observed and reviewed for medications. The facility census was 85.
Findings included:
1. Review of medical record revealed Resident #47 was admitted to the facility on [DATE]. Diagnosis included but not limited to surgical aftercare following surgery on the circulatory system, sick sinus syndrome, presence of cardiac pacemaker, COVID-19, bradycardia, tachycardia, tachypnea, and hypertensive crisis.
Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #47 had intact cognition.
Review of the investigation report revealed on 03/02/24 at 8:20 A.M. Licensed Practical Nurse (LPN) #211 administered to Resident #47 the following fourteen medications in error as follows: Colace 1 capsule (for constipation), Lactulose Solution 10 gram (GM)/15 milliner (ML) give 30 ml (for constipation), Glycolax powder 17 gm (for constipation), Ergocalciferol capsule 1.25 milligram (MG) 1 capsule (supplement), Duloxetine Hydrochloride (HCI) Delayed Release (DR) particles 60 mg (antidepressant), Loratadine 10 mg (for allergies), Ropinirole HCI 2 mg 1 tablet (for restless legs syndrome), Trelegy Ellipta inhalation aerosol powder breath activated 100-62.5-25 1 puff inhalation (for chronic obstructive pulmonary disease), Divalproex Sodium oral delayed release 250 mg 2 tablets (mood stabilizer), Namenda 5 mg 1 tablet (for cognitive decline), Apixaban 5 mg (anticoagulant), Metformin 500 mg 1 tablet (for diabetes mellitus), Metoprolol Succinate extended release (ER) 24 hours 50 mg 1 tablet (for hypertension), and Furosemide 40 mg (diuretic). LPN #211 and LPN #212 were suspended pending investigation and LPN #211 was terminated due to the medication errors and LPN #212 turned in her resignation.
Interview on 04/15/24 at 12:11 P.M. with Regional Administrator (RA) #193 revealed she was notified of the wrong medications given to Resident #47. RA #193 reported the physician was notified and ordered to monitor the resident at the facility. RA #193 reported Resident #47's family was notified. RA #193 reported later the day Resident #47 had an emesis and not feeling well and was sent to the hospital for evaluation and returned the same day with no negative outcomes.
Interview on 04/15/24 at 12:17 P.M. with Resident #47's family revealed she was notified immediately of the wrong medications given. Resident #47's family reported she had no negative consequences from the wrong medications given. Resident 47's family reported she had emesis and not feeling right and sent to hospital for evaluation and returned the same day with no new orders.
Interview on 04/16/24 at 9:30 A.M. with Physician # 197 revealed he was notified of the medications given in error to Resident #47 on 03/02/24. Physician #197 reported he doesn't believe the wrong medications caused any negative effect. Physician #197 reported he initially had the staff monitor Resident #47 at the facility. Physician #197 reported Resident #47 had some emesis and was sent to hospital for evaluation and returned same day. Physician #197 reported Resident #47 had similar symptoms prior to this incident and multiple hospital visits for those symptoms.
Interview on 04/17/24 at 9:10 A.M. with Administrator reported she was notified immediately on 03/02/24 by LPN #211 of the wrong medications given to Resident #47. The administrator reported she lives seven minutes from the facility and came to the facility immediately to start the investigation and ensure proper protocols were followed. The administrator reported LPN #211 did not do follow the five rights of medications and took the word of LPN #212 who the resident was.
Review of facility policy, Medication Administration, revised 07/2023, revealed to identify the resident and medications are to be given within one hour prior to or after time ordered.
2. Review of the medical record revealed Resident #86 was admitted to the facility on [DATE] and discharged on 04/02/24 to home. Diagnosis included but not limited to cerebral infarction, traumatic subdural hemorrhage with loss of consciousness, COVID-19, atrial fibrillation, dysphagia, type 2 diabetes mellitus (DM) without complications, depression, displaced comminuted fracture of shaft of right femur, displaced trimalleolar fracture of left lower leg, injury unspecified, unspecified fracture of unspecified lumbar vertebra, multiple fractures of ribs, unspecified, minor contusion of unspecified kidney, sternal manubrial dissociation, and subsequent encounter for fracture with routine healing, contusion of heart.
Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #86 had intact cognition.
Review of Resident #86's physician orders and Medication Administration Records (MARS) for January 2024 revealed the following medications were not administered the day of admission per physician orders: Gabapentin 600 mg 1 tablet three times a day (TID) (for pain) was ordered to start 01/12/24 at bedtime, but was first administered 01/13/24 at bedtime. Methocarbamol 1000 mg 1 tablet four times a day (QID) (for spasms and pain) was ordered to start 01/12/24 at evening, but was first administered on 01/15/24 at bedtime, Sennosides-Docusate Sodium 8.8-50 mg give 2 tablets bid, (for constipation) was ordered to start 01/12/24 in the evening but was first administered on 01/13/24 in the evening.
Review of Resident #86's physician orders and MARS for January 2024 revealed the following medications were ordered for administration the morning of 01/13/24 and were not administered as ordered: Potassium Chloride extended release (ER) 10 milliequivalent (MEQ) one tablet qd (for low blood potassium) was ordered for administration on 01/13/24 in the morning but was administered 01/13/24 in the evening, Aspirin 325 mg 1 tablet bid should have been administered 01/13/24 in the morning but was administered on 01/13/24 in the evening, Bisacodyl EC (enteric coated) DR (delayed release) 5 mg 1 tablet bid (for constipation) should have been administered 01/13/24 in the morning but was administered 01/13/24 in the afternoon, Calcium Citrate tablet 950 mg give 3 tablets bid (for low calcium levels) should have been administered on 01/13/24 in the morning but was administered 01/13/24 in the afternoon, Glycolax Powder give 17 gram bid (for constipation), should have administered 01/13/24 in the morning but was administered 01/13/24 in the afternoon. Resident #86 was ordered to receive Metoprolol Tartrate 75 mg 1 tablet bid (for hypertension) starting 01/13/24 in the morning but it was first administered 01/15/24.
Review of Resident #86's physician orders and MARS for January 2024 revealed the following medications were ordered for administration on 01/13/24 but were not administered as ordered until 01/14/24: Amlodipine Besylate 5 mg 1 tablet (for hypertension), Aspercreme Lidocaine external patch 4% (for pain) apply to skin topically one time a day (QD), Atorvastatin Calcium 40 mg 1 tabled qd (for cardiovascular disease), Docusate Sodium (for constipation) 50 mg capsule give two, Duloxetine HCI delayed release (DR) particles 30 mg 1 capsule in the afternoon (for depression), Farxiga 5 mg 1 tabled qd (for chronic kidney disease), Folic Acid 1 tablet qd (vitamin for anemia), Levothyroxine Sodium 125 micrograms (mcg) (for hypothyroidism), Lisinopril 20 mg 1 tabled qd (to treat high blood pressure/heart failure), Pantoprazole Sodium DR 40 mg qd (gastrointestinal medication).
Further review of Resident #86's physician orders and MARS for January 2024 revealed the resident should have received Trulicity 4.5 mg/0.5 ml inject 4.5 mg subcutaneous (SQ) every Friday (to treat type 2 diabetes mellitus) on 01/19/24 but it was administered 01/26/24.
Interview on 04/16/24 at 12:52 P.M. with RA #193 verified Resident #86's medications were not faxed to the pharmacy on 01/12/24 when the resident was admitted . RA #193 verified Resident #86 did start not receiving any of her medications until 01/13/24, the day following admission.
Interview on 04/17/24 at 11:06 A.M. with RA #193 verified LPN #213 did not put orders in the chart or faxed to pharmacy on 01/12/24 during admission.
Interview on 04/17/24 at 11:27 A.M. with LPN #109 (who is no longer employed at facility) revealed she worked on 01/13/24 and Resident #86's family informed her the resident didn't receive any medications last night. LPN #109 reported she immediately faxed over medications to pharmacy. LPN #109 verified Resident #86 did not receive any medications on 01/12/24.
Interview on 04/17/24 at 11:30 A.M. with LPN #213 via phone revealed she worked 01/12/24 dayshift (6:30 A.M. through 7:00 P.M.). LPN #213 reported she doesn't remember a lot because she is no longer employed at the facility. LPN #213 reported she did everything required for admission assessment and faxed medications to pharmacy. LPN #213 then reported the admission nurse should have faxed medications to pharmacy than changed the report to the midnight nurse should have faxed medications to pharmacy.
Interview on 04/17/24 at 12:46 P.M. with Quality Assurance (QA) Corporate Nurse #195 verified Resident #86 did not receive her medications as ordered by the physician.
Interview on 04/17/24 at 2:15 P.M. via phone with Previous Director of Nursing (DON) #214 revealed she worked as a floor nurse on 01/13/24. DON #214 reported the facility had a lot of admissions and she doesn't really remember this one. DON #214 reported the admission medications should have been done by the admitting nurse and faxed to the pharmacy. DON #214 reported if they weren't done and that was passed along in report she would have done it.
Review of facility policy, Medication Administration, revised 07/2023, revealed to identify the resident and medications are to be given within one hour prior to or after time ordered.
This deficiency represents non-compliance investigated under Complaint Number OH00152066 and Complaint Number OH00152042.
Feb 2024
1 deficiency
1 IJ
CRITICAL
(J)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Free from Abuse/Neglect
(Tag F0600)
Someone could have died · This affected 1 resident
Based on record review, review of the facility self-reported incident (SRI), review of associated investigations, interview with facility staff, and review of the facility's policy on abuse, the facil...
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Based on record review, review of the facility self-reported incident (SRI), review of associated investigations, interview with facility staff, and review of the facility's policy on abuse, the facility failed to provide appropriate supervision for Resident #55 to prevent sexual abuse of Resident #84. This resulted in Immediate Jeopardy on 02/16/24 at approximately 8:30 A.M. when Resident #55 was observed in Resident #84's room with his hand on Resident #84's vaginal area while Resident #84 said no, stop. This affected one resident (#84) reviewed for sexual abuse. The facility census was 83.
On 02/26/24 at 2:16 P.M., the Administrator and Corporate Quality Assurance (QA) Nurse were notified Immediate Jeopardy began on 02/16/24 when Resident #84 was observed against the wall in her room between two beds and with Resident #55 in his wheelchair in front of her. Resident #84's pants and brief were observed around her ankles and Resident #55 was observed with his hand on Resident #84's vaginal area. State Tested Nurse Aide (STNA) #207 responded to hearing Resident #84 saying no, stop and witnessed the incident. STNA #207 told Resident #55 to stop touching Resident #84, after which Resident #55 did stop momentarily and then resumed touching Resident #84's vaginal area. Resident #55 stopped and re-started twice while staff were in the process of separating the two residents. Resident #55 began displaying sexually inappropriate behaviors the day prior and no additional supervision was provided for Resident #55 to ensure the safety of all residents on the secured memory care unit. Upon review of the facility's investigation of the incident, the facility staff responsible for investigating this incident determined that abuse did not occur because both residents were cognitively impaired.
The Immediate Jeopardy was removed on 02/27/24 when the facility implemented the following corrective actions:
•
On 02/16/2024 at 8:35 A.M., Resident #55 was removed from Resident #84's room and placed on 1:1 supervision.
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On 02/16/24 at 8:36 A.M., Licensed Practical Nurse (LPN) #206 completed a body assessment on Resident #84. No signs of injuries were noted on Resident #84. Resident #84's spouse was notified of the event.
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On 02/16/24, LPN #206 completed a body assessment on Resident #55. No signs of injuries were noted on Resident #55.
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On 02/16/24, Director of Nursing (DON) notified Resident #55's guardian of the incident.
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On 02/16/24, Medical Director was notified of the incident and ordered Resident #84 be sent to the hospital.
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On 02/16/24, Resident #84 was sent to the hospital for evaluation.
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On 02/16/24, Resident #84 was transported from the hospital to another nursing facility and will not be returning to O'Brien Memorial Health Care Center.
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On 02/16/24 at 10:15 A.M., LPN #206 performed skin checks on all residents residing on the dementia unit with no noted injuries.
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On 02/16/24 at 12:39 P.M., Resident #55 was kept under direct supervision of staff at all times, until he was transferred to Generations Behavioral Health.
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On 02/16/24 at 12:45 P.M., Regional Quality Assurance (QA) Nurse #205 interviewed all residents on the dementia unit concerning any inappropriate behavior or touching directed to them. No concerns were identified.
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On 02/16/24 at 2:30 P.M., the Inter-Disciplinary Team (IDT) discussed all residents on the unit following a chart review. IDT noted no additional residents with sexualized behaviors.
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On 02/26/24 at 2:40 P.M., Regional QA Nurse #205 educated DON and Registered Nurse (RN) #210. DON and RN #210 began educating all staff on abuse policies, including reporting of escalating resident behaviors (physical, verbal or sexual). Behaviors will be documented in point click care (PCC) progress notes by floor nurses. Behaviors will be communicated to oncoming shift by nurse-to-nurse report, then reviewed by IDT daily (Monday thru Friday) and implement interventions as necessary and update the care plan accordingly. Interventions may include 15-minute checks, 1 on 1 supervision, and/or behavioral health hospitalization. Escalating behaviors that occur on the weekends will be reported to the DON and physician by the floor nurse and immediately addressed. In-service emphasized the facility abuse policies apply to all residents regardless of level of cognition. All staff will be in serviced by 02/27/2024 at 2:30 P.M. Those that are not in-serviced will not be permitted to work until in-servicing is completed.
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On 02/27/24, a Quality Assurance and Performance Improvement (QAPI) meeting was held with the Medical Director, Administrator, DON to discuss the review of the incident and the action plan. No additional measures were added.
•
Starting 02/27/24, the DON or designee will randomly interview three staff three times a week for four weeks to ensure staff understand the abuse policy and know signs and symptoms of escalating behaviors that may make residents at risk for abuse from other residents. The DON or designee will also randomly observe residents throughout the facility three times a week for four weeks for evidence of escalating behaviors and to determine if the behaviors are appropriately addressed.
•
As of 02/27/24 Resident #55 remains at Generations Behavioral Health Care with no current plans of being discharged .
Although the Immediate Jeopardy was removed on 02/27/24 the deficiency remained at a 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:
1. Review of the medical record for Resident #55 revealed an admission date of 10/31/23 with diagnoses including personal history of transient ischemic attack and cerebral infarction without residual deficits, aphasia following cerebral infarction, and dysphagia following cerebral infarction.
Review of the quarterly Minimum Data Set (MDS) Assessment, dated 02/06/24, revealed Resident #55 had severely impaired cognition, had no signs of psychosis or behaviors toward self or others in the previous seven days during the lookback period, and required supervision for wheelchair use.
Review of the progress note dated 02/15/24 at 7:18 A.M. revealed Resident #55 was attempting to grab or touch staff members inappropriately and Resident #55 was observed touching himself inappropriately in the hallway, while attempting to grab at a staff member's genital area. Resident #55 was redirected to his room with good results.
Review of the progress note dated 02/15/24 at 1:18 P.M. revealed Resident #55 had continuing sexual behaviors. Resident #55 saw staff enter the shower room, Resident #55 entered the shower room, pulled out his penis, and began touching himself. Staff redirected Resident #55 to a private area, returning to his room.
Review of the Psychiatric Nurse Practitioner note dated 02/15/24 revealed Resident #55 was assessed due to sexually inappropriate behaviors. Resident #55 began displaying sexually inappropriate behaviors on that day by exposing himself and grabbing at a nurse aide's vaginal area, which the note indicated was uncharacteristic for Resident #55. The note also indicated Resident #55 began to fondle himself while the Psychiatric Nurse Practitioner was evaluating him. There were no signs of mania, hypomania, psychosis, delusions, hallucinations, or paranoia. New diagnoses included cognitive decline likely vascular dementia and excess sexual drive. New orders were added for a urinalysis with culture and sensitivity to rule out a urinary tract infection as an organic cause of the behaviors, Exelon patch daily, Namenda daily, and continue to monitor and support with a follow-up scheduled for two to four weeks from the date of service.
Review of the behavior care plan, initiated on 02/15/24, revealed Resident #55 attempted to grab at staff members inappropriately. Interventions included administer medications as ordered and monitor/document for side effects and effectiveness, anticipate and meet the resident's needs, assist the resident to develop more appropriate methods of coping and interacting, encourage the resident to express feelings appropriately, caregivers to provide the opportunity for positive interaction and attention, stop and talk with resident as passing by, educate the resident on successful coping and interaction strategies, explain all procedures to the resident before starting and allow the resident time to adjust to changes, discuss the resident's behavior and explain why the behavior is inappropriate or unacceptable to the resident, intervene as necessary to protect the rights and safety of others, approach and speak in a calm manner, divert attention, remove from situation and take to alternate locations as needed, minimize potential for the resident's disruptive behaviors by offering tasks which divert attention, monitor behavior episodes and attempt to determine the underlying cause, consider the location/time of day/persons involved/situation and document the behavior with potential causes, praise any indication of the resident's progress or improvement in behavior, and provide a program of activities that is of interest and accommodates resident. There were no interventions identified to provide increased supervision for Resident #55 related to the change in behavior.
Review of Resident #55's urinalysis results, dated 02/15/24, revealed there was no indication of a urinary tract infection.
Review of the progress note dated 02/16/24 at 8:35 A.M. revealed Resident #55 had touched a female resident inappropriately. Resident #55 was assisted back to his room and placed on close observation. Both residents were examined, and no apparent injuries were noted. The physician was notified, and new orders were given for Paxil daily and a psychiatric consult.
Review of the progress note dated 02/16/24 at 10:29 A.M. revealed the nurse was in another room administering medications when she heard a STNA saying stop, no! get away and the nurse stepped into the hallway. Upon entering Resident #84's room, the nurse observed Resident #84 standing against the wall between the beds with her pants and brief down around her knees. The STNA was moving Resident #55 away from Resident #84 and Resident #55 had his arms outstretched toward Resident #84's genital area. Resident #55 was immediately removed from Resident #84's room and Resident #84 was assessed for injury with no injuries identified.
Review of the progress note dated 02/16/24 at 12:07 P.M. revealed the physician ordered for Resident #55 to be sent to a psychiatric hospital for evaluation.
Review of the progress note dated 02/16/24 at 12:39 P.M. revealed Resident #55 was transferred to the psychiatric hospital at that time.
2. Review of the medical record for Resident #84 revealed an admission date of 12/19/23 with diagnoses including dementia, Alzheimer's disease with early onset, unspecified mental disorder, and major depressive disorder.
Review of the quarterly Minimum Data Set (MDS) Assessment, dated 02/02/24, revealed Resident #84 had severe cognitive impairment, had no signs of psychosis or behaviors toward self or others in the previous seven days during the lookback period, and required supervision for activities of daily living (ADLs).
Review of the progress note dated 02/16/24 at 8:35 A.M. revealed a State Tested Nurse Aide (STNA) reported a male resident on the memory care unit was noted touching Resident #84 inappropriately and she yelled for him to stop. Facility staff separated the residents, performed skin checks, and obtained vital signs with no abnormal findings.
Review of the progress note dated 02/16/24 at 9:57 A.M. revealed the nurse was in another room administering medications when she heard a STNA saying stop, no! get away and the nurse stepped into the hallway. Upon entering Resident #84's room, the nurse observed Resident #84 standing against the wall between the beds with her pants and brief down around her knees. The STNA was moving Resident #55 away from Resident #84 and Resident #55 had his arms outstretched toward Resident #84's genital area. Resident #55 was immediately removed from Resident #84's room and Resident #84 was assessed for injury with no injuries identified.
Review of the progress note dated 02/16/24 at 11:18 A.M. revealed emergency services arrived to transport Resident #84 to the hospital for evaluation.
Review of the progress note dated 02/16/24 at 5:40 P.M. revealed Resident #84's husband arrived to the facility to collect Resident #84's belongings and he indicated he was happy Resident #84 was being transferred to another facility.
Review of the emergency department provider note, dated 02/16/24, revealed Resident #84 arrived to the emergency department on 02/16/24 at 10:24 A.M. for evaluation after a suspected sexual assault. Emergency Medical Services (EMS) staff reported to the hospital staff that Resident #84 was in her room when another resident with dementia had her pressed against the wall, Resident #84's pants were down, and she was screaming. EMS staff reported they administered Versed en route for agitation. The physical exam revealed a small, linear abrasion on the anterior wall of the vaginal canal and no other lesions, erythema, ecchymosis, or bleeding was noted. The emergency department physician reviewed and discussed the case, including pertinent history and exam findings, with the medical resident assigned to Resident #84 and agreed with a diagnosis of sexual assault of adult. Resident #84's hospital discharge plan was to discharge to a new nursing facility.
Review of the facility's Self-Reported Incident (SRI) #244255 for sexual abuse, dated 02/16/24, indicated Resident #55 was observed in Resident #84's room with his hands in Resident #84's vaginal area while Resident #84 was telling him to stop. Facility staff observed Resident #84 against the wall in her room between two beds and with Resident #55 in his wheelchair in front of her. Resident #84's pants and brief were observed around her ankles and Resident #55 was observed with his hand on Resident #84's vaginal area. State Tested Nurse Aide (STNA) #207 responded to hearing Resident #84 saying no, stop and witnessed the incident. STNA #207 told Resident #55 to stop touching Resident #84, after which Resident #55 did stop momentarily and then resumed touching Resident #84's vaginal area. Resident #55 stopped and re-started twice while staff were in the process of separating the two residents. Local law enforcement was notified of the incident and a criminal investigation was underway. After investigating the incident, the facility concluded that abuse did not occur because both Residents #55 and #84 were cognitively impaired. The facility came to this conclusion despite the fact that Resident #55 was observed with his hand on Resident #84's vaginal area and that Resident #84 kept saying no, stop while Resident #55 was touching her vaginal area, indicating it was unwanted sexual contact.
On 02/21/24 at 12:50 P.M., interview with Corporate Quality Assurance (QA) Nurse #205 stated the incident between Resident #55 and Resident #84 was reported to local law enforcement and the facility's investigation was still in progress.
On 02/21/24 at 1:48 P.M., interview with Licensed Practical Nurse (LPN) #206 stated, in regard to the incident that occurred on 02/16/24, she was across the hall and heard STNA #207 say no, stop. LPN #206 said upon entering Resident #84's room, she observed Resident #84 to be against the wall with her pants around her knees and her arms crossed over her chest in a guarded position. LPN #206 said STNA #207 removed Resident #55 from Resident #84's room. LPN #206 stated Resident #84 was guarded, and it was difficult to assess her for injury following the incident. LPN #206 said both Resident #55 and Resident #84 were cognitively impaired and unable to state what happened. LPN #206 stated Resident #55 had newly evident sexually inappropriate behaviors toward himself and facility staff within a couple days prior to the incident with Resident #84, but that those behaviors were not directed toward other residents.
On 02/21/24 at 1:56 P.M., interview with STNA #207 stated, in regard to the incident that occurred on 02/16/24, she was walking down the hall carrying a meal tray and pushing an empty wheelchair when she heard Resident #84 saying no, stop and saw Resident #55 in Resident #84's room. STNA #207 said she observed Resident #84 was against the wall between the two beds and Resident #55 was in his wheelchair in front of Resident #84. STNA #207 stated Resident #84's pants and brief were around her ankles and Resident #84 was saying no, no, stop while Resident #55 had his whole hand on her private area and was moving his fingers around. STNA #207 said she loudly told Resident #55 to stop, which he did momentarily and looked at STNA #207 before grabbing Resident #84's vaginal area and resuming moving his fingers around. STNA #207 said in the few seconds it took her to set the meal tray down and separate Resident #55 and Resident #84, she continued loudly telling Resident #55 to stop and he did stop momentarily twice before grabbing Resident #84's vaginal area again. STNA #207 said Resident #84 kept saying no, stop the entire time Resident #55 was touching her. STNA #207 said Resident #84 appeared terrified during the interaction. STNA #207 said Resident #55 had been displaying sexually inappropriate behaviors such as masturbating in the hallway and attempting to grab at staff, but she stated his behaviors were never directed toward another resident prior to this incident.
On 02/21/24 at 2:03 P.M., interview with STNA #208 stated, in regard to the incident that occurred on 02/16/24, she was in the dining room on the memory care unit when she heard STNA #207 yelling in the hallway. STNA #208 said she arrived to Resident #84's room at the same time as LPN #206. Upon entering Resident #84's room, Resident #84 was against the wall between the beds trying to back away from Resident #55 and STNA #207 was removing Resident #55 from the room. STNA #208 stated Resident #84's pants and brief were around her ankles. STNA #208 stated she assisted Resident #84 to the bathroom. STNA #208 stated Resident #84 was very agitated and resistive to allow staff to assess her. She stated staff assessed Resident #84 the best that they could and there were no apparent injuries noted.
On 02/21/24 at 3:49 P.M., interview with the Administrator and Corporate QA Nurse #205 stated the facility's investigation concluded no abuse had occurred because both residents were cognitively impaired. The Administrator stated Resident #84 had a history of being combative with staff and Resident #84 would have been fighting back if she wanted Resident #55 to stop what he was doing. Corporate QA Nurse #205 stated the fact that Resident #55 continued to touch Resident #84 after staff told him to stop was an indication of his impaired cognition because anyone who was caught doing something they knew was wrong would have stopped what they were doing and left the immediate area. Both the Administrator and Corporate QA Nurse #205 stated Resident #55's actions were not willful or deliberate because he did not have the cognition to recognize what he was doing was wrong, so they believed abuse did not occur.
On 02/27/24 at 4:04 P.M., interview with Corporate QA Nurse #205 verified that the emergency department provider note indicated Resident #84 had a small, linear abrasion on the anterior wall of the vaginal canal. In addition, Corporate QA Nurse #205 insisted there was nothing in the provider note that specifically indicated the injury occurred as a result of the incident between Resident #84 and Resident #55.
Review of facility policy titled Resident Abuse Prevention Practices, dated 10/2022, revealed all residents would be protected from verbal, mental, emotional, or financial abuse by staff, families, residents, visitors or outside ancillary service employees or in any situation that would be harmful to the resident. The facility's policy defines sexual abuse as Non-consensual sexual contact of any type with a resident. Includes but is not limited to sexual harassment, sexual coercion, or physical sexual assault. Sexual contact is non-consensual if either the resident appears to want the contact to occur but lacks the cognitive ability to consent or does not want the contact to occur.
This deficiency represents non-compliance investigated under Complaint Numbers OH00151199, OH00151206, and OH00151277.
Apr 2023
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and policy review the facility failed to ensure showers were completed as schedu...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and policy review the facility failed to ensure showers were completed as scheduled and per the resident's preference. This affected two residents (#50 and #73) out of four residents reviewed for showers. The facility census was 68.
Findings include:
1. Review of the medical record for Resident #50 revealed an admission date of 11/18/22. Review of the census revealed Resident #50 was hospitalized [DATE] through 03/02/23. Diagnoses included wedge compression fracture of the first lumbar vertebra, wedge compression fracture of thoracic vertebra number nine and ten, low back pain, personality disorder, major depression, post-traumatic stress disorder, and diabetes.
Review of the Activity Assessment- Comprehensive V2 dated 11/28/22 and completed by Activities Supervisor #675 revealed Resident #50 preferred a shower twice a week before dinner.
Review of the undated facility form labeled, Shower List Tuesday/ Friday revealed Resident #50 was scheduled to receive a shower every Tuesday and Friday in the afternoon.
Review of the facility form labeled Shower Sheet revealed Resident #50 had a shower on 02/07/23 and 03/16/23. She had shower sheets that revealed she had refused a shower on 02/14/23, 03/07/23, and 03/10/23. There were no showers sheets for the days she was scheduled a shower on 02/03/23, 02/10/23, 03/03/23, 03/14/23, 03/21/23, 03/24/23, 03/28/23, 03/31/23, and 04/04/23.
Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #50 had intact cognition. She rejected care daily. She required limited assistance of one person with bed mobility, transfers, and ambulation. She required extensive assistance of one person with personal hygiene. She required physical help from one person in part of bathing activity.
Review of the care plan dated 02/23/23 revealed Resident #50 had an activity of daily living self-care deficit related to decreased mobility, chronic pain, and anxiety. Interventions included one person to assist with showers per schedule, and staff to assist to finish personal hygiene as needed.
Interview on 04/03/23 at 10:05 A.M. with the Ombudsman revealed Resident #50 voiced a concern approximately a month ago that she had not been receiving her shower per her preference and as scheduled. She revealed Resident #50 had revealed she had only received four showers in the last two and a half months at the facility. She revealed she had reached out to the Director of Nursing regarding the concern, and they had not provided an update and/ or documentation that she had received showers.
Interview and observation on 04/03/23 at 12:27 P.M. with Resident #50 revealed she did not get her showers per her preference and as scheduled. She revealed she was to receive a shower twice a week but that she had not had a shower for at least 13 days. She revealed she felt her hair was greasy since it had not been washed in 13 days. Observation revealed her hair appeared greasy.
Interview on 04/03/23 at 4:24 P.M. and on 04/04/23 at 10:44 A.M. with the Director of Nursing verified Resident #50 had a preference and was scheduled to receive a shower every Tuesday and Friday. She verified she did not have documentation Resident #50 had a shower and/or was offered a shower on the following scheduled shower days: 02/03/23, 02/10/23, 03/03/23, 03/14/23, 03/21/23, 03/24/23, 03/28/23, 03/31/23, and 04/04/23. She verified she had no documentation Resident #50 received a shower and/or was offered a shower from 02/15/23 to 02/21/23 (seven days), and from 03/17/23 to 04/03/23 (18 days). She revealed she was not aware Resident #50 had voiced a previous concern to the Ombudsman regarding not getting her showers per her preference and/or as scheduled.
2. Review of the closed medical record for Resident #73 revealed an admission date of 12/14/22 and a discharge date of 12/29/22. Diagnoses included chronic obstructive pulmonary disease, muscle weakness, morbid obesity, lymphedema, and lack of coordination.
Review of the care plan dated 12/14/22 revealed Resident #73 had a person-centered care plan. Intervention included one staff assist with bathing and grooming.
Review of the facility form labeled Shower Sheet revealed Resident #73 had a shower on 12/18/22. On 12/27/22 she refused a shower but did have a bed bath completed on this day.
Review of the admission MDS assessment dated [DATE] revealed Resident #73 had intact cognition. She required extensive assistance of two people with bed mobility, transfers, dressing, personal hygiene, and toileting. She required physical help from two people in part of the bathing activity.
Review of the facility form labeled ITM Meeting-V1 dated 12/28/22 and completed by MDS/ Licensed Practical Nurse (LPN) #608 revealed an interdisciplinary team meeting was held on 12/28/22 with Resident #73. The form revealed her bathing preference was to have a shower twice a week.
Interview on 04/03/23 at 9:59 A.M. with Resident #73 revealed she preferred to have a shower at least twice a week while at the facility, but she had gone over ten days without a shower. She revealed she was unhappy with the care and services she received while at the facility, especially her personal hygiene including showers.
Interview on 04/03/23 at 4:24 P.M. and on 04/04/23 at 10:44 A.M. with the Director of Nursing verified staff were to document per the shower sheet when a resident had a shower. She verified Resident #73's preference and schedule were to receive a shower twice a week. She verified Resident #73 went from 12/19/22 to 12/26/23 (eight days) without any documentation that Resident #73 received a shower and/or had documentation she had refused a shower.
Review of the facility form labeled Shower Sheet revealed the facility staff were to document on the form when a shower was provided. The form revealed staff would complete the form and turn the form into the floor nurse. The form revealed the floor nurse would check and sign the completed sheet. The form revealed if a resident refused the shower and/or bath, the nurse would talk with the resident. The form revealed if the resident continued to refuse the nurse would document on the form the refusal and have the resident sign the form.
Review of the facility policy labeled Bath (Shower), dated August 2018, revealed the frequency of baths and showers were based on resident preference.
This deficiency represents non-compliance investigated under Master Complaint Number OH00141387, Complaint Number OH00139832, and Complaint Number OH00139091.
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 F0698
(Tag F0698)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the interview, record review, and review of the facility policy on Dialysis revealed the facility failed to ensure nurs...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the interview, record review, and review of the facility policy on Dialysis revealed the facility failed to ensure nursing staff completed pre and post dialysis assessments for residents receiving dialysis. This affected three residents (#19, #61, and #71) of three residents reviewed for dialysis. This had the potential to affect three residents (#19, #58 and #61) currently receiving dialysis.
Findings included:
1. Review of the closed medical record for Resident #71 revealed an admission date of 12/27/22 and discharge to the hospital on [DATE]. Diagnoses included nondisplaced fracture of the left ilium, end stage renal disease, dependence on renal dialysis, moderate protein-calorie malnutrition, congestive heart failure, and seizures.
Review of the physician orders for December 2022 and January 2023 revealed Resident #71 had an order to receive dialysis from an outside center every Tuesday, Thursday, and Saturday.
Review of the admission Minimum Date Set (MDS) assessment dated [DATE] revealed Resident #71 had impaired cognition. He required extensive assistance of one person with locomotion on and off the unit. He received dialysis.
Review of the care plan dated 01/10/23 revealed Resident #71 required hemodialysis due to renal failure. Interventions included check and change dressing at access site daily, document communication between dialysis center team and facility team, dialysis every Tuesday, Thursday, and Saturday, and monitor, document, and report any signs of infection to access site, changes in level of consciousness, changes in skin turgor, changes in heart and/or lung sounds. There was no intervention listed in the care plan to complete pre and post dialysis assessments with each dialysis scheduled day which included assessment of vital signs.
Review of the Pre and Post Dialysis Status Sheets from 12/27/22 to 01/26/23 revealed Resident #71 had one pre and post dialysis assessment dated [DATE] and completed by Licensed Practical Nurse (LPN) #615. There were no other pre and post dialysis forms in Resident #71's medical record.
Interview on 04/03/23 at 1:31 P.M. with Dialysis Center Registered Nurse (RN) #679 revealed Resident #71 had come to the dialysis center on 12/29/22, 12/31/22, 01/03/23, 01/05/23, 01/07/23, 01/10/23, 01/13/23, and 01/17/23 for dialysis. She revealed the dialysis center did not receive any pre- dialysis assessments and/or communication from the facility which she felt was a concern especially that Resident #71 had multiple medical co-morbidities as she felt he was medically unstable and displayed altered mental status symptoms at times requiring the center to send Resident #71 to the hospital during dialysis on a couple of occasions.
Interview on 04/04/23 at 10:44 A.M. with the Director of Nursing verified pre and post dialysis assessments were to be completed before and after any resident received dialysis and that the pre dialysis assessment should be sent to dialysis as a form of communication with dialysis regarding the resident's status. She verified Resident #71 had only one pre and post dialysis assessment in his medical record on 01/17/23. She verified pre and post dialysis assessments were not completed on: 02/29/22, 12/31/22, 01/03/23, 01/05/23, 01/07/23, 01/10/23, and 01/13/23.
2. Review of the medical record for Resident #61 revealed an admission date of 07/15/21 and diagnoses including end stage renal disease, dependence on renal dialysis, chronic kidney disease with heart failure, and morbid obesity.
Review of the care plan dated 08/05/22 revealed Resident #61 required hemodialysis due to renal failure. Interventions included check and change dressing at access site daily, dialysis three times a week, monitor vital signs and notify physician of abnormalities, monitor, document, and report any signs of infection to access site, changes in level of consciousness, changes in skin turgor, changes in heart and/or lung sounds. There was no intervention listed in the care plan to complete pre and post dialysis assessments with each dialysis scheduled day which included assessment of vital signs.
Review of the February 2023 and March 2023 physician orders revealed Resident #61 received dialysis every Tuesday, Thursday, and Saturday from an outside center.
Review of the quarterly MDS assessment dated [DATE] revealed Resident #61 had impaired cognition. She received dialysis.
Review of the Pre and Post Dialysis Status Sheets from 02/01/22 to 04/03/23 revealed Resident #61 had pre and post dialysis forms completed on: 02/04/23, 02/15/23, 02/28/23, 03/04/23, 03/07/23, and 03/14/23. There were no other pre and post dialysis forms in Resident #61's medical record.
Interview on 04/03/23 at 9:26 A.M. with Resident #61 revealed she had impaired cognition and could not remember if the facility nursing staff assessed her before and/or after dialysis.
Interview on 04/03/23 at 1:31 P.M. with Dialysis Center RN #679 revealed Resident #61 had dialysis three times a week: Tuesday, Thursday, and Saturday. She revealed the dialysis center did not receive any pre dialysis assessments and/ or communication from the facility from any of the residents that received dialysis from the facility.
Interview on 04/04/23 at 10:44 A.M. with the Director of Nursing verified pre and post dialysis assessments were to be completed before and after any resident received dialysis and that the pre dialysis assessment should be sent to dialysis as a form of communication with dialysis regarding the resident's status. She verified Resident #61 had dialysis every Tuesday, Thursday, and Saturday. She verified pre and post dialysis assessments were not completed on: 02/02/23, 02/07/23, 02/09/23, 02/11/23, 02/14/23, 02/18/23, 02/21/22, 02/23/23, 02/25/23, 03/02/23, 03/09/23, 03/11/23, 03/16/23, 03/18/23, 03/21/23, 03/23/23, 03/25/23, 03/28/23, 03/30/23, and 04/01/23.
3. Review of medical record for Resident #19 revealed an admission date of 03/24/23 with diagnoses including end stage renal disease, congestive heart failure, diabetes, and dependence on renal dialysis.
Review of the physician orders for March 2023 revealed Resident #19 had an order to receive dialysis every Monday, Wednesday, and Friday.
Review of the care plan dated 03/24/23 revealed Resident #19 had a person-centered plan of care. The care plan did not reveal anything regarding Resident #19 receiving dialysis three times a week and/or Resident #19 receiving pre and post dialysis assessments on dialysis days.
Review of the Pre and Post Dialysis Status Sheets from 03/24/23 to 04/03/23 revealed Resident #19 had one Pre and Post dialysis assessment completed on 04/03/23. There were no other pre and post dialysis forms in Resident #19's medical record.
Interview on 04/04/23 at 9:21 A.M. with Dialysis Center/ RN Manager #682 verified Resident #19 came to dialysis every Monday, Wednesday, and Friday. She revealed Resident #19 only comes with a bag and jacket with no binder in the bag that included a pre-dialysis assessment and/or communication form on her dialysis days.
Interview on 04/04/23 at 10:44 A.M. with the Director of Nursing verified pre and post dialysis assessments were to be completed before and after any resident who received dialysis and that the pre dialysis assessment should be sent to dialysis as a form of communication with dialysis regarding the resident's status. She verified Resident #19 had only one pre and post dialysis assessment in her medical record which was dated 04/03/23. She verified pre and post dialysis assessments for Resident #19 were not completed on: 03/27/23, 03/29/23, and 03/31/23.
Review of the facility policy labeled Dialysis Services, dated June 2022, revealed the facility clinical director would exchange important resident information with the dialysis center including change in condition and pertinent labs. The policy revealed the facility nursing staff would complete a pre and post dialysis assessment for residents that received dialysis with each dialysis schedule which included assessment of vital signs. The policy revealed upon return from dialysis an assessment was to be completed of the dialysis site to monitor for any complication including bleeding, signs and symptoms of infection, and for bruit (the presence of a bruit and a thrill means blood was moving through the Arteriovenous Fistula that was used for hemodialysis).
This deficiency represents non-compliance investigated under Complaint Number OH00141197.
Jul 2022
6 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review for Resident #12 revealed the resident was admitted to the facility on [DATE] with diagnoses including dementia...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review for Resident #12 revealed the resident was admitted to the facility on [DATE] with diagnoses including dementia, hypertensive emergency, difficulty walking, muscle wasting and atrophy, other lack of coordination, and other chronic pain.
Observation on 07/25/22 at 10:14 A.M. revealed Resident #12 was in bed. The call light touch pad was placed on a chair across the room out of Resident #12's reach.
Observation on 07/25/22 at 2:16 P.M. revealed Resident #12 was in bed and the call light touch pad remained on a chair across the room and was not in Resident #12's reach. Interview at the time of the observation with State Tested Nursing Assistant (STNA) #512 verified the call light touch pad was not within reach of Resident #12.
Observation on 07/26/22 at 2:50 P.M. with Licensed Practical Nurse (LPN) #578 revealed Resident #12 was in bed and the call light touch pad was placed on a tray table out of Resident #12's reach. Interview with LPN #578 confirmed, at the time of observation, Resident #12's call light touch pad was out of reach. After LPN #578 was observed to return the call light touch pad to within Resident #12's reach, Resident #12 activated the call light as LPN #578 exited the room.
Observation on 07/27/22 at 2:26 P.M. revealed Resident #12 was sitting in a wheelchair in his room, and the call light touch pad was placed at the top of the bed out of Resident #12's reach. Interview at the time of the observation with STNA #524 confirmed the call light touch pad was not within reach of Resident #12.
3. Record review for Resident #32 revealed the resident had an admission date of 05/26/22 with diagnoses including generalized anxiety disorder, diabetes without complications, dementia without behavioral disturbance, generalized weakness, and depressive disorder.
Observation on 07/26/22 at 2:55 P.M. revealed Resident #32 was in bed. The call light was observed placed in the chair at end of bed out of Resident #32's reach. Interview at the time of the observation with STNA #584 verified the call light was not within reach of Resident #32.
Review of facility policy titled, Call Light, Use Of, with a review date of July 2017, revealed when providing care to residents be sure to position the call light conveniently for the resident to use.
This deficiency substantiates Complaint Number OH00134006.
Based on observation, record review, interview, and policy review the facility failed to ensure call lights were within reach of residents. This affected three (Resident's #12, #32 and #238) of three residents reviewed for call lights. The facility census was 81.
Findings include:
1. Review of the medical record for Resident #238 revealed an admission date of 07/21/22 with diagnoses including multiple fractures of ribs left side, personal history of transient ischemic attack, hypertension, repeated falls, and type two diabetes mellitus.
Interview on 07/25/22 at 12:13 P.M. with Resident #238 revealed she needed to go to the bathroom, and she could not reach her call light to call for assistance. Observation at the time of interview revealed Resident #238 was sitting in a chair on the other side of the room from her bed and her call light was on her bed.
Interview on 07/25/22 at 12:19 P.M. with Nurse Aide #563 verified Resident #238's call light was on the bed and not within reach. Observation at the time of interview revealed Nurse Aide #563 moved the call light to the chair, within reach of Resident #238.
CONCERN
(D)
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 interview, record review, review of the facility self-reported incident (SRI), and policy review the facility failed to...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, review of the facility self-reported incident (SRI), and policy review the facility failed to ensure an allegation of abuse for Resident #57 was reported timely. This affected one (Resident #57) of one resident reviewed for abuse. The facility census was 81.
Findings include:
Review of the medical record for Resident #57 revealed an admission date of 08/09/18 with diagnoses including delusional disorder, dementia without behavioral disturbance, unspecified mood affective disorder, and osteoarthritis.
Review of the most recent quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #57 was cognitively intact. Resident #57 required total dependence for transfers and extensive assistance of two staff for bed mobility, dressing, toilet use, and personal hygiene.
Review of the progress note dated 07/06/22 at 2:48 P.M. revealed a staff member noted ecchymosis (a discoloration of the skin) on Resident #57's hand. A progress note dated 07/06/22 at 4:00 P.M. revealed an x-ray had been completed on Resident #57's right hand.
Review of the physician's orders for July 2022 for Resident #57 identified orders for application of ice to the right hand as needed for swelling beginning 07/06/22, elevate the right hand every shift beginning 07/06/22, and a splint to the fifth digit of right hand for five weeks beginning 07/07/22.
Review of the progress note dated 07/07/22 at 8:46 A.M. revealed the x-ray results showed a fracture at the fifth proximal phalanx (pinky finger).
Review of the facility's SRI tracking number 223694 dated 07/06/22 revealed Resident #57 alleged Nurse Aide #498 came into her room and bent her fingers back. Review of Nurse Aide #499's witness statement, not dated, indicated Resident #57 made the allegation to her on 07/05/22 between 3:30 A.M. and 4:00 A.M. and that the allegation was not reported to the nurse because she figured it was an old bruise.
Observation on 07/25/22 at 3:22 P.M. of Resident #57's hand revealed a splint on her right pinky finger and her right middle finger was dark purple from the middle of the finger to the knuckle. Interview with Resident #57 at the time of observation revealed a male staff member had injured her hand.
Interview on 07/26/22 at 3:35 P.M. with the Administrator verified Resident #57 alleged Nurse Aide #498 had caused the injury to her hand. The Administrator stated she was not informed of the incident until 07/06/22 at 1:30 P.M., approximately 34 hours after the resident initially made the allegation. She stated contracted staff who worked in the building acknowledged that they would follow the facility policy on abuse, and she confirmed it was not followed in this case.
Review of the facility policy titled Resident Abuse Prevention Practices, dated 09/2019, revealed staff must report the suspicion of any incident to the Administrator, Director of Nursing, or supervisor immediately so an investigation can be immediately initiated. It also indicated that consultants, contractors, volunteers, and other caregivers providing services to the residents would be educated on the policy.
Review of the facility policy titled Reporting Suspected Crimes Policy - Elder Justice Act, dated 10/2017, revealed all reporting must be done immediately but not later than two hours after forming the suspicion if the events that cause the suspicion result in serious bodily injury, or not later than 24 hours if the event that causes the suspicion does not result in serious bodily injury.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide Resident #37 with showers twice a week as scheduled. This af...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide Resident #37 with showers twice a week as scheduled. This affected one (Resident #37) of three (Residents #20, #37, #47) reviewed for showers. The facility census was 81.
Findings include:
Review of the medical record for Resident #37 revealed an admission date of 07/15/21. Diagnoses included end stage renal disease, herpes zoster eye disease, and dependence on renal dialysis.
Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #37 had no cognitive impairment. Resident #37 required extensive two-staff physical assistance for bed mobility, dressing, toilet use, and personal hygiene; total dependence of two staff for transfers; and supervision with set-up help only for eating. Resident #37 was frequently incontinent of urine and bowel.
Interview on 07/25/22 at 4:30 P.M. with Resident #37 revealed she had not received a shower for a month. She reported her shower days were scheduled for Mondays and Thursdays, but she rarely got a shower.
Review of the shower schedule in the north wing nursing assistant book posted at the north wing nurse's station revealed Resident #37 was scheduled for a shower every Monday and Thursday during the day shift.
Review of the shower sheets for Resident #37 from 06/01/22 to 07/27/22 revealed she only received showers on 06/03/22, 06/06/22, 06/13/22, 06/30/22, and 07/21/22.
Interview on 07/27/22 at 10:57 A.M. with the Director of Nursing (DON) confirmed Resident #37 did not receive her showers as ordered and did go almost a month without a shower.
This deficiency substantiates Complaint Number OH00134006.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0698
(Tag F0698)
Could have caused harm · This affected 1 resident
Based on record review and interview, the facility failed to complete pre and post dialysis assessments for Resident #75. This affected one (Resident #75) of two residents receiving dialysis treatment...
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Based on record review and interview, the facility failed to complete pre and post dialysis assessments for Resident #75. This affected one (Resident #75) of two residents receiving dialysis treatments. The facility census was 81.
Findings include:
Review of the medical record for Resident #75 revealed an admission date of 04/03/18 with diagnoses including end stage renal disease and dependence on renal dialysis.
Review of the physician orders for July 2022 identified orders for pre and post dialysis assessments every day and evening shift on Tuesday, Thursday, and Saturday beginning 06/23/22.
Review of the Medication Administration Record/Treatment Administration Record (MAR/TAR) for July 2022 for Resident #238 revealed a dialysis post assessment was not completed on 07/21/22 and 07/23/22.
Interview on 07/28/22 at 10:50 A.M. with the Director of Nursing (DON) verified the post dialysis assessment was not completed on 07/21/22 and 07/23/22.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Notice
(Tag F0623)
Could have caused harm · This affected multiple residents
Based on record review and interview, the facility failed to ensure a representative of the Office of the State Long-Term Care Ombudsman was notified of facility initiated discharges. This affected 43...
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Based on record review and interview, the facility failed to ensure a representative of the Office of the State Long-Term Care Ombudsman was notified of facility initiated discharges. This affected 43 residents (Resident's #17, #20, #36, #42, #43, #67, #68, #69, #80, #88, #240, #241, #242, #243, #244, #245, #246, #247, #248, #249, #250, #251, #252, #253, #254, #255, #256, #257, #258, #259, #260, #261 #262, #263, #264, #265, #266, #267, #268, #269, #270, #271 and #272). The facility census was 81.
Findings include:
1. Review of the medical record for Resident #88 revealed an admission date of 04/15/22 and discharge date of 04/26/22. Diagnoses included urinary tract infection, muscle wasting, chronic kidney disease, atrial fibrillation, and congestive heart failure.
Review of the Discharge Minimum Data Set (MDS) 3.0 assessment, dated 04/26/22, revealed Resident #88 was discharged with return not anticipated.
Review of nursing progress notes dated 04/26/22 revealed Resident #88 was transported to the hospital for a change in condition, and then admitted with altered mental status, congestive heart failure and elevated troponin levels.
Interview on 07/27/22 at 8:23 A.M. with Director of Nursing (DON) verified Resident #88 was transferred from the facility and admitted to the hospital due to a change in condition.
Interview on 07/27/22 at 3:50 P.M. with DON confirmed there was no evidence a representative of the Office of the State Long-Term Care Ombudsman was notified of Resident #88's discharge.
Interview on 07/28/22 at 8:20 A.M. with Administrator verified notifications of facility initiated discharges were not provided to the Office of the State Long-Term Care Ombudsman as required and stated the responsible staff member had stopped sending notifications in the recent past but was not certain of the exact date. Administrator indicated due to the error, a representative of the Office of the State Long-Term Care was emailed immediately facility initiated discharges which occurred from 01/01/22 through 07/28/22.
Review of the facility discharge report, dated 07/28/22, for residents discharged from 01/01/22 to 07/28/22 revealed Resident #88 was discharged to a hospital.
2. Review of the facility discharge report, dated 07/28/22, for residents discharged from 01/01/22 to 07/28/22 revealed the following residents received a facility-initiated discharge to a hospital:
•
Resident #17 was discharged on 03/12/22, again on 05/08/22, and again on 07/22/22.
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Resident #20 was discharged on 01/24/22.
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Resident #36 was discharged on 05/07/22, again on 05/28/22, and again on 06/01/22.
•
Resident #42 was discharged on 04/08/22.
•
Resident #43 was discharged on 06/01/22.
•
Resident #67 was discharged on 07/12/22.
•
Resident #68 was discharged on 06/25/22.
•
Resident #69 was discharged on 07/15/22.
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Resident #80 was discharged on 05/23/22 and again on 06/04/22.
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Resident #240 was discharged on 01/11/22.
•
Resident #241 was discharged on 01/25/22.
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Resident #242 was discharged on 02/16/22.
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Resident #243 was discharged on 03/27/22.
•
Resident #244 was discharged on 04/23/22.
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Resident #245 was discharged on 05/09/22.
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Resident #246 was discharged on 05/18/22, and again on 05/31/22.
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Resident #247 was discharged on 05/23/22.
•
Resident #248 was discharged on 01/05/22.
•
Resident #249 was discharged on 04/28/22.
•
Resident #250 was discharged on 06/16/22.
•
Resident #251 was discharged on 06/30/22.
•
Resident #252 was discharged on 07/03/22, and again on 07/15/22.
•
Resident #253 was discharged on 01/19/22.
•
Resident #254 was discharged on 01/20/22.
•
Resident #255 was discharged on 01/23/22.
•
Resident #256 was discharged on 01/25/22.
•
Resident #257 was discharged on 01/31/22.
•
Resident #258 was discharged on 02/01/22.
•
Resident #259 was discharged on 02/08/22.
•
Resident #260 was discharged on 02/23/22.
•
Resident #261 was discharged on 02/24/22.
•
Resident #262 was discharged on 04/13/22.
•
Resident #263 was discharged on 04/18/22, and again on 05/02/22.
•
Resident #264 was discharged on 04/26/22.
•
Resident #265 was discharged on 04/28/22.
•
Resident #266 was discharged on 04/29/22.
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Resident #267 was discharged on 05/13/22.
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Resident #268 was discharged on 06/11/22.
•
Resident #269 was discharged on 01/13/22.
•
Resident #270 was discharged on 02/06/22.
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Resident #271 was discharged on 04/26/22.
•
Resident #272 was discharged on 07/07/22.
Review of the facility notices of transfer/discharge forms revealed the following residents were discharged to a hospital due to need of emergent care:
•
Resident #17 was discharged on 03/12/22, on 05/08/22 and again on 07/22/22.
•
Resident #20 was discharged on 01/24/22.
•
Resident #36 was discharged on 05/07/22, on 05/28/22, and again on 06/01/22.
•
Resident #42 was discharged on 04/08/22.
•
Resident #43 was discharged on 06/01/22.
•
Resident #67 was discharged on 07/12/22.
•
Resident #68 was discharged on 06/25/22.
•
Resident #69 was discharged on 06/29/22.
•
Resident #80 was discharged on 05/23/22 and again on 06/04/22.
•
Resident #240 was discharged on 01/11/22.
•
Resident #241 was discharged on 01/25/22.
•
Resident #242 was discharged on 02/16/22.
•
Resident #243 was discharged on 03/27/22.
•
Resident #244 was discharged on 04/23/22.
•
Resident #245 was discharged on 05/09/22.
•
Resident #246 was discharged on 05/18/22 and again on 05/31/22.
•
Resident #247 was discharged on 05/23/22.
•
Resident #248 was discharged on 01/05/22.
•
Resident #249 was discharged on 04/28/22.
•
Resident #250 was discharged on 06/16/22.
•
Resident #251 was discharged on 06/30/22.
•
Resident #252 was discharged on 07/15/22.
•
Resident #253 was discharged on 01/19/22.
•
Resident #254 was discharged on 01/20/22.
•
Resident #255 was discharged on 01/23/22.
•
Resident #256 was discharged on 01/25/22.
•
Resident #257 was discharged on 01/31/22.
•
Resident #258 was discharged on 02/01/22.
•
Resident #259 was discharged on 02/08/22.
•
Resident #260 was discharged on 02/23/22.
•
Resident #261 was discharged on 02/24/22.
•
Resident #262 was discharged on 04/13/22.
•
Resident #263 was discharged on 04/18/22 and again on 05/02/22.
•
Resident #264 was discharged on 04/26/22.
•
Resident #265 was discharged on 04/28/22.
•
Resident #266 was discharged on 04/29/22.
•
Resident #267 was discharged on 05/13/22.
•
Resident #268 was discharged on 06/11/22.
•
Resident #269 was discharged on 01/13/22.
•
Resident #270 was discharged on 02/06/22.
•
Resident #271 was discharged on 04/26/22.
•
Resident #272 was discharged on 07/07/22.
Interview on 07/28/22 at 8:20 A.M. with the Administrator verified the above listed discharge notices were emailed on 07/28/22 to the representative of the Office of the State Long-Term Care Ombudsman due to the designated staff member not sending the notices as required.
Review of the facility generated email, dated 07/28/22 at 8:13 A.M., from the Administrator to the representative of the Office of the State Long-Term Care Ombudsman revealed an emailed adobe file which was attached.
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 observation, interview, record review, facility policy review, and review of the Centers for Disease Control and Prevention (CDC) guidance the facility did not ensure staff followed proper is...
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Based on observation, interview, record review, facility policy review, and review of the Centers for Disease Control and Prevention (CDC) guidance the facility did not ensure staff followed proper isolation precautions while entering and exiting rooms for five (Resident's #21, #49, #79, #83 and #238) and the facility failed to ensure staff used proper handwashing guidelines during wound care for Resident #32. This affected six (Resident's #21, #32, #49, #79, #83 and #238) and had the potential to affect all 81 residents residing in the facility.
Findings include:
1. Review of the medical record for Resident #79 revealed an admission date of 07/02/20. Diagnoses included COVID-19, dementia, and congestive heart failure. A physician order, dated 07/19/22, indicated droplet plus isolation for ten days.
Interview on 07/25/22 at 9:51 A.M. with Clinical Director #502 confirmed Resident #79 was on transmission-based precautions, droplet precautions, due to being positive with COVID-19.
Observation on 07/25/22 at 10:21 A.M. revealed Laundry #560 entered Resident #79's room, which was designated as a droplet precaution room, with clean personal clothing wearing a N95 respirator mask, eyewear, and gloves. Laundry #560 delivered the personal laundry into Resident #79's closet, closed the closet, and exited the room without replacing the N95 respirator mask, cleaning the eyewear, removing the gloves, or performing handwashing. Laundry #560 then retrieved clean personal laundry from the clean laundry cart while wearing the same soiled gloves and entered Resident #83's room and delivered the clean personal laundry into Resident #83's closet, closed the closet, and exited the room without removing the soiled gloves or performing hand hygiene. Laundry #560 then retrieved clean personal laundry from the clean laundry cart while wearing the same soiled gloves and entered Resident #49's room and delivered the clean personal laundry into Resident #49's closet, closed the closet, and exited the room without removing the soiled gloves or performing hand hygiene. Interview at the time of the observation with Laundry #560 verified not wearing a gown prior to entering Resident #79's room, and not replacing the N95 respirator mask, cleaning the eyewear, removing the gloves, and performing handwashing upon exiting Resident #79's room. Laundry #560 further confirmed not performing appropriate hand hygiene after leaving Resident #79's room and between Resident #83 and #49's room. Laundry #560 stated she was not sure what the droplet precautions included.
Review of the facility of droplet precautions titled Droplet Plus Precautions, dated 03/31/20, revealed the facility will use droplet precautions for residents with or suspected of having COVID-19. Personal protective equipment (PPE) would include masks, face shields/eye protection, isolation gowns, and gloves.
Review of the Infection Control Guidance, updated 02/02/22, from the Centers for Disease Control located at https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html, revealed to adhere to standard precautions and to wear a N95 respirator, gown, gloves, and eye protection for health care workers who enter a room of a resident with SARS-CoV-2 (COVID-19) infections.
Review of the Sequence for Removing Personal Protective Equipment https://www.cdc.gov/niosh/emres/2019_ncov_ppe.html from the Centers for Disease Control, revealed to put on gown, mask, eyewear, and gloves upon entering isolation room and upon exiting room, gloves should be removed, goggles should be disinfected, gown should be removed, N95 should be discarded, and hand hygiene should be performed.
3. Review of the medical record for Resident #238 revealed an admission date of 07/21/22 with diagnoses including multiple fractures of ribs left side, personal history of transient ischemic attack, hypertension, and type two diabetes mellitus.
Review of the physician orders for July 2022 identified orders for droplet-plus isolation precautions beginning 07/21/22.
Observation on 07/25/22 at 12:18 P.M. revealed Nurse Aide #563 entered Resident #238's room wearing a N95 mask and eye protection. No other PPE was donned prior to entering Resident #238's room. Further observation revealed signs posted outside Resident #238's room indicating to see the nurse before entering the room, donning and doffing procedures for PPE, and a cart containing PPE was located just outside the door.
Interview on 07/25/22 at 12:19 P.M. with Nurse Aide #563 verified only a N95 mask and eye protection was worn in Resident #238's room.
4. Review of the medical record for Resident #21 revealed an admission date of 11/02/21 with diagnoses including schizophrenia, schizoaffective disorder, chronic pain syndrome, type two diabetes mellitus, and COVID-19 (dated 09/17/21).
Review of the physician orders for July 2022 identified orders for COVID-19 precautions during outbreak and cared for by staff using full PPE beginning 07/25/22.
Observation on 07/26/22 at 9:03 A.M. revealed Nurse Aide #557 entered Resident #21's room wearing a N95 mask and eye protection to assist Resident #21. No other PPE was donned prior to entering Resident #21's room. Further observation revealed signs posted outside Resident #21's room indicating to see the nurse before entering the room, donning and doffing procedures for PPE, and a cart containing PPE was located just outside the door.
Interview on 07/26/22 at 9:04 A.M. with Nurse Aide #557 verified only a N95 mask and eye protection was worn. Nurse Aide #557 stated she did not pay attention to the precaution signs posted outside Resident #21's room.
2. Observation on 07/27/22 at 1:20 P.M. with Licensed Practical Nurse (LPN) #569 for wound care of Resident #32 revealed LPN #569 performed handwashing and donned gloves then removed the left heel soiled dressing dated 07/26/22, discarded the dressing, and removed the soiled gloved and performed handwashing. LPN #569 donned clean gloves, cleansed Resident #32's left heel with normal saline solution, then removed the soiled gloves, using a pen dated a foam dressing with the date 07/27/22, and without performing hand hygiene applied clean gloves to soiled hands and applied Mesalt (stimulates the cleansing of heavily discharging wounds in the inflammatory phase by absorbing exudate, bacteria, and necrotic material) and the dated foam dressing to Resident #32's left heel wound bed. LPN #569 removed the soiled gloves and performed handwashing. Interview at the time of the observation with LPN #569 verified soiled gloves were removed and clean gloves were applied without performing handwashing.
Interview on 07/27/22 at 2:14 P.M. with the Director of Nursing (DON) confirmed handwashing was required when gloves were changed during wound care.
Review of the facility policy titled Handwashing/Hand Hygiene, revised June 2022, revealed staff were to perform handwashing or if hands were not visibly soiled use an alcohol-based hand rub after removing gloves.
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?"
- "What safeguards are in place to prevent abuse and neglect?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • Licensed and certified facility. Meets minimum state requirements.
Concerns
- • Multiple safety concerns identified: Federal abuse finding, 1 life-threatening violation(s), 1 harm violation(s), $68,952 in fines, Payment denial on record. Review inspection reports carefully.
- • 23 deficiencies on record, including 1 critical (life-threatening) violation. These warrant careful review before choosing this facility.
- • $68,952 in fines. Extremely high, among the most fined facilities in Ohio. Major compliance failures.
- • Grade F (8/100). Below average facility with significant concerns.
Bottom line: This facility has a substantiated abuse finding. Extreme caution advised. Explore alternatives.
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About This Facility
What is O'Brien Memorial Health Care C's CMS Rating?
CMS assigns O'BRIEN MEMORIAL HEALTH CARE C 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 O'Brien Memorial Health Care C Staffed?
CMS rates O'BRIEN MEMORIAL HEALTH CARE C's staffing level at 3 out of 5 stars, which is average compared to other nursing homes. Staff turnover is 52%, compared to the Ohio average of 46%. RN turnover specifically is 60%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.
What Have Inspectors Found at O'Brien Memorial Health Care C?
State health inspectors documented 23 deficiencies at O'BRIEN MEMORIAL HEALTH CARE C during 2022 to 2025. These included: 1 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 1 that caused actual resident harm, 18 with potential for harm, and 3 minor or isolated issues. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates O'Brien Memorial Health Care C?
O'BRIEN MEMORIAL HEALTH CARE C 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 WINDSOR HOUSE, INC., a chain that manages multiple nursing homes. With 95 certified beds and approximately 70 residents (about 74% occupancy), it is a smaller facility located in MASURY, Ohio.
How Does O'Brien Memorial Health Care C Compare to Other Ohio Nursing Homes?
Compared to the 100 nursing homes in Ohio, O'BRIEN MEMORIAL HEALTH CARE C's overall rating (2 stars) is below the state average of 3.2, staff turnover (52%) is near the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.
What Should Families Ask When Visiting O'Brien Memorial Health Care C?
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?" "What safeguards and monitoring systems are in place to protect residents from abuse or neglect?" "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 substantiated abuse finding on record.
Is O'Brien Memorial Health Care C Safe?
Based on CMS inspection data, O'BRIEN MEMORIAL HEALTH CARE C has documented safety concerns. The facility has 1 substantiated abuse finding (meaning confirmed case of resident harm by staff or other residents). 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 O'Brien Memorial Health Care C Stick Around?
O'BRIEN MEMORIAL HEALTH CARE C has a staff turnover rate of 52%, which is 6 percentage points above the Ohio average of 46%. Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was O'Brien Memorial Health Care C Ever Fined?
O'BRIEN MEMORIAL HEALTH CARE C has been fined $68,952 across 1 penalty action. This is above the Ohio average of $33,768. Fines in this range indicate compliance issues significant enough for CMS to impose meaningful financial consequences. Common causes include delayed correction of deficiencies, repeat violations, or care failures affecting resident safety. Families should ask facility leadership what changes have been made since these penalties.
Is O'Brien Memorial Health Care C on Any Federal Watch List?
O'BRIEN MEMORIAL HEALTH CARE C 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.