ST CLARE COMMONS
Non profit - Corporation
60 Beds
COMMONSPIRIT HEALTH
Data: November 2025
Trust Grade
25/100
#901 of 913 in OH
Photo by St Clare Commons
Photo by St Clare Commons
Photo by St Clare Commons
1 / 5 photos
Last Inspection: October 2023
Over 2 years since last inspection. Current conditions may differ from available data.
Overview
St. Clare Commons has received a Trust Grade of F, indicating significant concerns about their care quality. It ranks #901 out of 913 nursing homes in Ohio, placing it in the bottom half of facilities statewide and #11 out of 11 in Wood County, meaning there are no better local options available. While the facility is improving in some areas, reducing issues from 5 in 2024 to 2 in 2025, its staffing situation is alarming, with a low 1-star rating and a high turnover rate of 60%, well above the state average. The facility has also incurred fines totaling $40,433, which is concerning as it is higher than 86% of Ohio facilities. Specific incidents have raised red flags, including a failure to assist a resident with transfers as required, potentially putting them at risk for falls, and issues with kitchen sanitation that could lead to foodborne illnesses. Overall, while there are some positive quality measures, significant weaknesses in staffing and compliance raise serious concerns for families considering this nursing home.
- Trust Score
- F
- In Ohio
- #901/913
- Safety Record
- Moderate
- Inspections
- Getting Better
- Staff Stability ⚠ Watch
- 60% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ⚠ Watch
- $40,433 in fines. Higher than 91% of Ohio facilities. Major compliance failures.
- Skilled Nurses ○ Average
- RN staffing data not reported for this facility.
- Violations ⚠ Watch
- 44 deficiencies on record. Higher than average. Multiple issues found across inspections.
25/100
Bottom 2%
Needs review
5 → 2 violations
★☆☆☆☆
1.0
Overall Rating
★☆☆☆☆
1.0
Staff Levels
★★★★☆
4.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2024: 5 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
1-Star Overall Rating
Below Ohio average (3.2)
Significant quality concerns identified by CMS
Staff Turnover: 60%
14pts above Ohio avg (46%)
Frequent staff changes - ask about care continuity
Federal Fines: $40,433
Above median ($33,413)
Moderate penalties - review what triggered them
Chain: COMMONSPIRIT HEALTH
Part of a multi-facility chain
Ask about local staffing decisions and management
Staff turnover is elevated (60%)
12 points above Ohio average of 48%
The Ugly 44 deficiencies on record
1 actual harm
Apr 2025
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, interview, and policy review, the facility failed to ensure a resident had call light withi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, interview, and policy review, the facility failed to ensure a resident had call light within reach while up in wheelchair. This affected one resident (#1) of nine residents reviewed for call lights. The facility census was 56.
Findings include:
Review of medical record for Resident #1 revealed an admission date of 05/08/24 with diagnoses including but not limited to dementia, unspecified psychosis, hypertension, anxiety, alcohol use with withdrawal delirium, depression, and need for assistance with personal care.
Review of the Minimum Data Set (MDS) dated [DATE] revealed the resident had severe cognitive impairment. Resident #1 was dependent on staff for toileting.
Observation on 04/02/25 at 1:35 P.M. revealed Resident #1 was sitting up in wheelchair in room. Call light was observed lying on the bed out of reach for the resident.
Interview on 04/02/25 at 1:37 P.M. with Certified Nursing Assistant (CNA #174) verified Resident #1 call light was not within reach of the resident. CNA #174 verified Resident #1 was capable of using the call light.
Review of policy titled, Call Lights: Accessibility and Timely Response, revised 02/11/25 revealed staff will ensure the call light is within reach of resident and secured as needed.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected multiple residents
Based on record review, review of late medication report, interview, and policy review, the facility failed to ensure medications were administered in a timely manner. This affected four (#2, #33, #36...
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Based on record review, review of late medication report, interview, and policy review, the facility failed to ensure medications were administered in a timely manner. This affected four (#2, #33, #36, and #54) of four residents reviewed for late medications. The facility census was 56.
Findings include:
1. Review of medical record for Resident #2 revealed an admission date of 03/30/25 with diagnoses including but not limited to hypertensive heart disease with heart failure, chronic kidney disease, atrial fibrillation, congenital malformation of the heart, hypertension, and fibrothorax.
Review of current physician orders revealed furosemide 40 milligrams (mg) daily at 7:00 A.M. (water pill), Jardiance 10 mg daily at 8:00 A.M. (diabetes), metoprolol tartrate 25 mg twice daily at 9:00 A.M. and 9:00 P.M. (blood pressure), amiodarone 200 mg daily at 9:00 A.M. (heart), and apixaban 2.5 mg twice daily at 9:00 A.M. and 6:00 P.M.
Review of late medication report dated 03/31/25 revealed the above listed medications were administered at 11:38 A.M.
2. Review of medical record for Resident #33 revealed an admission date of 09/30/24 with diagnoses including but not limited to acute respiratory failure with hypoxia, peripheral vascular disease, rheumatoid arthritis, asthma, chronic obstructive pulmonary disease, dysphagia, and major depressive disorder.
Review of current physician orders revealed metoprolol tartrate 25 mg one half tablet twice daily at 6:45 A.M. and 6:45 P.M., Trelegy Ellipta 200-62.5-25 micrograms(mcg)/act daily at 7:00 A.M. (asthma), Jardiance 10 mg daily at 8:00 A.M., multivitamin with minerals daily at 9:00 A.M., ferrous sulfate 325 mg daily at 9:00 A.M., bumex 1 mg daily at 9:00 A.M. (water pill), aspirin 81 mg daily at 9:00 A.M., and ipratropium-albuterol 0.5-2.5 (3) mg/3 milliliters (ml) via nebulizer every six hours at 12:00 A.M., 6:00 A.M., 12:00 P.M., and 6:00 P.M. (asthma).
Review of late medication report dated 03/31/25 revealed the above listed medications were administered at 11:31 A.M.
Review of late medication report dated 04/01/25 revealed Jardiance 10 mg and ipratropium-albuterol was administered at 9:27 A.M. and ipratropium-albuterol was administered at 3:24 P.M.
3. Review of medical record for Resident #36 revealed an admission date of 07/14/21 with diagnoses including but not limited to type one diabetes, peripheral vascular disease, heart failure, hypertension, major depressive disorder, and personal history of diabetic foot ulcer.
Review of current physician orders revealed insulin lispro 100 unit/ml per sliding scale 151-200 2 units, 201-250 4 units, 251-300 6 units, 301-350 8 units, 351-400 10 units, 401-999 12 units before meals and at bedtime.
Review of late medication report dated 03/31/25 revealed insulin lispro was ordered at 7:30 A.M. was administered at 9:31 A.M. after breakfast.
4. Review of medical record for Resident #54 revealed an admission date of 03/13/23 with diagnoses including unspecified severe protein-calorie malnutrition, congestive heart failure, chronic kidney disease stage three, anxiety, major depressive disorder, and chronic obstructive pulmonary disease.
Review of current physician orders revealed zoloft 100 mg daily at 8:00 A.M. (depression), ferrous sulfate 325 mg at 8:00 A.M., ondansetron 4 mg at 8:00 A.M. (nausea), tylenol 325 mg at 9:00 A.M., vitamin B 12 1000 mcg at 9:00 A.M. and folate 1 mg at 9:00 A.M.
Review of late medication report dated 04/01/25 revealed the above listed medications were administered at 11:20 A.M.
Interview on 04/02/25 at 3:35 P.M. with the Director of Nursing (DON) verified the late medications for Residents #2, #33, #36 and #64.
Review of policy titled, Medication Administration, revised 12/30/24 revealed administer medications within 60 minutes prior to or after scheduled time unless otherwise ordered by physician.
This deficiency represents noncompliance investigated under Complaint Number OH00162010.
Jul 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
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and review of the facility policy, the facility failed to ensure timely orders ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and review of the facility policy, the facility failed to ensure timely orders were in implemented to address the care and needs of a stage III pressure ulcer (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed) affecting Resident #5, failed to ensure accurate and ongoing skin monitoring for Resident #39, and failed to ensure wound care recommendations were implemented for Residents #5 and #39. This affected two (#5 and #39) of three residents reviewed for pressure ulcers. The facility census was 52.
Findings include:
1. Review of the medical record for Resident #5 revealed an admission date of 06/28/24. Diagnoses included chronic kidney disease, type II diabetes mellitus, and a urinary tract infection.
Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #5 was cognitively intact, independent for toilet and personal hygiene, was occasionally incontinent of urine, and had one stage III unhealed pressure ulcer to the left buttock.
Review of the admission skin assessment completed on 06/28/24 revealed Resident #5 had impaired skin to the sacrum, the physician was notified, and orders were obtained. The physician orders to treat the pressure ulcer on the sacrum were not initiated until 07/01/24, three days after the physician provided the orders.
Review of the stage III pressure ulcer care plan for Resident #5 dated 07/01/24 included interventions to complete a nutritional assessment, turn and reposition frequently, pressure reducing mattress, evaluate skin for blanching or redness, treatments as ordered, and to ensure enhanced barrier precautions.
Review of the wound care note dated 07/01/24 revealed Resident #5 had a full thickness stage III pressure wound to the left buttock, measurements 0.5 centimeters (cm) long by 0.2 cm wide and 0.1 cm deep with a light amount of serous drainage. The wound care provider wrote a recommendation for Vitamin C 500 milligrams (mg) twice a day. The wound care note did not state a treatment was applied to Resident #5's pressure wound.
Review of Resident #5's physician order dated 07/01/24 (Monday) revealed to cleanse the stage III pressure ulcer of the coccyx with wound cleanser, pat dry, apply collagen and secure with foam dressing every Monday, Thursday and Saturday on night shift.
Review of the treatment administration record (TAR) for June 2024 and July 2024 revealed Resident #5's stage III pressure ulcer did not receive a treatment on 06/28/24, 06/29/24, 06/30/24, and 07/01/24. Treatment was completed on 07/04/24 and 07/06/24.
Review of the medication administration record from 07/01/24 to 07/07/24 revealed Resident #5 had no physician order for vitamin C 500 mg twice a day written as recommended by the wound care provider.
Interview on 07/08/24 at 2:30 P.M. with the Assistant Director of Nursing (ADON) #500 verified the treatment order obtained from the physician on 06/28/24 for Resident #5's stage III pressure ulcer was not entered into the medical record until 07/01/24. The treatment entered 07/01/24 was not completed on 07/01/24. The first treatment to Resident #5's stage III pressure ulcer was completed on 07/04/24. ADON #500 verified the wound care provider's recommendation to start Vitamin C 500 mg twice a day on 07/01/24 had not been written or implemented.
2. Review of the medical record for Resident #39 revealed an admission date of 12/05/22. Diagnoses included chronic obstructive pulmonary disease and congestive heart failure.
Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #39 was cognitively intact, was dependent on staff for toilet hygiene, and was incontinent of both bowel and bladder.
Review of the care plan dated 12/07/22 revealed Resident #39 was identified at risk for skin breakdown. Interventions included to monitor for skin breakdown, administer medications and treatments as ordered, and monitor nutritional status.
Review of a skin assessment completed on 06/01/24 revealed Resident #39 had small open areas to the left and right buttock due to Resident #39 scratching. The next skin assessment was completed on 06/24/24 with no wounds identified (however wound care provider noted Resident #39 had a stage III pressure ulcer on left buttock on 06/24/24), and on 06/29/24, a new wound was noted to the left buttock.
Review of the Wound Care Provider evaluation dated 06/24/24 revealed Resident #39 was noted to have a full thickness stage III pressure ulcer to the left buttock, measurements were 2.0 centimeter (cm) long by 3.0 cm wide by 0.2 cm deep. An order was written to cleanse the wound with wound cleanser, pat dry, apply collagen with silver, cover with border foam three times a week for thirty days with an additional recommendation for a dietician consult for nutritional needs to promote wound healing.
Review of the shower sheet dated 06/30/24 revealed Resident #39 had no skin issues. The shower sheets did not identify a pressure ulcer noted on the left buttock which was noted by the wound care provider on 06/24/24.
Review of Resident #39's medical record from 06/24/24 to 07/07/24 revealed there was no evidence a dietician consult for nutritional needs to promote wound healing was completed.
Interview on 07/08/24 at 2:30 P.M. with the Assistant Director of Nursing (ADON) #500 verified the skin assessment completed by the nurse dated 06/24/24 was inaccurate and the shower sheet dated 06/30/24 was inaccurate and did not reflect Resident #39 did have a stage III pressure ulcer on her left buttocks. ADON #500 verified lack of ongoing monitoring of the scratches noted on 06/01/24 to the left and right buttock of Resident #39 and further verified the dietician had not been consulted to evaluate Resident #39's nutritional status as recommended by the wound care provider.
Review of the facility policy titled Pressure Injury Prevention and Management dated 10/24/22 revealed after completing a thorough assessment /evaluation, the interdisciplinary team shall develop a relevant care plan that includes measurable goals for prevention and management of pressure injuries. Interventions will be based on specific factors identified in the risk assessment, skin assessment, and any pressure injury assessment and may include but are not limited to the redistribution of pressure, minimizing pressure and maintaining or improving nutritional and hydration status. Additionally, the Unit Manager will review all relevant documentation regarding skin assessments, pressure risks progression toward healing and compliance at least weekly.
Review of the facility policy titled Wound Treatment Management dated 11/23/22 revealed to promote wound healing, the facility will provide evidence-based treatments in accordance with current standards of practice and physician orders. Wound treatments will be provided in accordance with physician orders, including the cleansing method, type of dressing and frequency of dressing change with the effectiveness of treatments will be monitored through ongoing assessment of the wound.
This deficiency represents non-compliance investigated under Master Complaint Number OH00154788 and Complaint Number OH00154178.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, medical record review, and review of the facility policy, the facility failed to ensure t...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, medical record review, and review of the facility policy, the facility failed to ensure the appropriate care and treatment of a resident's urinary catheter. This affected one (#13) resident of three residents reviewed for urinary catheters. The facility census was 52.
Finding include:
Review of the medical record for Resident #13 revealed an admission date of 04/24/24. Diagnoses included acute cystitis with hematuria, neuromuscular dysfunction of the bladder, and paraplegia.
Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #13 was cognitively intact, required maximal assistance from staff for toilet hygiene.
Review of a nurse progress note dated 06/18/24 revealed Resident #13 was sent to the Emergency Department for evaluation of blood in urine. On 06/21/24 at 9:13 A.M., Resident #13 returned from hospital with an indwelling urinary catheter in place to gravity with yellow colored urine with sediment. The nurse progress note dated 06/26/24 at 2:19 P.M. revealed a new catheter holder was applied to the right thigh.
Review of the physician orders revealed an order dated 07/05/24 for a urinalysis for culture and sensitivity due to hematuria (blood in urine) and an order dated 07/09//24 for levofloxacin 500 mg once daily for cystitis hematuria. There were no physician orders for Resident #13's catheter care and maintenance from 06/21/24 to 07/03/24.
Review of Resident #13's care plan revealed there was no care plan in place for Resident #13's catheter care and maintenance from 06/21/24 to 07/03/24.
Observation on 07/03/24 at 10:00 A.M. revealed Resident #13 was sitting upright in bed with uncovered quarter full urinary drainage bag hanging off the right side of the bed with a dependent loop with cloudy yellow urine in the catheter hanging off the mattress.
Additional observation on 07/03/24 at 10:55 A.M. of urinary catheter care completed for Resident #13 by State Tested Nursing Assistant (STNA) #146 revealed a kink in the urinary catheter between the leg strap on the right leg and the catheter insertion site at the meatus (urethral opening) preventing urine from draining. The urinary catheter was straight up at the meatus with cloudy white colored urine sitting in the drainage tube. STNA #146 verified this catheter was kinked and urine was not draining with Resident #13 at which time the urinary catheter was removed from the leg strap and readjusted to ensure the catheter tubing was laying flat on the thigh of Resident #13. STNA #146 then picked up the drainage tubing and the catheter drainage bag to make sure urine was flowing freely before hanging the urinary drainage back on the bed and positioning the catheter drainage tubing on the bed along side the resident. Following the observation on 07/03/24 at 11:05 A.M., an interview with STNA #146 verified the urine in Resident #13's catheter was not draining due to a dependent loop and a kink in the urinary catheter.
Interview on 07/08/24 at 2:30 P.M. with the Assistant Director of Nursing (ADON) #500 verified Resident #13 had an indwelling urinary catheter in place since 06/21/24 when Resident #13 returned from the hospital. ADON #500
verified Resident #13 had no physician orders in place for the care or maintenance of the indwelling urinary catheter nor was Resident #13's plan of care updated to reflect an indwelling urinary catheter.
Review of the facility policy titled Catheter Care, dated 05/10/23 revealed residents with indwelling catheters will receive appropriate catheter care, catheter care will be performed every shift and as needed by nursing personnel. Privacy bags are available and catheter bags should be covered at all times while in use. Catheter drainage bags are emptied when bag is half-full or every three to six hours, and drainage bags are to be below the level of the bladder to discourage the backflow of urine.
This deficiency represents non-compliance investigated under Complaint Number OH00154178.
Apr 2024
3 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0602
(Tag F0602)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of self-reported incidents, resident and staff interview, and review of facility policy, ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of self-reported incidents, resident and staff interview, and review of facility policy, the facility failed to prevent misappropriation of resident funds. This affected one (#40) of one resident reviewed for misappropriation. The facility census was 55.
Findings include:
Review of the medical record revealed Resident #40 was admitted on [DATE]. Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, acute respiratory failure with hypoxia, dysphagia, chronic kidney disease stage three, and major depressive disorder recurrent.
Review of the Minimum Data Set (MDS) assessment, dated 03/31/24, revealed the resident was moderately cognitively impaired.
Review of Self-Reported Incident (SRI) #242873, created 01/08/24 and completed on 01/12/24, revealed the Administrator was notified by Resident #40's financial administrator the resident's credit card was taken and used to make in person purchases at three stores (grocery and gas stations) within the area of the facility and many of the purchases were for lottery. Resident #40 denied making the purchases and the resident's financial administrator verified the purchases were not normal purchases made by the resident. The credit card was reported to the bank fraud department and the card was canceled. The local police department was called and a police officer came to the facility to take a report. The facility was informed the case would be given to a detective. On 01/09/24, the Administrator met with the detective and was asked to not share information with the suspect or facility staff until he had the opportunity to bring the suspect in for questioning. The Administrator informed the detective the employee would need to be suspended pending investigation. The detective stated he would be contacting the Ohio Board of Nursing. The complaint was found unsubstantiated due to inconclusive evidence, with abuse/neglect/misappropriation suspected.
Further review of SRI #242873 revealed Resident #40 did not authorize anyone to use her credit card. The credit card statement had unauthorized charges posted from three stores (gas and grocery). The unauthorized charges totaled approximately $5,000.00 and included 31 charges for $100 each for the state lottery. The alleged perpetrator, Licensed Practical Nurse (LPN) #300, had been a facility employee since 2019 and the last date worked was 01/09/24. LPN #300 resigned on 01/18/24. The SRI included correspondence with the Ohio Board of Nursing and Ohio Department of Health.
Interview on 04/24/24 at 11:43 A.M. with the Administrator revealed at the time SRI #242873 was submitted the facility did not have all of the information and otherwise would have substantiated the SRI. The Administrator stated misappropriation of Resident #40's credit card was from 11/06/23 through 01/05/24 with an estimated total of $5,000.00 in unauthorized charges on the resident's credit card. The Administrator verified on 01/09/24 (prior to the facility investigation being completed), the detective brought in surveillance footage of the alleged perpetrator and the Administrator confirmed the suspect was facility employee LPN #300.
Interview on 04/25/24 at 2:20 P.M. with Resident #40 verified she provided her credit card to LPN #300. Resident #40 expressed she was hurt when she learned the staff had used her credit card for unauthorized charges.
Review of the facility policy, Abuse, Neglect and Exploitation, dated 10/24/22, verified the facility is to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Misappropriation of resident property means the deliberate misplacement, exploitation, or wrongful, temporary or permanent, use of resident's belongings or money without the resident's consent.
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
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of self-reported incidents, staff interview, and review of facility policy, the facility ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of self-reported incidents, staff interview, and review of facility policy, the facility failed to thoroughly investigate misappropriation of resident funds. This affected one (#40) of one resident reviewed for misappropriation. The facility census was 55.
Findings include:
Review of the medical record revealed Resident #40 was admitted on [DATE]. Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, acute respiratory failure with hypoxia, dysphagia, chronic kidney disease stage three, and major depressive disorder recurrent.
Review of the Minimum Data Set (MDS) assessment, dated 03/31/24, revealed Resident #40 was moderately cognitively impaired.
Review of Self-Reported Incident (SRI) #242873, created 01/08/24 and completed on 01/12/24, revealed the Administrator was notified by Resident #40's financial administrator the resident's credit card was taken and used to make in person purchases at three stores (grocery and gas stations) within the area of the facility and many of the purchases were for lottery. Resident #40 denied making the purchases and the resident's financial administrator verified the purchases were not normal purchases made by the resident. The credit card was reported to the bank fraud department and the card was canceled. The local police department was called and a police officer came to the facility to file a report. The facility was informed the case would be given to a detective. On 01/09/24, the Administrator met with the detective and was asked not to share any information with the suspect or facility staff until he had the opportunity to bring the suspect in for questioning. The Administrator informed the detective she would need to suspend the employee pending investigation. The detective stated he would be contacting the state board of nursing. Further review of the SRI revealed Resident #40 did not authorize anyone to use her credit card. The credit card statement of unauthorized charges were posted from three stores (gas and grocery). The unauthorized charges totaled approximately $5,000.00 and included 31 charges for $100 each for the state lottery. The alleged perpetrator, Licensed Practical Nurse (LPN) #300, had been a facility employee since 2019 and the last date worked was 01/09/24. LPN #300 resigned on 01/18/24. The SRI included correspondence with the state board of nursing and the state health department. The investigation included five resident interviews, resident/victim pertinent medical records, alleged perpetrators personnel file, timecards, and door access times. The facility unsubstantiated misappropriation due to inconclusive evidence, however, abuse/neglect/misappropriation was suspected.
Interview on 04/24/24 at 11:43 A.M. with the Administrator revealed at the time SRI #242873 was submitted, the facility did not have all of the information and otherwise misappropriation would have been substantiated. The Administrator stated misappropriation of Resident #40's credit card was from 11/06/23 through 01/05/24 with an estimated total of $5,000.00. On 01/09/24 (prior to the facility investigation being completed), the detective brought in surveillance footage of the suspect and the Administrator confirmed the suspect was a facility employee, LPN #300. While the Administrator stated the detective conducted two staff interviews and requested the facility not interview staff, the facility investigation did not include the confirmation of LPN #300 in the surveillance footage, only included five resident interviews, no in-service was conducted, and no audits were initiated.
Review of policy, Abuse, Neglect and Exploitation, dated 10/24/22, verified the facility is to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Written procedures for investigation include identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations. The facility must also focus the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause. In addition, the facility will provide complete and thorough documentation of the investigation.
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 medical record review, observation, resident representative and staff interview, and review of facility policy, the fac...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, resident representative and staff interview, and review of facility policy, the facility failed to ensure fall interventions were in place for two (#21 and #47) of three residents reviewed for falls. In addition, the facility failed to ensure one (#28) of three residents reviewed for transfers were assisted by two staff for transfer with a mechanical hoyer lift. The facility census was 55.
Findings include:
1. Review of the medical record review revealed Resident #21 was admitted on [DATE]. Diagnoses included fracture of neck, unspecified fracture of shaft of humerus left arm, malignant neoplasm of unspecified breast, and non-Hodgkin lymphoma.
Review of the Minimum Data Set (MDS) assessment, dated 04/12/24, revealed the resident was cognitively intact.
Review of the most recent care plan revealed Resident #21 was at risk for falls, with an actual fall on 3/9/24. Fall interventions, updated 03/13/24, included to keep the bed in the lowest position when in it to prevent from rolling out and being injured.
Observation on 04/24/24 at 2:55 P.M. revealed Resident #21 in bed. The bed was not in the lowest position.
Interview on 04/24/24 at 3:44 P.M. with State Tested Nursing Assistant (STNA) #202 verified Resident #21 was in bed and the bed was not in the lowest position.
2. Review of the medical record review revealed Resident #47 was admitted on [DATE]. Diagnoses included memory deficit following cerebral infarction, unspecified diastolic heart failure, hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, and pneumonia.
Review of the MDS assessment, dated 03/26/24, revealed the resident was rarely understood. The resident was dependent on staff for showers and bathing.
Review of the most recent care plan revealed Resident #47 was care planned for falls, with interventions including bilateral mats to the floor and ensure the bed was kept in the lowest position.
Interview on 04/24/24 at 10:24 A.M. with Resident #47's resident representative revealed there had been no fall mats in place and the bed was often not in the lowest position.
Observation on 04/24/24 at 2:53 P.M. revealed Resident #47 was in bed. There were no fall mats in place and the bed was not in the lowest position.
Interview on 04/24/24 at 2:54 P.M. with STNA #111 verified Resident #47 was in bed with no fall mats in place and the bed was not in the lowest position. STNA #111 stated she did not know the resident used fall mats because there were none in the room.
Review of policy, Fall Risk Assessment, revised 09/07/21, verified the facility will provide an environment that is free from accident hazards over which the facility has control and provides supervision and assistance devices to each resident to prevent avoidable accidents. An at risk for falls care plan will be completed for each resident to address each item identified on the risk assessment and will be updated accordingly. The care plan will include interventions to reduce the risk and the interventions will be monitored and modified as necessary.
3. Review of the medical record review revealed Resident #28 was admitted on [DATE]. Diagnoses included Alzheimer's disease, major depressive disorder, supraventricular tachycardia, muscle weakness, abnormal posture and age-related physical debility.
Review of the MDS assessment, dated 03/31/24, revealed Resident #28 was rarely understood. Resident #28 had functional range of motion impairment on both sides and utilized a wheelchair. Resident #28 was dependent for chair/bed to chair transfer.
Review of the most recent care plan revealed Resident #28 required a mechanical hoyer lift for transferring with assistance of two staff members.
Observation on 04/25/24 at 7:46 A.M. revealed Resident #28 was in bed.
Observation on 04/25/24 at 8:21 A.M. revealed STNA #209 entered Resident #28's with a mechanical hoyer lift. Continued observation at 8:40 A.M. revealed STNA #209 exited Resident #28's room with the resident in a wheelchair. No other staff were observed in the area.
Interview on 04/25/24 at 8:41 A.M. with STNA #209 verified she transferred Resident #28, utilizing the mechanical hoyer lift, from bed to wheelchair without assistance from a second staff. STNA #209 stated, at times, the nurse would help; however, Resident #28 was small enough that she could transfer the resident by herself.
Review of facility policy, Using a Mechanical Lifting Machine, dated July 2017, verified at least two nursing assistants are needed to safely move a resident with a mechanical lift.
This deficiency represents non-compliance investigated under Master Complaint Number OH00153040.
Oct 2023
17 deficiencies
1 Harm
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Accident Prevention
(Tag F0689)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of the medical record for Resident #42 revealed an admission date of 03/23/23 with diagnoses of cerebral infarction an...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of the medical record for Resident #42 revealed an admission date of 03/23/23 with diagnoses of cerebral infarction and dementia. Resident #42 was admitted under the care of hospice.
Review of the quarterly MDS assessment dated [DATE] revealed Resident #42 had impaired cognition and required extensive assistance of two people for bed mobility and transfers. Further review revealed Resident #42 had no falls since the previous assessment.
Review of the fall risk assessments completed 03/24/23, 05/05/23 and 09/28/23 revealed Resident #42 was at high risk for falls.
Review of the care plan for Resident #42 revealed she was at risk for falls. Interventions included keeping the bed in a low position while she was in it and keeping her call light within reach. Further review revealed Resident #42 had an activities of daily life (ADL) self care performance deficit related to fatigue and limited mobility. Interventions included encouraging Resident #42 to use the bell to call for assistance and for staff to praise all efforts at self care. The care plan did not identify the type of assistance Resident #42 needed for transfers.
Review of the MDS [NAME] Report dated 07/06/23 revealed Resident #42 required extensive physical assistance of two or more people for transfers.
Review of the facility's Incident Log revealed Resident #42 fell on [DATE] and 09/28/23.
Review of a progress note dated 07/03/23 revealed Resident #42 fell out of bed in her room, was assessed and treated for pain, and the family was notified.
Further review of the medical record revealed no evidence a fall investigation was completed.
Observation on 10/10/23 at 10:30 A.M. revealed Resident #42 dressed and sitting in her wheelchair. Further observation revealed State Tested Nurse Aide (STNA) #313 pushing Resident #42 in her wheelchair from the dining table to the common area to watch television.
Observation on 10/10/23 at 10:41 A.M. revealed Resident #42 in her room sleeping in a recliner.
Interview on 10/10/23 at 10:44 A.M. with STNA #313 revealed she worked for a staffing agency, but worked frequently enough at the facility to be familiar with Resident #42. STNA #313 stated Resident #42 was able to transfer from the wheelchair to the recliner with one staff providing assistance, and STNA #313 transferred Resident #42 by herself from the wheelchair to the recliner where Resident #42 was sleeping.
Interview on 10/10/23 at 1:41 P.M. with the Interim Director of Nursing (IDON) revealed she spoke with the nurse who wrote the progress note on 07/03/23 and confirmed Resident #42 fell on [DATE]. The IDON stated the nurse was busy and failed to complete an incident report or Fall Risk Assessment after Resident #42's fall. The IDON confirmed the facility was unaware of Resident #42's fall on 07/03/23 and did not conduct an investigation into the fall.
Interview on 10/10/23 at 2:07 P.M. with the IDON confirmed Resident #42's care plan did not reflect the type and amount of assistance Resident #42 needed to complete ADL tasks, such as transferring. Continued interview with the IDON revealed STNAs relied on the [NAME] to determine the type of assistance each resident required for ADL tasks. Continued interview with the IDON confirmed the MDS [NAME] Report for Resident #42 revealed she required extensive physical assistance of two people for transfers.
Review of the policy, Fall Prevention Program, revised 10/20/22, revealed the nurse would indicate on the care plan and the [NAME] the resident's fall risk and interventions. Further review revealed after a fall, the facility would complete a post-fall assessment, complete an incident report, and document all assessments and actions.
Based on record review, staff interview, and review of facility policy, the facility failed to conduct a thorough investigation to determine potential hazards and resident-specific interventions to reduce and/or eliminate falls with injury. Additionally, the facility failed to update a resident's care plan with person centered fall interventions to potentially prevent future falls. This resulted in Actual Harm for one resident when Resident #34 experienced a fall on 07/12/23 which was not investigated to implement effective interventions to potentially prevent future falls. As a result of the fall, Resident #34 sustained a fracture of the nasal bones and a spleen laceration Grade 3 from this fall. Additionally, the facility failed to complete a fall investigation for Residents #43 and #42 to potentially prevent future falls. This affected three (Residents #34, #43, and #42) of three residents reviewed for falls. Lastly, the facility failed to ensure staff were knowledgeable of a resident's transfer requirements to potentially prevent falls. This affected one (Resident #42) of one resident reviewed for staff competence. The facility census was 50.
Findings include:
1. Review of the medical record of Resident #34 revealed an admission date of 06/02/23 with a hospital stay from 07/12/23 to 07/18/23. Diagnoses include dementia without behavioral disturbance, difficulty in walking, generalized muscle weakness, fracture of the nasal bones, and encounter for other orthopedic aftercare. Resident #34 was admitted to the skilled nursing facility from the attached assisted living facility after having experienced a fall with a femur fracture in late May of 2023. Following the fracture, Resident #34 had surgery and was then admitted to the nursing home on [DATE].
Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #24 was cognitively impaired and required extensive assistance for transfers and activities of daily living (ADLs).
Review of the fall risk assessment dated [DATE] revealed Resident #34 was at high risk for falls.
Review of the care plan for Resident #34, initiated on 06/05/23 with no updates, revealed the resident was at risk for injury related to falls due to gait/balance problems. Interventions included the following: PT (physical therapy) evaluate and treat as ordered and PRN (as needed), be sure call light is within reach when in room and encourage to use it before attempting to transfer, and the need to be evaluated for, and supplied appropriate adaptive equipment or devices as needed. Re-evaluate and as needed for continued appropriateness per therapy recommendations.
Review of the progress note dated 07/12/13 at 11:42 A.M. written by the Director of Nursing (DON) revealed Resident #34 was transferred to the ER (emergency room) for an evaluation after a fall.
Review of a Skilled/Episodic Note dated 07/12/23 at 1:30 P.M. written by agency Registered Nurse (RN) #352 revealed an ice pack was placed on Resident #34's nose and the resident was transported to the ER for an evaluation and treatment. The resident's skin was intact, and she was dependent for toileting and required substantial/maximal assistance with sit to lying and lying to sitting on the side of the bed.
Review of the hospital history and physical dated 07/12/23 revealed Resident #34 fell out of her chair after PT at her nursing home. Resident #34 had baseline dementia and did not remember the fall. She complained of facial pain. The resident denied loss of consciousness, denied hitting her head, however had a facial abrasion, and a small one-centimeter laceration to the bridge of her nose and bilateral ecchymosis (bruising) around her eyes. Resident #34 was also experiencing left sided weakness on the initial examination. A cervical collar was in place related to hitting her head. Per the medication administration record, Resident #34 was on Plavix (anticoagulant) and Aspirin 81 milligrams. The hospital provided diagnoses of solid organ injury splenic laceration Grade 3 and nasal laceration/nasal bone fracture.
Interview on 10/10/23 at 3:04 P.M. with Project Manager (PM) #300 revealed when reviewing the facility fall investigation, there were no witness statements documented. PM #300 was not employed at the facility at the time of the fall and investigation so could only go by what was documented. The investigation revealed Resident #34 was in her wheelchair, unable to give location, and an activity staff member, unable to give name, notified the nurse (RN #352). Resident #34 was found face down in front of her wheelchair, conscious. Resident #34 was transported to the ER for evaluation. The report revealed RN #352 completed an assessment (ABCs [airway, breathing, and circulation]) and sent Resident #34 to the ER as soon as possible. The report indicated the fall was unwitnessed, the fall risk assessment was high, and Resident #34 had non-skid socks on. The report indicated RN #352 turned Resident #34 on her back, obtained vital signs (blood pressure and pulse) and placed a cold washcloth on her nose. The skin was broken, and blood was coming from the open area. PM #300 confirmed no witness statements were in the investigation. PM #300 stated the report was initiated on 07/12/23 at 11:00 A.M. The investigation was closed on 07/24/23 by the Executive Director.
Interview on 10/10/23 at 3:44 P.M. with Physical Therapy Assistant (PTA) #351 and Therapy Program Manager (TPM) #350 revealed PTA #351 worked with Resident #34 on 07/12/23 from 8:32 A.M. to 9:02 A.M. and toileted her in that time frame. After the session was complete, PTA #351 left Resident #34 in her wheelchair in the common area of the 100 hall. PTA #351 was unsure of whom she had let know (aide or nurse) Resident #34 was in the common area but would not leave the area without having told someone.
Interview on 10/11/23 at 9:00 A.M. with the (DON) verified Resident #34's care plan was not revised to include person-centered interventions to prevent future falls, following the fall on 07/12/23. The DON further verified the care plan was not person-centered for Resident #34 and had generic fall interventions listed.
Review of the facility policy titled Fall Prevention Program dated 10/20/22 revealed each resident will be assessed for fall risk and receive care and services in accordance with their individualized level of risk to minimize the likelihood of falls. When a resident experiences a fall the facility will: assess the resident; complete a post fall assessment; complete an incident report; notify physician and family; review the resident's care plan and update as indicated; document all assessments and actions; and obtain witness statements in the case of injury.
2. Review of the medical record of Resident #43 revealed an admission date of 01/14/23. Diagnoses include progressive supranuclear ophthalmoplegia, Parkinson's disease, abnormalities of gait and mobility, muscle weakness, and bipolar disorder.
Review of the quarterly MDS dated [DATE] revealed Resident #43 was cognitively intact and required extensive assistance of two staff for transfers, bed mobility, and toileting. Walking in the room did not occur.
Review of the care plan for Resident #43, initiated 01/17/23, revealed a focus of at risk for injury related to falls due to deconditioning and gait/balance problems. Interventions included as follows: PT evaluate and treat as ordered or PRN; be sure call light is within reach when in room and encourage to use it before attempting to transfer; educate resident/family about safety reminders and what to do if a fall occurs; the need to be evaluated for and supplied appropriate adaptive equipment or devices as needed, re-evaluate as needed for continued appropriateness per therapy recommendations; encourage to participate in activities that promote exercise, physical activity for strengthening and improved mobility as tolerated; ensure resident is wearing appropriate footwear when out of bed; make sure floor/path is clutter free and properly lighted.
Review of the progress note dated 07/23/23 at 10:13 A.M. revealed Resident #43 had a witnessed fall. No visual injuries or complaints of pain at the time of the injury.
Further review of the medical record revealed no fall investigation to determine the root cause of the fall and identify potential interventions to prevent future falls was completed.
Interview on 10/10/23 at 4:53 P.M. with PM #300 revealed no fall investigation had taken place and the only documentation of Resident #43's fall was the progress note dated 07/23/23.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0569
(Tag F0569)
Could have caused harm · This affected 1 resident
Based on medical record review, staff interview, and review of the facility policy, the facility failed to issue notifications to residents who receive Medicaid benefits when their funds accounts were...
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Based on medical record review, staff interview, and review of the facility policy, the facility failed to issue notifications to residents who receive Medicaid benefits when their funds accounts were 200 dollars ($) less than the resource limit. This affected three (#14, #16, and #33) of five residents reviewed for resident trust accounts. The facility census was 50.
Findings include:
1. Review of the medical record for Resident #14 revealed an admission date of 02/27/19 and a payor source of Medicaid. The facility identified Resident #14 had a Resident Trust Account with the facility.
Review of the quarterly statements for Resident #14's Trust Account from 07/19/22 through 09/30/23 revealed a month-end balance on 12/31/22 of $1,826.87, on 04/30/23 of $1,815.18, on 05/31/23 of $1,870.78, on 06/30/23 of $1,926.88, on 07/31/23 of $1,982.93, on 08/31/23 of $2,014.55, and on 09/30/23 of $2,070.39.
2. Review of the medical record for Resident #16 revealed an admission date of 03/20/18 and a payor source of Medicaid. The facility identified Resident #16 had a Resident Trust Account with the facility.
Review of the quarterly statements for Resident #16's Trust Account from 10/31/22 through 09/30/23 revealed a month-end balance on 11/30/22 of $1,870.52, on 12/31/22 of $3,519.43, on 01/31/23 of $3,564.30, on 02/28/23 of $3,628.19, on 03/31/23 of $1,957.16, on 04/30/23 of $5,290.44, on 05/31/23 of $5,359.77, on 06/30/23 of $5,413.67, on 07/31/23 of $5,484.25, on 08/31/23 of $5,318.97, and on 09/30/23 of $5,370.40.
Review of a letter, dated 10/01/23, revealed Resident #16 was notified his Resident Trust Account was over the asset limit.
3. Review of the medical record for Resident #33 revealed an admission date of 07/08/20 and a payor source of Medicaid. The facility identified Resident #33 had a Resident Trust Account with the facility.
Review of the quarterly statements for Resident #33's Trust Account from 10/05/22 through 09/30/23 revealed a month-end balance on 12/31/22 of $1,892.67, on 01/31/23 of $2,244.98, on 04/30/23 of $1,889.32, on 05/31/23 of $2,242.15, on 06/30/23 of $2,596.22, on 07/31/23 of $3,053.95, on 08/31/23 of $3,411.14, and on 09/30/23 of $3,768.04.
Interview on 10/11/23 at 8:40 A.M. with the Administrator confirmed Resident #14 and Resident #33 were not notified when they were within $200.00 of their asset limit, and further confirmed no additional letters were sent to Resident #16 prior to 10/01/23 regarding his resident trust account approaching and/or exceeding the asset limit.
Review of the Ohio Medicaid Income and Asset Limits for Nursing Homes and In-Home Long Term Care, accessed on 10/12/23 and found at https://www.medicaidplanningassistance.org/medicaid-eligibility-ohio/, revealed individual assets must be under $2,000.00.
Review of the policy titled Resident Personal Funds, dated 10/10/23, revealed the facility must notify each resident that receives Medicaid benefits when the amount in the resident's account reaches $200.00 less than the resource limit for one person. Further, if the amount in the account, in addition to the value of the resident's other resources, reaches the resource limit for one person, the resident may lose eligibility for Medicaid.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected 1 resident
Based on medical record review, staff interview, and policy review, the facility failed to ensure resident advance directives for code status were accurate. This affected one (#33) of 12 residents rev...
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Based on medical record review, staff interview, and policy review, the facility failed to ensure resident advance directives for code status were accurate. This affected one (#33) of 12 residents reviewed for advance directives. The facility census was 50.
Findings include:
Review of the medical record revealed Resident #33 had an admission date of 05/19/20 and a readmission date of 01/02/21. Resident #33's diagnoses included atrial fibrillation, cerebral infarction, dementia, chronic pain, and chronic obstruction pulmonary disease.
Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/26/23, revealed Resident #33 had intact cognition.
Review of a physician order, dated 11/10/21, revealed Resident #33 had elected a full code status.
Review of the electronic medical record code status line for Resident #33 revealed Resident #33's code status was a full code.
Review of a physician order, dated 09/12/23, revealed Resident #33 had elected for a Do Not Rescuscitate (DNR) comfort care arrest (DNRCC-A) code status (the provider would treat Resident #33 as any other resident without a DNR order until the point of cardiac or respiratory arrest, at which point all interventions would cease and the DNR Comfort Care protocol would be implemented).
Review of Resident #33's care plan, initiated on 09/26/23, revealed Resident #33 requested a DNRCC-A code status. Interventions included for the medical record to reflect the resident's wishes for a DNR code status.
Interview on 10/03/23 at 2:02 P.M., with Social Services Director (SSD) #223 revealed SSD #223 was aware of the Resident #33's request to change code status. SSD #223 revealed only a nurse could change a resident's code status in the electronic medical record.
Interview on 10/03/23 at 3:26 P.M., with Licensed Practical Nurse (LPN) #203 revealed a resident's code status was found in the electronic medical record on the code status line.
Interview on 10/04/23 at 3:59 P.M., with the Director of Nursing (DON) revealed Resident #33 was documented in the electronic medical record (EMR) as a full code status. The DON revealed the physician had signed a DNRCC-A order for Resident #33 on 09/12/23 and the EMR had not been updated to reflect the change in code status.
Review of the policy titled Do Not Resuscitate Order, revised 04/2017, revealed the facility would not use cardiopulmonary resuscitation and related emergency measures to maintain life function on a resident when there was a Do Not Resuscitate Order in effect. Further review of the policy revealed no guidelines for updating the medical record after a code status change.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
Based on medical record review, staff interview, and review of the facility policy, the facility failed to ensure the comprehensive person centered care plan adequately addressed resident activity pre...
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Based on medical record review, staff interview, and review of the facility policy, the facility failed to ensure the comprehensive person centered care plan adequately addressed resident activity preferences/interests and activities of daily living. This affected two residents (#31 and #42) of 15 residents reviewed for care plans. The faciity census was 50.
Findings include:
1. Review of the medical record for Resident #31 revealed an admission date of 09/11/23 with a diagnosis of depression.
Review of the comprehensive Minimum Data Set (MDS) assessment, dated 09/15/23, revealed Resident #31 had impaired cognition and required limited assistance of one person for transfers and locomotion. Resident #31 did not exhibit rejection of care. Resident #31 was not interviewed for her activity preferences.
Review of the active care plan for Resident #31 revealed the care plan did not address activities and/or Resident #31's activity preferences.
Interview on 10/11/23 at 8:40 A.M. with the Administrator confirmed Resident #31's care plan did not address Resident #31's interests or desired activities.
2. Review of the medical record for Resident #42 revealed an admission date of 03/23/23 with a diagnosis of dementia.
Review of the quarterly MDS assessment, dated 07/06/23, revealed Resident #42 had impaired cognition and required extensive assistance of two people for bed mobility and transfers, and extensive assistance of one person for locomotion.
Review of the active care plan for Resident #42 revealed Resident #42 had an activities of daily living (ADL) self care performance deficit related to fatigue and limited mobility. Interventions included encouraging Resident #42 to use the bell to call for assistance and for staff to praise all efforts at self care.
Interview on 10/10/23 at 2:07 P.M. with the Interim Director of Nursing (IDON) confirmed Resident #42's care plan did not identify the type and/or amount of assistance Resident #42 needed to complete ADL tasks, such as transferring and eating.
Review of the policy titled Comprehensive Care Plans, dated 10/24/22, revealed the facility would develop and implement a comprehensive person-centered care plan for each resident, including measurable objectives to meet a resident's medical, mental, and psychosocial needs. Additionally, the comprehensive care plan will describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.
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
Based on medical record review, staff interview, and policy review, the facility failed to ensure residents were bathed/showered as scheduled and requested. This affected one (Resident #7) of three re...
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Based on medical record review, staff interview, and policy review, the facility failed to ensure residents were bathed/showered as scheduled and requested. This affected one (Resident #7) of three residents reviewed for bathing. The facility census was 50.
Finding include:
Review of Resident #7's medical record revealed Resident #7 had an admission date of 02/21/23. Resident #7's diagnoses included chronic obstructive pulmonary disease, anxiety, depression, and fibromyalgia.
Review of the quarterly Minimum Data Set (MDS) assessment, dated 08/21/23, revealed Resident #7 had impaired cognition. Resident #7 required extensive assistance of two staff for personal hygiene. The assessment indicated the bathing activity had not occurred in the look back period for Resident #7.
Review of Resident #7's care plan, dated 03/19/23, revealed the resident had an activities of daily living (ADL) self care performance deficit related to limited mobility. There were no interventions specific to bathing or showering.
Review of Resident #7's care plan, dated 09/01/23, revealed the resident was resistive to care related to anxiety. Interventions included if the resident resisted activities of daily living, reassure resident, leave and return at a later time if possible and try again.
Review of Resident #7's ADL bathing task documentation, revealed the resident had showers scheduled on Tuesday and Friday mornings. Resident #7 received a shower on 09/05/23, 09/15/23, 09/29/23 and 10/03/23. Resident #7 received a bed bath on 09/08/23, 09/26/23 and 09/28/23. Resident #7 received no shower or bed bath on 09/12/23, 09/19/23 and 09/22/23.
Review of Resident #7's nurses note, dated 09/13/23 at 7:37 A.M., revealed the resident had not been showered for four days and the resident refused a shower. Further review of the nurse's notes from 09/03/23 through 10/03/23 revealed no other instances when Resident #7 refused a shower.
Interview on 10/02/23 at 11:58 A.M., with Resident #7 revealed staff would sometimes wash her up instead of give her a shower.
Interview on 10/04/23 at 3:58 P.M., with the Director of Nursing (DON) revealed there was no documentation to indicate Resident #7 refused showers or was offered a shower on 09/01/23, 09/08/23, 09/12/23, 09/19/23, 09/22/23, 09/26/23 and 09/28/23.
Review of the policy titled Resident Showers, last revised 03/29/22, revealed residents would be provided showers as per request or as per facility schedule protocols and based upon resident safety.
This deficiency represents non-compliance investigated under Complaint Number OH00146367.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0679
(Tag F0679)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview, and review of the facility policy, the facility failed to provide resident...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview, and review of the facility policy, the facility failed to provide resident-centered activities for two (Residents #31 and #34) of three residents reviewed for activities. The facility census was 50.
Findings include:
1. Review of the medical record for Resident #31 revealed an admission date of 09/11/23 with a diagnosis of depression.
Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #31 had impaired cognition and required limited assistance of one person for transfers and locomotion. Resident #31 did not exhibit rejection of care.
Further review of Resident #31's MDS assessment revealed a section for addressing her preferences for customary routine and activities with the following instructions: Attempt to interview all residents able to communicate. If resident is unable to complete, attempt to complete interview with family member or significant other. The assessment was marked no indicating the resident was rarely/never understood and family/significant other were not available.
Review of the contact information for Resident #31 revealed she had two emergency contacts, one of whom was designated as her power of attorney for care.
Review of the medical record revealed no attempts to contact Resident #31's emergency contacts regarding her activity preferences.
Review of the Activity Initial Interview dated 09/20/23 revealed Resident #31 was not interviewed or assessed for her activity preferences.
Review of the current care plan for Resident #31 revealed no goals or interventions in place for activities.
Review of the documented activities for Resident #31 revealed she refused an opportunity for group activities five times in the last 30 days, and participated in social activities nine times in the last 30 days resulting in 14 opportunities for social activities in 30 days.
Various observations on 10/02/23 from 8:00 A.M. to 3:00 P.M. revealed Resident #31 not involved in any activities. Resident #31 was observed seated in her wheelchair in the common area with her eyes closed or lying in a quiet room.
Various observations on 10/03/23 from 8:00 A.M. to 3:00 P.M. revealed Resident #31 not involved in any activities. Resident #31 was observed seated in her wheelchair in the common area with her eyes closed or lying in a quiet room.
Various observations on 10/04/23 from 8:00 A.M. to 3:00 P.M. revealed Resident #31 not involved in any activities. Resident #31 was observed seated in her wheelchair in the common area with her eyes closed or lying in a quiet room.
Interview on 10/11/23 at 8:40 A.M. with the Administrator confirmed Resident #31's medical record showed no attempt to contact Resident #31's family regarding her activities of interest. Further interview confirmed the Activity Initial Interview was not conducted and the care plan contained nothing to address Resident #31's interests or desired activities.
Review of the policy, Activities, revised 02/27/23, revealed the policy of the facility was to provide an ongoing program to support residents in their choice of activities based on their comprehensive assessment, care plan, and preferences. Further, each resident's interest and needs would be assessed on a routine basis and activities would be designed with the intent to enhance the resident's sense of well-being, belonging and usefulness and create opportunities for each resident to have a meaningful life. Additionally, special considerations would be made for developing meaningful activities for residents with dementia.
2. Review of the medical record of Resident #34 revealed an admission date of 06/02/23 with a hospital stay from 07/12/23 to 07/18/23. Diagnoses included dementia without behavioral disturbance, difficulty in walking, generalized muscle weakness, fracture of nasal bones, and encounter for other orthopedic aftercare. Resident #34 was admitted to the skilled nursing facility from the attached assisted living facility after having experienced a fall with a femur fracture.
Review of the Minimum Data Set 3.0 (MDS) for Resident #34 dated 06/06/23 revealed the resident was cognitively impaired and required extensive assistance of one staff for transfers and activities of daily living (ADLs). The assessment further revealed the resident nor a family member was not interviewed for preferences for customary routine and activities.
Review of the fall risk assessment for Resident #34 dated 06/02/23 revealed her to be a high fall risk.
Review of the care plan for Resident #34 initiated on 06/07/23 with no updates, revealed the resident had a diagnosis of dementia and requires adoptions when engaging in activities. Interventions included as follows: engage resident in actives comparable with cognition; offer one on one visits and independent leisure materials of choice; provide adaptation related to cognition (hand over hand, cueing and tasks); remind, invite and encourage resident to participate in leisure of choice.
Review of the activity task revealed a daily chronicle was provided daily, resident engaged in only eight group activities over the previous 30 days. The form indicated six family visits and nine days of receiving communion.
Review of the facility document titled Activity Participation Review dated 09/14/23 revealed the Attendance and Participation Summary section did not have any documentation. The Activity Plan Review section revealed no changes, appropriate. Goal met.
Various observations on 10/02/23 from 8:00 A.M. to 3:00 P.M. revealed Resident #23 was lying in her bed or reclining in bed. The Daily Chronicle was lying on her bedside stand and at no time did this surveyor observe her to be looking at it. The only staff members observed entering the resident's room was State Tested Nursing Assistants.
Various observations on 10/03/23 from 8:00 A.M. to 3:00 P.M. revealed Resident #23 was lying in her bed or reclining in bed. The Daily Chronicle was lying on her bedside stand and at no time did this surveyor observe her to be looking at it. The only staff members observed entering the resident's room was State Tested Nursing Assistants.
Various observations on 10/04/23 from 8:00 A.M. to 3:00 P.M. revealed Resident #23 was lying in her bed or reclining in bed. The Daily Chronicle was lying on her bedside stand and at no time did this surveyor observe her to be looking at it. The only staff members observed entering the resident's room was State Tested Nursing Assistants.
Various observations on 10/05/23 from 8:00 A.M. to 3:00 P.M. revealed Resident #23 was lying in her bed or reclining in bed. The Daily Chronicle was lying on her bedside stand and at no time did this surveyor observe her to be looking at it. The only staff members observed entering the resident's room was State Tested Nursing Assistants.
Interview on 10/10/23 at 11:11 A.M. with Activity Assistant (AA) #225 revealed every resident receives a daily newsletter. One on one activities include manicures, talks, and offered materials such as puzzles and magazines. AA #225 could not identify any specific time spent with Resident #34.
Interview on 10/11/23 at 9:00 A.M. with Director of Nursing (DON) provided verification the activity care plan for Resident #34 was not person-centered.
Review of the facility policy titled Activities dated 02/27/23 revealed special consideration will be provided for residents with dementia, developing meaningful activities including residents who remain isolated in room/bed most of day.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
Based on observation, staff interview, review of the medical record, and review of the facility policy, the facility failed to ensure residents received medications as ordered. This affected one (Resi...
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Based on observation, staff interview, review of the medical record, and review of the facility policy, the facility failed to ensure residents received medications as ordered. This affected one (Resident #49) of six residents reviewed for medication administration. Further, the facility failed to separate and dispose of medications for discharged residents and expired residents. This affected three (Residents #306, #307, and #308) of three discharged residents and one (Resident #14) of one resident reviewed for expired medications. The facility census was 50.
Findings include:
1. Review of the medical record for Resident #49 revealed an admission date of 08/09/23 with a diagnosis of type two diabetes mellitus.
Review of a physician order dated 08/09/23 revealed Resident #49 should receive insulin glargine (to lower blood sugar) subcutaneous (below the skin) solution pen-injector 100 units per milliliter (ml); inject 20 units subcutaneously at bedtime for diabetes mellitus.
Review of the October 2023 Medication Administration Record (MAR) for Resident #49 revealed a 9 documented on 10/09/23 for insulin glargine scheduled for 9:00 P.M. Review of the Chart Code on the MAR revealed 9 indicated Other/See Nurse Notes.
Review of the progress note dated 10/09/23 at 11:26 P.M. revealed the insulin glargine was on order.
Review of the facility provided list of contingency (if needed) insulin available revealed insulin glargine was available.
Interview on 10/11/23 at 8:12 A.M. with the Interim Director of Nursing (IDON) confirmed the insulin glargine was not given to Resident #49 and confirmed the medication was available in the contingent medications.
2. Review of the medical record for Resident #306 revealed an admission date of 08/31/23 and a discharge date of 09/15/23.
Interview and observation on 10/04/23 at 9:52 A.M. with Licensed Practical Nurse (LPN) #256 revealed her medication cart contained medications for discharged Resident #306, including a bottle of timolol (eye drops), a bottle of latanoprost (eye drops), a bottle of nystatin (to treat mouth infections) and a fluticasone inhaler (to treat breathing problems). LPN #256 stated she worked at the facility for four years and was unsure what to do with medications after residents discharged and confirmed the medications for Resident #306 remained in the cart among current medications for other residents.
3. Review of the medical record for Resident #307 revealed an admission date of 08/16/23 and a discharge date of 09/06/23.
Interview and observation on 10/04/23 at 9:52 A.M. with LPN #256 revealed her medication cart contained medication cards (cards with individual punch-out doses of medications) for discharged Resident #307, including two cards of omeprazole (for heartburn relief) 20 milligrams (mg), one card of finasteride (to treat enlarged prostate) 5 mg, three cards of gabapentin (for nerve pain) 100 mg, one card of metoprolol (for high blood pressure) 25 mg, three cards of midodrine (for low blood pressure) 5 mg, one card of Requip (for Parkinson's disease) 1 mg, one card of Requip 0.5 mg, one card of Flomax (for enlarged prostate) 0.4 mg, one card of lopressor (for blood pressure) 25 mg, one card of trazadone (for depression) 50 mg, and a bottle of lidocaine (a numbing liquid). LPN #256 stated she worked at the facility for four years and was unsure what to do with medications after residents discharged and confirmed the medications for Resident #307 remained in the cart among current medications for other residents.
4. Review of the medical record for Resident #308 revealed an admission date of 03/10/23 and a discharge date of 07/20/23.
Observation and interview on 10/04/23 at 10:45 A.M. with the IDON of medications stored in the refrigerator revealed two expired medications for discharged Resident #308: vancomycin (an antibiotic) with a use-by date of 04/25/23 and Firvanq (an antibiotic) with a use-by date of 04/04/23. The IDON confirmed the medications were past the use-by date and remained in the refrigerator with medications in use for other residents.
5. Review of the medical record for Resident #14 revealed an admission date of 02/27/19 with a diagnosis of kidney transplant status.
Observation and interview on 10/04/23 at 10:45 A.M. with the IDON of medications stored in the refrigerator revealed a bottle of tacrolimus (to reduce organ rejection after a transplant) with a use-by date of 05/03/23 for Resident #14. The IDON confirmed the medication was past the use-by date and remained in the refrigerator with medications in use for other residents.
Review of the policy titled, Discontinued Medications, revised 08/2020, revealed when medications were discontinued or the resident was discharged , the medications should be marked as discontinued and stored in a secure and separate area from the active medications until destroyed or returned to the pharmacy.
This deficiency represents non-compliance investigated under Complaint Number OH00146367.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and review of the facility policy, the facility failed to timely respond to pharmacist ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and review of the facility policy, the facility failed to timely respond to pharmacist recommendations. This affected two (Residents #41 and #43) of five residents reviewed for pharmacy recommendations. The facility census was 50.
Findings include:
1. Review of the medical record for Resident #41 revealed an admission date of 01/10/23 with diagnoses of dementia, anxiety, restless legs, and mood disorder due to known physiological condition with major depressive-like episode.
Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #41 was rarely/never understood and received an antidepressant seven times during the previous seven days.
Review of a current physician order dated 03/06/23 revealed Resident #41 received Zoloft (an anti-depressant) 100 milligrams (mg) by mouth once daily for anxiety.
Review of the progress notes for Resident #41 revealed she was seen by Psych Group #500 to manage her psychotropic (mood altering) medications on 07/05/23 and 08/16/23.
Review of the document, Consultant Pharmacist Recommendation to Physician, dated 08/24/23 stated the resident has been using Zoloft 100 mg daily since 01/10/23. If this therapy is required to prevent future depressive episodes, please document to that effect in your progress notes. The document included no response from the physician.
Review of the document, Consultant Pharmacist Recommendation to Nursing Staff, dated 05/16/23 revealed Resident #41 had an order for Voltaren gel without a dose (such as 4 grams). The pharmacist requested a dose be included in the physician order.
Review of a current physician order dated 06/23/23 revealed Resident #41 received Voltaren Gel 1% (a gel applied to the skin for pain), apply 4 grams topically (on the skin) every six hours for pain.
Interview on 10/10/23 at 4:04 P.M. with Director of Social Services #223 confirmed Psych Group #500 had not provided services to Resident #41 since 08/16/23 and therefore no additional progress notes regarding Zoloft were available in the medical record.
Interview on 10/11/23 at 7:53 A.M. with the Interim Director of Nursing (IDON) confirmed the Voltaren gel order was updated on 06/23/23 after the pharmacist's recommendation dated 05/16/23 (over one month later).
2. Review of the medical record of Resident #43 revealed an admission date of 01/14/23. Diagnoses include progressive supranuclear opthalmoplegia, Parkinson's disease, abnormalities of gait and mobility, muscle weakness, and bipolar disorder.
Review of the quarterly MDS dated [DATE] revealed Resident #43 was cognitively intact and required extensive assistance of two staff for transfers, bed mobility, and toileting. Walking in room did not occur.
Review of the physician orders for Resident #43 revealed an order dated 03/02/23 for Escitalopram oxalate (Lexapro, antidepressant) 10 milligrams (mg) to be administered by mouth one time a day for depression. A second order dated 06/02/23 for Quetiapine Fumarate (Seroquel, antipsychotic) 59 mg to be administered by mouth twice daily for bipolar disorder.
Review of the, Consultant Pharmacist Recommendation to Physician, form dated 04/18/23 and 07/25/23 revealed resident has been taking Seroquel 50 mg twice daily since 01/17/23 without a gradual dose reduction. Could we attempt a dose reduction-perhaps to 37.5 mg in the morning and 50 mg at bedtime at this time to verify this resident is on the lowest dose possible? If not, please indicate response below. As of 10/11/23 this has not been addressed by the physician.
Review of the, Consultant Pharmacist Recommendation to Physician, form dated 06/19/23 and 09/23/23 revealed this resident has been using Lexapro 10 mg daily since 01/14/23. If this therapy is required to prevent future depressive episodes, please document to that effect in your progress notes. Review of the physician progress notes as of 10/11/23 revealed no response to the request.
Interview on 10/11/23 at 7:51 A.M. with the Director of Nursing verified the requests from the pharmacy regarding Resident #43's Seroquel and Lexapro were not addressed by the physician.
Review of the policy titled, Medication Regimen Review, dated 08/2020 revealed the pharmacist's monthly recommendations are acted upon and documented by the facility staff and/or the prescriber. The prescriber accepts and acts upon the recommendation or rejects and provides an explanation for disagreeing. The policy does not define a timeframe for response from the provider/facility to the pharmacist's recommendations.
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
Based on observation of medication pass, staff interview, and facility policy review, the facility failed to ensure residents were free of significant medication errors. This affected one resident (#3...
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Based on observation of medication pass, staff interview, and facility policy review, the facility failed to ensure residents were free of significant medication errors. This affected one resident (#35) of one observed to receive insulin. The facility identified four residents who receive insulin in the 100 hall. The facility census was 50.
Findings include:
Review of the medical record of Resident #35 revealed an admission date of 09/02/23 with a diagnosis of type II diabetes mellitus without complications.
Review of the physician order dated 09/07/23 for insulin Glargine inject 23 units subcutaneously daily for diabetes mellitus.
Observation on 10/04/23 at 7:30 A.M. revealed Licensed Practical Nurse (LPN) #256 obtained a blood glucose on Resident #35 of 123 millimeters of mercury. LPN #256 obtained a pen of Insulin Glargine from the medication cart, verified the resident's name and expiration date and dialed the pen to 23. LPN #256 proceeded to and inject the 23 units in the resident's left arm. LPN #256 did not prime the insulin pen prior to administration. Interview at the time of observation with LPN #256 verified she did not prime the insulin pen prior to administration.
Review of the facility supplied instructions for insulin administration, Instructions for Use, dated 11/22 revealed it was important to prime the insulin pen before each injection so that it will work correctly. Additional review revealed, If you do not prime before each injection, you may get too much or too little insulin. To prime your pen, turn the dose knob to select 2 units and push the dose n=knob in until it stops. You should see insulin at the tip of the needle.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0883
(Tag F0883)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and review of the facility policy, the facility failed to ensure residents were offered...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and review of the facility policy, the facility failed to ensure residents were offered the pneumococcal vaccine. This affected three (Residents #22, #41, and #47) of five residents reviewed for pneumococcal vaccination. The facility census was 50.
Findings include:
1. Review of the medical record for Resident #22 revealed an admission date of 01/19/23 with diagnoses of end stage renal disease and type two diabetes mellitus. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #22 had intact cognition.
Review of the immunizations for Resident #22 revealed no information regarding a pneumococcal vaccination.
2. Review of the medical record for Resident #41 revealed an admission date of 04/04/23. Review of the quarterly MDS assessment dated [DATE] revealed Resident #41 had impaired cognition.
Review of the immunizations for Resident #41 revealed no information regarding a pneumococcal vaccination.
3. Review of the medical record for Resident #47 revealed an admission date of 05/01/23. Review of the quarterly MDS assessment dated [DATE] revealed Resident #47 had impaired cognition.
Review of the immunizations for Resident #47 revealed no information regarding a pneumococcal vaccination.
Interview on 10/05/23 at 9:21 A.M. with Interim Unit Manager #314 confirmed the facility could provide no evidence Resident #22, Resident #41 and Resident #47 were offered the pneumococcal vaccine.
Review of the policy titled, Pneumococcal Vaccine (Series), dated 03/02/23, revealed each resident would be offered a pneumococcal immunization unless it was medically contraindicated or the resident had already been immunized. Additionally, the resident's medical record shall include documentation that indicates at a minimum, the following: the resident or representative was provided education regarding the benefits and potential side effects of the pneumococcal immunization and the resident received the pneumococcal immunization or did not receive due to medical contraindication or refusal.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
Based on medical record review, observation, staff and resident interview, and policy review, the facility failed to ensure residents were provided a clean, comfortable, and homelike environment. This...
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Based on medical record review, observation, staff and resident interview, and policy review, the facility failed to ensure residents were provided a clean, comfortable, and homelike environment. This affected eight (#7, #17, #18, #22, #30, #36, #38, and #41) of 14 residents reviewed for environment. The facility census was 50.
Finding include:
1. Review of the medical record for Resident #36 revealed an admission date of 04/30/21.
Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/25/23, revealed Resident #36 had intact cognition.
Observation on 10/02/23 at 10:39 A.M. in Resident #36's room revealed there were several stains on the carpet as well as large wrinkles in the carpet.
Interview on 10/02/23 at 10:39 A.M., with Resident #36 revealed the carpet had been in bad shape for around the past year.
2. Review of the medical record for Resident #41 revealed an admission date of 04/04/23.
Review of the quarterly MDS assessment, dated 09/08/23, revealed Resident #41 had impaired cognition.
Observation on 10/02/23 at 10:35 A.M. in Resident #41's room revealed there was approximately a nine inch snag and vertical hole in the carpet in the room with carpet fiber strings still attached.
Interview on 10/02/23 at 10:35 A.M., with Resident #41 revealed the carpet had been snagged since she moved into the room.
3. Review of the medical record for Resident #7 revealed an admission date of 02/21/23.
Review of the quarterly MDS assessment, dated 08/21/23, revealed Resident #41 had impaired cognition.
Observation on 10/02/23 at 12:03 P.M. in Resident #7's room revealed the carpet had multiple stains.
Interview on 10/02/23 at 12:03 P.M., with Resident #7 revealed she was sick of the carpet stains, and indicated the carpet stains were there when she moved into the room. Resident #7 revealed she asked for the carpet to be cleaned but it never got done.
4. Review of the medical record for Resident #38 revealed an admission date of 04/18/22.
Review of the quarterly MDS assessment, dated 07/28/23, revealed Resident #38 had intact cognition.
Observation on 10/02/23 at 11:43 A.M. in Resident #38's room revealed there were multiple stains on the carpet along with wrinkles in the carpet.
Interview on 10/02/23 at 11:43 A.M. with Resident #38 revealed the stained carpet bothered her.
5. Review of the medical record for Resident #30 revealed an admission date of 05/27/21.
Review of the quarterly MDS assessment, dated 08/24/23, revealed Resident #30 had impaired cognition.
Observation on 10/02/23 at 11:47 A.M. in Resident #30's room revealed the carpet was heavily stained next to the resident's bed.
Interview on 10/03/23 from 4:48 P.M. through 4:58 P.M., with Director of Housekeeping (DOH) #267 verified the carpets in the rooms of Resident #36, #41, #7, #38, #30 were stained throughout the rooms. DOH #267 also revealed the carpet was rippling and wrinkled in the rooms of Resident #38 and Resident #35 from previously cleaning the carpet causing the carpet glue to no longer hold down the carpet.
Review of the policy titled Cleaning/Repairing Carpeting and Cloth Furnishings, revised 12/2009, revealed the carpets would be deep-cleaned periodically (approximately once per month) or more often as needed.
6. Review of Resident #17's medical record revealed an admission date of 03/10/22.
Review of the MDS assessment, dated 07/30/23, revealed Resident #17 had impaired cognition.
Observation on 10/02/23 at 2:20 P.M. in Resident #17's room revealed a four inch area of the carpet was frayed by the bathroom door.
Interview on 10/02/23 at 2:20 P.M. with Resident #17 revealed she has trimmed the carpet in order to prevent from falling.
Interview on 10/02/23 at 2:25 P.M. with Housekeeping Aide (HA) #271 verified the carpet was frayed in Resident #17's room.
7. Review of Resident #18's medical record revealed an admission date of 01/24/22.
Review of the quarterly MDS assessment, dated 07/03/23, revealed Resident #18 was cognitively intact.
Observation on 10/02/23 at 2:40 P.M. revealed the carpet in the room of Resident #18 had a large amount of wrinkles. The wall to the lower left of the window had a large white area where the wall had been patched but was not painted.
Interview on 10/02/23 at 2:40 P.M. with Resident #18 revealed the carpet looked bad and the wall had been like that for some time.
Interview on 10/03/23 at 4:58 P.M. with DOH #267 verified the carpet was wrinkled and the wall needed painted in Resident #18's room.
8. Review of Resident #22's medical record revealed an admission date of 01/26/23.
Review of the quarterly MDS assessment, dated 08/03/23, revealed Resident #22 was cognitively intact.
Observation on 10/02/23 at 11:03 A.M. revealed the wall at the corner of Resident #22's bathroom had an approximately three foot long and six inch wide area of white repaired plaster which was not painted. The bathroom had no toilet paper holder and only had a screw sticking out of the wall.
Interview on 10/02/23 at 11:03 A.M. with Resident #22 revealed the wall had been like almost his entire stay at the facility and the toilet paper holder had been missing for over two months.
Interview on 10/10/23 at 2:20 P.M. with State Tested Nursing Assistant #251 verified the wall of Resident #22's bathroom had an area that had not been painted as well as verified the lack of toilet paper holder in Resident #22's bathroom.
Review of the policy titled Maintenance Service, revised 12/2009, revealed maintenance personnel would maintain the building in compliance with current federal, state and local laws, regulations and guidelines. The building would be maintained in good repair and free from hazards.
This deficiency represents noncompliance investigated under Complaint Number OH00146367.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
Based on observation, staff interview, and review of the facility policy, the facility failed to ensure refrigerated medications were stored at an appropriate temperature. This affected one (Resident ...
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Based on observation, staff interview, and review of the facility policy, the facility failed to ensure refrigerated medications were stored at an appropriate temperature. This affected one (Resident #37) and had the potential to affect 12 residents with refrigerated medications. The facility identified 12 (Residents #1, #2, #5, #11, #14, #15, #22, #29, #30, #35, #37 and #41) who had refrigerated medications. The facility census was 50.
Findings include:
Review of the medical record for Resident #37 revealed an admission date of 04/07/22 and a readmission date of 04/21/23 with a diagnoses of type two diabetes mellitus.
Review of a physician order dated 09/21/23 revealed Resident #37 received Novolog FlexPen Subcutaneous Solution Pen-Injector 100 units per milliliter (ml) (insulin aspart), inject 18 units subcutaneously one time a day related to type two diabetes mellitus.
Observation and interview on 10/04/23 at 10:45 A.M. with the Interim Director of Nursing (IDON) revealed the locked medication room had one small and one large refrigerator for storing residents' medications. Observation of the temperature logs for October 2023 revealed no temperature was documented on either refrigerator.
Continued observation revealed inside the small refrigerator, there was a thermometer with an ice crystal stuck to the top suction cup and a clear liquid inside the face of the thermometer. An additional observation revealed two boxes of Novolog flex pens, for Resident #37, were rubberbanded together. The tops of both boxes had ice coating the boxes in such a way that it was difficult to open the boxes until the ice thawed. Continued observation after the ice thawed revealed eight Novolog flex pens were contained in the two iced boxes. The IDON confirmed there was ice on the thermometer, liquid moving inside it, and two boxes of Novolog flex pens for Resident #37 were iced over. No additional medications were observed to have ice on them. Additional boxes of Novolog flex pens for Resident #37 were available.
Review of the temperature logs for the medication refrigerators from July 2023 through September 2023 revealed the facility could provide only one set of logs and could not determine which refrigerator temperatures (the large or small one) was documented on the log. Further review of the log revealed instructions for staff to document the temperature twice daily. Continued review revealed the temperatures were not documented at all on 07/21/23, 07/22/23, 07/24/23, 07/25/23, 08/10/23, 08/14/23, 08/17/23, 08/19/23, 08/21/23, 08/24/23, 08/26/23, 08/27/23, 08/30/23, 08/31/23, 09/05/23, 09/09/23, and 09/13/23. Additionally, there were no days when the temperature was documented twice daily, per instructions.
Interview on 10/05/23 at approximately 10:00 A.M. with the IDON confirmed the facility could not provide temperature logs for both medication refrigerators from January 2023 through September 2023, and could not determine which refrigerator's temperatures were documented on the logs. Further, the IDON confirmed the temperatures were not documented per instructions. Additionally, no temperatures were documented for either medication refrigerator for 10/01/23, 10/02/23, 10/03/23 and 10/04/23.
Review of the undated policy titled, Medication Storage Information, revealed a refrigerator temperature log must be posted on outside of refrigerator and logged daily.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0800
(Tag F0800)
Could have caused harm · This affected multiple residents
Based on observation, medical record review, staff interview, and review of the menu spreadsheet, the facility failed to provide a pureed meal as approved by the dietitian for four (Residents #11, #21...
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Based on observation, medical record review, staff interview, and review of the menu spreadsheet, the facility failed to provide a pureed meal as approved by the dietitian for four (Residents #11, #21, #28, and #42) of four reviewed for pureed diets. The facility was 50.
Findings include:
1. Review of the medical record for Resident #11 revealed an admission date of 06/30/21. Review of the physician orders for Resident #11 revealed an order dated 08/06/21 for a regular diet, pureed texture.
2. Review of the medical record for Resident #21 revealed an admission date of 06/23/20. Review of the physician orders for Resident #21 revealed an order dated 07/14/22 for a regular diet, pureed texture.
3. Review of the medical record for Resident #28 revealed an admission date of 07/04/22. Review of the physician orders for Resident #28 revealed an order dated 07/30/22 for a regular diet, pureed texture.
4. Review of the medical record for Resident #42 revealed an admission date of 03/23/23. Review of the physician orders for Resident #42 revealed an order dated 05/01/23 for a regular diet, pureed texture.
Review of the dietary spreadsheet dated 10/04/23 revealed the pureed meal to be served with gyro sandwiches served on pita bread with gyro meat, onion, lettuce, and tomatoes, with sweet potato fries.
Observation on 10/04/23 at 10:50 A.M. with Director of Dietary (DD) #235 revealed he prepared four plates of pureed gyro meat, pureed sweet potatoes, and pureed peas (as a substitute for the lettuce, tomato, and onions). No pureed pita bread was served to the four residents.
Interview on 10/04/23 at 10:55 A.M. with DD #235 revealed he did not puree pita bread and therefore did not follow the planned meal for pureed meals.
The facility did not provide a policy for following dietitian approved meals.
This deficiency represents non-compliance investigated under Complaint Number OH00146367.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
Based on medical record review, observation, staff interview, and review of the facility policy, the facility failed to ensure gloves were worn when obtaining a blood glucose level and injecting insul...
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Based on medical record review, observation, staff interview, and review of the facility policy, the facility failed to ensure gloves were worn when obtaining a blood glucose level and injecting insulin to one resident (#35) of two observed for receiving insulin and having blood glucose level monitored. The facility further failed to ensure the glucometer was disinfected after use. Additionally, the facility failed to ensure staff appropriately completed hand hygiene following the completion of incontinence care. This affected one resident (#28) of six reviewed for activities of daily living (ADLs). The facility census was 50.
Findings include:
1. Review of the medical record of Resident #35 revealed an admission date of 09/02/23. Diagnosis of type II diabetes mellitus without complications.
Review of the physician order dated 09/07/23 for insulin Glargine inject 23 units subcutaneously daily for diabetes mellitus.
Observation on 11/03/23 at 7:40 A.M. revealed Licensed Practical Nurse (LPN) #256 obtained a glucometer from the medication cart and used it to monitor the blood glucose level for Resident #35. LPN #256 did not put on gloves prior to pricking the finger of Resident #35 and obtaining a blood sample applied to the test strip. LPN #256 placed the glucometer back into the medication cart without having disinfecting the device. Interview with LPN #256 provided verification she had not worn gloves to monitor Resident #35's blood sugar, injected the insulin into his left arm and did not disinfect the glucometer after use.
Review of the facility policy titled, Personal Protective Equipment, dated 03/02/23 revealed gloves would be worn when direct contact with blood is anticipated.
Review of the facility policy titled, Glucometer Disinfection, dated 10/24/22 revealed the facility shall ensure blood glucometers will be cleaned and disinfected after each use and according to manufacturers' instructions for multi-use residents.
2. Review of the medical record for Resident #28 revealed an admission date of 07/04/22 with a diagnosis of Alzheimer's disease.
Review of the quarterly Minimum Data Set assessment, dated 07/11/23, revealed Resident #28 was cognitively impaired and required extensive assistance of one staff for personal hygiene.
Observation on 10/02/23 at 1:20 P.M. of State Tested Nursing Assistants (STNA) #209 and #251 providing incontinence care for Resident #28 revealed they completed incontinence care and did not change their gloves after performing incontinence care. The observation further revealed upon the completion of incontinence care, STNA #209 and STNA #251 proceeded to arrange the clothing and bed linens for Resident #28 however neither STNA #209 and STNA #251 completed hand hygiene or changed their gloves after completing incontinence care for Resident #28 and prior to arranging Resident #28's bed linens and clothing.
Interview on 10/02/23 at 12:30 P.M. with STNA #209 and STNA 251 verified they did not change their gloves after completing incontinence care and prior to arranging Resident #28's bed linens and clothing.
Review of the facility policy titled Personal Protective Equipment, dated 03/02/23, revealed change gloves and perform hand hygiene between clean and dirty tasks and when moving form one body part to the anther.
This deficiency represents non-compliance investigated under Complaint Number OH00146367.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0887
(Tag F0887)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and review of the facility policy, the facility failed to ensure residents were offered...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and review of the facility policy, the facility failed to ensure residents were offered the COVID-19 vaccine or booster vaccine. This affected four (Residents #22, #33, #41, and #47) of five residents reviewed for COVID-19 vaccination. The facility census was 50.
Findings include:
1. Review of the medical record for Resident #22 revealed an admission date of 01/19/23 with diagnoses of end stage renal disease and type two diabetes mellitus. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #22 had intact cognition.
Review of the immunizations for Resident #22 revealed he received a COVID-19 booster vaccine on 10/22/21.
2. Review of the medical record for Resident #33 revealed an admission date of 01/02/21. Review of the quarterly MDS assessment dated [DATE] revealed Resident #33 had impaired cognition.
Review of the immunizations for Resident #33 revealed she received a COVID-19 vaccine on 01/04/21 and 01/25/21. Additionally, the documentation revealed Resident #33 received a historical COVID-19 vaccination on 08/02/23, however, there was no evidence the vaccine was administered.
3. Review of the medical record for Resident #41 revealed an admission date of 04/04/23. Review of the quarterly MDS assessment dated [DATE] revealed Resident #41 had impaired cognition.
Review of the immunizations for Resident #41 revealed she received a COVID-19 vaccination booster on 11/03/21.
4. Review of the medical record for Resident #47 revealed an admission date of 05/01/23. Review of the quarterly MDS assessment dated [DATE] revealed Resident #47 had impaired cognition.
Review of the immunizations for Resident #47 revealed no information regarding the COVID-19 vaccination.
Interview on 10/05/23 at 9:21 A.M. with Interim Unit Manager #314 confirmed the facility could provide no evidence Resident #22, Resident #41 and Resident #47 were offered COVID-19 vaccination or booster while residing in the facility, and confirmed she could find no evidence Resident #33 received a COVID-19 vaccination booster on 08/02/23.
Review of the Centers for Disease Control (CDC) guidelines for COVID-19 booster revealed the bivalent booster (for COVID-19 vaccination and to protect against variants Omicron BA.4 and BA.5) was available and recommended from 09/01/22 until 09/11/23. Websites accessed 10/12/23: https://www.cdc.gov/media/releases/2022/s0901-covid-19-booster.html and https://www.cdc.gov/coronavirus/2019-ncov/vaccines/stay-up-to-date.html.
Review of the policy titled, COVID-19 Vaccination, revised 05/09/23, defined up to date as a person who had completed a COVID-19 vaccine primary series and received the most recent booster dose recommended by the CDC. Further, the vaccine will be offered to residents when supplies are available, as per the CDC and/or FDA (Food and Drug Administration) guidelines unless such immunization is medically contraindicated, the individual has already been immunized during this timer period, or refuses to receive the vaccine. Additionally, the resident's medical record will include documentation regarding education regarding the risks, benefits, and potential side effects and each dose of the vaccine administered to the resident.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observation and staff interview, the facility failed to maintain the kitchen in a sanitary manner and failed to serve meals in a sanitary manner to potentially prevent foodborne illnesses. Th...
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Based on observation and staff interview, the facility failed to maintain the kitchen in a sanitary manner and failed to serve meals in a sanitary manner to potentially prevent foodborne illnesses. This had the potential to affect all 50 residents who received food from the kitchen. The facility census was 50.
Findings include:
1. Observations and interview during an initial tour of the kitchen on 10/02/23 at 8:22 A.M. along with Director of Dietary (DD) #235 revealed the following concerns:
•
Two rolling large trash receptacles were observed to have no lid. DD #235 obtained one lid from behind a rolling metal cart. The lid was noted to have a large amount of oily looking grease on both sides and black substances on the rim. DD #235 placed the lid in the sink.
•
The smaller, reach-in refrigerator had a moderate amount of food particles laying on the floor, and a large amount of dried food smeared on the door, the door handles, and the inner frame. Small dessert dishes were stored on an open shelf with the inside facing up.
•
A small chest-type freezer, holding ice cream, had a small dish of ice cream without a cover or date, and a large container of ice cream with the lid halfway crushed in, exposing ice cream.
•
The wall behind the small freezer had a pink substance dried on it.
•
The oven had a large amount of dried, baked-on food particles on the floor.
•
The floor drain, beneath a large electric pot, had a large amount of debris in the drain screen. DD #235 stated the drain grate was tack-welded in place with no way to clean the drain screen. This surveyor lifted the grate with ease.
•
Both of the gas stoves had a fair amount of food debris around the burners.
2. Observation on 10/02/23 at 11:50 A.M. of meal service in the 300 hall kitchenette revealed [NAME] #310 wearing gloves. [NAME] #310 rummaged through a drawer with papers and various items, touched the handles of cupboards and the heated serving cart, and proceeded to touch pita bread, to be served to a resident, with the same gloved hand. [NAME] #310 was then observed to grab meat and diced vegetables with the same gloved hand, and placed on the pita bread. [NAME] #310 never changed his gloves after touching non-food items and food items. Interview at the time of observation with [NAME] #310 verified he touched numerous surfaces and then resident food using the same gloved hand.
Observation on 10/02/23 at 12:05 P.M. of meal service in the 200 hall kitchenette revealed [NAME] #257 wearing gloves and touching various surfaces, including cupboard handles and papers and then grabbing pita bread and the vegetable toppings with the same gloved hand. Interview at the time of observation with [NAME] #257 confirmed she touched various surfaces and then resident food items with the same gloved hand.
MINOR
(C)
Minor Issue - procedural, no safety impact
Staffing Data
(Tag F0851)
Minor procedural issue · This affected most or all residents
Based on review of the Payroll-Based Journal (PBJ) staffing data report, review of staffing schedule, review of an employee time card, staff interview, and policy review, the facility failed to ensure...
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Based on review of the Payroll-Based Journal (PBJ) staffing data report, review of staffing schedule, review of an employee time card, staff interview, and policy review, the facility failed to ensure staffing information submitted for the PBJ report was accurate. This had the potential to affect all residents. The facility census was 50.
Findings include:
Review of the PBJ staffing data report for 01/01/23 through 03/31/23 revealed the facility had no Registered Nurse (RN) coverage on 03/04/23.
Review of the facility schedule dated 03/04/23 revealed agency Registered Nurse (RN) #312 was scheduled from 2:00 P.M. to 10:00 P.M. Review of the employee timecard for RN #312 revealed the nurse worked from 2:00 P.M. to 10:03 P.M.
Interview on 10/04/23 at 5:30 P.M., the Project Manager (PM) #300 revealed the facility incorrectly submitted data to the PBJ for RN #312. PM #300 stated the nurse was entered into the PBJ as a licensed practical nurse and should have been entered as a registered nurse.
Review of the policy, Staffing, revised 10/2017, revealed direct care staffing information per day (including agency and contract staff) would be submitted to the CMS payroll-based journal system on the schedule specified by CMS but no less than once a quarter.
Review of the policy, Reporting Direct-Care Staffing Information (Payroll-Based Journal), revised 10/2017 revealed for auditing purposes, reported staffing information was based on payroll records, or other verifiable information.
Jul 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and review of facility policy, the facility failed to provide the residents with wound ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and review of facility policy, the facility failed to provide the residents with wound care as physician ordered. This affected two (Residents #6 and #45) of three residents reviewed for wound care. The facility census was 54.
Findings include:
1. Review of the medical record for Resident #6 revealed an admission date of 05/01/23. Diagnoses included cellulitis right lower leg, sepsis, and dementia.
Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #6 was cognitively impaired and required extensive assistance of one staff for toilet use. Resident #6 was always incontinent of bowel and bladder. Resident #6 had no identified skin breakdown but was identified at risk and used a pressure reduction device for the bed.
Review of the care plan dated 05/03/23 revealed Resident #6 was at risk for skin breakdown due to immobility. The goal identified skin integrity will be maintained. Interventions included treatments to be administered as ordered.
Review of the care plan updated on 05/22/23 revealed Resident #6 had actual skin impairment with moisture associated skin damage (MASD) related to incontinence. Interventions included to follow facility protocols for treatment injury, monitor, document location, size and treatment of skin injury.
Review of a wound care note dated 05/22/23 revealed Resident #6 had MASD of partial thickness to the right and left buttock. Wound size for the right buttock MASD was 2.5 centimeters (cm) long by 1.0 cm wide by 0.01 cm deep and for the left buttock, 2.0 cm long by 1.0 cm wide and 0.01 cm deep. The treatment plan included alginate calcium with silver once daily and cover with silicone foam border. The wound care note dated 05/29/23 revealed the MASD of the right buttock resolved and the left buttock measured 6.0 cm long by 1.5 cm wide by 0.01 cm deep.
Review of Resident #6's physician orders written 05/29/23 revealed an order to cleanse the left buttock with wound cleanser, pat dry, cover with alginate calcium with silver daily and cover with foam silicone border. Barrier cream to be applied around the wound with treatments to start on 05/30/23.
Review of the treatment administration records from 05/30/23 to 07/04/23 revealed there were 13 missed treatments record for Resident #6 on the following dates: 05/30/23, 06/02/23, 06/03/23, 06/04/23, 06/08/23, 06/09/23, 06/10/23, 06/12/23, 06/13/23, 06/16/23, 06/23/23, 06/24/23, and 07/03/23.
Review of the weekly wound notes dated 06/05/23, 06/12/23, 06/19/23 and 06/26/23 revealed the left buttock MASD had improved with measurements on 06/26/23 of 0.5 cm long by 0.4 cm wide by 0.01 cm deep.
Interview with the Director of Nursing on 06/29/23 at 4:00 P.M. verified the wound care treatments for Resident #6 were not completed as physician ordered on 05/30/23, 06/02/23, 06/03/23, 06/04/23, 06/08/23, 06/09/23, 06/10/23, 06/12/23, 06/13/23, 06/16/23, 06/23/23, 06/24/23, and 07/03/23.
2. Review of the medical record for Resident #45 revealed an admission date of 04/07/22 with a readmission date of 04/21/23. Diagnoses included hemiplegia and hemiparesis following a cerebral infarction affecting left, non-dominant side, type II diabetes mellitus, morbid obesity, and chronic osteomyelitis. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #45 was cognitively intact.
Review of the care plan dated 04/21/22 revealed Resident #45 had a pressure ulcer to the sacrum. Goals included for the wound to show signs of healing without complications and interventions included to provide treatments as ordered.
Review of the current physician orders dated 05/02/23 revealed an order to for the right heel to clean daily and as needed with wound cleaner, pat dry and leave open to air. Review of the treatment administration record (TAR) from 05/02/23 to 06/30/23 revealed the treatment was not completed as physician ordered 23 times on the following dates: 05/03/23, 05/05/23, 05/08/23, 05/12/23, 05/13/23, 05/14/23, 05/22/23, 05/23/23, 05/26/23, 05/29/23, 06/02/23, 06/03/23, 06/04/23, 06/08/23, 06/09/23, 06/10/23, 06/12/23, 06/13/23, 06/16/23, 06/20/23, 06/24/23, 06/27/23, and 06/29/23
Review of the current physician orders dated 05/02/23 revealed an order for the right hip to clean with wound cleanser, pat dry, pack surgical incision with roll gauze moistened in Dakin's solution, cover with five inch by nine-inch dry dressing and secure with tape daily and as needed. Review of the TAR from 05/02/23 to 06/30/23 revealed the treatment was not completed as physician ordered 24 times on the following dates: 05/03/23, 05/05/23, 05/08/23, 05/12/23, 05/13/23, 05/14/23, 05/22/23, 05/23/23, 05/26/23, 05/29/23, 06/02/23, 06/03/23, 06/04/23, 06/08/23, 06/09/23, 06/10/23, 06/11/23, 06/12/23, 06/13/23, 06/16/23, 06/19/23, 06/20/23, 06/24/23, and 06/29/23.
Review of the current physician orders dated 05/02/23 revealed an order for the coccyx to cleanse with wound cleaner, pat dry, pack wound with roll gauze moistened with Dakin's solution, cover with calcium alginate, cover with Opti foam dressing daily and as needed. Review of the TAR from 05/02/23 to 06/30/23 revealed the treatment was not completed as physician ordered 22 times on the following dates: 05/03/23, 05/05/23, 05/08/23, 05/12/23, 05/13/23, 05/14/23, 05/22/23, 05/26/23, 05/29/23, 06/02/23, 06/03/23, 06/04/23, 06/08/23, 06/09/23, 06/10/23, 06/11/23, 06/12/23, 06/13/23, 06/16/23, 06/20/23, 06/24/23, and 06/29/23.
Review of the current physician orders dated 05/02/23 revealed an order for the scrotum to cleanse with wound cleaner, pat dry, apply Medi honey and cover with nonadherent dressing and brief daily and as needed. Review of the TAR from 05/02/23 to 06/30/23 revealed the treatment was not completed as physician ordered 23 times on the following dates: 05/03/23, 05/05/23, 05/08/23, 05/12/23, 05/13/23, 05/14/23, 05/22/23, 05/23/23, 05/26/23, 05/29/23, 06/02/23, 06/03/23, 06/04/23, 06/08/23, 06/09/23, 06/10/23, 06/11/23, 06/12/23, 06/13/23, 06/16/23, 06/20/23, 06/24/23, and 06/29/23.
Review of the current physician orders dated 05/02/23 revealed an order for the left heel to clean with wound cleanser, pat dry, cover with calcium alginate and roll gauze daily and as needed. Review of the TAR from 05/02/23 to 06/30/23 revealed the treatment was not completed as physician ordered 22 times on the following dates: 05/03/23, 05/05/23, 05/08/23, 05/12/23, 05/13/23, 05/14/23, 05/22/23, 05/23/23, 05/26/23, 05/29/23, 06/02/23, 06/03/23, 06/04/23, 06/08/23, 06/09/23, 06/10/23, 06/12/23, 06/13/23, 06/16/23, 06/24/23, 06/27/23, and 06/29/23
Interview with the Director of Nursing on 06/29/23 at 4:00 P.M. verified Resident #45 had several missing wound treatments to the right heel, right hip, coccyx, scrotum, and left heel between 05/02/23 to 06/30/23.
Review of the facility policy titled Wound Treatment Management, dated October 2010, stated to promote wound healing evidenced-based treatments will be provided in accordance with current standards of practice and physician orders, including the cleansing method, type of dressing and frequency of the dressing change.
This deficiency represents non-compliance investigated under Complaint Number OH00142936.
Jan 2023
6 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
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, resident and staff interview, and policy review, the facility failed to ensure resi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, resident and staff interview, and policy review, the facility failed to ensure residents were transferred with adequate staff using a mechanical lift. This affected one resident (#11) out of three residents reviewed for mechanical lift transfers. The facility census was 51.
Findings include:
Review of the medical record for Resident #11 revealed an admission date of 12/14/22. Diagnoses included a fracture of the right femur, difficulty walking, and muscle weakness.
Review of the 5-day Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #11 had intact cognition and was totally dependent on two people for transfers. Resident #11 was dependent for sit to stand transfers.
Review of the care plan for Resident #11 revealed no guidance regarding transfers.
Review of the current physician orders for Resident #11 revealed no guidance regarding transfers.
Review of a nurse progress note dated 01/30/23 revealed Resident #11 required a stand lift for transfers.
Observation on 01/30/23 at 9:18 A.M. revealed the MDS Coordinator #116 entered Resident #11's room with a stand lift. Subsequent interview on 01/30/23 at 9:29 A.M., with MDS Coordinator #116 verified he transferred Resident #11 by himself using a stand-lift. Further interview revealed he believed only one staff was required when using a stand lift.
Interview on 01/30/23 at 2:40 P.M., with the Interim Director of Nursing (IDON) revealed two staff were required when using a stand lift.
Interview on 01/31/23 at 11:08 A.M., with Resident #11 who verified she used a stand lift for transfers.
Interview on 01/31/23 at 11:56 A.M., with the Physical Therapy Assistant (PTA) #122 revealed Resident #11 should be transferred by staff using a stand lift. The PTA #122 said two staff should perform the transfer when using a stand lift.
Interview on 01/31/23 at 12:26 P.M., with the Director of Rehabilitation #123 verified two staff should perform transfers when using a stand lift.
Review of the policy titled Lifting Machine, Using a Mechanical, revised July 2017 revealed types of mechanical lifts included sit-to-stand lifts, and at least two nursing assistants were needed to safely move a resident with a mechanical lift.
This deficiency represents non-compliance investigated under Complaint Number OH00139151.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
Based on medical record review, observation, staff interview, and policy review, the facility failed to provide timely and necessary incontinence care. This affected one resident (#38) out of three re...
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Based on medical record review, observation, staff interview, and policy review, the facility failed to provide timely and necessary incontinence care. This affected one resident (#38) out of three residents reviewed for incontinence. The facility census was 51.
Findings include:
Review of the medical record for Resident #38 revealed an admission date of 12/18/19. Diagnoses included dementia, chronic ischemic heart disease, major depressive disorder, asthma.
Review of the quarterly Minimum Data Set (MDS) assessment, dated 12/31/22, revealed Resident #38 had impaired cognition and required extensive assistance of two staff for toileting. Resident #38 was identified frequently incontinent of bladder and bowel.
Review of the care plan dated 01/17/21 revealed Resident #38 had bladder and bowel incontinence. Interventions included the resident to be checked every two hours and assisted with toilet use as needed and for peri-care after each episode of incontinence.
Observation of Resident #38 on 01/20/23 at 8:30 A.M., 9:30 A.M., 10:56 A.M. and 11:35 A.M. revealed the resident was sitting in the dining room in a wheelchair. Observation at 11:40 A.M. revealed a strong smell of urine when passing by the resident as the resident ate lunch.
Observation of incontinence care completed by State Tested Nursing Assistant (STNA) #100 on 01/30/23 at 12:40 P.M. revealed Resident #38 was incontinent of urine and further verified Resident #38 smelled of urine.
Interview with the STNA on 01/30/23 at 12:45 P.M. verified Resident #38 had not been checked for incontinence every two hours. STNA stated the last time Resident #38 had been provided incontinent care was with activities of daily living when the resident was assisted out of bed in the morning.
Review of the facility policy titled Urinary Continence and Incontinence - Assessment and Management, dated September 2010 stated as part of the initial and ongoing assessments, the nursing staff will screen for information related to urinary continence and for a resident identified as incontinent the staff will provide scheduled toileting.
Review of the facility policy titled Call Lights: Accessibility and Timely Response, dated 08/10/22 stated each resident will be evaluated for unique needs and preferences to determine any special accommodations and further stated the special accommodations will be identified on the residents person-centered care plan and provided accordingly.
This deficiency represents non-compliance investigated under Complaint Number OH00139151 and Complaint Number OH00138088.
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
Based on medical record review, observation, staff and resident interview, and policy review, the facility failed to ensure medications were administered as ordered to prevent a significant medication...
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Based on medical record review, observation, staff and resident interview, and policy review, the facility failed to ensure medications were administered as ordered to prevent a significant medication error. This affected one resident (#27) out of four residents observed during medication administration. The facility census was 51.
Findings include:
Review of the medical record for Resident #27 revealed an admission date of 04/30/21. Diagnoses included hemiplegia, and hemiparesis following cerebral infarct, acute respiratory failure, pulmonary hypertension, rheumatoid arthritis, and congestive heart failure.
Review of a physician order dated 07/25/22 revealed Resident #27 was ordered immunosuppressive therapy with hydroxychloroquine sulfate 200 milligrams (mg) twice daily.
Observation on 01/30/22 at 8:50 A.M. revealed Licensed Practical Nurse (LPN) #110 prepared and administered morning medications for Resident #27 revealed hydroxychloroquine sulfate 200 mg was not administered.
Interview with the LPN #110 at the time of the observation verified the hydroxychloroquine sulfate 200 mg was not administered because the medications was not available.
Interview with Resident #27 on 01/30/23 at 9:00 A.M., verified the hydroxychloroquine sulfate 200 mg was not administered.
Review of the medication administration record for Resident #27 on 01/31/23 at 12:30 P.M. revealed neither dose of the hydroxychloroquine sulfate 200 mg was administered on 01/30/23.
Review of a progress note for Resident #27 dated 01/30/23 at 3:54 P.M. revealed the facility was waiting on the pharmacy to drop ship the hydroxychloroquine sulfate 200 mg.
Review of a progress note made for Resident #27 on 01/30/23 at 9:18 P.M. revealed the hydroxychloroquine sulfate 200 mg would be delivered in the night tote.
Review of an additional progress note made on 01/30/23 at 10:19 P.M. stated the hydroxychloroquine sulfate 200 mg would be sent in tomorrow's tote.
Interview on 01/31/23 at 2:19 P.M., with the Regional Clinical Nurse #124 verified the and progress notes for Resident #27 indicated the medication was not given.
Interview with the Interim Director of Nursing on 01/31/23 at 2:19 P.M., stated the hydroxychloroquine sulfate for Resident #27 left the pharmacy on 01/30/23 at 9:20 P.M.
Interview on 01/31/23 at 2:45 P.M., with LPN #126 verified the delivery date on the hydroxychloroquine sulfate was 1/30/23 and further confirmed only one dose was given out of the package, which was given this morning, for Resident #27. Observation of the medication package at the time of the interview verified only one dose dispensed.
Review of the facility policy titled Administering Medications, dated April 2019 stated medications are administered in a safe and timely manner, and as prescribed.
This deficiency represents non-compliance investigated under Complaint Number OH00139151 and Complaint Number OH00138088.
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
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and medical record review, the facility failed to ensure accuracy of the medical record. This affected ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and medical record review, the facility failed to ensure accuracy of the medical record. This affected three residents (#10, #09, and #38) out of six residents reviewed for accuracy of the medical record. The facility census was 51.
Findings include:
1. Review of the medical record for Resident #10 revealed an admission date of 12/24/22 with diagnoses of lumbar region spinal stenosis, neurogenic claudication, and type II diabetes mellitus.
Review of the comprehensive minimum data set (MDS) assessment dated [DATE] revealed Resident #10 had intact cognition and required extensive assistance of two people for bed mobility, extensive assistance of one person for transfers, dressing, and personal hygiene.
Review of the medication administration progress notes for Resident #10 revealed a note dated 01/16/23 stating medication on order, three notes dated 01/19/23 stating, not available, supervisor notified, not available, on order, and on order, and a note dated 01/20/23 documented medication is on order, not yet received.
Review of Resident #10's medication administration record (MAR) for January 2023 revealed all medications had check marks on them, indicating they were given to the resident, on 01/16/23, 01/19/23, and 01/20/23.
Interview on 01/31/23 at 3:56 P.M., with the Regional Clinical Nurse (RCN) #124 verified the progress notes for Resident #10 dated 01/16/23, 01/19/23 and 01/20/23 indicated medications were not available and the January 2023 MAR indicated all medications were given as ordered, resulting in a medical record documentation error.
2. Review of the medical record for Resident #09 revealed an admission date of 12/06/22 with diagnoses of myocardial infarction, pneumoconiosis and cerebral infarction.
Review of the comprehensive MDS assessment dated [DATE] revealed Resident #09 had impaired cognition, required extensive assistance of two people for bed mobility and transfers, extensive assistance for dressing, toileting, and hygiene, and total assistance of one person for eating.
Review of a progress note dated 12/10/22 revealed Resident #09 had an unwitnessed fall. He reported rib pain at that time and an x-ray was ordered and showed no acute fracture.
Review of the neurological checks started for Resident #09 on 12/10/22 revealed they were not completed as defined on the form: every 15 minutes for one hour, every 30 minutes for one hour, every hour for four hours, and every four hours for 24 hours.
3. Review of the medical record for Resident #38 revealed an admission date of 12/18/19. Diagnoses included dementia, chronic ischemic heart disease, major depressive disorder, asthma.
Review of the quarterly MDS assessment dated [DATE] revealed Resident #38 had impaired cognition and required extensive assistance of two staff for toileting. Resident #38 was identified frequently incontinent of bladder and bowel.
Review of a progress note dated 01/02/23 revealed Resident #38 had an unwitnessed fall and was assessed for injuries with no concerns.
Review of a progress note dated 01/25/23 revealed Resident #38 had an unwitnessed fall and was assessed for injuries with no concerns.
Review of the neurological checks for Resident #38 dated 01/02/23 and 01/25/23 revealed they were incomplete.
Interview on 01/31/23 at 1:35 P.M., with the Interim Director of Nursing (DON) verified the neurological checks for Resident #09's fall on 12/10/22 were incomplete. Further interview verified the neurological checks for Resident #38's falls on 01/02/23 and 01/25/23 were incomplete.
Review of the policy titled Falls and Fall Risk, Managing, revised March 2018 revealed no guidance regarding completion of neurological checks after an unwitnessed fall.
This deficiency represents non-compliance investigated under Complaint Number OH00138088.
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 staff interview, review of the staffing schedules, and policy review, the facility failed to ensure a Registered Nurse (RN) worked eight consecutive hours daily. This had the potential to aff...
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Based on staff interview, review of the staffing schedules, and policy review, the facility failed to ensure a Registered Nurse (RN) worked eight consecutive hours daily. This had the potential to affect all residents in the facility. The facility census was 51.
Findings include:
Review of the facility staffing schedules from 01/01/23 through 01/07/23 revealed the facility had insufficient RN coverage on 01/01/23 and 01/07/23.
Interview on 01/30/23 at 3:55 P.M., with the Scheduler #118 verified there was no RN coverage at the facility on 01/01/23 and less than eight hours of RN coverage on 01/07/23.
Review of the facility policy titled Staffing, revised October 2017 revealed no guidance regarding daily RN coverage.
This deficiency represents non-compliance investigated under Master Complaint Number OH00139618, and Complaint Numbers OH00139151, and OH00138088.
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 F0919
(Tag F0919)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interview, review of the call light audit, review of resident council minutes, and poli...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interview, review of the call light audit, review of resident council minutes, and policy review, the facility failed to ensure the call light system accurately and consistently reflected activated call lights. This affected all residents in the facility. The facility census was 51.
Observations during the survey completed 01/30/23 and 01/31/23 revealed call light notifications were visible on a telephone display at one desk on each hall and an overhead bell would ring. Further observation on the 100-hall revealed after a call light alarmed for approximately 15 minutes, the call light display would disappear from the telephone and the overhead bell would cease. At that time, the call light notification would alert on the telephone on the 200-hall and the overhead bell on the 200-hall would ring. No illuminated call lights were mounted outside resident doors.
Interview on 01/30/23 at 8:20 A.M., with Resident #10 revealed concerns regarding lengthy call light response times.
Interview on 01/30/23 at 10:28 A.M., with Resident #09 revealed his call light had been on for a couple of hours. Resident #09 asked the surveyor to cancel the call light. Resident #09 denied any needs at that time and appeared to be in no distress.
Interviews on 01/30/23 between 10:40 A.M. and 11:24 A.M. with three State Tested Nurse Aides (STNA) (#113, #114, and #115) revealed the call light notifications were displayed on a single phone in each hall and they did not carry a device to alert them to the call lights. Further interview with STNA #115 revealed she normally worked on the 200-hall and the call light alerts from 100-hall would appear on the phone display on the 200-hall. STNA #115 stated staff did not respond to call light alerts from other halls because they knew staff were available on the other halls.
Interview on 01/30/23 at 11:42 A.M., with Resident #11 revealed concerns regarding long call light wait times, but could not identify specific times or problems that occurred as a result of long wait times.
Interview on 01/30/23 at 2:00 P.M., with STNA #117 revealed she did not have a pager and viewed the phone display to monitor call lights.
Interview on 01/30/23 at 3:43 P.M., with the Scheduler #118 verified the call light alert would stop displaying on the 100-hall after a period of time.
Interview on 01/30/23 at 4:10 P.M., with STNA #119 verified there was no way to identify a call light was alerting once it left the display on the 100-hall phone.
On 01/30/23 at 4:14 P.M., the surveyor activated a call light in vacant room [ROOM NUMBER] on the 100-hall. Observation at that time revealed an overhead alarm could be heard and the display on the phone showed the call light for room [ROOM NUMBER] was activated.
Observation on 01/30/23 at 5:16 P.M. revealed the call light in room [ROOM NUMBER] remained lit. The phone display on the 100-hall showed no call light alerts. Subsequent observation on the 200-hall revealed the phone display showed an active call light for room [ROOM NUMBER].
Interview on 01/30/23 at 5:18 P.M., with LPN #111 revealed the facility had two phones for nurses to carry, and she had not carried one on her shift. Two phones were observed on the countertop of the nurses' station at that time. Only LPN #111 was in the station.
Interview on 01/30/23 at approximately 5:30 P.M., with LPN #110 verified she had not carried a phone or pager with her during her shift and had not received alerts regarding call lights.
Review of the call light audit for 01/30/23 revealed Resident #09's call light alarmed from 8:08 A.M. until the surveyor canceled it at 10:31 A.M. (two hours and twenty-three minutes).
Interview with the Administrator throughout the day on 01/30/23 revealed she was unaware the 100-hall call light alerts would disappear from the display on the 100-hall after a period of time.
Follow-up interview on 01/31/23 at 11:45 A.M., with the Administrator verified the call light for Resident #09 alerted for two hours and twenty-three minutes.
Review of Resident Council meeting minutes for 10/24/22 revealed old business of slow call light response with no new concerns noted, and concerns regarding long call wait times at the meeting on 12/27/22.
Review of facility policy titled Call Lights: Accessibility and Timely response, dated 08/10/22 revealed the call system alerts either staff members directly or goes to a centralized staff work area.
This deficiency represents non-compliance investigated under Complaint Numbers OH00139151 and OH00138088.
May 2021
5 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected 1 resident
Based on record review, observations, resident interview, staff interview, and review of the facility's policy, the facility failed to ensure resident rooms were clean and sanitary. This affected two ...
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Based on record review, observations, resident interview, staff interview, and review of the facility's policy, the facility failed to ensure resident rooms were clean and sanitary. This affected two (#4 and #34) of 56 resident rooms reviewed for the environment. The facility census was 56.
Findings include:
Medical record review for Resident #4 revealed an admission date 03/28/18. Diagnoses included cerebrovascular disease and osteoarthritis. Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/18/21, revealed the resident had intact cognition.
Observation on 04/26/21 at 11:44 A.M. of Resident #4's bathroom shower wall revealed it had a large area of plaster and had not been painted. In the resident's room, the carpet had a large stain area located in front of the resident's bed.
Interview on 04/29/21 at 11:42 A.M., with Resident #4 reported the bathroom wall had been that way for two years. It was fixed with plaster and never painted. The plaster fell out and was plastered again and had not been painted.
2. Medical record review for Resident #34 admission date 06/23/20. Diagnoses included hypothyroidism and atherosclerotic heart disease. Review of the quarterly Minimum Data Set (MDS) assessment, dated 04/27/21, revealed the resident had impaired cognition.
Interview on 04/26/21 at 11:42 A.M. with Resident #34's responsible party revealed stains on the resident's flooring were caused when the toilet over flowed and they had requested the floor be cleaned.
Observation on 04/26/21 at 11:42 A.M., of Resident #34's room revealed multiple areas of dark stains around the bed and on the entrance to the room.
Interview on 04/29/21 at 8:50 A.M. with the Housekeeping Supervisor (HS) #210 reported the person that was scrubbing the carpets quit and they have been trying to hire someone. HS #210 verified Resident #4 and Resident #34's rooms with multiple areas of large dark stains and Resident #4's bathroom with plaster shower wall and it was not painted.
Review of the facility's policy titled Environmental Services Cleaning Guidelines, dated 06/20/20, revealed it is the policy of this facility that the workplace will be maintained in a clean and sanitary condition with written schedules of cleaning and decontamination based on the area of the facility, type of surface to be cleaned , type of soil present and tasks being performed in the area. Carpets will be cleaned on a regular bases determined in areas where heavy soiling or spilling may occur.
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 review of the facility's Self-Reported Incident (SRI), medical record review, staff interviews and facility policy revi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility's Self-Reported Incident (SRI), medical record review, staff interviews and facility policy review, the facility failed to timely report allegations of misappropriation to the State Survey Agency as required. This affected two residents (#3 and #8) of three residents reviewed for misappropriation. The facility census was 56.
Findings include:
1. Review of the medical record for Resident #3 revealed an admission date of 10/09/19. Diagnoses included anxiety disorder and attention deficit hyperactivity disorder (ADHD). Review of the quarterly Minimum Data Set (MDS) assessment, dated 04/15/21, revealed the resident had intact cognition.
Review of the Medication Administration Records (MARs) revealed the Adderall 30 milligrams (mg.) was scheduled for before lunch and before dinner. The Xanax was scheduled daily at HS (hours of sleep/bedtime).
Review of a Customer Concern Form, dated 03/01/21, revealed Resident #3 reported Licensed Practical Nurse (LPN) #202 tried to administer Adderall (medication used to treat ADHD) instead of the scheduled Xanax (medication used to treat anxiety).
Review of the facility's investigation revealed the interim Director of Nursing (DON) interviewed the resident on 03/03/21. Resident #3 alleged that LPN #202 tried to give her Adderall instead of her scheduled Xanax and reported that the LPN argued with her at first and then went to the cart and brought in the Xanax. Resident then asked for the Adderall from LPN #201 to provide proof that he was trying to give her the wrong medication and LPN #202 refused to allow the resident to keep it. Resident questioned what LPN #201 did with the medication.
Facility interview with LPN #201 on 03/04/21 revealed the nurse gave Resident #3 an extra dose of Adderall with no negative outcome of resident since receiving the extra dose. Continued review of the facility's investigation revealed LPN #201 had a total of nine other instances of signing out narcotics on narcotic sheets but not on the Medication Administration Records (MAR). LPN #201 was suspended during the investigation on 03/04/21 and was sent to Occupational Health for a drug screen to be completed on 03/04/21 of which he did not go for the screen until 03/08/21.
Review of a corrective action report on file for LPN #201 revealed a written warning and suspension on 03/04/21 for six days.
Review of LPN #201's statement, dated 03/04/21, revealed one extra dose of Adderall 30 mg. had been administered to Resident #3 who had already had her before dinner scheduled dose. The statement indicated observation of the resident taking the medication with one eight ounce glass of water.
Review of the facility's self-reported incident control number 203201 revealed the allegation of misappropriation was not reported to the State Survey Agency until 03/05/21, involving Resident #3 and LPN #201.
Interview with the Administrator and the Director of Nursing (DON) on 04/28/21 at 2:20 P.M. verified the facility received an allegation of misappropriation on 03/01/21 and failed to report an allegation of misappropriation to the State Survey Agency until 03/05/21.
2. Review of medical record for Resident #8 revealed an admission date of 07/08/15. Diagnoses included Alzheimer's disease with late onset, unspecified dementia, scoliosis, spinal stenosis, abnormal posture, difficulty walking, and muscle weakness. Review of the significant change MDS assessment, dated 01/26/21, revealed the resident had severe cognitive impairment.
Review of the facility's internal investigation revealed the DON had received an anonymous note under her door alleging that an agency LPN #200 had administered extra doses of Morphine (narcotic pain medication) to Resident #8. The staffing agency was contacted on 03/05/21 regarding the allegation and reported they were notifying the pharmacy and nursing licensing boards. The LPN was sent to do a drug screen on 03/05/21 and a negative drug screen was received on 03/05/21. Internal investigation revealed LPN #200 on multiple occasions between 01/07/21 and 02/06/21 had given Morphine around 4:00 A.M. and 4:45 A.M. and another dose at 9:00 A.M. for an every eight hour order. A meeting with LPN #200, DON and Executive Director was held on 03/07/21 for further clarification of LPN #200's statement on 03/05/21 from the agency. LPN #200 reported that she takes medication cups at the start of her med pass, writes the resident name on it and all of the medications that she needs to give for all of the residents, goes and gives the medication and after all medications were given then documents her administration in the electronic mediation administration record (EMAR). The agency nurse was banned from coming back to the facility on [DATE].
Review of the facility's self-reported incident control number 203292 revealed the facility did not report the allegation of misappropriation to State Survey Agency until 03/08/21, involving Resident #8 and LPN #200.
Interview with the Administrator and the DON on 04/28/21 at 2:15 P.M. confirmed the facility was aware of the allegation of misappropriation on 03/05/21 but did not report to the State Survey Agency until 03/08/21.
Review of the facility's policy titled Abuse, Neglect, Exploitation, Mistreatment and Misappropriation - Prevention and Reporting Policy, with a revision date of 11/2016, revealed the facility would ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately to the administrator of the facility and to other officials (including to the state survey and certification agency and adult protective services where state law provides jurisdiction in long-term care facilities) in accordance with state law through established procedures. The policy further states the facility to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment including injuries of unknown source and misappropriation of resident property mistreatment, are reported immediately but not later than two hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury to the administrator of the facility and to other officials (including to the State Survey Agency).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
Based on record review, staff interview, and resident interview, the facility failed to provide proper wound care to residents as ordered by the physician. This affected one (#19) of two residents rev...
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Based on record review, staff interview, and resident interview, the facility failed to provide proper wound care to residents as ordered by the physician. This affected one (#19) of two residents reviewed for wound care. The facility identified five residents with pressure ulcers. The facility census was 56.
Findings included:
Review of Resident #19's medical record revealed an admission date of 08/11/14. Diagnosis included multiple sclerosis, paraplegia, neuromuscular bladder, chronic kidney disease, diabetes mellitus, and malignant neoplasm of the palate.
Review of the quarterly Minimum Data Set assessment, dated 02/22/21, revealed the resident had a high cognitive function. The resident was at a high risk for developing a pressure ulcer and did have one stage two pressure ulcer (partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough), and two stage four pressure ulcers (Full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed).
Review of the physician orders, dated 04/13/21, revealed an order to cleanse the right buttock with soap and water. Use collage and Negative Pressure Wound Therapy (NPWT) black foam as the primary dressing. Take a piece of black foam and spiral roll it under the undermining using one piece of foam. Use VAC-OP site as the secondary dressing. Complete the dressing change three times per week for three weeks every Tuesday. For the left trochanter (hip), cleanse peri ulcer with soap and water. Use collagen with black foam. Set the wound vac at 125 millimeter of mercury (mmHg) continuous as the primary dressing. Take the black foam and spiral under the undermining using one piece of foam. Use abdominal (ABD) gauze pad as secondary dressing. This order was to be carried out three times a week for three weeks every Thursday.
Review of the medical record revealed a wound care nurse practitioner (WCNP) visited the facility weekly and the resident had appointments at the local hospital wound care clinic every two weeks.
Interview with Resident #19 on 04/26/21 at 11:22 A.M. revealed staff were completing wound care timely, but per the physician the foam was not being placed in the wound properly.
Interview with Licensed Practical Nurse (LPN) #213 on 04/27/21 at 8:55 A.M. revealed the facility staff had been struggling with applying the foam dressings with Resident #19's wound vac. The nurse stated the facility was planning an in-service program, but had not received training at that time.
Telephone interview with WCNP #225 on 05/04/21 at 9:23 A.M. revealed the facility had not been completing Resident #19's wound care as ordered. The WCNP stated the nurses seemed unfamiliar with caring for a resident with a wound vac in place due the the foam packing had not being place properly in the wound. The WCNP revealed she notified the wound vac company and asked for a representative to visit the facility and train the nurses. As of the time of this telephone interview, the WCNP was unaware if the training had been completed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
Based on record review, staff interview, and review of the facility's policy, the facility failed to ensure medications were available as ordered by the physician. This affected two (#3 and #8) of fiv...
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Based on record review, staff interview, and review of the facility's policy, the facility failed to ensure medications were available as ordered by the physician. This affected two (#3 and #8) of five residents reviewed for medications. The facility census was 56.
Findings Include:
1. Review of the medical record for Resident #3 revealed an admission date of 10/09/19. Diagnoses included chronic obstructive pulmonary disease, major depressive disorder, asthma, fibromyalgia, pain in right shoulder, pain in left shoulder, and low back pain.
Review of the quarterly Minimum Data Set (MDS) assessment, dated 04/15/21, revealed the resident had intact cognition.
Review of the physician orders revealed Resident #3 was prescribed Lyrica (pain medication) 50 milligrams (mg.) orally three times a day, Incruse Ellipta Aerosol (used to treat respiratory ailments) 62.5 microgram per inhalation one puff once daily and Remeron (used to treat depression) 15 mg. orally once daily.
Review of the medication administration records (MARs) for 02/2021 and 04/2021 revealed Lyrica, Incruse Ellipta Aerosol and Remeron were documented as nine, indicating 'other/see nurses notes'. Review of the nursing progress notes revealed the following medications were not available for administration for the following dates and times: Lyrica 50 mg. on 02/07/21 at bedtime, Lyrica 50 mg. on 02/08/21 before lunch, before dinner and at bedtime, Incruse Ellipta Aerosol 62.5 microgram on 04/01/21 before lunch and Remeron 15 mg. on 04/09/21 at bedtime.
Interview on 04/28/21 at 2:15 P.M. with the Director of Nursing (DON) verified Lyrica 50 mg. on 02/07/21 at bedtime, Lyrica 50 mg. on 02/08/21 before lunch, before dinner and at bedtime, Incruse Ellipta Aerosol 62.5 microgram on 04/01/21 before lunch and Remeron 15 mg. on 04/09/21 at bedtime were held on these dates per the MAR and nursing progress notes. The DON stated the facility had a contingency box in which medications can be pulled from.
2. Review of the medical record for Resident #8 revealed an admission date of 07/08/15. Diagnoses included Alzheimer's disease with late onset, unspecified dementia, disorders of bone density and structure, lack of coordination, major depressive disorder, , osteoarthritis, , neuromuscular dysfunction of bladder, scoliosis, spinal stenosis weakness, and abnormal posture. Review of the significant change MDS assessment, dated 01/26/21, revealed the resident had severe cognitive impairment.
Review of the physician orders revealed an order for Morphine Sulfate ER (pain medication) 15 milligrams (mg.) orally every eight hours for pain to be administered at 6:00 A.M., 2:00 P.M., and 10:00 P.M.
Review of the MARs, from 01/2021 to 04/2021, revealed the medication was documented as nine indicating other/see nurses notes on 16 occurrences Review of the nursing progress notes revealed the medication not being available for administration for the following dates and times: on 01/03/21 at 2:00 P.M., 01/11/21 at 6:00 A.M., 01/12/21 at 6:00 A.M., 02/07/21 at 6:00 A.M., 02/07/21 at 2:00 P.M., 02/08/21 at 6:00 A.M., 02/08/21 at 2:00 P.M., 02/08/21 at 10:00 P.M., 02/10/21 at 6:00 A.M., 03/12/21 at 6:00 A.M., 03/30/21 at 6:00 A.M., 03/30/21 at 10:00 P.M., 03/31/21 at 6:00 A.M., 04/10/21 at 2:00 P.M., 04/20/21 at 10:00 P.M., and on 04/21/21 at 6:00 A.M.
Interview on 04/28/21 at 2:15 P.M. with the DON verified the documentation on the MARs and nursing progress notes indicated Morphine was not administered several times due to the medication was not available for administration. The DON confirmed the facility has a contingency box in which medications could be pulled from.
Review of the facility's policy titled, Emergency Pharmacy Service, dated 09/04/19, revealed emergency pharmaceutical service is available on a 24 hour basis. Emergency needs for medication are met by using the facility's approved emergency medication supply or special order from the primary pharmacy. Continued review of the policy revealed arrangements will be made for a back-up pharmacy in the event medications cannot be supplied by the primary pharmacy in a timely manner.
This deficiency substantiates Complaint Number OH00121666.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected 1 resident
Based on record review, review of the facility's policy and staff interview, the facility failed to ensure the physician acted timely to address pharmacy recommendations. This affected three (Resident...
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Based on record review, review of the facility's policy and staff interview, the facility failed to ensure the physician acted timely to address pharmacy recommendations. This affected three (Resident #2, #3 and #13) of five residents reviewed for unnecessary medications. The facility census was 56.
Findings include:
1. Review of the medical record for Resident #2 revealed an admission date of 05/10/19 and a readmission date of 05/13/20. Diagnoses included major depressive disorder. Review of the annual Minimum Data Set (MDS) assessment, dated 04/17/21, revealed the resident had intact cognition.
Review of the pharmacy recommendations, dated 02/26/21, revealed Resident #2 was on Sertraline (antidepressant) 50 milligrams (mg.) by mouth daily. The pharmacist requested the physician consider a gradual dosage reduction for the medication. The physician declined and signed the recommendations on 04/27/21, which was 60 days after the medication review by the pharmacist.
2. Review of the medical record for Resident #3 revealed an admission date of 10/09/19. Diagnoses included anxiety disorder and major depressive disorder. Review of the quarterly MDS assessment, dated 04/15/21, revealed the resident had intact cognition.
Review of the pharmacy recommendations, dated 02/26/21, revealed Resident #3 was on Duloxetine (antidepressant) 60 mg. by mouth daily and Xanax (antianxiety) 0.5 mg. by mouth every evening. The pharmacist requested the physician consider a gradual dosage reduction for the medications. The physician declined and signed the recommendations on 04/27/21, which was 60 days after the medication review by the pharmacist.
Interview on 05/03/21 at 12:10 P.M. with the Director of Nursing (DON) confirmed the monthly medication reviews for Resident #2 and #3 were completed on 02/26/21 and was not signed by the physician until 04/27/21 and was unable to explain the delay.
3. Review of Resident #13's medical record revealed an admission date of 12/04/21. Diagnosis included Parkinson's disease, major depression, dementia, and anxiety. Review of the significant change Minimum Data Set (MDS) assessment, dated 02/26/21, revealed the resident received antidepressant and hypnotic medications seven days per week.
Review of the physician's orders, dated 12/04/19, revealed an order for Mirtazapine 30 mg table by mouth once daily for sleep. A physician's order, dated 12/04/19, for Restoril (Temazepam) capsule 7.5 milligrams (mg) to be given by mouth one time a day for insomnia.
Review of the Pharmacy Note to Attending Physician/Prescriber, dated 04/26/20, revealed the pharmacist suggested, per the guideline for managing antidepressant drug therapy, Temazepam 7.5 mg. by mouth at bedtime were due for an evaluation for continued use. The physician failed to respond to the pharmacy request.
Review of the Pharmacy Note to Attending Physician/Prescriber, dated 12/29/20, revealed the pharmacist suggested, per the guideline for managing antidepressant drug therapy, Remeron 30 mg. by mouth at bedtime were due for an evaluation for continued use. The physician failed to respond to the pharmacy request.
Review of the Pharmacy Note to Attending Physician/Prescriber, dated 02/26/21, revealed the pharmacist suggested, per the guideline for managing antidepressant drug therapy, Remeron 30 mg. by mouth at bedtime were due for an evaluation for continued use. The physician declined and signed the recommendations on 04/27/21, which was 60 days after the medication review by the pharmacist.
Review of the Pharmacy Note to Attending Physician/Prescriber, dated 02/26/21, revealed the pharmacist suggested, per the guideline for managing antidepressant drug therapy, Temazepam 7.5 mg. by mouth at bedtime were due for an evaluation for continued use. The physician declined and signed the recommendations on 04/27/21, which was 60 days after the medication review by the pharmacist.
Interview on 05/03/21 at 12:10 P.M. with the Director of Nursing (DON) confirmed the monthly medication reviews were completed on 04/26/20 and 12/29/20 for Resident #13 and the physician failed to address them. In addition, the monthly medication review, dated 02/26/21, were not reviewed nor signed by the physician until 04/27/21 and was unable to explain the delay.
Review of the facility's policy titled Medication Review and Recommendation, dated 03/22/19, revealed when a recommendation is made it will be emailed to the DON or designee to be printed and given to the appropriate staff or physician. Non-emergency recommendations are to be addressed within the next 30 days. Urgent irregularities that need immediate attention will be verbally communicated to the responsible nurse, for that resident to be addressed immediately. If a recommendation has not been answered within 30 days, the consultant will notify the DON that the recommendation in still pending. If after 60 days, there is still no response the recommendation will be made again
May 2019
8 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
Based on medical record review, staff interview, and review of a facility policy, the facility failed to ensure a resident's family was notified prior to outside appointments and scheduled surgery. Th...
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Based on medical record review, staff interview, and review of a facility policy, the facility failed to ensure a resident's family was notified prior to outside appointments and scheduled surgery. This affected one (Resident #52) of three residents reviewed for care planning. The facility census was 51.
Findings include:
Review of Resident #52's medical record revealed an admission date of 04/03/19. Medical diagnoses included displaced trimalleolar fracture of right lower leg, generalized muscle weakness, cognitive communication deficit, age related physical debility, anxiety disorder, atrial fibrillation, atherosclerotic heart disease, major depressive disorder, hypertension, hypoosmolality, hyponatremia, osteoarthritis, difficulty walking, and long term use of anticoagulants.
Review of the admission Minimum Data Set (MDS) assessment, dated 04/10/19, revealed the resident had moderate impairment in cognition.
Review of the physician's notes and hospital discharge paperwork revealed the resident was seen for follow up orthopedic appointment on 04/17/19. The resident had follow up orthopedic surgery on 04/23/19 due a failed fixation of her right ankle. The resident was seen for another follow up orthopedic appointment on 04/26/29
Review of the resident's medical record revealed no documentation indicating the resident or the resident's family was notified of the orthopedic follow up appointments on 04/17/19 and 04/26/19 or the surgery to the right ankle on 04/26/19.
Interview with Registered Nurse #220 on 05/23/19 at 12:32 P.M. verified there was no documentation indicating the resident's family was notified of the follow up orthopedic appointments scheduled on 04/17/19 or 04/26/19, or the resident's surgery on 04/26/19. She stated the resident's family did not attend the appointment on 04/17/19.
Review of an undated facility policy titled Notification of Changes revealed when there was a need to alter treatment significantly, immediate notification of the resident will occur. There will also be consultation with the resident's physician , and the resident representative if consistent with his/her authority. Need to alter treatment significantly included the following: a need to change a current treatment, discontinuing a current treatment, or commencing a new treatment.
This deficiency substantiates Complaint Number OH00104287.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Transfer Notice
(Tag F0623)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview and review of facility policy, the facility failed to ensure residents and resid...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview and review of facility policy, the facility failed to ensure residents and resident representatives were provided with a notice of transfer upon transfer from the facility. Additionally, the facility failed to notify the Ombudsman's office of resident transfers from the facility. This affected two (#8 and #105) of four residents reviewed for hospitalization. The facility identified 11 residents who were transferred from the facility in the last 30 days. The facility census was 51.
Findings include:
1. Review of the medical record for resident #8 revealed the resident was admitted to the facility on [DATE]. Diagnoses included acute and chronic respiratory failure, chronic embolus, right shoulder pain, right lower leg pain, abnormal posture, insomnia, weakness, antero-spinal artery compression syndrome of the cervical region, cervical disc disorder with myelopathy, heart failure, mononeuropathy, chronic kidney disease, stage III, benign prostatic hypertrophy, anemia, cervicalgia, low back pain, obesity, anxiety, gastro-esophageal reflux disease, chronic viral hepatitis type C, sickle cell trait, chronic obstructive pulmonary disease, depression, chronic pain syndrome and fusion of the cervical spine.
Review of the face sheet of the medical record revealed the resident was his own responsible party.
Review of quarterly Minimum Data Set 3.0 (MDS) assessment, dated 03/07/19, revealed Resident #8 had no cognitive deficits.
Review of a Transfer Form dated 12/28/18, revealed the resident was transferred to the hospital due to pain. Review of a physician order dated 02/12/19 revealed the resident was transferred to the hospital due to pain. The medical record revealed no documentation of a notice of transfer being provided to the resident or of the Ombudsman being notified of the resident's transfers.
Review of emails of resident transfer notifications to the Ombudsman for the month of February 2019 revealed Resident #8 was not included on the list.
Interview with Resident #8 on 05/20/19 at 2:32 P.M. revealed he had been transferred to the hospital on two occasions since he was admitted to the facility and no one had provided him with a notice of transfer at the time of or after his transfer.
Interview with Social Service Director #260 on 05/22/19 at 4:00 P.M. verified the notice of transfer form was given to the hospital but not to the resident or family.
Additional interview with Social Service Director #260 on 05/23/19 at 10:45 A.M. verified the Ombudsman was not notified of Resident #8 being transferred to the hospital on [DATE] or 02/12/19.
2. Review of the medical record for Resident #105 revealed the resident was admitted to the facility on [DATE]. Diagnoses included congested heart failure, thrombocytopenia, hypertension, diabetes mellitus type II, anemia, urine retention, atrial fibrillation , atrial flutter, chronic obstructive pulmonary disease, closed compression fracture of lumbar area, anxiety, depression, fracture of right humerus and low back pain.
Review of an annual comprehensive MDS assessment dated [DATE] revealed the resident had no cognitive deficits.
Review of a Transfer Form dated 03/16/19 revealed the resident was transferred to the hospital due to a fever. The medical record revealed no documentation of a notice of transfer being provided to the resident or of the Ombudsman being notified of the resident's transfers.
Interview with Social Service Director #260 on 05/23/19 at 10:45 A.M. verified the resident and resident representative were not provided a notice of transfer upon the resident's transfer to the hospital on [DATE]. She stated the notice of transfer was provided to the hospital but not to any resident and representative.
Further interview with Social Service Director #260 on 04/23/19 at 10:50 A.M. verified there was no documentation of the Ombudsman being notified of the resident's transfer to the hospital on [DATE]. She stated the resident's name did not show up on a discharge roster so she did not now to send it in.
Review of facility policy Transfer of Discharge Notice, dated 12/2016, revealed the facility was to provide the resident and/or the resident's representative with a 30 day written notice of impending transfer or discharge. The notice could be provided as soon as practicable, but before the transfer if the transfer was necessary for the resident's welfare and the resident's needs could not be met in the facility and if an immediate transfer or discharge was required by the resident's urgent needs. The resident and representative was to be notified in writing of the reason for the transfer or discharge, the effective date of the transfer, the location being transferred to, instructions on how to appeal the transfer, the bed-hold policy, name, address and phone number to the Office of the State Long-term Care Ombudsman the phone number to the agency responsible for the advocacy of residents with intellectual and developmental disabilities and the phone number to the state heath department.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0625
(Tag F0625)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview and facility bed hold policy, the facility failed to ensure adequate notificatio...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview and facility bed hold policy, the facility failed to ensure adequate notification of available bed hold days was provided to residents at the time of discharge to the hospital. This deficient practice affected three (#54, #8, #105) of three residents reviewed for bed hold notification. The facility identified 11 residents who were transferred from the facility in the last 30 days. The facility census was 51
Findings include;
1. Review of the medical record revealed Resident #54 admitted to the facility on [DATE]. Diagnoses included malignant neoplasm of right and left ovary, insomnia, deep vein thrombosis, type 2 diabetes mellitus, pulmonary embolism, agranulocytosis, and anemia.
Review of the admission Minimum Data Set (MDS) assessment, dated 02/19/19, Resident #54 was identified as alert, oriented and able to make needs known.
Review of the progress notes dated 02/27/19 documented the resident was sent to the hospital at approximately 5:00 P.M. The resident did not return to the facility. There was no documentation contained in the medical record which indicated the resident or Responsible Party were informed of bed hold policy or the procedure for reserving the bed.
Interview on 05/23/19 at 11:00 A.M., Licensed Social Worker (LSW) #260 verified the resident and/or responsible party were not contacted or informed of bed hold policy.
2. Review of the medical record for resident #8 revealed the resident was admitted to the facility on [DATE]. Diagnoses included acute and chronic respiratory failure, chronic embolus, right shoulder pain, right lower leg pain, abnormal posture, insomnia, weakness, antero-spinal artery compression syndrome of the cervical region, cervical disc disorder with myelopathy, heart failure, mononeuropathy, chronic kidney disease, stage III, benign prostatic hypertrophy, anemia, cervicalgia, low back pain, obesity, anxiety, gastro-esophageal reflux disease, chronic viral hepatitis type C, sickle cell trait, chronic obstructive pulmonary disease, depression, chronic pain syndrome and fusion of the cervical spine.
Review of the face sheet of the medical record revealed the resident was his own responsible party.
Review of quarterly MDS assessment, dated 03/07/19, revealed the resident had no cognitive deficits.
Review of a Bed-Hold Reservation form dated 10/16/17 revealed the resident had been given information regarding bed-holds on admission and the resident agreed to pay for the facility to hold his bed if his bed-hold days were used up and he was out of the facility.
Review of a Notice of Bed-Hold Days, dated 08/10/18, revealed as of 08/01/18 the resident had used three of his 30 bed-hold days for the year. It revealed when the 30 days were exceeded, the resident must be discharged from the facility and re-admitted in the next available semi-private room as long as he was still Medicaid eligible. The form did not offer a choice for the resident to choose a bed hold or deny.
Review of a Transfer Form, dated 12/28/18, revealed the resident was transferred to the hospital due to pain. Review of a physician order dated 02/12/19 revealed the resident was transferred to the hospital due to pain. The medical record revealed no documentation of a bed hold notice policy was provided to Resident #8.
Interview with Resident #8 on 05/20/19 at 2:32 P.M. revealed he had been transferred to the hospital on two occasions since he was admitted to the facility and no one had ever discussed a bed hold with him.
Interview with Business Office Manager #425 on 05/23/19 at 10:40 A.M. verified the bed hold notice was not provided to residents and responsible parties on each transfer or discharge. She verified there was no bed hold notice given to Resident #8 for 12/28/18 or 02/12/19. She stated the bed hold policy was signed was on admission and after that it was not offered. She stated she did provide them a letter when they returned to the facility to provide them with how many bed-hold days had been used.
3. Review of the medical record for Resident #105 revealed the resident was admitted to the facility on [DATE]. Diagnoses included congested heart failure, thrombocytopenia, hypertension, diabetes mellitus type II, anemia, urine retention, atrial fibrillation , atrial flutter, chronic obstructive pulmonary disease, cloyed compression fracture of lumbar area, anxiety, depression, fracture of right humerus and low back pain.
Review of an annual MDS assessment dated [DATE] revealed the resident had no cognitive deficits.
Review of a Bed-Hold reservation form dated from admission, 04/20/18, revealed the resident accepted a bed hold agreement at that time and agreed to pay 100 percent of the current rate if she required a bed to be held due to a transfer. No further bed-hold information was present.
Review of a transfer form dated 03/16/19 revealed the resident was transferred to the hospital due to a fever. The medical record revealed no documentation of a bed hold notice policy was provided to Resident #
Review of Notice of Bed Hold Days, dated 03/18/19, revealed as of 03/17/19 the resident had not used any of the allowed 30 Medicaid bed hold days. When the 30 days were exceeded the resident was to be discharged from the facility and readmitted in the next available semi private room as long as the resident was still medicaid eligible. The document provided no opportunity for the resident or resident representative the option to pay for the bed hold privately.
Interview with Business Office Manager #425 on 05/23/19 at 10:40 A.M. verified there was no bed hold notice given to Resident #105 for 03/17/19 when the resident was transferred to the hospital. She stated the bed hold policy was signed was on admission and after that, it was not offered. She stated she did provide them a letter when they returned to the facility to provide them with how many bed-hold days had been used.
Review of facility policy titled Bed-Holds and Returns, dated 03/2017, revealed residents or representatives will be informed in writing of the bed-hold and return policy. The policy was to apply to Medicaid residents in the facility. Prior to a transfer, written information was to be given to the resident and the resident representative that explained the rights and limitations of the resident regarding bed-holds, the reserve bed payment policy as indicated by the state plan, the facility per diem rate required to hold a bed for non-Medicaid residents or to hold a bed beyond the stated bed-hold period for Medicaid residents, and the details of the transfer (per the Notice of Transfer).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure an adaptive device post operative device was i...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure an adaptive device post operative device was in place as ordered for one (#52) of two residents reviewed for limited range of motion. The facility census was 51.
Findings include:
Review of Resident #52's medical record revealed an admission date of 04/03/19. Medical diagnoses included displaced trimalleolar fracture of right lower leg, generalized muscle weakness, cognitive communication deficit, age related physical debility, anxiety disorder, atrial fibrillation, atherosclerotic heart disease, major depressive disorder, hypertension, hypoosmolality, hyponatremia, osteoarthritis, difficulty walking, and long term use of anticoagulants.
Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had moderate impairment in cognition. The resident had no behaviors and no rejection of care. She required extensive assistance of two plus staff for bed mobility, transfers, dressing, toilet use, and personal hygiene. She required extensive assistance with one staff for locomotion on the unit. She had no impairment in upper extremities but had impairment on one side lower extremity.
Review of the resident's hospital discharge paperwork dated 04/22/19 revealed the resident had the application of external ring fixator to her right lower extremity. Weight bearing instructions included right lower extremity partial 50% weight bearing in Ilizarov shoe (special shoe adapted for use in a patient with an Ilizarov external fixator).
Review of the resident's physician's orders revealed an order dated 04/26/19 for a Ilizarov boot on during the day and off at night.
Review of the nursing notes on 04/27/19 at 4:46 P.M. documented foam in place, no boot observed. On 04/29/19 at 10:47 A.M. it was documented the Ilizarov boot was being ordered.
Review of a nursing late entry for 04/29/19 at 10:47 A.M., dated 05/23/19 from Registered Nurse (RN) Unit Manager #200, revealed a call was placed to orthopedic office in regards to Ilizarov boot. Ilizarov boot was sent with resident on her most recent appointment with orthopedic office. Room checked and boot was in her room in her personal belongings.
Interview with RN Unit Manager #200 on 05/23/19 at 10:10 A.M. revealed she worked as a unit nurse on 04/29/19 and could not find the resident's physician ordered Ilizarov boot. She thought the facility needed to order the llazarov boot, however she called the orthopedic office and found it had been sent to the facility with the resident. She stated she looked in the resident's room and found it on 04/29/19.
This deficiency substantiates Complaint Number OH00104287.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0697
(Tag F0697)
Could have caused harm · This affected 1 resident
Based on medical record review and staff interview, the facility failed to provide effective pain management for one (#52) of three residents reviewed for pain management. The facility census was 51. ...
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Based on medical record review and staff interview, the facility failed to provide effective pain management for one (#52) of three residents reviewed for pain management. The facility census was 51.
Findings include:
Review of Resident #52's medical record revealed an admission date of 04/03/19 and a readmission date of 04/22/19 following orthopedic surgery. Medical diagnoses included displaced trimalleolar fracture of right lower leg, generalized muscle weakness, cognitive communication deficit, age related physical debility, anxiety disorder, atrial fibrillation, atherosclerotic heart disease, major depressive disorder, hypertension, hypoosmolality, hyponatremia, osteoarthritis, difficulty walking, and long term use of anticoagulants.
Review of the admission Minimum Data Set (MDS) assessment, dated 04/10/19, revealed the resident had moderate impairment in cognition. The resident had no behaviors and no rejection of care. She required extensive assistance of two plus staff for bed mobility, transfers, dressing, toilet use, and personal hygiene. She required extensive assistance with one staff for locomotion on the unit. She had no impairment in upper extremities but had impairment on one side lower extremity. The resident's primary medical condition for admission was fracture. The resident was assessed as having pain occasionally with no affect on function. Pain level was rated as a three out of ten.
Review of the 14 day MDS assessment, dated 05/05/19, revealed moderate impairment in cognition. No behaviors and no rejection of care were noted. She was assessed as having occasional pain with no effect on function. Pain was rated as a four. She received opioid pain medication six of the seven days of the look-back period.
Review of the resident's physician's orders revealed an order dated 04/03/19 for Tylenol Extra Strength (ES) (a mild drug to reduce pain and fever) 1000 milligrams (mg) every 12 hours as needed (PRN) for pain, which was discontinued and changed to 1000 mg three times daily for pain on 04/26/19. The resident also had an order dated 04/22/19 for tramadol (opioid pain medication used to treat moderate to moderately severe pain) 50 milligrams (mg) every four hours PRN for pain. The resident had an order written 04/24/19 at 4:00 P.M. for Buprenorphine (Butrans) 5 micrograms (mcg)/1 hour patch (a narcotic opiate analgesic used to help relieve moderate to severe ongoing pain) weekly transdermally.
Review of the resident's Medication Administration Record (MAR) revealed she received tramadol 50 mg on 04/23/19 at 1:54 A.M. for a pain level of six. Follow up was documented as ineffective. At 2:43 A.M. she received Tylenol ES for a pain level of ten. Follow up was documented as ineffective. At 5:41 A.M. she received another dose of tramadol 50 mg for a pain level of ten. This dose was documented as effective. At 5:48 P.M. the resident received another dose of tramadol 50 mg for a pain level of nine. The follow up was documented as ineffective. At 9:00 P.M., the resident's pain level was documented as nine and she received another dose of tramadol 50 mg. This dose was documented as effective.
Continued review of the MAR revealed on 0424/19 the resident did not receive any as needed Tylenol. She received tramadol 50 mg at 5:02 A.M. for a pain level of seven, which was documented as effective. At 4:00 P.M., a new order was obtained for Butrans patch (not administered until 04/25/19). At 5:26 P.M., she received tramadol 50 mg for a pain level of seven, which was documented as ineffective. At 8:07 P.M. the nurse obtained a one time order to administer another dose of tramadol 50 mg for a pain level of ten. No follow up was documented.
Continued review of the resident's MAR for 04/25/19 revealed she received tramadol 50 mg at 4:45 A.M. for a pain level of six, which was documented as ineffective. At 10:00 A.M., she received tramadol 50 mg for a pain level of seven, which was documented as ineffective. She did not receive the Butrans patch until 04/25/19 at 10:33 A.M. when the resident's pain level was documented as a seven. At 2:40 P.M. she received another dose of tramadol 50 mg for a pain level of seven, which was documented as ineffective. At 5:06 P.M., she received a dose of Tylenol ES for a pain level of seven, which was documented as ineffective. At 8:40 P.M. she received a dose of tramadol for a pain level of six, which was documented as effective.
Review of a physician's note dated 4/25/19 at 1:09 P.M. revealed a Butrans patch was prescribed to address the resident's pain. The physician's plan was to control the resident's pain.
Review of the MAR for 04/26/19 revealed the resident's as needed medications were effective.
Review of an orthopedic physician's note dated 04/26/19 revealed the resident and the resident's family did not feel the facility was managing the resident's pain effectively.
Review of the MAR for 04/27/19 revealed she received tramadol 50 for a pain level of ten, which was documented as ineffective.
Review of the scheduled drug record for buprenorphine (Butrans) 5 mcg/1 hr patch (a narcotic opiate analgesic used to help relieve moderate to severe ongoing pain) revealed the facility received four patches on 04/24/19. The resident's first dose was not administered until at 10:33 A.M. on 04/25/19.
Review of a nursing noted dated 04/27/19 at 5:44 P.M. revealed a fax was sent to the physician to request an order to change the resident's tramadol from as needed to scheduled as the resident will not call for medication and goes too long without it per the Director of Nursing (DON). Review of the nursing notes and physician's orders revealed the resident's tramadol was not changed to scheduled. There was no indication the physician responded to the fax and no indication nursing staff followed up. There was no further documentation indicating the physician was notified of ineffective pain relief.
Interview with the DON on 05/23/19 at 2:11 P.M. revealed Resident #52's family expressed concern on 04/27/19 about the resident not asking for her as needed tramadol pain medication. They requested the medication be administered on a routine basis. The DON stated she advised the unit nurse to fax the physician to obtain orders for scheduled pain medication. She verified no one followed up on the fax and the physician did not respond. The resident's pain medication was not changed to routine throughout her stay at the facility. The DON also verified there were multiple times from 04/23/19 through 04/27/19 when the resident received as needed pain medication and the follow up was documented as ineffective with no further intervention. She also verified the resident's Butrans pain patch was ordered 04/24/19 at 4:00 P.M. and was not administered to the resident until 04/25/19 at 10:33 A.M. She verified the Butrans control sheet indicated it arrived at the facility on 04/24/19.
This deficiency substantiates Complaint Number OH00104287.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
Based on medical record review, staff interview and review of facility policies, the facility failed to administer medications as ordered for one (#52) of three residents reviewed for pain management....
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Based on medical record review, staff interview and review of facility policies, the facility failed to administer medications as ordered for one (#52) of three residents reviewed for pain management. The facility census was 51.
Findings include:
Review of Resident #52's medical record revealed an admission date of 04/03/19. Medical diagnoses included displaced trimalleolar fracture of right lower leg, generalized muscle weakness, cognitive communication deficit, age related physical debility, anxiety disorder, atrial fibrillation, atherosclerotic heart disease, major depressive disorder, hypertension, hypoosmolality, hyponatremia, osteoarthritis, difficulty walking, and long term use of anticoagulants.
Review of the resident's admission Minimum Data Set (MDS) assessment, dated 04/10/19, revealed the resident had moderate impairment in cognition. The resident had no behaviors and no rejection of care.
Review of the resident's physician's orders dated 04/03/19 revealed the resident was to receive Colace (stool softener) 100 milligrams (mg) twice daily (bid), diltiazem (calcium channel blocker and antihypertensive) 30 mg every 12 hours, Lasix (diuretic) 20 mg bid, nitrofurantoin (antibiotic) 100 mg bid, calcium citrate (calcium supplement) 200 mg three times daily (tid), gabapentin (medication used for neuropathy pain) 300 mg tid, omeprazole (medication used to treat gastroesophageal reflux disease) 20 mg once daily, oxybutynin chloride (antispasmotic and anticholinergic drug used to relax the smooth muscles of the bladder) extended release 5 mg once daily, atorvastatin calcium (medication used to help lower cholesterol) 20 mg once daily, cholecalciferol tablet (a vitamin D supplement) 2000 units once daily, and citalopram (antidepressant medication) 20 mg once daily.
Review of the resident's medication administration record (MAR) for April 2019 revealed the resident did not receive the above listed medications on 04/03/19 or 04/04/19.
Interview with Registered Nurse Unit Manager #200 on 05/23/19 at 10:10 A.M. verified the resident did not receive her medications as ordered on 04/03/19 and 04/04/19. She stated the nurse should have followed the policy for obtaining medications for new admissions.
Review of a facility policy titled Pharmacy Hours of Operation, revised on 02/24/17, revealed the pharmacy provides access to 24 hour consultation and emergency deliveries to meet the pharmaceutical needs of the resident and facility in a timely manner. Processes included a staffed pharmacy Monday through Saturday 8:00 A.M. through 5:00 P.M. Routine deliveries Monday through Saturday, except holidays and unforeseen circumstances. Filling new orders transmitted via facsimile machine, E-Rx, or E-MAR interface, for delivery the same night, provided they are received by the pharmacy before 5:00 P.M. Monday through Saturday. Accepting phoned in orders until 5:00 P.M. Monday through Saturday.
Review of a facility policy titled Contingency Cabinet Medications, revised on 11/30/18, revealed a supply of commonly used medications are maintained at the facility by the pharmacy in order to initiate stat therapies until a regular supply of medication can be obtained.
This deficiency substantiates Complaint Number OH00104287.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and review of facility policy, the facility failed to ensure food items were stored in a ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and review of facility policy, the facility failed to ensure food items were stored in a safe, clean manner. This affected 50 of 50 residents who receive food from the kitchen. Resident (#107) did not receive food from the facility. The facility census was 51.
Findings include:
Observation of the kitchen during the initial tour on 05/20/19 between 8:25 A.M. and 9:00 A.M. the small reach in freezer near the oven had a brown syrup like substance frozen on the bottom of the inside of the freezer. The freezer also contained an open package of breaded meat, one open package of partially used onion rings, one open bag of french toast sticks, one open bag of waffles, two open bags of potato wedges, one open bag of fish and one open bag of chicken tenders. Each of these containers were previously opened and had no labels or dates when the items were opened or to be used by. Observation of the reach in cooler, which sat on top of the reach in freezer, revealed one container of tartar sauce which was not labeled or date marked. The bottom floor of the reach in cooler had dried food particles on the base. The handle to the reach in cooler had hard, dried food particles on the surface
Interview with [NAME] #460 on 05/20/19 at 8:35 A.M. verified the above findings of the reach in cooler and reach in freezer.
Observation of the walk in cooler on 05/20/19 at 8:40 A.M. revealed a container of fried rice, one container of pudding, and one container of cooked green and red peppers, each which were not labeled or date marked when opened. Observation of the walk in freezer on 05/20/19 at 8:45 A.M. revealed one opened bag of vegetable blend and one opened bag of wax beans which were not date marked.
Observation of the dry food storage area on 05/20/19 at 8:50 A.M. revealed one opened bag of coconut flakes and one opened bag of [NAME] Butter cookies with no labels or dates. A large box of food thickener was observed in the dry food storage area, with the plastic bag open and the thickener exposed to air.
Interview with Dietary Director #475 on 05/20/19 at 8:50 A.M. verified the containers of fried rice, pudding, peppers, vegetable blend, wax beans, coconut flakes and cookies should have been labeled and dated when they were put into use. She further verified the thickener should have been in a secured container.
Review of facility policy titled Food Storage, dated 2013, revealed food was to be stored in an area that was clean, dry and free from contaminants. Plastic containers with tight-fitting covers must be used for storing cereals, cereal products, flour, sugar, dried vegetables and broken lots of food. All containers were to be legible and accurately labeled and dated. Leftover food was to be stored in covered containers or wrapped carefully and securely. Each item was to be clearly labeled and dated before being refrigerated and was to be used within three days or discarded. All freezer units were to be kept clean and in good working condition at all times. all foods should be covered, labeled and dated.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0919
(Tag F0919)
Could have caused harm · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interviews, and staff interview, the facility failed to ensure an operational call system. This h...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interviews, and staff interview, the facility failed to ensure an operational call system. This had the potential to affect all 51 residents residing in the facility.
Findings include:
Interview with Resident #42 on 05/20/19 at 1:18 P.M. revealed it could take a long time for her call light to be answered, sometimes up to one and a half hours. She stated she has had to yell for help and the staff would say the call light was not activated, however it would be lit up inside her room.
Interview with Resident #49 on 05/20/19 at 2:33 P.M. revealed she had a concern of staff not answering her call light timely. She stated the staff have indicated they have been having trouble with the call light system and they had to call the company to have it reset.
Interview on 05/22/19 at 11:07 A.M., State Tested Nursing Assistant (STNA) #250 and STNA #230 revealed there had been some inconsistencies with the call light system. They stated they were to carry electronic pagers (pagers) which would indicate which resident's call light had been activated but they had not been working for some time. STNA #230 and STNA #250 were unable to locate pagers on their unit. They stated they could look on a telephone panel located at the STNA substation to see which call light had been activated, however, after ten minutes the room number would cease to show up at the STNA substation and would transfer to another hall. They stated they had also carried telephones and walkie talkies in the past, but all had stopped working and not been replaced. They indicated there was no light outside of a resident's room to indicate a call light had been activated.
Interview and observation on 05/22/19 at 12:59 P.M. STNA #240 revealed she had a pager in her pocket she was unable to turn on. She stated it appeared as if the battery was dead.
Observation on 05/22/19 at 1:05 P.M. revealed the activation of the call light inside room [ROOM NUMBER].
Interview on 05/22/19 at 1:08 P.M., STNA #280 revealed call lights were activated at the unit STNA substation and via means of a pager. STNA #280 indicated she had left the pager with STNA #290. Interview with STNA #290 revealed he had left the pager at the STNA substation. STNA #280 proceeded to the STNA substation and located the call light phone and pager. Neither device was indicating the call light was activated inside room [ROOM NUMBER]. At 1:15 P.M. Registered Nurse (RN) Unit Manager #200 increased the volume on the call light phone located at the STNA substation. Continued observation noted an electronic audible tone sounding on the unit, however, no location of the call light was able to be discovered. At 1:22 P.M. the audible tone increased to a rapid sequence, however, no location was able to be established indicating the activated call light inside room [ROOM NUMBER].
Observation on 05/22/19 at 1:35 P.M. with RN Unit Manager #200 noted the continued activation of the call light in room [ROOM NUMBER]. Further observation at the central nursing station lacked a visual or audible signal indicating the call light inside room [ROOM NUMBER] had been activated.
Interview on 05/22/19 at 1:40 P.M., RN Unit Manager #200 and STNA #280 verified the inconsistent activation of the pager and lack of call light notification at a central location including the ability to silence the audible signal.
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
- "Why is there high staff turnover? How do you retain staff?"
- "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
- • 44 deficiencies on record, including 1 serious (caused harm) violation. Ask about corrective actions taken.
- • $40,433 in fines. Higher than 94% of Ohio facilities, suggesting repeated compliance issues.
- • Grade F (25/100). Below average facility with significant concerns.
- • 60% turnover. Above average. Higher turnover means staff may not know residents' routines.
Bottom line: Trust Score of 25/100 indicates significant concerns. Thoroughly evaluate alternatives.
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About This Facility
What is St Clare Commons's CMS Rating?
CMS assigns ST CLARE COMMONS an overall rating of 1 out of 5 stars, which is considered much 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 St Clare Commons Staffed?
CMS rates ST CLARE COMMONS's staffing level at 1 out of 5 stars, which is much below average compared to other nursing homes. Staff turnover is 60%, which is 14 percentage points above the Ohio average of 46%. High turnover can affect care consistency as new staff learn residents' individual needs. RN turnover specifically is 62%, which is notably high. RNs provide skilled clinical oversight, so turnover in this role can affect medical care quality.
What Have Inspectors Found at St Clare Commons?
State health inspectors documented 44 deficiencies at ST CLARE COMMONS during 2019 to 2025. These included: 1 that caused actual resident harm, 42 with potential for harm, and 1 minor or isolated issues. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.
Who Owns and Operates St Clare Commons?
ST CLARE COMMONS is owned by a non-profit organization. Non-profit facilities reinvest revenue into operations rather than distributing to shareholders. The facility is operated by COMMONSPIRIT HEALTH, a chain that manages multiple nursing homes. With 60 certified beds and approximately 56 residents (about 93% occupancy), it is a smaller facility located in PERRYSBURG, Ohio.
How Does St Clare Commons Compare to Other Ohio Nursing Homes?
Compared to the 100 nursing homes in Ohio, ST CLARE COMMONS's overall rating (1 stars) is below the state average of 3.2, staff turnover (60%) is significantly higher than the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.
What Should Families Ask When Visiting St Clare Commons?
Based on this facility's data, families visiting should ask: "How do you ensure continuity of care given staff turnover, and what is your staff retention strategy?" "Can you walk me through typical staffing levels on day, evening, and night shifts?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" These questions are particularly relevant given the facility's high staff turnover rate and the below-average staffing rating.
Is St Clare Commons Safe?
Based on CMS inspection data, ST CLARE COMMONS has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 1-star overall rating and ranks #100 of 100 nursing homes in Ohio. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at St Clare Commons Stick Around?
Staff turnover at ST CLARE COMMONS is high. At 60%, the facility is 14 percentage points above the Ohio average of 46%. Registered Nurse turnover is particularly concerning at 62%. RNs handle complex medical decisions and coordinate care — frequent RN changes can directly impact care quality. High turnover means new staff may not know residents' individual needs, medications, or preferences. It can also be disorienting for residents, especially those with dementia who rely on familiar faces. Families should ask: What is causing the turnover? What retention programs are in place? How do you ensure care continuity during staff transitions?
Was St Clare Commons Ever Fined?
ST CLARE COMMONS has been fined $40,433 across 1 penalty action. The Ohio average is $33,483. While any fine indicates a compliance issue, fines under $50,000 are relatively common and typically reflect isolated problems that were subsequently corrected. Families should ask what specific issues led to these fines and confirm they've been resolved.
Is St Clare Commons on Any Federal Watch List?
ST CLARE COMMONS 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.