Vancrest-Upper Valley
Non profit - Corporation
135 Beds
VANCREST HEALTH CARE CENTERS
Data: November 2025
Trust Grade
63/100
#369 of 913 in OH
Photo by Vancrest - Upper Valley
Last Inspection: July 2024
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Vancrest-Upper Valley in Troy, Ohio has a Trust Grade of C+, indicating it is slightly above average but not exceptional. It ranks #369 out of 913 facilities in Ohio, placing it in the top half, and #2 out of 6 in Miami County, meaning only one local facility rates higher. However, the facility is experiencing a worsening trend, with issues increasing from 11 in 2021 to 13 in 2024. Staffing ratings are below average at 2/5 stars, although the turnover rate of 37% is better than the state average, suggesting some stability among staff. On the downside, there have been concerning incidents, such as failing to monitor a resident’s deteriorating pressure ulcer and not informing a resident's representative about new medication orders, which indicates a need for improvement in communication and care practices. Despite these weaknesses, the facility does have excellent quality measures and a good overall star rating of 4/5.
- Trust Score
- C+
- In Ohio
- #369/913
- Safety Record
- Moderate
- Inspections
- Getting Worse
- Staff Stability ○ Average
- 37% turnover. Near Ohio's 48% average. Typical for the industry.
- Penalties ✓ Good
- $4,233 in fines. Lower than most Ohio facilities. Relatively clean record.
- Skilled Nurses ⚠ Watch
- Each resident gets only 22 minutes of Registered Nurse (RN) attention daily — below average for Ohio. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 32 deficiencies on record. Higher than average. Multiple issues found across inspections.
63/100
Top 40%
Needs review
11 → 13 violations
★★★★☆
4.0
Overall Rating
★★☆☆☆
2.0
Staff Levels
★★★★★
5.0
Care Quality
★★★☆☆
3.0
Inspection Score
↔
Stable
2021: 11 issues
2024: 13 issues
The Good
-
5-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
-
Staff turnover below average (37%)
11 points below Ohio average of 48%
Facility shows strength in quality measures, fire safety.
The Bad
Staff Turnover: 37%
Near Ohio avg (46%)
Typical for the industry
Federal Fines: $4,233
Below median ($33,413)
Minor penalties assessed
Chain: VANCREST HEALTH CARE CENTERS
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 32 deficiencies on record
1 actual harm
Jul 2024
13 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0552
(Tag F0552)
Could have caused harm · This affected 1 resident
Based on medical record review, resident representative interview, and staff interview, the facility failed to notify resident representative of new order for antibiotic and reason for the use of the ...
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Based on medical record review, resident representative interview, and staff interview, the facility failed to notify resident representative of new order for antibiotic and reason for the use of the medication. This affected one (#1) resident out of two residents reviewed for antibiotic use. The facility census was 99.
Findings include:
Review of the medical record for Resident #1 revealed an admission date of 03/08/13. Diagnoses included quadriplegia, chronic respiratory failure, anoxic brain damage, persistent vegetative state, and tracheostomy. Review of the quarterly Minimum Data Set (MDS) assessment, dated 05/30/24, revealed Resident #1 was in a persistent vegetative state.
Review of the physician order dated 07/18/24 revealed an order for amoxicillin-pot Clavulanate (Augmentin) 875-125 (antibiotic) milligram (mg) one tablet via gastrostomy (g-tube) every 12 hours for bacterial infection.
Review of the physician note, dated 07/18/24, revealed Resident #1 was seen due to redness and swelling of the right jaw. Resident #1's examination was positive for swollen glands and was ordered Augmentin 875-125 mg via g-tube every 12 hours for seven days.
Review of the nurse progress note, dated 07/24/24 at 11:21 A.M., revealed Resident #1 continued on Augmentin for swollen lymph node to the right neck.
The medical record for Resident #1 revealed no documentation to support the facility notified Resident #1's representative of the order for antibiotic to treat a bacterial infection.
Interview on 07/22/24 at 11:11 A.M. with Resident #1's representative stated she was notified Resident #1 was on an antibiotic a few days after the antibiotic started and was told the antibiotic was for a throat infection. Resident #1's representative stated she was not aware of the name of the antibiotic or for how long Resident #01 was to receive the medication.
Interview on 07/24/24 at 11:21 A.M. with Director of Nursing (DON) confirmed the medical record for Resident #1 did not contain documentation to support Resident #1's representative was notified of the order for the antibiotic or the reason for the use of the medication. The DON stated the facility did not have a policy for notifying the resident and/or resident representative of order changes.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Grievances
(Tag F0585)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff and resident interviews, and policy review, the facility failed to make prompt efforts to ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff and resident interviews, and policy review, the facility failed to make prompt efforts to resolve a resident's grievance related to missing property. This affected one (#83) of three residents reviewed for missing property. The facility census was 99.
Findings include:
Review of the medical record for Resident #83 revealed an admission date of 10/26/22. Diagnoses included diabetes mellitus with diabetic peripheral angiopathy, peripheral vascular disease, and congestive heart failure. Resident #83 was admitted to the hospital on [DATE] and returned to the facility on [DATE].
Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #83 was cognitively intact.
Interview on 07/22/24 at 9:26 A.M. with Resident #83 stated she was hospitalized in early June 2024 and while she was at the hospital, her roommate at the facility had discharged . Resident #83 stated her roommate's family packed all the roommate's belongings and took the items home. Resident #83 stated when she returned to the facility, she noticed three of her blankets were missing and she notified Social Service of the missing items. Resident #83 stated she had not heard any updates related to her missing blankets.
Interview on 07/24/24 at 10:06 A.M. with Social Service (SS) #329 confirmed Resident #83 informed her that she was missing three blankets upon her return to the facility in early June 2024. SS #329 stated Resident #83's roommate discharged at the time Resident #83 was in the hospital and she believed the roommate's family took Resident #83's blankets home. SS #329 stated she called Resident #83's roommate's family to determine if they accidentally took Resident #83's blankets home but did not get an answer and left a message. SS #329 stated she had not followed up on the missing blankets since the initial call to Resident #83's roommate's family. SS #329 confirmed Resident #83's concern related to missing blankets was not documented on the grievance log or in Resident #83's medical record.
Review of the facility policy titled Lost and Found revealed the facility shall assist all personnel and residents in safeguarding their personal property. The policy stated the resident or family complaints of missing items must be reported to the DON and reports of misappropriation or treatment of resident property are immediately investigated.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0637
(Tag F0637)
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, policy review, and review of the Resident Assessment Instrument (RAI) manual 3....
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, policy review, and review of the Resident Assessment Instrument (RAI) manual 3.0, the facility failed to ensure a significant change Minimum Data Set (MDS) assessment was completed timely after a resident experienced a significant change of condition. This affected one (#83) of seven residents reviewed for significant change in condition. The facility census was 99.
Findings include:
Review of the medical record for Resident #83 revealed an admission date of 10/26/22. Diagnoses included nondisplaced intertrochanteric fracture of right femur and right clavicle, diabetes mellitus with diabetic peripheral angiopathy, peripheral vascular disease, and congestive heart failure. Resident #83 was admitted to the hospital on [DATE] and returned to the facility on [DATE].
Review of the Medicare five-day MDS assessment, dated 04/14/24, revealed Resident #83 was cognitively intact and required supervision or touching assistance with toilet hygiene, transfers, and toilet transfers, partial/moderate staff assistance with showers and was independent with bed mobility. Resident #83 did not ambulate, did not have a pressure ulcer, and did not have weight loss.
The quarterly MDS assessment, dated 05/13/24, revealed Resident #83 was cognitively intact and was dependent upon staff for toilet hygiene, bed mobility, and transfers, required substantial/maximum staff assistance for bathing, and did not ambulate. Resident #83 had no weight loss and did not have a pressure ulcer.
Review of the Skin/Wound note dated 05/20/24 revealed Resident #83 had a Stage III pressure ulcer (Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed) to the sacrum.
Review of the nutrition/dietary note, dated 06/25/24, revealed Resident #83 had a significant weight loss within the last 30 days. The note stated Resident #83's weight loss was nine pounds or 5.4% weight loss in 30 days. The note stated Resident #83's weight was 156.2 pounds. The nutrition/dietary note, dated 07/09/24, revealed Resident #83 was noted to have 16.6-pound unplanned significant weight loss or 10% in 180 days and weighed 148.6 pounds.
Review of Resident #83's MDS assessments from 05/13/24 to 07/23/24 revealed the facility had not completed a significant change MDS assessment for Resident #83.
Interview on 07/24/24 at 4:17 P.M. with Quality Assurance (QA) nurse #328 confirmed the facility had not completed a significant change MDS assessment after Resident #83 had a significant weight loss, development of a Stage III pressure ulcer, and decline in two or more Activities of Daily Living (ADLs). QA Nurse #328 stated the facility utilized the RAI 3.0 manual for guidelines on when to complete a significant change MDS assessment.
Review of the facility policy titled, Change in Resident's Condition or Status, stated a significant change of condition was a major decline or improvement in the resident's status that would not normally resolve itself without intervention by the staff or implementing standard disease-related clinical interventions and impacts more than one area of the resident's health status. The policy also stated if a significant change in the resident's physical or mental condition occurs, a comprehensive assessment of the resident's condition would be conducted as outlined in the MDS RAI manual.
Review of the RAI manual 3.0 October 2023 pages two through 24 stated a significant change is a major decline in a resident's status that would not normally resolve without intervention by staff or by implementing standard disease-related clinical interventions, impacts ore than one area of the resident's health status and required interdisciplinary review and/or revision of the care plan. The RAI manual stated a significant change MDS is appropriate when the resident's condition was not expected to return to baseline within two weeks. The RAI manual also stated a resident must have a decline in two or more areas that included any decline in ADL physical functioning area, emergence of unplanned weight loss problem (5% change in 30 days or 10% change in 180 days), and the emergence of a new pressure ulcer at Stage II or higher.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure a resident had a care plan in place for his be...
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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 a resident had a care plan in place for his behavior with wandering and residing on a secure unit. This affected one (Resident #20) of 27 residents reviewed for care plans. The facility census was 99.
Findings include:
Review of the medical record of Resident #20 revealed an admission dated of 05/13/24. Diagnoses included dementia with behavioral disturbance and Alzheimer's disease.
Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #20 was at a risk for wandering.
Review of the form Wandering Risk Assessment dated 06/18/24 revealed Resident #20 was at a high risk for wandering.
Review of Resident #20's care plan revealed there was no focus area of wandering or residing on a secure unit.
Interview on 07/24/24 at 3:27 P.M. with Licensed Practical Nurse (LPN) #327 verified Resident #20's care plan contained no focus or interventions for wandering or residing in a secure unit.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, policy review, record review, and staff interview, the facility failed to follow proper mechanical lift pr...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, policy review, record review, and staff interview, the facility failed to follow proper mechanical lift protocols during a resident's transfer from the bed to a wheelchair. This affected one resident (#47) of three residents reviewed for transfers with lifts. The facility census was 99.
Findings include:
Record review for Resident #47 revealed the resident was originally admitted to the facility on [DATE]. Diagnoses for Resident #47 included cerebral infarction, diabetes mellitus type two, obesity, and heart disease.
Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #47 had impaired cognition and was dependent on staff for transfers.
Review of Resident #47's care plans dated 05/01/17 revealed a focus for falls and injuries relating to mobility. Resident #47 utilized a lift for transfers. Interventions included using a Hoyer lift for all transfers with two staff members.
Continuous observation on 07/23/24 from 9:16 A.M. to 9:30 A.M. revealed State Tested Nurse Aide (STNA) #271 was observed pulling a mechanical lift into Resident #47's room where Resident #47 was observed laying in bed. At 9:30 A.M., STNA #271 was observed opening the door and pulling the lift out of the resident's room. Resident #47 was observed sitting in her wheelchair at 9:30 A.M. During the continuous observation from 9:16 A.M. to 9:30 A.M., there was no other staff observed entering or exiting or standing in Resident #47's room.
Interview on 07/23/24 at 9:32 A.M. with STNA #271 verified she was the only staff to use the mechanical lift to transfer Resident #47 at the time of the observation. STNA #271 verified it was in the resident's care plan she was to be transferred using two staff members in the lift.
Review of the undated facility policy titled 'Mechanical Lift Policy' revealed two trained staff are to be present at all times while using the mechanical lift.
CONCERN
(D)
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 and staff interview, the facility failed to ensure a resident with an indwelling catheter had a valid medical justification for the use. This affected one (Resident #50)...
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Based on medical record review and staff interview, the facility failed to ensure a resident with an indwelling catheter had a valid medical justification for the use. This affected one (Resident #50) of three residents reviewed for indwelling catheter. The facility census was 99.
Findings include:
Review of the medical record for Resident #50 revealed an admission date of 05/27/24. Diagnoses included right above the knee amputation (AKA), atrial fibrillation, diabetes mellitus, hypertension, peripheral vascular disease, and anemia.
Review of the admission Minimum Data Set (MDS) assessment revealed Resident #50 had moderate cognitive impairment and was dependent upon staff for toileting, and had an indwelling catheter.
Review of Resident #50's physician order dated 05/28/24 revealed an order for an indwelling urinary catheter 16 French with 10 milliliter (ml) balloon to continuous drainage. There was diagnosis for the use of the catheter on the physician order.
Review of the bladder and bowel assessment, dated 06/22/24, revealed Resident #50 had a history of bladder continence, used a urinal, and required extensive assistance with toileting. The assessment also noted Resident #50 had an indwelling catheter in place upon admission to the facility.
Interview on 07/24/24 at 2:02 P.M. with Director of Nursing (DON) stated Resident #50 was admitted to the facility with an indwelling catheter because of urinary obstruction while hospitalized . The DON confirmed the medical record for Resident #50 did not contain documentation to support the medical justification for the continued use of the indwelling catheter or that the facility attempted to discontinue the catheter. The DON stated the facility did not have a policy related to use of indwelling catheter but only on how to care for an indwelling catheter.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0700
(Tag F0700)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of the facility policy, observation, and staff interview the facility failed to assess the need f...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of the facility policy, observation, and staff interview the facility failed to assess the need for bed rails on a resident's bed. This affected one (Resident #21) of three residents reviewed for bed rails. The facility census was 99.
Findings include:
Record review for Resident #21 revealed the resident was admitted to the facility on [DATE] and started to receive hospice services on 10/05/23. Diagnoses for Resident #21 included Alzheimer's disease, dementia, weakness, kidney failure, and heart disease. Review of admission Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #21 had impaired cognition, was not using bed rails, and was receiving hospice services.
Review of Resident #21's documentation revealed as of 09/2014 the resident's daughter was medical Power of Attorney (POA). The census record revealed Resident #21's daughter was designated as the POA and emergency contact family representative.
Review of a consent form dated 10/05/23 revealed half partial rails for the left and right upper bed to be used at all times. No purpose for the side rails, no release schedule, and no other release orders or physician orders were noted on the consent form. Resident #21's signature with the date of 10/05/23 was noted on the form. No POA or family representative signature or physician signature was noted on the form.
Review of Resident #21's care plans dated 10/05/23 revealed a focus for required assistance with Activities of Daily Living (ADL) related to dementia. Interventions included for the resident to use half upper side rails bilaterally for bed mobility.
Review of Resident #21's physician orders dating from 10/05/23 to 07/23/24 revealed no order for bed rails in the medical records.
Review of Resident #21's progress notes and assessments from 10/05/23 to 07/23/24 revealed there were no bed rail assessments.
Observation on 07/24/24 at 8:50 A.M. revealed State Tested Nurse Aide (STNA) #298 provided incontinence care for Resident #21. After incontinence care was provided, STNA #298 lowered the bed and raised both bilateral half bed rails at the head of the bed.
Interview on 07/24/24 at 9:00 A.M. with STNA #298 verified Resident #21's half bilateral bed rails were to be used for the resident.
Interview on 07/24/24 at 10:20 A.M. with Quality Assurance (QA) Nurse #238 verified for the MDS assessments dating from 10/2023 to 05/2024, no bed rails were coded as being used for Resident #21. QA Nurse #238 stated bed rails were not considered restraints so despite being used in care the facility, they did not code in the MDS assessments for the use of the bed rails. QA Nurse #238 verified the only bed rail assessment completed for Resident #21 was completed on 12/05/22 from a prior admission. QA #238 verified there were no current bed rail assessments for the 10/05/23 admission for Resident #21.
Review of the facility policy titled 'Bed Safety and Bed Rails', dated 08/2022, revealed the use of bed rails are prohibited unless the criteria had been met for the use, alternatives have been assessed, resident assessment completed, and the interdisciplinary team has evaluated the appropriateness of the bed rails use.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure pharmacy recommendations were responded to in a timely...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure pharmacy recommendations were responded to in a timely manner. This affected one (Resident #23) of five residents reviewed for unnecessary medication use. The facility census was 99.
Findings include:
Record review for Resident #23 revealed the resident was admitted to the facility on [DATE]. Diagnoses for Resident #23 include Parkinson's disease, depression, anxiety, vascular dementia, and unspecified psychosis.
Review of Resident #23's Minimum Data Set, (MDS) comprehensive assessment dated [DATE] revealed the resident had intact cognition, no behaviors, and was receiving an antipsychotic medication.
Review of Resident #23's care plans dated 10/23/13 revealed a focus for complications of vitamin deficiency. Interventions include administer medications per order, monitor lab results and report abnormalities to physician, and schedule/arrange for resident to attend diagnostic testing as ordered.
Review of the pharmacy recommendation dated 04/21/24 revealed the pharmacist recommended vitamin B12 level, vitamin D level and an iron panel be completed for Resident #23. The physician responded on 04/25/24 to have the labs drawn on the next laboratory draw.
Review of Resident #23's laboratory results revealed on 07/09/24 the vitamin B12, iron panel, and the vitamin D level orders were completed. Resident #23 had a laboratory draw on 05/01/24 but it did not include vitamin B12, iron panel and vitamin D level.
Interview on 07/25/24 with the Director of Nursing (DON) verified the physician signed the recommendation for the vitamin and iron panels to be ordered on next laboratory draw on 04/25/24. Per the DON, the orders for the vitamin B12, vitamin D, and iron panel were not ordered until 07/2024, three months after the recommendation. The DON verified the next lab draw for Resident #23 was dated 05/01/24.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0757
(Tag F0757)
Could have caused harm · This affected 1 resident
Based on medical record review, outside provider interview, and physician interview, the facility failed to ensure residents were free from unnecessary medication use. This affected one (Resident #38)...
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Based on medical record review, outside provider interview, and physician interview, the facility failed to ensure residents were free from unnecessary medication use. This affected one (Resident #38) of five residents reviewed for unnecessary medication use. The facility census was 99.
Findings include:
Review of the medical record of Resident #38 revealed an admission date of 01/20/21. Diagnoses include acquired absence of kidney and renal cancer.
Review of the medical record revealed Resident #38 had been diagnosed with a urinary tract infection (UTI) on 10/02/23, 02/25/24, and 03/19/24.
Review of the physician orders dated 04/03/24 revealed an order for Macrodantin macrocrystal 50 milligrams one time daily for prophylactic/indefinitely.
Review of a outside practitioners report dated 05/16/24 revealed Resident #38 was seen for a follow-up regarding a UTI. The report indicated Resident #38 was currently experiencing nocturnal one time per night, but was not experiencing hematuria, dysuria, urinary frequency, fever, chills, nausea, vomiting or urgency. The form indicated doing well, continue Macrodantin and Estrace. A follow-up was needed in one year.
A telephone interview on 07/25/24 at 12:56 P.M. with Doctor #505 revealed Resident #38 was on the antibiotic as recommended by the urologist related to frequent UTIs.
A telephone interview on 07/25/24 at 1:29 P.M. with Urology Nurse Practitioner (UNP) #506 revealed Resident #38 was a newer patient of the practice and had been prescribed Trimethoprim but was changed to Macrodantin indefinitely on 10/26/23. The goal of the antibiotic was to prevent any further UTIs and to guard the one remaining kidney. UNP #506 stated Resident #38 has experienced four UTIs in the past year but could give no dates.
CONCERN
(D)
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, medical record review, staff interview, review of Medscape guidance, review of the insulin pen quick reference guide, and policy review, the facility failed to prime an insulin p...
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Based on observation, medical record review, staff interview, review of Medscape guidance, review of the insulin pen quick reference guide, and policy review, the facility failed to prime an insulin pen per manufacturer instructions prior to administration, resulting in a significant medication error. This affected one (#83) of three residents observed for medication administration. The facility census was 99.
Findings include:
Review of the medical record for Resident #83 revealed an admission date of 10/26/22. Diagnosis included diabetes mellitus (DM). Review of the quarterly Minimum Data Set (MDS) assessment, dated 05/13/24, revealed Resident #83 was cognitively intact and received insulin.
Review of the physician order dated 07/08/24 for Humalog Kwikpen 100 unit per milliliter (ml) solution pen injector, inject 10 units of insulin subcutaneous (SQ) before meals related to DM.
Observation on 07/23/24 at 7:45 A.M. revealed Licensed Practical Nurse (LPN) #248 prepared Humalog kwikpen for Resident #83. LPN #248 attached the needle to injector pen and set the dose on the pen to 10 units of insulin. The observation revealed LPN #248 did not prime the insulin syringe prior to setting the dose to 10 units. LPN #248 was observed to administer the Humalog Kwikpen 10 units SQ to Resident #83's abdomen.
Interview on 07/23/24 at 7:58 A.M. with LPN #248 confirmed she did not prime the Humalog Kwikpen injector with two units for air shot prior to administration of 10 units of insulin.
Review of the facility policy titled, Administering medications, revised April 2019, revealed medications are to be administered in a safe and timely manner, and as prescribed and only by persons licensed or permitted by this state to prepare, administer, and document the administration of medications may do so. Prior to the administration of insulin with the insulin pen, the nurse verified that the correct pen is used for that resident.
Review of Medscape guidance titled Intermittent Insulin Injections Insulin Overview dated 11/05/20 and located at https://emedicine.medscape.com/article/2049311-overview#a1 revealed to avoid air and to ensure proper dose, you will need to prime the syringe each time; to do this, dial two units; hold the pen with the needle pointing up and tap the cartridge gently a few times to get rid of any air bubble; press the push button all the way in until the dose selector returns to zero; a drop of insulin must appear at the needle tip; if not, change the needle and repeat the procedure.
Review of the Kwikpen reference guide stated to prep the injection pen by doing an appropriate air shot before each use of the insulin pens. The reference guide stated to use two units air shots before each use.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
Based on observation, resident and staff interviews, medical record review, and policy review, the facility failed to ensure medications were consumed at the time of administration and not left at the...
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Based on observation, resident and staff interviews, medical record review, and policy review, the facility failed to ensure medications were consumed at the time of administration and not left at the resident's bed side unsupervised. This affected one (#302) resident out of the three residents reviewed for medication administration. The facility census was 99.
Findings include:
Review of the medical record for Resident #302 revealed an admission date of 07/17/24. Diagnoses included aftercare following joint replacement, acquired absence of right hip joint, anemia, anxiety, and hypertension. Review of the admission assessment, dated 07/17/24, revealed Resident #302 was alert and oriented to person, place, time, and situation.
Review of the physician orders dated 07/23/24 to be administered at 8:00 A.M. revealed celecoxib (anti-inflammatory drug) 200 milligram (mg) one tablet by mouth, cholecalciferol (supplement) 1,000 units one tablet by mouth, Cymbalta (anti-depressant) 60 mg one tablet by mouth, folic acid (vitamin) one mg one tablet by mouth, leflunomide (treats rheumatoid arthritis) 20 mg one tablet by mouth, metoprolol (lowers blood pressure) 25 mg one tablet by mouth, multivitamin one tablet by mouth, aspirin 81 mg one tablet by mouth, rifampin (antibiotic) 300 mg one tablet by mouth, ferrous sulfate (vitamin) 325 mg one tablet by mouth, gabapentin (treats nerve pain) 300 mg one tablet by mouth, and pantoprazole (treats gastroesophageal reflux disease) 40 mg one tablet by mouth.
Observation with interview with Resident #302 on 07/23/24 at 8:48 A.M. revealed a medication cup with medications in the cup sitting on Resident #302's bedside table. Resident #302 stated the nurse left the medications sitting at the bedside while Licensed Practical Nurse (LPN) #259 went to get supplies for her intravenous medication. There was no nurse observed to be in Resident #302's room or in the hallway.
Interview on 07/23/24 at 8:52 A.M. with LPN #259 confirmed she did not observe Resident #302 consume medications and left the medication cup with all Resident #302's medications due at 8:00 A.M. sitting on her bedside table while she left to get supplies for the intravenous medication.
Review of the facility policy titled Administering Medications, revised April 2019, revealed medications are to be administered in a safe and timely manner, and as prescribed and only by persons licensed or permitted by this state to prepare, administer, and document the administration of medications may do so. Medications are to be administered in accordance with prescriber orders.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, record review and review of the facility policy the facility failed to follow isolation p...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, record review and review of the facility policy the facility failed to follow isolation protocols while providing care to residents. This affected one (Resident #47) of five residents reviewed for isolation precautions. The facility census was 99.
Findings include:
Record review for Resident #47 revealed the resident was originally admitted to the facility on [DATE]. Diagnoses for Resident #47 included cerebral infarction, diabetes type two mellitus, and heart disease.
Review of the care plan dated 08/02/22 revealed Resident #47 was at risk for infection. Interventions included isolation protocols per policy. There was also a focus for wounds and skin breakdown. Interventions included to follow isolation protocols per policy.
Review of the facility's infection control list dated 07/22/24 for all residents requiring isolation protocols, revealed Resident #47 was on the list for a wound.
Observation on 07/22/24 at 9:00 A.M. of Resident #47's hallway revealed hanging on the doorway to the resident's room was a posted sign reading Enhanced Barrier Precautions (EBP). Per the sign, all caregivers were to don a gown and gloves to provide care to the resident.
Observation on 07/23/24 at 9:16 A.M. of Resident #47's care provided by State Tested Nursing Aide (STNA) #271 revealed STNA #271 entered the room with the mechanical lift and did not don any gloves or gown. No gown or gloves were observed in the resident's room. STNA #271 performed personal care which included incontinence care and transfer from the bed to the wheelchair.
Interview on 07/23/24 at 9:32 A.M. with STNA #271 verified she did not follow the proper EBP. STNA #271 verified she did not wear gloves or a gown while providing personal care and transferring Resident #47.
Interview on 07/24/23 at 11:00 A.M. with the Infection Control Preventionist (ICP) #326 revealed Resident #47 was in isolation protocols for the open wounds. ICP #326 stated it was the facility's policy to place all residents with active infections or open wounds into EBP precautions to prevent the spread of infection. LPN #326 stated all staff were to wear appropriate PPE while providing personal care, including transferring, for Resident #47 per the EBP protocols.
Review of the facility policy titled 'Enhanced Barrier Precautions', dated 07/15/22, revealed it is the policy to place all residents who have wounds into EBP. While providing care which included dressing, transferring, and changing linens, all staff are to wear gowns and gloves to prevent the spread of infection.
MINOR
(B)
Minor Issue - procedural, no safety impact
Deficiency F0582
(Tag F0582)
Minor procedural issue · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to provide the residents with the Skilled Nursing Facility Advan...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to provide the residents with the Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNF ABN) and the Notice of Medicare Provider Non-Coverage (NOMNC). This affected two (#58 and #91) of three residents reviewed for beneficiary notices. The facility census was 99.
Findings include:
1. Review of the medical record of Resident #58 revealed an admission date of 02/08/24.
Review of the SNF ABN for Resident #58 revealed the last covered day of Part A service was 03/11/24. Review of the NOMNC indicated the service will end on 03/11/24. A handwritten note by Quality Assurance (QA) #328 stated the daughter was notified of LCD (last covered day) for skilled care to end on 03/11/24 and the right to appeal Livanta (third party auditor to review documentation to cover Medicare) at [PHONE NUMBER]. The note was signed on 03/06/24. The form was not signed by Resident #58 or family.
Interview on 07/24/24 at 9:44 A.M. with QA #328 revealed she had called the responsible party for Resident #58 and had sent the letter via certified mail. QA #238 stated the facility had no verification the letter had been sent.
2. Review of the medical record for Resident #91 revealed an admission date of 02/01/24.
Review of the SNF ABN for Resident #91 revealed the last covered day of Part A service was 03/08/24. Review of the NOMNC indicated the service will end on 03/08/24. A handwritten note by Quality Assurance #328 stated the daughter was notified of LCD (last covered day) for skilled care to end on 03/08/24 and the right to appeal Livanta (third party auditor to review documentation to cover Medicare) at [PHONE NUMBER]. The note was signed on 03/06/24. The form was not signed by Resident #91 or family.
Interview on 07/24/24 at 9:44 A.M. with QA #328 revealed she had called the responsible party for Resident #91 and had sent the letter via certified mail. QA #238 stated the facility had no verification the letter had been sent.
Nov 2021
11 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0558
(Tag F0558)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, staff and resident interviews, and policy review, the facility failed to ensure a r...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, staff and resident interviews, and policy review, the facility failed to ensure a resident had a call light within reach at all times. This affected one (#10) of 32 residents observed for call light use. The facility census was 109.
Findings include:
Review of Resident #10's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included multiple sclerosis, quadriplegia, obesity, and diabetes mellitus.
Review of the Minimum Data Set (MDS) assessment, dated 11/11/21, revealed Resident #10 was cognitively intact and he was totally dependent on one to two staff members for all activities of daily living.
Review of the plan of care, dated 07/07/21, revealed Resident #10 had a muscular skeletal disorder and limited range of motion. The interventions included to be sure his call light was within reach and respond promptly to all requests for assistance.
Observation on 11/21/21 at 10:20 A.M. revealed Resident #10's soft touch call light cord was draped over the top left side of the mattress with the call light on the floor. Resident #10 was asleep in the bed. Subsequent observations on 11/21/21 at 12:30 P.M. revealed Resident #10's call light was in the same place as the observation on 11/21/21 at 10:20 A.M.
Observation and interview with Resident #10 on 11/21/21 at 1:15 PM revealed the call light was hanging from the top left corner of the mattress with the call light touching the floor out of the resident's reach. Resident #10 stated the call light has to be in his hand so he can use it. Resident #10 stated he was unaware of where his call light was now. Resident #10 verified he has some movement of his fingers and can use a soft touch call light and he verified he could not turn himself in bed or raise his arms to feed himself. Resident #10 verified his call light was not in his hand.
Interview with Licensed Practical Nurse (LPN) #300 on 11/21/21 at 1:20 P.M. stated Resident #10 can use a soft touch call light if it was in his hand as he has some movement of his hands. LPN #300 verified Resident #10's call light was hanging from the top left corner of his mattress and was out of the resident's reach.
Review of the facility's policy titled Call Lights, last revised 04/2019, revealed before leaving the resident's room, check to see that the resident's call light is within reach.
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 record review, review of the facility's policy, and staff interview, the facility failed to notify the resident and resident's representative when the resident's amount exceeded the resource ...
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Based on record review, review of the facility's policy, and staff interview, the facility failed to notify the resident and resident's representative when the resident's amount exceeded the resource limit. This affected one (Resident #84) of five residents reviewed for personal trust fund accounts. The facility identified 70 residents who have personal trust fund accounts. The facility census was 109.
Findings include:
Review of Resident #84's medical record revealed an admission date of 01/29/16 with diagnoses which included spastic hemiplegia, cerebral vascular accident, diabetes, and depression. Review of the Minimum Data Set (MDS) assessment, dated 10/02/21, revealed Resident #84 had impaired cognitive skills.
Review of Resident #84's profile revealed the resident's brother was the resident's responsible party and emergency contact.
Interview on 11/22/21 at 7:45 A.M. with the Business Office Manager (BOM) #140 revealed Resident #84's current balance was $4,593.21. The BOM #140 identified the resident's amount included a stimulus check of $600 received in January 2021 and a $1,400 stimulus check received in April 2021. BOM #140 confirmed Resident #84's trust account, excluding the stimulus amounts, exceeded the maximum allowed by Medicaid. BOM #140 confirmed knowledge that exceeding the allowed amount puts the resident at risk for loss of their Social Security Income (SSI) benefits. BOM #140 confirmed the resident's representative had not been notified.
Review of the facility's policy titled Resident Trust Policy, dated 07/2019, revealed a resident on medical assistance must be notified whenever their accounts are within $200 of their asset limit. The policy revealed the resident's balances should be monitored monthly to ensure the state maximum balances are not exceeded.
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, review of the facility's policy, and staff interviews, the facility failed to ensure the resident's Ohio Comfort Care Do Not Resuscitate (DNR) form was accurately compl...
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Based on medical record review, review of the facility's policy, and staff interviews, the facility failed to ensure the resident's Ohio Comfort Care Do Not Resuscitate (DNR) form was accurately completed. This affected one (Resident #38) of three residents reviewed for advanced directives. The facility census was 109.
Findings include:
Review of Resident #38's medical record revealed an admission date of 12/16/20. Diagnoses included pneumonia, morbid obesity, and cerebrovascular disease.
Review of the Minimum Data Set (MDS) assessment, dated 11/05/21, revealed Resident #38 had impaired cognition and the resident required extensive one-person assistance for bed mobility, dressing, toileting, and personal hygiene.
Review of Resident #38's Ohio Comfort Care Do Not Resuscitate (DNR) order form, dated 12/23/20, revealed the form was completed by the Certified Nurse Practitioner (CNP) #450. The form included a statement which read; REQUIRED for APRN (advanced practice nurse) or PA (physician assistants): Name of supervising physician (PA) or collaborating physician (APRN) for this patient and the physician's National Provider Identifier (NPI), Drug Enforcement Administration (DEA), or the Ohio medical license number. The form did not have the physician's name and/or NPI, DEA, or medical license number.
Interview on 11/22/21 at 1:35 P.M. with the Administrator confirmed Resident #38's Ohio Comfort DNR form was incomplete.
Interview on 11/22/21 at 1:55 P.M. with the facility's Medical Director (MD) #500 confirmed the form was incomplete.
Review of the facility's policy titled Promoting the Right of Self-Determination for Healthcare Decisions and Advanced Healthcare Directives, dated 03/2021, revealed the physician is responsible for determining the resident's diagnosis, prognosis, and capacity for making healthcare decisions and to educate the resident and legal healthcare-decision-maker.
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
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident and staff interviews, and policy review, the facility failed to notify the physician of...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident and staff interviews, and policy review, the facility failed to notify the physician of significant weight gain for one resident (#60) of five residents reviewed for alteration in weight. The facility identified nine residents with unplanned significant weight gain or loss. The facility census was 109.
Findings include:
Review of Resident #60's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including non alcoholic liver cirrhosis, diabetes mellitus, and psoriasis. Review of the annual Minimum Data Set (MDS) assessment, dated 10/12/21, revealed Resident #60 had no cognitive deficits.
Review of the History and Physical, dated 11/17/20 (prior to admission on [DATE]) revealed on 05/04/20, the resident experienced elevated liver enzymes . On 10/12/20, the resident was diagnosed with lactic acidemia and liver cirrhosis due to non alcoholic fatty liver disease.
Review of the plan of care, dated 07/12/21, revealed the goals were for Resident #60 to be adequately hydrated and consume at least 50% of most meals through next review. The interventions included to assess the resident for signs and symptoms of dehydration (increased confusion, agitation, decreased urine output, dry mucous membranes) and notify the physician of abnormalities. Monitor the resident's oral intake and weight routinely.
Review of the nutrition progress note, dated 07/12/21, revealed Resident #60's weight was 109 pounds with no significant change. The resident's oral intakes were between 25 to 75% and she was receiving Ensure
(a nutritional supplement ) twice a day.
Review of the physician visit, dated 08/19/21, seen by Certified Nurse Practitioner (CNP) #400, stated Resident #60's weight was 109 pounds.
Review of the nutrition progress note, dated 09/15/21, revealed Resident #60 triggered a significant weight gain of 23.4 % in two months. Her weight was 133 pounds. A request was made for the resident to be re-weighed with no re-weigh available. The resident's appetite has increased since July 2021. She was receiving Ensure twice a day. Will monitor her weight and discontinue the Ensure if weight increases continue.
There was no documentation in Resident #60's medical record the physician and/or CNP was notified of Resident #60's significant weight gain from 09/15/21 to 10/18/21.
Review of the physician visit, dated 10/19/21, revealed Resident #60 was seen by CNP #400 and her weight was noted to be 133 pounds. There was no mention of the cirrhosis of the liver.
Review of the nutrition progress note, dated 10/21/21, revealed Resident #60 triggered an additional significant weight gain of 7.2% in one month. Her weight was 140 pounds and it was up by seven pounds in one month. The resident's oral intakes remained at 50 to 100% of meals. The recommendation was to discontinue the Ensure supplements.
Review of the nursing progress notes, dated 10/24/21, revealed Resident's #60 family member called and stated an appointment with Gastroenterologist #410 was missed on Friday, 10/22/21. The family member stated the appointment needs to be rescheduled.
Review of the nutrition progress note, dated 11/16/21, revealed Resident #60 continues to have a significant weight gain with current weight of 145 pounds. Her meal intakes continue to be 50-100% of a carbohydrate controlled no added diet . The Ensure supplements were discontinued on 10/28/21.
There was no documentation in Resident #60's medical record the physician and/or CNP was notified of Resident #60's significant weight gain from 10/20/21 to 11/21/21.
Observation on 11/22/21 at 8:51 A.M. revealed Resident #60 was lying in bed on her right side. Her abdomen was exposed revealing her abdomen to be very large.
Interview with Resident #60 on 11/22/21 at 8:51 A.M. stated she has not been able to get out of bed for two days due to back pain. She stated she was able to get up in a wheelchair but the past two days she can't even sit up. She verified she has experienced an increase in the size of her abdomen over the past few months.
Interview with Director of Nursing (DON) on 11/23/21 at 2:30 P.M. verified Gastroenterologist #410 was managing the resident's care for cirrhosis of the liver. She verified the resident had missed an appointment on 10/22/21 due to the transportation was not arranged by the facility. She verified the appointment has been rescheduled for 11/30/21. She verified CNP #400 and Gastroenterologist #410 were not updated on the continued significant weight gain. She verified the resident had gained 36 pounds in four months.
Subsequent interview with Resident #60 on 11/23/21 at 2:45 P.M. verified she had missed an appointment with the gastroenterologist on 10/22/21 because the facility did not take her. Resident #60 stated she was aware her abdomen has increased in size. Resident #60 stated she doesn't feel she was eating that much and feels it could be fluid due to her liver disease. She verified this has happened in the past.
Review of the facility's policy titled Notification of Change, revised 06/2019, stated under Examples of Notification of Physician and Family, physicians should be notified for significant changes in weight.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff and resident interview, and policy review, the facility failed to ensure care conferences ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff and resident interview, and policy review, the facility failed to ensure care conferences were completed quarterly for Resident #50. The facility also failed to ensure the care plans were revised quarterly for Resident #60. This affected two (#50 and #60) out of 22 residents reviewed for care plans during the annual survey.
Findings include:
1. Medical record review for Resident #50 revealed an admission date of 09/21/17. Diagnoses included bipolar disorder. Review of the quarterly Minimum Data Set (MDS) assessment, dated 10/19/21, revealed Resident #50 was cognitively intact.
Review of the care conferences, dated 01/13/21, revealed this was the last care conference provided to Resident #50.
Interview with Resident #50 on 11/21/21 at 10:30 A.M. revealed she had not received a care conference in a long time.
Interview with Licensed Social Worker (LSW) #204 on 11/23/21 at 9:31 A.M. confirmed she was only doing quarterly care conference if the residents and the families requested one to be completed.
Review of the facility's policy titled Care Plan Policy, dated 08/01/18, revealed each resident will have an initialized care plan based on comprehensive assessment and developed by the interdisciplinary team. Care conferences will be held quarterly and as needed.
2. Review of Resident #60's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including non alcoholic liver cirrhosis, diabetes mellitus, and psoriasis. Review of the annual Minimum Data Set (MDS) assessment, dated 10/12/21, revealed Resident #60 had no cognitive deficits.
Review of the plan of care, dated 07/12/21, revealed the goals were for Resident #60 to be adequately hydrated and consume at least 50% of most meals through next review. The interventions included to assess the resident for signs and symptoms of dehydration (increased confusion, agitation, decreased urine output, dry mucous membranes) and notify the physician of abnormalities. Monitor the resident's oral intake and weight routinely.
Review of the nutrition progress note, dated 07/12/21, revealed Resident #60's weight was 109 pounds with no significant change.
Review of the nutrition progress note, dated 09/15/21, revealed Resident #60 triggered a significant weight gain of 23.4% in two months. Her weight was 133 pounds.
Review of the nutrition progress note, dated 10/21/21, revealed Resident #60 triggered an additional significant weight gain of 7.2% in one month. Her weight was 140 pounds and it was up by seven pounds in one month.
Review of the nutrition progress note, dated 11/16/21, revealed Resident #60 continues to have a significant weight gain with current weight of 145 pounds.
Further review of the plan of care in the electronic record revealed the revealed the plan of care was last updated on 07/12/21. There was an alert in the medical record stating the plan of care update was over due. There was no mention in the plan of care concerning the weight gain of 37 pound weight gain in the past four months or new interventions in place.
Interview with the Director of Nursing (DON) on 11/23/21 at 2:30 P.M. verified the resident had gained 36 pounds in four months.
Interview with Registered Nurse (RN) MDS Coordinator #500 on 11/22/21 at 2:30 P.M. verified the plan of care for Resident #60 was not updated since 07/12/21. The plan of care should have been updated following the quarterly MDS review that was completed 10/12/21. RN MDS Coordinator #500 verified there was not mention in the plan of care regarding a significant weight gain of 36 pounds.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
Based on medical record review, staff interview, and policy review, the facility failed to ensure weights were obtained and documented as ordered for Resident #85. This affected one (#85) of two resid...
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Based on medical record review, staff interview, and policy review, the facility failed to ensure weights were obtained and documented as ordered for Resident #85. This affected one (#85) of two residents reviewed for edema. The facility census was 109.
Findings include:
Review of Resident #85's medical record revealed an admission date of 11/20/19. Diagnosis included cerebrovascular disease, hypertension, atherosclerotic heart disease of native coronary artery without angina pectoris, paroxysmal atrial fibrillation, and chronic kidney disease.
Review of the plan of care, dated 06/24/21, revealed Resident #85 was at risk for alteration in cardiac function related to coronary artery disease, cardiac arrhythmia, hypertension, and history of myocardial infarction. Interventions included to assess for edema and report any problems to the physician.
Review of the annual Minimum Data Set (MDS) assessment, dated 10/21/21, revealed Resident #85 received diuretics.
Review of the physician orders, dated 10/20/21, revealed an order for weekly weights every Wednesday for edema.
Review of the weight documentation in the electronic medical record, revealed there were weights obtained on 10/05/21 and 11/03/21. There was no documentation that weights were obtained on five Wednesdays: 10/20/21, 10/27/21, 11/03/21, 11/10/21, and 11/17/21. Review of the Treatment Administration Record (TAR) for November 2021 revealed weekly weight day shift every Wednesday was signed off by nursing staff on 11/03/21, 11/10/21, and 11/17/21 with no weights documented in the medical record.
Interview on 11/22/21 at 2:07 P.M. with the Director of Nursing (DON) stated she was not able to produce the actual weights obtained on 11/10/21 and 11/17/21 that were signed off by nursing staff.
Review of the facility's policy titled Weight Policy, revised date 02/2019, revealed to determine weight gain or loss, weights will be monitored on admission/readmission, weekly times four weeks, and monthly thereafter, unless otherwise ordered.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0688
(Tag F0688)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observations, resident and staff interviews, the facility failed to implement a palm protector t...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observations, resident and staff interviews, the facility failed to implement a palm protector to prevent further decline in range of motion for one resident (#49). This affected one (#49) of three residents reviewed for limited range of motion. The facility identified 27 residents with contractures. The facility census was 109.
Findings include:
Review of Resident #49's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included dementia, contracture of multiple sites and Parkinson's disease.
Review of the annual Minimum Data Set (MDS) assessment, dated 07/06/21, revealed Resident #49 had moderate cognitive deficits. Resident #49 required extensive assistance one person for personal hygiene and dressing. He had no rejection of care.
Review of the plan of care, dated 07/09/21, revealed Resident #49 had Parkinson's disease. The goal was for Resident #49 to remain free of further signs and symptoms of discomfort or complications related to Parkinson's disease. The interventions included adaptive devices as recommended by therapy or physician and monitored for safe use.
Review of the physician order, dated 09/15/21, stated Resident #49 was to wear a palm protector splint in his left hand at all times except for care as tolerated. Remove for care and monitor for skin integrity.
Review of the Occupational Therapy Discharge Summary, dated 11/19/21, revealed the discharge recommendations and status stated a splint and brace program and staff was trained on the use of a left hand palm protector to be worn at all times except during care to prevent further decline in range of motion of his left hand.
Interview with Occupational Therapist (OT) #425 on 11/22/21 at 3:00 P.M. verified Resident #49 had a palm protector order to be in his left hand at all times except during for care. OT #425 verified Resident #49 had received occupational therapy and was discharged on 11/19/21. OT #425 verified the discharge recommendation for Resident #49 was to wear a palm protector in his left hand to prevent further decline in the range of motion in his left hand. OT #425 stated Resident #49 was very cooperative and had no complaints regarding wearing the palm protector.
Observation on 11/22/21 at 9:00 A.M. revealed Resident #49 was in bed with soft touch call light in place. Both hands appeared contracted. There were no splint or palm protector in place.
Interview with Licensed Practical Nurse (LPN) #100 on 11/22/21 at 9:20 A.M. stated Resident #49 had bilateral contracture of his hands. LPN #100 verified Resident #49 did not have his splints in place. She stated sometimes they place rolled wash clothes in his hands.
Observation on 11/22/21 at 11:00 A.M. revealed Resident #49 was in bed. Resident #49's left hand was contracted. There was no splint or palm protector in place.
Interview on 11/22/21 11:00 A.M. with LPN #151 verified Resident #49 did not have a splint. LPN #151 stated sometimes the staff used wash clothes in his hands.
Interview on 11/22/21 at 2:30 P.M. with State Tested Nursing Assistant (STNA) #160 verified she works with Resident #49 and Resident #49 does not have any splints for his hands.
Observation on 11/23/21 at 2:00 P.M. revealed Resident #49 was in a wheelchair in his room and not wearing a palm protector or a splint. A palm protector was noted to be on the over bed table.
Interview with Resident #49 on 11/23/21 at 2:00 P.M. verified the palm protector was on the over bed table. Resident #49 stated the staff was supposed to put it in his left hand but they do not do this. Resident #49 verified he does not refuse to let staff put it on as he thinks it was comfortable.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
Based on medical record review, staff interview, and policy review, the facility failed to ensure an anti-anxiety medication was addressed every 14 days. This affected one (#88) of five residents revi...
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Based on medical record review, staff interview, and policy review, the facility failed to ensure an anti-anxiety medication was addressed every 14 days. This affected one (#88) of five residents reviewed during the annual survey for unnecessary medications. The facility census was 109.
Findings include:
Medical record review for Resident #88 revealed an admission date of 02/22/21. Diagnoses included anxiety disorder. Review of the quarterly Minimum Data Set (MDS) assessment, dated 11/05/21, revealed Resident #88 was severely cognitively impaired.
Review of the physician orders, dated 10/17/21, revealed Lorazepam 0.5 milligram (mg) to give one tablet every six hours as needed (PRN) for anxiety. There was no physician order to extend Lorazepam past the 14 days from 10/17/21 and there was not a specified duration of the medication noted by the prescriber. Lorazepam was discontinued on 11/20/21.
Review of the Note to Attending Physician recommendation from the pharmacy, dated 10/28/21, revealed Resident #88 was receiving a PRN psychotic therapy Lorazepam and per the Center of Medicare and Medicaid Services (CMS) guidance, this medication order cannot be extended beyond 14 days without a specified duration of therapy by the prescriber indicating the appropriateness of continuing the medication. This was not signed by the physician.
Review of the Medication Administration Record (MAR) from 10/17/21 through 10/31/21 revealed Lorazepam was administered six times during this time period. From 11/01/21 through 11/19/21, Lorazepam was administered six times.
Interview with the Director of Nursing (DON) on 11/23/21 at 12:00 P.M. verified the Lorazepam for Resident #88 did not have a specified duration of therapy by the prescriber and it was administered beyond the 14 days for a PRN antipsychotic medication. The DON stated the physician was given 45 days to address the pharmacy recommendation even if it was for something that would be considered a significant medication change.
Review of the facility's policy titled Medication Regimen Review Policy, dated 06/01/18, revealed the pharmacist must report irregularities to the Attending Physician and the DON, and the irregularities must be acted upon. Any irregularities noted by the pharmacist must be documented on a separate report and sent to the facility for review by the Attending Physician and the DON. For non-urgent recommendations, the Attending Physician must address in a timely manner to best needs of the resident, which should be on the next scheduled visit but no later then 45 days.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
Based on record review, observation, review of the facility policy, and staff interview, the facility failed to ensure stored medications were within expiration dates. This affected one of four medica...
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Based on record review, observation, review of the facility policy, and staff interview, the facility failed to ensure stored medications were within expiration dates. This affected one of four medication carts reviewed for medication storage. The facility had a total of six medication carts. This affected two residents (#24 and #41) who had insulin stored in the medication cart. The facility census was 109.
Findings include:
Observation of the facility's South medication cart on 11/22/21 at 3:48 P.M. with Licensed Practical Nurse (LPN) #243 revealed a vial of Lantus Insulin Glargine Injection 100 units/milliliter (units/ml) for Resident #41 with an open date 09/25/21. Review of the pharmacy label on the vial revealed instructions to discard 28 days after opening. Observation of Lantus Insulin Glargine Injection Flexpen 100 units/ml for Resident #41 revealed an open date of 09/19/21. Observation of Novolin 70/30 Human Insulin Isophane Suspension Flexpen for Resident #24 revealed an open date 10/09/21. Review of the pharmacy label to discard 28 days after opening. These findings were verified by LPN #243.
Review of the facility's undated policy titled Medication Storage, dated 06/21/17, revealed contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication destruction, and reordered from the pharmacy, if replacements are needed.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Laboratory Services
(Tag F0770)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and staff interview, the facility failed to obtain laboratory tests as ordered by t...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and staff interview, the facility failed to obtain laboratory tests as ordered by the physician for one resident (#60) of six residents reviewed for laboratory results. The facility census was 109.
Findings include:
Review of Resident #60's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including non alcoholic liver cirrhosis and psoriasis. Review of the annual Minimum Data Set (MDS) assessment, dated 10/12/21, revealed Resident #60 had no cognitive deficits.
Review of the physician progress note from Gastroenterologist #410, dated 07/22/21, revealed Resident #60 was seen in the office for alternating constipation and diarrhea and cirrhosis of the liver. The plan stated to obtain an ultrasound of the liver, laboratory studies including complete blood count (CBC), comprehensive metabolic panel (CMP), ammonia level and pro-time (PT) in three months and follow up with the Gastroenterologist for a 30-minute follow up visit. The gastroenterologist appointment was scheduled for 10/22/21.
Review of the laboratory results revealed on 10/21/21, the CBC and CMP were drawn and results were obtained. There was no results for ammonia or protime levels. There was no indication in Resident #60's medical record ammonia level or protime was obtained. The medical record was silent as to an ultrasound of the liver being obtained.
Observation on 11/22/21 at 8:51 A.M. revealed Resident #60 was lying in bed on her right side. Resident #60's abdomen was exposed revealing her abdomen to be very large.
Interview with Director of Nursing (DON) on 11/23/21 at 2:30 P.M. verified Gastroenterologist #410 was managing Resident #60's care for cirrhosis of the liver. The DON verified the ammonia level, protime, and ultrasound of the liver as ordered by Gastroenterologist #410 had not been obtained. The DON verified the laboratory studies and ultrasound of the liver was to be completed prior to the 10/22/21 appointment with the Gastroenterologist and had not been obtained. The DON stated she called the Gastroenterologist office that day (11/23/21) and verified the tests were to be completed prior to Resident #60's follow up appointment on 10/22/21. The DON verified Resident #60 missed her gastroenterologist appointment on 10/22/21 because the facility did not schedule transportation. The DON stated the appointment has been rescheduled for 11/30/21.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0921)
Could have caused harm · This affected 1 resident
Based on record review, observation, review of the facility's policy, and staff interviews, the facility failed to ensure resident care equipment was maintained in a clean condition. This affected one...
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Based on record review, observation, review of the facility's policy, and staff interviews, the facility failed to ensure resident care equipment was maintained in a clean condition. This affected one (Resident #26) of 32 residents observed for clean environment. The facility census was 109.
Findings include:
Medical review for Resident #26 revealed admission date 03/08/13 and readmission date 05/16/21. Diagnoses included anoxic brain damage, dysphagia, aphasia, gastrostomy, and tracheostomy.
Review of the annual Minimum Data Set (MDS) assessment, dated 09/10/21, revealed Resident #26 required tube feed nutrition and tracheostomy care.
Observation on 11/21/21 at 2:18 P.M. revealed there was tube feed dried on Resident #26's platform for the tracheostomy mist machine. A thick layer of dried tube feed covered the entire back ledge of the platform. A housekeeper was cleaning the room and had sprayed a cleaner on the dried tube feed spots on the floor. The housekeeper stated she did not clean the tube feed pump, stand, platform, or the tracheostomy mist machine.
Interview on on 11/21/21 at 2:25 P.M. with Registered Nurse (RN) #20 verified the dried tube feeding on the tracheostomy mist machine platform.
Interview on 11/22/21 at 2:08 P.M. with the Director of Nursing (DON) stated it was housekeeping responsibility to clean the floors. She stated nursing should clean the equipment poles, pumps, and the tracheostomy mist machine.
Review of the facility's policy titled Cleaning Resident Rooms Policy, revision date of 04/2019, revealed cleaning should be top to bottom, and dirtiest surfaces should be cleaned last.
Aug 2019
8 deficiencies
1 Harm
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Pressure Ulcer Prevention
(Tag F0686)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, resident and staff interview, and review of the facility policy, the facility faile...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, resident and staff interview, and review of the facility policy, the facility failed to ensure staff provided ongoing monitoring of a resident's left heel pressure ulcer and failed to notify the physician when the wound deteriorated/began draining. This resulted in Actual Harm to one resident (#75) when facility staff did not provide ongoing monitoring of Resident #75's left heel pressure ulcer including measuring/staging the wound, did not notify the physician when the wound began to drain and Resident #75's left heel ulcer subsequently deteriorated into an unstageable pressure ulcer (the area could not be staged due to presence of slough and/or eschar). Additionally, the facility failed to ensure preventative measures were in place and treatments were completed as ordered by the physician for a second resident's (#112) pressure ulcer, which placed the resident at risk for potential harm. This affected two (#75 and #112) of six residents reviewed for pressure ulcers. The facility identified 10 residents with pressure ulcers. The facility census was 120.
Findings include:
1. Review of medical record of Resident #75 revealed the resident was admitted to the facility on [DATE]. Diagnoses included diabetes mellitus, arthritis, pressure ulcer Stage IV (full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed), muscle weakness, depression, psychotic disorder, anemia and heart disease.
Review of the comprehensive Minimum Data Set (MDS) assessment, dated 08/12/19, revealed the resident had intact cognition and had unhealed pressure ulcers.
Review of the care plan, dated 06/10/19, revealed a focus for skin breakdown related to pressure ulcers. Interventions for the focus included to monitor the skin, treatments per order, notify physician of changes in skin and to complete weekly skin assessments.
Review of the physician orders, dated 06/20/19, revealed an order to wash the left heel with normal saline, pat dry, apply Medihoney and calcium alginate. Cover with heel protector then wrap with Kerlix every evening shift for wound care and every 24 hours as needed for wound care.
Review of the skin assessment to the resident's left heel, dated 06/26/19, revealed the left heel wound was measured at five centimeters (cm) in length by five cm in width and noted as a pressure wound. This was the first measurement of the resident's wound to her left heel since admission. There was no other description of the wound and no staging of the pressure ulcer.
Review of the physician's progress notes, dated 07/16/19, revealed when Resident #75 was admitted to the facility, the resident had bilateral heel wounds, large sacral decubitus ulcer, and myositis of the left gluteal maximus with osteomyelitis to the left iliac bone and sacrum. Foot wounds were noted to be healing after skin grafts applied.
Further review of Resident #75's weekly skin assessments revealed there was no documentation on the left heel from 06/26/19 until 08/14/19. On 08/14/19, the left heel was documented as the area continued, treatment was in place and there was moderate amount of drainage from the wound. There were no measurements of the wound, description of the wound and what stage the pressure ulcer was.
Interview on 08/20/19 at 8:53 A.M. with Resident #75 revealed she had to go to the hospital when she had a wound on her backside. Resident #75 stated she had wounds on her feet which caused her to lay down more which caused the wound on her coccyx. The resident stated she felt the wounds were improving but was unsure of the wound on her left heel. Resident #75 stated she didn't have any pain associated with the left heel wound.
Observation on 08/22/19 at 9:37 A.M. of Resident #75's dressing change, with Registered Nurse (RN) #182 and Physician Assistant (PA) #200, revealed the PA was measuring and ordering treatments for the resident's coccyx wound but not the left heel wound.
Interview on 08/22/19 at 10:29 A.M. with PA #200 revealed she does care for all the pressure ulcers for all the residents residing in the facility. The PA stated she was not aware Resident #75 had skin breakdown on her left heel and verified she was not currently caring for Resident #75's heel wound and was unaware if it was a pressure ulcer.
Observation and interview with Licensed Practical Nurse (LPN) #183 and LPN #186 on 08/22/19 at 11:30 A.M. of Resident #75's left heel wound revealed the wound appeared to be an unstageable pressure ulcer (slough and/or eschar: Known but not stageable due to coverage of wound bed by slough and/or eschar). The heel was covered with a heel protector and Kerlix. Upon removal of the dressing, dated 08/21/19, the wound bed was not visible, there was moderate amount of drainage noted on the dressing, and the tissue covering the wound appeared to be necrotic. LPN #186 measured the wound to be 8.5 cm by 7.5 cm.
Interview on 08/22/19 at 11:30 A.M. with LPN #186 and LPN #183 revealed the evening shift nurses do all dressing changes not associated with the wound team and the nurses were to document all findings in the weekly skin assessments. Per LPN #186, all wounds appearing to be pressure related were to be reported to the wound nurse, RN #182.
Interview on 08/22/19 at 11:35 A.M. with RN #182 verified Resident #75 had an unstageable pressure wound on her left heel. Per RN #182, the LPNs at the facility do not stage pressure ulcers per facility policy. RN #182 stated as the wound nurse she was to be notified of all skin issues once discovered by nurses and aides to be assessed for treatment by the wound team. RN #182 verified the left heel wound was measured on 06/26/19 to be five cm by five cm. The RN verified LPN #186 measured the wound to be increasing in size. RN #182 stated she had not been notified of the wound and had not assessed the wound herself.
2. Review of Resident #112's medical record revealed an admission date of 07/24/19. Diagnoses included abnormal levels of serum enzymes, chronic atrial fibrillation and chronic obstructive pulmonary disease. Review of the resident's Minimum Data Set (MDS) assessment, dated 07/31/19, revealed the resident had no impairment in cognition and was always incontinent of urine and bowel. She required extensive assistance of one staff member for bed mobility and dressing. She required extensive assistance with two staff members for transfers. She was at risk for pressure ulcer, with no unhealed pressure ulcers. She had a pressure reducing device for her bed.
Review of the resident's care plan, initiated on 07/25/19 and revised on 08/02/19, revealed the resident was at risk for skin breakdown, skin tears, bruising and pressure ulcers due to weakness, fragile skin, decreased mobility and incontinence. Interventions included to apply a protective barrier cream as ordered, assess and record changes in skin status, report pertinent changes to physician, minimize pressure over bony prominence, provide/monitor effectiveness of pressure relieving or reduction device(s) (pressure reduction mattress to bed), treatments per Treatment Administration Record (TAR), and weekly skin assessments by nurse.
Review of the resident's admission nursing assessment, dated 07/24/19, revealed the only skin impairment the resident had was a spine abrasion. It measured 5.0 centimeters (cm) in length by 3.0 cm wide. There was no further description of the area.
Review of the physician's order, dated 07/25/19, revealed to apply bordered foam daily to mid back spine area until healed for abrasion. This order was discontinued on 08/19/19.
Review of the resident's TAR revealed bordered foam daily to mid back spine area was signed off daily as completed.
Further review of the physician's orders, dated 08/07/19, revealed to apply skin prep (a liquid that when applied to the skin forms a protective film or barrier) to tips of bilateral great toes due to redness. On 08/09/19, an order was written to apply a foot cradle (a device that attaches to the bed to keep sheets and blankets from touching and rubbing your legs or feet) to the end of the bed. The resident's TAR had multiple blank entries noted for the resident's bed cradle.
Continued review of the medical record revealed no further documentation of the resident's skin impairment to the mid back area until 08/06/19. The note indicated redness to area, skin intact. No further description was documented. The next entry for the resident's mid back area was dated 08/19/19 and indicated the physician wanted to discontinue the foam border to the reddened area on her back and a new order was obtained to apply skin prep to reddened area to mid upper back daily. There was no documentation regarding the impairment to the resident's toes.
Observation of the resident on 08/19/19 at 10:02 A.M. revealed she had a bed cradle on her bed. The resident's sheet and blanket were under the bed cradle, touching her feet and legs.
Observation of care and interview with State Tested Nursing Assistant (STNA) #180 on 08/19/19 at 10:05 A.M. verified the bed cradle was not being used properly. Observation during care also revealed a dressing to the resident's mid back dated 08/13/19.
Observation and interview on 08/19/19 at 10:56 A.M. with Registered Nurse (RN) #181 revealed the resident's right great toe was red, but blanchable. She verified there was a large bandage on the resident's back dated 08/13/19.
Further observations of the resident on 08/21/19 at 8:35 A.M. and 9:02 A.M. revealed she was in bed with her sheet and blankets resting on her feet and legs. The bed cradle was on the bed but not being used properly.
Observation of the resident on 08/21/19 at 10:05 A.M. with Licensed Practical Nurse (LPN) #177 revealed the resident had a large foam dressing on her mid back dated 08/19/19. LPN #177 verified the order for a dressing to the resident's back had been discontinued. She stated the order was changed to skin prep on 08/21/19. The reddened area on the resident's mid-back spine area was measured at 7.0 cm by 1.0 cm and was red and not blanchable per LPN #177. She stated the area was a Stage I pressure area. The resident's right great toe was also observed to be red and not blanchable. It measured 1.0 cm by 1.5 cm with skin starting to flake off the middle portion of the reddened area. LPN #177 stated this area was also a Stage I pressure area.
Interview with RN Wound Nurse #182 on 08/21/19 at 12:22 P.M. revealed LPNs were not permitted to stage pressure areas at their facility. She stated she assessed the resident and the area to the resident's back was a Stage I, but the right great toe was red and blanchable per her assessment, and therefore, not a Stage I pressure ulcer. She verified there was no documentation indicating the resident's toes were being monitored and there was no additional documentation on the resident's back impairment.
Interview with the Director of Nursing on 08/22/19 at 11:06 A.M. verified there were multiple blank entries on the TAR for the resident's bed cradle. She also verified nurses had signed they were placing a dressing on the resident's back from 08/13/19 through 08/19/19 when it had not been changed since 08/13/19.
Review of the facility policy titled Pressure Prevention Policy, revised on 01/05/17, revealed the geriatric population is at risk for skin breakdown. The risk becomes greater with co-morbidities, and during times of acute illness. The facility will ensure the nursing staff are providing preventative practices which help decrease the risk of skin breakdown. Procedures included: assessing skin daily during activities of daily living, weekly skin checks by nursing staff, protect skin against friction and shearing force.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, resident interview and staff interview, the facility failed to ensure the dignity of reside...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, resident interview and staff interview, the facility failed to ensure the dignity of residents with indwelling catheters was upheld. This affected two (Resident #23 and #323) of two residents reviewed for catheters. The facility identified five residents with catheters. The facility census was 120.
Findings include:
1. Review of the medical record for Resident #23 revealed the resident was admitted to the facility on [DATE]. Diagnoses included multiple sclerosis, urinary tract infection, obesity, quadriplegia, anxiety, depression and disorder of bladder.
Review of the annual Minimum Data Set (MDS) assessment, dated 03/01/19, revealed Resident #23 had intact cognition and had an indwelling urinary catheter.
Observations on 08/20/19 at 8:00 A.M., 08/20/19 at 9:13 A.M. and 08/21/19 at 8:56 A.M. revealed Resident #23's room door was open. Resident #23's catheter bag was hanging on the bed frame uncovered and was visible from the hallway in front of the resident's room.
Interview on 08/20/19 at 8:00 A.M. with Resident #23 revealed the resident felt 'uncomfortable' about his catheter and preferred for the bag to not be visible to others.
Interview on 08/20/19 at 9:20 A.M. with State Tested Nurse Aide (STNA) #201 revealed the procedure for catheter bags was to be hung on the opposite side of the door and to be covered at all times. STNA #201 verified Resident #23's bag was uncovered and visible from the hallway of Resident #23's room.
Interview on 08/20/19 at 8:50 A.M. with Licensed Practical Nurse (LPN) #185 verified Resident #23's catheter bag was hanging on the side of the bed facing the resident's open doorway. Per the nurse, the procedure was to have all catheter bags covered for dignity.
2. Review of Resident #323's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included muscle weakness, dementia and prostatic hyperplasia.
Review of the comprehensive Minimum Data Set (MDS) assessment, dated 08/10/19, revealed the resident has intact cognition and an indwelling urinary catheter.
Observation on 08/22/19 at 9:19 A.M. revealed the resident was lying in bed awake eating breakfast. Resident #323's urinary catheter bag was observed visible from the hallway into the resident's room.
Interview on 08/22/19 at 9:22 A.M. with Registered Nurse (RN) #187 verified Resident #323's catheter bag was visible from the hallway. Per the RN, the facility was to cover the bags for dignity of the residents.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0569
(Tag F0569)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of resident accounts, staff interview and review of facility policy, the facility failed to notify Medicaid Resi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of resident accounts, staff interview and review of facility policy, the facility failed to notify Medicaid Residents/Representatives, when their account was $200.00 less than the Supplemental Security Income (SSI) limit of $2,250, and the facility failed to return a resident funds to the State after his death. This affected four (Resident #27, #54, #101 and #177) of five residents accounts reviewed. The facility census was 120.
Findings include:
1. Review of Resident #27's personal funds account revealed a copy of a letter of notification, dated [DATE], sent to the resident's representative that the residents funds account balance was $4905.00. On [DATE], review of the residents account balance revealed a balance of $5195.93.
2. Review of Resident #54's personal funds account revealed a copy of a letter of notification, dated [DATE], sent to the resident's representative that the residents funds account balance was $2490.93. On [DATE], review of the residents account balance revealed a balance of $3207.61.
3. Review of Resident #101's personal funds account revealed a copy of a letter of notification, dated [DATE], sent to the resident's representative that the residents funds account balance was $5467.10. On [DATE], review of the residents account balance revealed a balance of $4465.84.
4. Review of Resident #177's personal funds account revealed the resident expired on [DATE]. The residents account summary on [DATE] revealed a balance of $1975.08.
On [DATE] at 2:22 P.M., during an interview Receptionist #56 revealed she manages the resident accounts and confirmed the resident representatives were not notified when the resident account balances were within $200.00 of the SSI limit for notification, and confirmed Resident #177's funds have not been returned to the State.
Review of the facility policy titled Resident Trust, dated [DATE], revealed number seven was regarding monitoring balances: per Omnibus Budget Reconciliation Act (OBRA) regulations, a resident on medical assistance must be notified whenever their funds are within $200.00 of their resource asset limit. The Resident Trust Custodian is responsible for sending a notification letter to the resident/responsible party whenever their funds are within $200.00 of their resource limit. Number nine was regarding deceased residents/closed accounts: in the event of a resident's death while a resident of the facility, any funds remaining, after financial obligation to the facility shall be disbursed within 30 days
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the medical record for Resident #22 revealed the resident was admitted to the facility on [DATE]. Diagnoses include...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the medical record for Resident #22 revealed the resident was admitted to the facility on [DATE]. Diagnoses included weakness, sepsis, atrial fibrillation, muscle weakness, depression, lymphoma and dementia. Review of the comprehensive MDS assessment, dated [DATE], revealed the resident had intact cognition.
Review of the care plans, dated 02/2019, revealed the resident had a focus for code status as Do Not Resuscitate Comfort Care (DNRCC).
Review of the physician orders for Resident #22 revealed an order dated [DATE] for a DNRCC code status.
Further review of the care conference note, dated [DATE] and [DATE], documented the resident as being a Full Code status.
Interview on [DATE] at 10:40 A.M. with Licensed Practical Nurse (LPN) #185 revealed the nurse's report for Resident #22 documented as the resident being a 'Full Code'. Per LPN #185, the nurse's would check the report for code status and then the chart if there was an issue with care. LPN #185 then verified there was a DNRCC order, dated [DATE], in Resident #22's paper chart.
Review of a facility policy titled Full Code (CPR) Policy, last revised 01/2019, revealed in the case of cardiac and/or pulmonary arrest, the resident's chart is checked to determine code status. Code status is located in the front of the medical record, and a valid do not resuscitate comfort care (DNRCC) or do not resuscitate comfort care arrest (DNRCCA) has a physician signature. If the state of Ohio sheet is not signed in the chart, CPR is initiated immediately and may include all measures to prevent and/or reverse death.
Based on record review, review of facility policy and staff interview, the facility failed to ensure resident's advance directives were accurate. This affected two (#22 and #112) of 32 residents reviewed for advance directives. The facility census was 120.
Findings include:
1. Review of Resident #112's medical record revealed an admission date of [DATE]. Medical diagnoses included abnormal levels of serum enzymes, chronic atrial fibrillation, chronic obstructive pulmonary disease, dysphagia, hypertension, and hypothyroidism. Review of the resident's Minimum Data Set (MDS) assessment, dated [DATE], revealed no impairment in cognition.
Review of the resident's electronic medical record physician's orders and face sheet revealed no evidence of the resident's code status. Review of the resident's paper chart revealed no physician's orders to clarify the resident's code status. The front of the resident's chart contained a full code form with a blank space for resident/representative signature and the nurse signature. The front of the chart also contained a blank do not resuscitate advance directives form.
Interview with Registered Nurse #181 on [DATE] at 11:03 A.M. verified the resident's record did not contain clarification of what the resident's code status was. She stated she would assume the resident was a full code. She verified the full code form and do not resuscitate form were in the front of the chart and blank. She stated they should have been completed on admission.
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 observation, record review and resident and staff interview, the facility failed to monitor an open wound on a resident...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and resident and staff interview, the facility failed to monitor an open wound on a resident. This affected one (Resident #22) of three residents reviewed for skin conditions. The facility census was 120.
Findings include.
Review of the medical record for Resident #22 revealed the resident was re-admitted to the facility on [DATE] with an original admission of 10/08/18. Diagnoses included weakness, sepsis, atrial fibrillation, muscle weakness, depression, lymphoma, arthritis and dementia.
Review of the comprehensive Minimum Data Set (MDS) assessment, dated 02/06/19, revealed the resident had intact cognition and was at risk for skin breakdown.
Review of the care plans, dated 10/08/18 and revised on 04/25/19, revealed a focus for skin breakdown. One intervention for the focus included monitor left lower leg skin integrity for breakdown.
Review of the weekly skin assessments, dated 06/04/19, revealed the resident had intact skin and no open areas to bilateral arms were resolved. Review of the weekly skin assessment, dated 08/02/19, revealed the resident had an open wound to the left lower leg and was documented as being four centimeters (cm.) in length by 1.5 cm. wide by 0.1 cm. depth. with green sloth and odor. No other weekly skin assessment were noted in the record between 06/04/19 and 08/02/19. On 08/21/19 at 2:15 P.M., a weekly assessment was completed by wound team. Per the assessment, the area to the left lower leg was 1.5 cm. by 0.9. cm by 0.9 cm depth.
Observation on 08/20/19 at 9:58 A.M. of Resident #22's left lower leg revealed a dressing dated 08/20/19 was in place, no drainage was noted on the dressing and the wound appeared to be healing.
Interview on 08/21/19 at 11:00 A.M. with Registered Nurse, (RN), #182 revealed she was the wound nurse and was to be notified of all wounds the residents had. RN #182 stated Resident #22 did have a history of vascular wounds to her legs and was to have a weekly skin assessment completed to ensure no new areas developed. RN #182 stated she was unaware of the left lower leg wound on Resident #22. RN #182 stated she would assess the wound and notify the physician for treatment. RN #22 verified there was no weekly skin assessments for Resident #22 in the chart from 06/04/19 to 08/02/19.
Interview on 08/22/19 at 11:03 A.M. with Resident #22 revealed she was aware there was an open wound on her left lower leg. Per Resident #22, she had no pain associated with the wound and stated the nurses were treating the wound by changing the dressing daily. Resident #22 was unable to remember the day the wound started but stated she had told the nurse who started to put a dressing on the wound.
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 medical record review, staff interview, and review of a facility policy, the facility failed to ensure pneumococcal vac...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and review of a facility policy, the facility failed to ensure pneumococcal vaccinations were offered. This affected one (Resident #92) of five residents reviewed for pneumococcal vaccinations. The facility census was 120.
Findings include:
Review of Resident #92's medical record revealed she was admitted to the facility on [DATE]. There was no evidence in the medical record the resident was screened for the necessity of a pneumococcal vaccination upon admission or annually thereafter.
Interview with the Director of Nursing on 08/20/19 at 3:00 P.M. verified Resident #92 did not have a pneumonia consent completed upon admission or annually thereafter. She verified the facility had no documentation the resident had received a pneumonia vaccine.
Review of the facility policy titled Pneumococcal Policy, revised in 04/2019, revealed residents admitted to the facility will be given the opportunity to receive the pneumococcal vaccine per physician order. The nurse will research the medical record and resident history to determine if pneumococcal has been given. After determining that the vaccine has not been given within five years, the nurse will obtain an order for the vaccine from the attending physician, and consent from the resident or responsible party.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Laboratory Services
(Tag F0770)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of facility policy and staff interview, the facility failed to ensure laboratory values were obta...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of facility policy and staff interview, the facility failed to ensure laboratory values were obtained per physcian orders and/or the results provided to the facility timely for four (Resident #3, #54, #84 and #112) of five residents reviewed for unnecessary medications. The facility census was 120.
Findings include:
1. Review of Resident #3's medical record revealed an admission date of 09/14/17. Diagnoses included coronary artery disease, chronic atrial fibrillation and hypertension. Review of the comprehensive Minimum Data Set (MDS) assessment, dated 08/01/19, revealed Resident #3 was cognitively impaired and indicated the resident received an anticoagulant medication daily.
Review of the resident's care plan, dated 09/14/17, revealed the resident was at risk for bleeding related to Coumadin (blood thinning medication). Interventions included to monitor labs as ordered and report abnormal findings to physician.
Review of the physician orders for April 2019 and May 2019 revealed Resident #3 received 2.5 milligrams (mg.) of Coumadin daily and was ordered laboratory blood tests, to be done monthly, for Prothrombin Time/International Normalized Ratio (PT/INR) to monitor the effectiveness of Coumadin. Further review of Resident #3's medical record revealed an absence of laboratory results for PT/INR for April 2019 and May 2019.
On 08/22/19 at 9:12 A.M., during an interview the Director of Nursing (DON) confirmed Resident #3's ordered lab tests for PT/INR for April 2019 and May 2019 were not completed as ordered.
3. Review of Resident #84's medical record revealed an admission date of 06/14/19. Diagnoses included dementia, chronic obstructive pulmonary disease and rheumatoid arthritis.
Review of the resident's nursing notes revealed an entry dated 07/13/19 at 3:46 P.M. indicating the resident's urine was dark amber in color with a foul odor.
Review of the resident's physician's orders revealed an order dated 07/13/19 for a one time urinalysis with culture and sensitivity.
Review of the resident's laboratory results revealed a urinalysis was collected on 07/13/19. The results of the urine culture were completed on 07/17/19 at 2:37 P.M. with evidence of Escherichia coli. The facility did not receive fax results of the culture until 07/20/19 at 4:49 P.M. and did not receive orders to treat the resident's urinary tract infection (UTI) until 07/21/19 at 8:00 A.M.
Continued review of the physician's orders revealed an order dated 07/21/19 for Macrobid (antibiotic) twice daily for seven days.
Interview with the Director of Nursing (DON) on 08/21/19 at 11:08 A.M. verified there was a delay in treatment for the resident's urinary tract infection (UTI). She verified the results of the urine culture were completed on 07/17/19 and the facility did not receive results until 07/20/19, with no physician's orders to treat the resident until 07/21/19.
4. Review of Resident #112's medical record revealed an admission date of 07/24/19. Diagnoses included chronic obstructive pulmonary disease and hypothyroidism. Review of the resident's Minimum Data Set assessment dated [DATE] revealed no impairment in cognition.
Review of the resident's nursing notes revealed an entry dated 08/14/19 at 10:51 A.M. indicating the resident complained of pain with urination and fluids were encouraged. Continued review of the nursing notes revealed an entry dated 08/15/19 at 11:19 A.M. indicating the resident complained of burning and pain while urinating. Urine was greenish/yellow in color with foul odor noted and the physician was notified.
Review of the resident's physician's orders revealed an order dated 08/15/19 for a one time urinalysis with culture and sensitivity.
Review of the resident's laboratory results revealed a urinalysis was collected on 08/15/19. The results of the urine culture were completed on 08/17/19 at 10:46 A.M. with evidence of Escherichia coli. The facility did not receive results of the culture until 08/20/19 at 4:24 P.M. and received orders to treat the resident's UTI on 08/20/19.
Interview with the Director of Nursing (DON) on 08/21/19 at 11:08 A.M. verified there was a delay in treatment for the resident's urinary tract infection (UTI). She verified the results of the urine culture were completed on 08/17/19 and the facility did not receive results or orders to treat the UTI until 08/20/19.
Review of the facility policy titled Lab Policy, revised 04/2016, revealed each resident will have laboratory services performed as ordered by the attending physician. Procedures included to obtain order from the resident's physician, or on-call physician. Complete requisition for the lab, obtain specimen, notify the physician when results are available. Non-life threatening labs will be reported to the physician via Tiger Text, paging system or during physician visits.
2. Medical record review for Resident #54 revealed an admission date of 09/28/15. Diagnoses included Alzheimer's disease, dementia without behavioral disturbance, hypothyroidism, diabetes mellitus type two, chronic kidney disease, hyperlipidemia, cerebral infarction, osteoporosis, unspecified psychosis not due to substance or known physiological, atherosclerotic heart disease, acute gastric ulcer without hemorrhage, osteoarthritis and hypertensive heart disease.
Review of the current physician orders revealed the resident was to receive a Synthroid 50 micrograms (mcg.) daily to control hypothyroidism. In addition, there were lab orders which consisted of complete blood count (CBC), complete metabolic panel (CMP) and thyroid stimulating hormones (TSH) and lipid levels to be drawn every six months, September and March.
Further review of the medical record found labs which consisted of CBC,CMP, TSH and lipid levels which had been drawn on 08/28/18. The medical record was silent to any labs drawn in March 2019.
Interview with the Director of Nursing (DON) on 08/22/19 at 11:30 A.M. verified the labs ordered to be drawn in March 2019 were not done as ordered.
MINOR
(C)
Minor Issue - procedural, no safety impact
Abuse Prevention Policies
(Tag F0607)
Minor procedural issue · This affected most or all residents
Based on review of personnel files, staff interview and review of a facility policy, the facility failed to implement their abuse policy by ensuring reference checks were completed upon hire. This aff...
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Based on review of personnel files, staff interview and review of a facility policy, the facility failed to implement their abuse policy by ensuring reference checks were completed upon hire. This affected seven of seven newly hired personnel files reviewed. This had the potential to affect all 120 residents residing in the facility.
Findings include:
Review of the following personnel files revealed no evidence of reference checks completed prior to hire for the following staff members:
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The Director of Nursing was hired on 07/29/19
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The Administrator was hired on 03/18/19
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Registered Nurse (RN) #190 was hired on 07/10/19
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Director of Sales #191 was hired on 06/18/19
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Social Services Director #189 was hired on 05/24/19
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State Tested Nursing Aide (STNA) #191 was hired on 07/11/19
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STNA #192 was hired on 08/05/19
Interview with Staff Development Nurse #178 on 08/22/19 at 3:29 P.M. verified the facility did not have reference checks for any of the new employees. She stated the staff person who performed reference checks was no longer employed and the facility was unable to locate any reference checks.
Review of a facility policy titled Resident Abuse Policy, revised on 08/2018, revealed persons applying for employment with the facility will be screened for a history of abuse, neglect or mistreating resident to include: references from previous or current employers.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • $4,233 in fines. Lower than most Ohio facilities. Relatively clean record.
- • 37% turnover. Below Ohio's 48% average. Good staff retention means consistent care.
Concerns
- • 32 deficiencies on record, including 1 serious (caused harm) violation. Ask about corrective actions taken.
Bottom line: Mixed indicators with Trust Score of 63/100. Visit in person and ask pointed questions.
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About This Facility
What is Vancrest-Upper Valley's CMS Rating?
CMS assigns Vancrest-Upper Valley an overall rating of 4 out of 5 stars, which is considered above average nationally. Within Ohio, this rating places the facility higher than 99% of the state's 100 nursing homes. This rating reflects solid performance across the metrics CMS uses to evaluate nursing home quality.
How is Vancrest-Upper Valley Staffed?
CMS rates Vancrest-Upper Valley's staffing level at 2 out of 5 stars, which is below average compared to other nursing homes. Staff turnover is 37%, compared to the Ohio average of 46%. This relatively stable workforce can support continuity of care.
What Have Inspectors Found at Vancrest-Upper Valley?
State health inspectors documented 32 deficiencies at Vancrest-Upper Valley during 2019 to 2024. These included: 1 that caused actual resident harm, 29 with potential for harm, and 2 minor or isolated issues. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.
Who Owns and Operates Vancrest-Upper Valley?
Vancrest-Upper Valley is owned by a non-profit organization. Non-profit facilities reinvest revenue into operations rather than distributing to shareholders. The facility is operated by VANCREST HEALTH CARE CENTERS, a chain that manages multiple nursing homes. With 135 certified beds and approximately 118 residents (about 87% occupancy), it is a mid-sized facility located in TROY, Ohio.
How Does Vancrest-Upper Valley Compare to Other Ohio Nursing Homes?
Compared to the 100 nursing homes in Ohio, Vancrest-Upper Valley's overall rating (4 stars) is above the state average of 3.2, staff turnover (37%) is near the state average of 46%, and health inspection rating (3 stars) is at the national benchmark.
What Should Families Ask When Visiting Vancrest-Upper Valley?
Based on this facility's data, families visiting should ask: "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?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the below-average staffing rating.
Is Vancrest-Upper Valley Safe?
Based on CMS inspection data, Vancrest-Upper Valley 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 4-star overall rating and ranks #1 of 100 nursing homes in Ohio. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Vancrest-Upper Valley Stick Around?
Vancrest-Upper Valley has a staff turnover rate of 37%, which is about average for Ohio nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was Vancrest-Upper Valley Ever Fined?
Vancrest-Upper Valley has been fined $4,233 across 1 penalty action. This is below the Ohio average of $33,121. 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 Vancrest-Upper Valley on Any Federal Watch List?
Vancrest-Upper Valley 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.