Wesleyan Village

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide a clean and homelike environment for Resident #11, who was admitted with multiple diagnoses including type II diabetes mellitus, heart failure, and depression. The resident, who was cognitively intact and required supervision for transfers and walking, reported that her bed linens had not been washed for approximately one month. She also mentioned that the fitted sheet on her bed had been coming off the corner for a while, and she was unable to fix it herself. Despite having extra sheets available, the resident's bed linens remained unchanged. Observations confirmed the resident's account, revealing a light purple fitted sheet that was off the top-left corner of the bed, with numerous brownish-red smears identified as dried blood stains from the resident picking at her skin. These conditions were visible from the hallway. Interviews with a CNA revealed there was no set schedule for changing bed linens, and the CNA was unaware of the resident having her own sheets. The CNA verified the condition of the sheets and offered to change them after confirming with the resident that they had been dirty for a while.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to assist residents in obtaining routine dental care, specifically affecting Resident #68. This resident was admitted with diagnoses including type II diabetes mellitus, depression, anxiety, hypertension, and peripheral vascular disease. Despite being cognitively intact and having a physician's order allowing for dental consultation as needed, there was no evidence in the medical record that Resident #68 was ever offered or received routine dental services during their stay at the facility. Interviews and observations further highlighted the deficiency. Another resident, identified as Resident #11, reported needing dentures due to rotting teeth and stated that no one at the facility had inquired about dental services. The Regional Director of Clinical Services confirmed that a dentist visited the facility quarterly and that residents were screened for dental services upon admission. However, the facility could not locate Resident #68's admission documents to verify if dental services were offered, confirming the lack of routine dental care for this resident.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a resident received a timely evaluation by therapy services for a motorized wheelchair. The resident, who was admitted with diagnoses including type II diabetes mellitus, depression, anxiety, hypertension, and peripheral vascular disease, was cognitively intact and dependent on staff assistance for activities of daily living. Despite expressing interest in a motorized wheelchair and having a new order for a therapy consultation on two separate occasions, there was no evidence that the resident was ever evaluated by therapy for this need. Interviews with the resident and facility staff confirmed the lack of evaluation. The resident reported requesting a motorized wheelchair multiple times without receiving an evaluation or the wheelchair itself. Observations confirmed the absence of a wheelchair in the resident's room. Both the Director of Therapy Services and the Regional Director of Clinical Services verified the existence of the order for a therapy evaluation and acknowledged that the evaluation had not been conducted.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide sufficient staffing to meet the care needs of all residents, directly affecting three residents and potentially impacting additional residents on the fourth floor. Resident #4, who was cognitively intact and had multiple diagnoses including type II diabetes mellitus and chronic kidney disease, did not have blood glucose levels documented before meals on two occasions and did not have weights obtained as per physician orders. Interviews with staff confirmed that these omissions were due to insufficient staffing, which also led to delays in obtaining resident weights. Resident #15, who was at risk for malnutrition, did not have weekly weights obtained as recommended by the dietitian. The facility's policy required weekly weights to be completed on a designated day each week, but this was not adhered to due to staffing shortages. Interviews with staff verified that weights were often not obtained because staff prioritized more immediate resident needs. Resident #16, who had chronic pain and required assistance with personal care, did not receive medications as ordered on several occasions. The MAR revealed that pain medications and topical treatments were not administered as prescribed due to timing constraints caused by insufficient staffing. Interviews with staff confirmed that medications were not administered within the prescribed timeframes, and the facility's policy on administering medications in a timely manner was not followed.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that resident weights were obtained and monitored according to physician orders, dietitian recommendations, and the plan of care. This deficiency affected two residents. Resident #4, who was cognitively intact, had a physician order for weekly weights for four weeks and then monthly, due to being at nutritional risk related to diagnoses, recent surgery, and therapeutic diet restrictions. However, the resident's weight was not obtained from 10/20/24 until 12/04/24, which was confirmed by both an LPN and the Regional Director of Clinical Operations. Resident #15, who was cognitively impaired, had a plan of care that included monitoring for signs of malnutrition and maintaining weight with no significant changes. A dietitian recommended weekly weights for four weeks, but the resident's weight was not obtained between 07/10/24 and 08/20/24. This was also verified by the Regional Director of Clinical Operations. The facility's policy required monthly weights by the tenth of each month and weekly weights on a designated day, which was not adhered to, leading to this deficiency.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to administer medications in accordance with physician orders for two residents. Resident #6, who had diagnoses including type II diabetes mellitus and heart failure, was prescribed Olopatadine solution for dry eyes. However, the medication administration record (MAR) showed that the eye drops were not administered on multiple occasions. An interview with the Regional Director of Clinical Operations confirmed that the staff likely could not locate the eye drops, resulting in the medication not being given as ordered. Resident #16, diagnosed with conditions such as rheumatoid arthritis and chronic pain syndrome, was prescribed Lac-hydrin lotion to be applied to the soles of the feet every morning and at bedtime. The MAR for October 2024 indicated that the lotion was not administered on several mornings. An interview with the resident revealed that they sometimes did not receive their medications, including the lotion. A Licensed Practical Nurse confirmed the lotion was not applied as ordered. The facility's policy on administering medications requires that they be given in a safe and timely manner, as prescribed, which was not adhered to in these cases.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to adequately monitor blood glucose levels for a resident receiving sliding scale insulin, as ordered by the physician. The resident, who was admitted with diagnoses including type II diabetes mellitus, muscle weakness, and chronic kidney disease, had a physician's order for insulin lispro to be administered before meals based on blood glucose levels. However, the medical record review revealed that blood glucose levels were not documented before the lunch meal on two specific dates in October 2024, which meant that the appropriate insulin dosage could not be determined or administered. An interview with an LPN confirmed that the blood glucose levels were not obtained on the specified dates, leading to uncertainty about the insulin dosage required. This deficiency was identified during an investigation under a specific complaint number, indicating non-compliance with the requirement to ensure each resident's drug regimen is free from unnecessary drugs.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that residents were free from significant medication errors, specifically affecting one resident. This resident, who was cognitively intact, had a medical history that included rheumatoid arthritis, chronic pain syndrome, and heart failure. The resident was prescribed gabapentin and Ultram for pain management. However, the medication administration record for October 2024 showed that the morning doses of these medications were not documented as administered on two separate occasions. The nursing progress notes indicated that the medications were not given due to timing and time constraints. Interviews with the resident and a Licensed Practical Nurse confirmed that the medications were not administered as ordered on the specified dates. The facility's policy on administering medications, which was revised in December 2012, required that medications be administered in a safe and timely manner, as prescribed. The failure to administer the medications as ordered was a violation of this policy and was investigated under a specific complaint number.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide adequate bathing as scheduled for three residents, affecting their activities of daily living. Resident #212, who was severely cognitively impaired and required substantial assistance, was scheduled for showers twice a week but only received eight out of the 25 scheduled showers over a nearly three-month period. The resident was hospitalized on one occasion, which may have impacted the schedule. Resident #277, who was cognitively intact but required substantial assistance, was scheduled for showers twice a week but only received 12 out of the 25 scheduled showers. Resident #300, who was dependent on assistance for bathing, was scheduled for 18 showers but only received one and refused another. The deficiency was confirmed through interviews with the Regional Director of Clinical Services, the Administrator, the Director of Nursing, and the Regional Director of Operations, who acknowledged the failure to provide adequate bathing as scheduled. The lack of documentation further supported the finding that these residents did not receive the necessary care. This issue was investigated under Complaint Number OH00156525, highlighting a significant lapse in the facility's adherence to scheduled care routines for residents requiring assistance with personal hygiene.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide adequate supervision to prevent the elopement of a resident who was assessed and care planned for elopement risk. The resident, who had diagnoses including Alzheimer's dementia and was assessed as severely cognitively impaired, was independently ambulatory and had been identified as a high risk for elopement. Despite these assessments, the resident was able to elope from their room onto the facility's roof by using a spoon to remove the window screen and pushing the window open. The incident was discovered when staff observed the resident on the roof and promptly intervened to bring the resident back inside without incident. Interviews with staff revealed that the resident was on the roof for less than five minutes and was found sitting against a wall in a corner of the roof area. The window from which the resident exited led to a flat roof covered in rocks, and the resident was found on a part of the roof with a parapet wall. This deficiency was investigated under a specific complaint number.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to protect a resident from staff-to-resident physical and verbal abuse, resulting in Immediate Jeopardy. On the evening of May 19, 2024, a Registered Nurse (RN) was observed by two State Tested Nursing Assistants (STNAs) swearing and yelling at a cognitively impaired resident in the memory care unit. The RN removed the resident from the dining room, took her to her room, and slammed the door. The RN remained alone with the resident for approximately 10 to 15 minutes, during which time the STNAs heard the resident crying louder. After the RN exited the room, the resident was found crying with blood spots on her Geri sleeves and a bruise on her hand. A total of nine wounds were later confirmed by a Wound Care Certified Nurse Practitioner. The facility did not take immediate action to protect the resident or investigate the incident thoroughly. Despite the severity of the situation, the RN was allowed to return to work with the resident unsupervised on May 27, 2024. Interviews with staff revealed that the RN had previously expressed frustration with the resident and had been reported for using profanity towards her. The facility's failure to recognize and appropriately respond to the abuse allegation resulted in the resident experiencing severe psychosocial harm. The resident involved had a history of neurocognitive disorder with Lewy Bodies, Parkinson's disease, dementia, anxiety disorder, and Pseudobulbar affect, which made her severely cognitively impaired. She required assistance with activities of daily living and used a wheelchair for mobility. Prior to the incident, there were no documented skin tears or bruises on the resident. The facility's lack of effective interventions and failure to conduct a thorough investigation contributed to the deficiency.

Removal Plan

• RN #521 notified Resident #19's daughter/Power of Attorney (POA) of new skin tears and bruising to the resident's arms.
• RN #521 notified Assistant Director of Nursing (ADON) #522 Resident #19 had skin tears and bruising to bilateral arms.
• ADON #522 notified the Administrator of the skin tears and bilateral bruising to the arms on Resident #19.
• The Administrator notified RDCS #510 of Resident #19's skin tears and bilateral bruising to the arms.
• The Administrator notified RDO #503 of Resident #19's injuries.
• The Administrator opened an SRI for an injury of unknown origin.
• The Administrator interviewed RN #521, via phone, regarding Resident #19's injuries.
• RN #521 notified CNP #524 of Resident #19's new skin tears and bilateral bruising to arms. New orders were obtained for bilateral x-rays of hands and arms.
• The Director of Nursing (DON) interviewed RN #500, via phone, due to staff report of RN #500 feeling frustrated with Resident #19 on the night of the incident. RN #500 was suspended pending the outcome of the investigation.
• Assistant Administrator (AA) #523 interviewed 12 random staff regarding witnessing abuse or reporting abuse, with no findings.
• ADON #522 initiated Residents Rights and Abuse Inservice for all staff.
• Resident #19 was seen by CNP #524. New orders were received for oxycodone for pain from skin tears and bruising and Keflex (antibiotic) for prevention of infection from skin tears.
• CNP #524 ordered Resident #19's assist rails be removed from the resident's bed to reduce risk of injury.
• Laboratory (lab) orders, which included a Complete Blood Count (CBC) with differential, was completed for Resident #19.
• Resident #19's lab results were received and reported to the physician. No new orders were received.
• The Administrator and DON re-interviewed RN #500. No additional information was obtained.
• An x-ray was completed for Resident #19's bilateral arms and hands.
• Resident #19 was evaluated by WCCNP #502 for skin tears to bilateral arms.
• ADON #522 interviewed alert residents on the memory care unit regarding abuse reporting, witnessing abuse and ensured residents felt safe with no negative findings.
• ADON #522 completed skin assessments of all residents on the memory care unit with no negative findings.
• Resident #19 was evaluated by Medical Director (MD) #750. No bruising was noted to the resident's face at the time of the examination. A new order was received for referral to hematology.
• X-ray results of bilateral arms and hands received for Resident #19 with no fractures identified.
• The SRI for injury of unknown origin was closed with an unsubstantiated finding.
• The DON informed RN #500 Resident #19's family requested, due to the incident, she no longer work with the resident. RN #500 was offered the option to work on another unit.
• Resident #19 was seen by psychiatric services, Psychiatric CNP (PCNP) #700, with no negative findings.
• Resident #19 was evaluated by hematology and no new orders were received.
• The Administrator, RDCS #510 and RDO #503 interviewed MD #750 regarding potential causes of Resident #19's injuries.
• The Administrator, RDCS #510 and RDO #503 completed a root cause analysis and determined a thorough investigation was not completed related to the incident involving RN #500 and Resident #19 and abuse likely occurred.
• An Ad Hoc Quality Assurance and Performance Improvement (QAPI) meeting was held by the Administrator to review the Immediate Jeopardy findings and reviewed prevention of resident abuse and facility policies related to prevention, identification and investigation of allegations of resident abuse.
• RDO #503 and RDCS #510 re-educated all department heads, including the Administrator and DON, on the facility's abuse policy and prevention, reporting and investigation of allegations of abuse.
• The Administrator filed a report with the Ohio Board of Nursing related to suspected resident abuse involving RN #500.
• The Administrator filed a police report with the local police department related to suspected staff-to-resident abuse.
• Department heads re-educated all staff on the facility's Abuse Policy, Abuse Prevention Policy and Abuse Investigation Policy.
• AA #523 completed interviews with all staff who worked on specific dates.
• RDCS #510, RDO #503 and the Administrator interviewed WCCNP #502 regarding Resident #19's injuries.
• The DON and ADON #522 completed skin audits on all residents.
• The Administrator will review all potential SRIs with VPO #640 and VPCS #641 to ensure the appropriate SRI category is filed and thoroughly investigated.
• The Administrator, or designee will ensure written staff statements are validated for authenticity by reviewing the statement with the reporting staff.
• VPO #640 and VPCS #641 will audit each initial SRI prior to submission to ensure the facility files incidents under the correct investigation category for four weeks.
• RDO #503, RDCS #510 or designee will audit every SRI submitted for four weeks, then as needed, to ensure a thorough investigation was completed.
• The Administrator or designee will conduct 10 random resident interviews with alert residents to ensure residents are free from abuse for four weeks, then as needed.
• The DON or designee will conduct 10 random skin assessments weekly for four weeks, then monthly thereafter, on non-interviewable residents to ensure residents are free from abuse.
• SSD #535 will meet with Resident #19 three times weekly for four weeks to assess psychosocial well-being and provide additional support.
• Results of audits will be reviewed at the QAPI meeting weekly for four weeks, then monthly thereafter to determine on-going compliance.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure an allegation of staff-to-resident abuse was accurately reported and thoroughly investigated, resulting in Immediate Jeopardy. On the night of the incident, two State tested Nursing Assistants (STNAs) alleged verbal and physical abuse of a resident by a Registered Nurse (RN). The resident sustained nine separate wounds, including skin tears and bruising, as a result of the incident. The facility did not accurately file a Self-Reported Incident (SRI), failed to interview staff witnesses and medical providers regarding the potential cause of the resident's injuries, and did not validate staff witness statements. The facility also failed to file a police report and notify the Ohio Board of Nursing of the suspected staff-to-resident abuse. Despite the allegations, the facility allowed the RN to return to work with the resident unsupervised. The facility's investigation was inadequate, as it did not include interviews with the only two staff witnesses present during the incident, nor did it involve the Wound Care Certified Nurse Practitioner or the Medical Director, who could have provided insights into the resident's injuries. The resident involved had a history of neurocognitive disorder with Lewy Bodies, Parkinson's disease, dementia, anxiety disorder, and Pseudobulbar affect, which made her severely cognitively impaired. Prior to the incident, the resident had no documented skin tears or bruises. The facility's failure to conduct a thorough investigation and take immediate protective actions for the resident led to the deficiency being identified.

Removal Plan

• The Administrator opened an SRI for an injury of unknown origin.
• The Administrator interviewed RN #521, via phone, regarding Resident #19's injuries.
• RN #521 notified Certified Nurse Practitioner (CNP) #524 of Resident #19's new skin tears and bilateral bruising to her arms.
• The DON interviewed RN #500, via phone, due to staff report of RN #500 feeling frustrated with Resident #19 on the night of the incident.
• Assistant Administrator (AA) #523 interviewed 12 random staff regarding witnessing abuse or reporting abuse, with no findings.
• Assistant Director of Nursing (ADON) #522 initiated Residents Rights and Abuse Inservice for all staff.
• The Administrator and DON re-interviewed RN #500.
• ADON #522 interviewed alert residents on the memory care unit regarding abuse reporting, witnessing abuse and ensured residents felt safe, with no negative findings.
• ADON #522 completed skin assessments on all residents on the memory care unit with no negative findings.
• An SRI for injury of unknown origin was closed with an unsubstantiated finding.
• RN #500 was informed by the DON that Resident #19's family requested she no longer work with the resident.
• The Administrator, RDCS #510 and RDO #503 interviewed MD #750 regarding potential causes of Resident #19's injuries.
• The Administrator, RDCS #510 and RDO #503 completed a root cause analysis.
• An Ad Hoc Quality Assurance and Performance Improvement (QAPI) meeting was held by the Administrator.
• RDO #503 and RDCS #510 re-educated all department heads on the facility's abuse policy.
• The Administrator filed a report with the Ohio Board of Nursing.
• The Administrator filed a police report with the local police department.
• Department heads re-educated all staff on the facility's Abuse Policy.
• AA #523 completed interviews with all staff who worked on 05/17/24, 05/18/24 and 05/19/24.
• RDCS #510, RDO #503 and the Administrator interviewed Wound Care Certified Nurse Practitioner (WCCNP) #502.
• The DON and ADON #522 completed skin audits on all residents.
• The Administrator will review all potential SRIs with VPO #640 and VPCS #641.
• The Administrator, or designee will ensure written staff statements are validated for authenticity.
• VPO #640 and VPCS #641 will audit each initial SRI prior to submission.
• RDO #503, RDCS #510 or designee will audit every SRI submitted for four weeks.
• The Administrator or designee will conduct 10 random resident interviews with alert residents.
• The DON or designee will conduct 10 random skin assessments weekly for four weeks.
• Results of audits will be reviewed at the weekly QAPI meeting for four weeks then monthly thereafter.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide necessary care and services to prevent and treat pressure ulcers for several residents, leading to severe consequences. Resident #91, who was at risk for pressure ulcer development, did not receive appropriate interventions such as turning, repositioning, and incontinence care. The facility also failed to conduct timely and accurate skin assessments, resulting in the development and worsening of a pressure ulcer. This resident was eventually transferred to the hospital due to a fall and weakness secondary to E. coli bacteremia from an infected pressure ulcer and subsequently died from E. coli sepsis. Resident #34, who was also at risk for pressure ulcer development, did not receive weekly assessments of a stage three pressure ulcer, and physician-ordered treatments were not completed as ordered. This resident was admitted to the hospital with septic shock in the setting of a coccygeal wound. The facility's failure to provide consistent wound care and incontinence care contributed to the worsening of the resident's condition. Additionally, the facility failed to provide adequate care for another resident, Resident #40, who was at risk for pressure ulcers. The facility did not ensure proper interventions were in place to prevent, identify, and treat pressure ulcers, affecting multiple residents. The lack of appropriate care and documentation led to significant harm and potential for further harm to the residents involved.

Removal Plan

• RMDSC #914 and MDSC #915 completed an assessment of all resident care plans to ensure they were updated with appropriate interventions to prevent and treat pressure ulcers.
• LPN #916, LPN #917 and ADON #522 completed a skin assessment on all residents.
• A Root Cause Analysis was completed by RDCS #510, RDO #503 and the Administrator. It was determined the Root Cause was the DON and ADON #522 did not ensure preventative interventions and necessary care and treatments were in place to prevent, promote healing and/or worsening of Resident #91's wound.
• RDCS #510 re-educated ADON #522 on the facility's Wound Care policy, Prevention of Pressure Ulcers/Injuries, and New Admission/Re-Admission Skin and Wound Care Best Practices Policy. RDCS #510 will provide the education to the DON prior to returning to work.
• RDCS #510 provided in-service education for all licensed nurses, in person and via telephone, on the facility's Wound Care Policy, Prevention of Pressure Ulcers/Injuries, and New Admission/Re-Admission Skin and Wound Care Best Practices Policy.
• An AD Hoc QAPI meeting was held by the Administrator, with MD #750, to review the Immediate Jeopardy findings, discuss ensuring necessary care and treatments are in place to prevent and promote healing and/or worsening of wounds, and review facility polices related to prevention, identification, and investigation.
• RDCS #510 provided wound care education, including policies and procedures, in person and via telephone, for STNA.
• RDCS #510 completed a Braden Scale audit for all residents.
• The DON or designee will audit all new admissions to ensure skin prevention/treatment orders are in place, Braden Scale orders are in place and skin prevention and wound care interventions appropriately care planned. The audits will be completed within 48 hours of admission.
• The DON or designee will audit all weekly skin assessments to ensure all assessments are completed accurately and any identified areas of concern are timely assessed and treated.
• The DON or designee will visually validate all wound treatments are completed as ordered and audit the TAR to ensure all treatments have been signed off on the TAR.
• The DON or designee will audit all residents with wounds to ensure weekly wound assessments are completed, monitor for wound progress and ensure treatment orders and appropriate care plan interventions are in place for each wound.
• The DON or designee will audit seven incontinent residents daily to ensure incontinent residents were checked and changed and incontinence care provided.
• The QAPI committee will meet to review all audit findings to ensure continued compliance.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide physician-ordered treatments for a resident's surgical wound, leading to significant harm. Upon admission, the resident's abdominal surgical wound was not assessed until five days later, revealing 60% slough and 40% granulation. The prescribed treatments, including the application of Santyl and wet-to-dry dressings, were not administered as ordered, resulting in an infection that required hospitalization, intravenous antibiotics, and a wound vacuum for healing. Upon the resident's readmission to the facility, the wound vacuum was not initiated for three days, and subsequent dressing changes were not performed as ordered. The Treatment Administration Record (TAR) showed no evidence of wound care being completed on several occasions. The resident's wound care orders were not correctly entered into the electronic medical record, preventing nurses from seeing and completing the orders. This oversight led to the wound vac not being changed as needed, contributing to excoriation and worsening of the wound. Interviews with staff confirmed the lapses in care, with the Assistant Director of Nursing acknowledging the failure to place wound vac orders in the TAR. The Wound Care Certified Nurse Practitioner noted that the lack of proper treatment could have worsened the wound, despite some improvement in the wound's external appearance. The facility's policy on wound care, which includes verifying physician orders, was not followed, resulting in non-compliance and harm to the resident.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide timely incontinence care for several residents, resulting in actual psychosocial harm. Resident #40, who was moderately cognitively impaired and dependent on staff for toileting and personal hygiene, was found sitting in a wheelchair with a strong odor of urine and stool. Her gown, blanket, and wheelchair cushion were saturated with urine, and she had not received incontinence care for over five hours. The resident expressed distress over the situation, and staff confirmed that due to understaffing, they were unable to provide care more frequently. Similarly, Resident #62, who was also moderately cognitively impaired and dependent on staff for personal hygiene, reported waiting up to 45 minutes for incontinence care. Observations revealed that the resident's bed pads were wet with urine, and care had not been provided for over four hours. Staff acknowledged the lack of time to attend to all residents as needed, resulting in infrequent incontinence care. Additionally, the facility failed to provide appropriate catheter care for Resident #98, who was admitted with a Foley catheter but without a relevant diagnosis or care plan. The resident did not receive catheter care for five days after admission, and there was no documentation of catheter output. The DON confirmed the absence of a care plan and physician orders for catheter care, which should have been established upon admission. This lack of care and monitoring was contrary to the facility's policy aimed at preventing catheter-associated urinary tract infections.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure sufficient staffing to meet the individualized needs of residents, affecting three specific residents and potentially impacting the remaining 83 residents. The deficiency was identified through observations, interviews, and record reviews, revealing that residents were not receiving timely incontinence care. For instance, Resident #62, who was moderately cognitively impaired and dependent on staff for transfers and toileting, frequently had to wait long periods for incontinence care, resulting in her lying in a wet brief for extended periods. Resident #40, also moderately cognitively impaired and dependent on staff for personal hygiene and mobility, was observed sitting in a wheelchair with a strong odor of urine. She reported not receiving incontinence care that day, and her assigned STNA confirmed this was due to being busy with other residents. The STNA admitted that residents were often changed only once or twice during an eight-hour shift due to insufficient staffing. Resident #34, who was cognitively intact but dependent on staff for mobility and personal care, expressed frustration over not being able to get out of bed when desired. She had not received incontinence care since early morning, and when care was finally provided, it was noted that she had a large bowel movement with partially dried stool on her skin. Interviews with staff, including the DON and Administrator, confirmed ongoing staffing challenges, with staff expressing difficulty in completing tasks timely even when the facility was fully staffed.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to accurately assess and identify the necessary competent nursing staff resources to meet the individualized needs of residents, particularly those with high acuity. This deficiency affected three residents who required substantial assistance with personal hygiene and incontinence care. Observations and interviews revealed that residents were not receiving timely incontinence care, with some waiting several hours for assistance. Staff members, including State Tested Nursing Assistants (STNAs) and Licensed Practical Nurses (LPNs), confirmed that they struggled to meet residents' basic needs due to insufficient staffing levels. Resident #62, who was dependent on staff for transfers and toileting, frequently experienced delays in receiving incontinence care. Interviews with the resident and staff indicated that the resident often had to wait a long time for assistance, resulting in discomfort and prolonged exposure to wet briefs. Similarly, Resident #40, who was dependent on staff for toileting and personal hygiene, was found saturated with urine and had not received incontinence care for several hours. The resident expressed frustration over the lack of timely care, and staff confirmed that they were unable to provide adequate assistance due to being overwhelmed with other duties. Resident #34, who was always incontinent of bowel and bladder, also experienced significant delays in receiving care. The resident reported wanting to get out of bed but was often told by staff that they did not have time to assist. Observations confirmed that the resident had dried stool on their skin, indicating a lack of timely incontinence care. Interviews with staff and the Director of Nursing (DON) revealed that the facility was fully staffed according to their assessment, but the staffing levels did not adequately reflect the residents' acuity and care needs. The Administrator acknowledged staff concerns about insufficient staffing but did not provide a resolution.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain a safe and homelike environment for its residents, as evidenced by the conditions in Resident #67's room and bathroom. The resident, who has hemiplegia and hemiparesis following a cerebral infarction and is moderately cognitively impaired, reported that the windows in her room were inoperable due to a broken handle and a piece of wood covering one pane. This prevented her from opening the windows to get fresh air. Additionally, the toilet handle in her bathroom was broken, creating sharp edges that posed a risk of injury, and the light fixture above the bathroom mirror was malfunctioning, taking a long time to turn on and blinking continuously. These issues had been present since the resident's admission, and the housekeeper confirmed that maintenance was aware of the problems but had not addressed them, despite the facility having two maintenance staff members at the time of the survey. The facility also failed to ensure that common areas accessible to residents were free from mold. In the men's bathroom located in the main lobby, a large portion of wallpaper was separated at the seam, exposing a black mold-like substance on the wallpaper and drywall. Additionally, a black mold-like substance was observed covering the lower corner molding behind the toilet. The Maintenance Director and another maintenance staff member confirmed the presence of mold in the bathroom, which was used by both residents and visitors. This deficiency was investigated under multiple complaint numbers, indicating ongoing issues with the facility's maintenance and environmental safety.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide routine dressing changes to a central line for a resident, leading to a deficiency in care. Resident #62, who was moderately cognitively impaired and had multiple health issues including type two diabetes mellitus and an acquired absence of the right lower leg, had a central line inserted for the administration of IV antibiotics. Despite the presence of a central line, there was no care plan initiated for its maintenance. The physician orders for dressing changes and needleless device changes were discontinued and not reinstated after the resident's return from the hospital, resulting in the dressing not being changed since 05/12/24. Observations revealed that the dressing on the central line was lifted, exposing the insertion site, and the dressing was dated 05/12/24. Interviews with the RN and DON confirmed that the dressing had not been changed as required, and there were no active orders for the care of the central line from 01/14/24 until 06/04/24. The facility's policy required dressing changes every five to seven days or as needed, but this was not followed. The ADON acknowledged the oversight as a nursing error, as the orders were not in the system to ensure timely dressing changes.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure an incident of alleged resident-to-resident physical abuse was reported. Resident #99, who had a history of delusional disorder and moderately impaired cognition, was involved in an aggressive incident with Resident #101. Resident #99 exhibited aggressive behavior, including hitting and grabbing another resident, and attempted to bite a nurse. The incident was severe enough to require police intervention and Resident #99's transfer to a hospital. Despite the severity of the incident, it was not reported to the Director of Nursing (DON) or the Ohio Department of Health, nor was it investigated as required by the facility's policy. Resident #101, who had severe cognitive impairment and was receiving hospice services, was the victim of the aggression. There was no documentation in Resident #101's medical record indicating that he had been assessed for injuries following the incident. Interviews with staff revealed that the incident was known but not reported to the appropriate authorities. The facility's policy mandates immediate reporting and investigation of such incidents, but this protocol was not followed in this case.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to investigate an alleged incident of resident-to-resident physical abuse involving Resident #99 and Resident #101. Resident #99, who had a history of delusional disorder and moderately impaired cognition, was noted to have aggressive behaviors and was transferred to a hospital following the incident. The incident was documented in Resident #99's progress notes, but the Director of Nursing (DON) and Regional Director of Clinical Services (RDCS) were not aware of it, and it was not reported to the Ohio Department of Health as required by the facility's policy. Additionally, there was no evidence that Resident #101, who had severely impaired cognition and was receiving hospice services, was assessed for injuries following the incident. The incident occurred when Resident #99 aggressively grabbed Resident #101's shoulder and attempted to flip him out of his wheelchair, causing his feet to be in the air. This aggressive behavior led to the involvement of the local police and the transfer of Resident #99 to the hospital. Despite the severity of the incident, it was not reported or investigated by the facility, as the DON was not notified and missed the documentation in the progress notes. The facility's policy mandates immediate reporting and investigation of all alleged violations involving abuse, but this protocol was not followed in this case.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that resident showers were completed as planned, affecting three residents. Resident #05, with diagnoses including Alzheimer's disease, anxiety, depression, and anemia, was supposed to receive showers twice weekly but only received them on three occasions within a month. Resident #05 confirmed that she rarely received the scheduled showers. Similarly, Resident #44, who has muscular dystrophy, morbid obesity, bed confinement status, and depression, was supposed to receive showers twice weekly but only received them on three occasions within the same period. Resident #44 also confirmed that she rarely received the scheduled bed baths and linen changes. Resident #56, with diagnoses including congestive heart failure, morbid obesity, type II diabetes mellitus, and chronic obstructive pulmonary disease, was also supposed to receive showers twice weekly but only received them twice within the month. Resident #56 could not recall the last time she had a shower and confirmed that it was not recent. Interviews with the Director of Nursing (DON) and the Regional Director of Clinical Services (RCDS) revealed that the facility's shower records did not reflect the scheduled showers for the three residents. The DON was unable to locate the missing shower sheets, and the RCDS confirmed that there was no additional documentation to prove that the showers had been completed as planned. This deficiency was investigated under Master Complaint Number OH00152961.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a resident with specific dietary restrictions was served meals in accordance with her physician-ordered diet. The resident, who had end-stage renal disease, type II diabetes mellitus, and was lactose intolerant, was hospitalized due to persistent vomiting and diarrhea after consuming ranch dressing, which contained dairy. Despite clear dietary instructions, the resident continued to receive inappropriate food items, including cheese ravioli, potato soup, and a banana, which were against her dietary restrictions. The resident expressed frustration over repeatedly receiving food that made her ill or going hungry. An interview with the Dietary Manager confirmed that the meal provided did not meet the resident's dietary and allergy restrictions, despite the correct tray ticket being present. The Dietary Manager acknowledged that the staff likely did not read or understand the tray ticket. The facility's policy on therapeutic diets emphasized that diets should be modified according to the resident's medical needs and preferences, as ordered by the attending physician. This deficiency was investigated under Complaint Number OH00152235.