Altercare of Cuyahoga Falls Ctr for Rehab & Nursin

Inspectors wrote2. Review of the medical record for Resident #61 revealed a date of admission of 05/07/24 with diagnoses including chronic kidney disease, anxiety disorder, and unspecified abnormalities of gait and mobility. Review of the comprehensive Minimum Data Set (MDS) 3.0 assessment, dated 02/11/25, revealed the resident had intact cognition. The resident required supervision for activities of daily living. Observations on 06/02/25 at 9:35 A.M. noted Resident #61 lying in bed on a clearly visible fitted sheet that had multiple dry stains of various colors covering 50 percent of the sheet. Resident #61 stated staff don't change the sheets that often. A interview on 06/02/25 at 9:42 A.M. with Activity Coordinator (AC) #377 in Resident #61's room revealed AC #377 observed the stained sheets and stated the sheets were unacceptable and needed to be changed immediately. [...]

Inspectors wrote4. Review of the medical record for Resident #284 revealed an admission date of 08/06/23. Resident #284 was discharged on 05/22/25. Diagnoses included peripheral vascular disease, hypertension, type two diabetes, obstructive pulmonary disease, anxiety, and acute osteomyelitis. Review of the comprehensive MDS 3.0 assessment, dated 02/21/25, revealed the resident had intact cognition. The resident was dependent for activities of daily living. Review of the Medication Administration Records (MAR) for Resident #284 revealed Resident #284 was ordered fluticasone propion-salmeterol inhaler dated 08/06/23 twice a day. Further review noted the inhaler was not available on 04/18/25, 04/20/25, 04/21/25 and 04/22/25. Interview on 06/09/25 at 1:40 P.M., the Regional Nurse Consultant (RNC) #431 provided pharmacy documentation indicating facility staff called in a refill on 04/21/25. [...]

Inspectors wroteBased on observations, interviews, record reviews, and review of facility policy, the facility failed to provide nursing staff in sufficient numbers to attain or maintain the highest practical physical, mental and psychosocial well-being of each resident. This affected eight residents (#4, #6, #12, #16, #20, #32, #70, and #241) out of 37 residents reviewed for staffing with potential to affect all residents in the facility. The facility census was 76.

Inspectors wroteBased on observation, interview, record review and review of facility policy the facility failed to ensure infection control measures were consistently implemented during care of Resident #20, Resident #235, Resident #241, Resident #32 and Resident #139. This affected five residents out of seven residents reviewed for infection control. The facility identified 18 residents (#4, #6, #7, #16, #25, #32, #33, #49, #52, #53 #57, #60, #67, #80, #238, #240, #286, #295) who were on Enhanced Barrier Precautions (EBP) and two resident's (Resident's #70 and #139) who were on Contact precautions. The facility census was 76.

Inspectors wroteBased on record review, interview, and review of Centers for Disease Control and Prevention (CDC) guidance the facility failed to ensure residents were offered, screened, educated and received pnuemococcal vaccinations as required. This affected five residents (Resident's #4, #6, #32 #49, #139) of five reviewed for vaccinations with the potential to affect all residents in the facility excluding five residents (Resident's #43, #60, #285, #293 and #294) the facility identified as not eligible for the vaccine. The facility census was 76.

Inspectors wroteBased on observation, interview, record review and review of the facility policy the facility failed to ensure Resident #9 was treated with respect and dignity. This affected one resident (Resident #9) out of three residents reviewed for abuse prevention. The facility census was 76.

Inspectors wroteBased on observation, interview, record review and review of the facility policy the facility failed to ensure an allegation of resident mistreatment by a staff member was reported to the State Agency. This affected one resident (Resident #9) of three residents reviewed for abuse prevention. The facility census was 76.

Inspectors wroteBased on review of medical record, interviews, and review of facility policy, the facility failed to ensure a member from food and nutrition services was participating in the care conferences as required. This affected one resident (#284) out of one resident reviewed for care planning. The facility census was 76.

Inspectors wroteBased on observation, interview, record review and review of the facility policy the facility failed to ensure all residents who are unable to carry out activity of daily living (ADL) received the necessary services by staff. This affected four residents (Resident's #4, #16 #20, and #65) out of five residents reviewed for ADLs. The facility census was 76.

Inspectors wroteBased on observation, interview, record review and review of the facility policy the facility failed to ensure Resident #32's care planned interventions were implemented and physician orders were followed for passive range of motion exercises. This affected one resident (Resident #32) out of three residents reviewed for restorative services. The facility census was 76.

Inspectors wroteBased on record review, interview and review of facility policy, the facility did not ensure post-fall investigations were accurate and complete to mitigate risk of future accidents for Resident #3. This affected one resident (#3) of six residents reviewed for accidents. The facility census was 76.

Inspectors wroteBased on observation, interview, record review and review of the facility policy the facility failed to provide scheduled toileting to promote continence for Resident #20 and failed to ensure Resident #4's received the appropriate care and services to prevent and treat a urinary tract infection (UTI). This affected two resident's (Resident's #4 and #20) out of three reviewed for bowel and bladder. The facility census was 76.

Inspectors wroteBased on record review, interview and review of facility policy, the facility did not ensure a significant weight loss was assessed by the dietitian for Resident #285 . This affected one resident (#285) of two residents reviewed for nutrition. The facility census was 76.

Inspectors wroteBased on observation, interview, record review and review of facility policy the facility did not ensure Resident #20 was treated for pain in accordance with physician orders and care planned interventions. Also, the facility did not ensure pain assessments were completed as ordered by the physician for Resident #3. This affected two residents (Resident #20 and #3) out of three residents reviewed for pain. The facility census was 76.

Inspectors wroteBased on record review, interview and review of facility policy, the facility failed to work collaboratively with the dialysis center to ensure person-centered care consistent with professional standards of practice was provided to Resident #26. This affected one resident (#26) out of one resident reviewed for dialysis. The facility identified one resident (Resident #26) as the only resident in the facility who was receiving dialysis. The facility census was 76.

Inspectors wroteBased on medical record review, interview, and review of facility policy, the facility did not adequately assess Resident #285 for triggers and effective interventions to prevent the risk of re-traumatization related to a diagnosis of post-traumatic stress disorder (PTSD). This affected one resident (#285) out of one resident the facility identified with a diagnosis of PTSD. The facility census was 76.

Inspectors wroteBased on record review, observation, and interview the facility failed to administer medications as ordered. This affected one (Resident #135) of five residents reviewed for medication administration. The facility census was 76.

Inspectors wroteBased on observation, interviews, record review, review of diet spreadsheets, and review of the facility document Mechanical Soft Diet, the facility failed to ensure residents on a mechanical soft diet received the appropriate diet consistency. This affected three residents (#14, #286, and #292) of three residents observed for mechanical soft diets. The facility identified eight residents (#14, #22, #29, #42, #55, #59, #286, and #292) as being on a mechanically altered diet. The facility census was 76.

Inspectors wrote3. Review of the medical record for resident #284 revealed an admission date of 03/29/25. Diagnoses included encounter for orthopedic aftercare related to the displaced fracture of the ulna (one of two bones in the forearm) and right femur (thigh bone) and fracture of lower end of right radius (one of two bones in the forearm), Alzheimer's disease, depression, age related osteoporosis, and other abnormalities of gait and mobility. Review of Resident #284's admission MDS assessment, dated 04/04/25, revealed the resident was severely impaired cognitively; exhibited inattention and disorganized thinking which was present but fluctuated; had functional limitation in range of motion on one side of the upper and lower extremity; was dependent on staff for toileting hygiene, lower body dressing, and personal hygiene; [...]

Inspectors wroteBased on observation, interview, record review, and review of the facility policy, the facility failed to ensure residents were either supervised during smoking breaks or residents signed out and left the facility premises prior to smoking independently. The facility also failed to ensure smoking materials, including cigarettes and lighters were kept in a secured area. This affected four residents (#56, #52, #57, and #46) reviewed for smoking and had the potential to affect 12 additional residents (#8, #12, #22, #28, #29, #32, #39, #44, #45, #49, #54, and #65) who were smokers residing at the facility. The facility census was 68.

Inspectors wroteBased on observation, interview, record review, and review of the facility policy, the facility failed to provide thorough incontinence care for Resident #45. This affected one resident (#45) of one resident observed for incontinence care. The facility census was 68.

Inspectors wroteBased on observation and interview with staff the facility failed to ensure soiled linens were not placed directly on the floor in the room of Resident #25 and #50. This affected two residents ( Resident #25 and #50) of three reviewed for a safe, clean environment. The facility census was 69.

Inspectors wroteBased on observation, review of the medical record, review of the facility policy and interview with the staff the facility failed to ensure aerosol masks were stored in a sanitary protective barrier while not in use for Resident #25 and #50. This affected two residents ( Resident #25 and #50) of three reviewed for respiratory care. The facility census was 69.

Inspectors wroteBased on observation, review of the medical record and interview with staff the facility failed to maintain a medication error rate of less than five percent. Ten errors occurred within 31 opportunities for error resulting in a medication error rate of 32.2 %. This affected one resident (Resident #5) of four reviewed for medication administration. The facility census was 69. Fining included: Review of the medical record revealed Resident #5 was admitted to the facility on [DATE]. Diagnoses included convulsions, encephalopathy, clostridium difficile, temporo-parietal lesion, cognitive communication deficit, dysphagia, cerebral infarction, anemia, hypertension, embolism and thrombosis of the deep veins of the right upper extremity, asthma, aphasia, dysphagia, osteoarthritis, gastrostomy, alcohol abuse and intracerebral hemorrhage. [...]

Inspectors wroteBased on observations, review of the medical record, review of the facility policy and interview with staff the facility failed to administer medication as ordered for Resident #5. This affected one resident (Resident #5) of four residents observed for medication administration. The facility census was 69.

Inspectors wroteBased on observation, record review, interviews, photographic evidence and review of policy and procedures, the facility failed to ensure correct medications were provided upon discharge. This affected one (#272) of six residents(#273, #274, #275, #276 and #277) reviewed for discharge planning.

Inspectors wroteBased on interview and record review the facility failed to provide a quarterly care conference for two (Resident #14 and #158) of two residents reviewed. The facility census was 52.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide nail care for two dependent residents (Resident #32 and #158) and failed to provide shaving for one resident (Resident #158). This affected two (Residents #32 and #158) of five residents reviewed for activities of daily living (ADL) care. The facility census was 52.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide wound care for two residents (Resident #158 and #5) of two residents reviewed for non-pressure wounds. The facility census was 52.

Inspectors wroteBased on observation, review of the medical record, and staff interview the facility failed to ensure Residents #27 and #44 had their physician's ordered adaptive devices for eating. This affected two residents (Residents #27 and #44) of 11 residents reviewed for nutrition. The facility census was 52.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure resident foods were stored in a safe and sanitary manner. These practices had the potential to affect the 58 residents receiving food from the kitchen. The facility identified Resident #1, Resident #8 and Resident #26 as receiving nothing by mouth. The facility census was 61 residents.

Inspectors wroteBased on observation, interviews and review of the facility policy and procedure for medication administration, the facility did not ensure medications were properly secured on the D hall during medication preparation for Resident #26. This had the potential to affect the seven residents in the dining room, Resident #22, #29, #33, #37, #41, #43 and #46. The census was 61 residents.

Inspectors wroteBased on observation, record review and interview the facility failed to provide dignified care for Resident #22 who had an indwelling urinary catheter. This affected one of one resident reviewed for dignity. The facility census was 61.