Altercare of Mayfield Village, Inc

Inspectors wroteBased on medical record review, observation, interview, review of the Centers for Disease Control guidelines and facility policy review, the facility failed to ensure hand hygiene, enhanced barrier precautions (EBP) and contact isolation precautions were implemented and maintained. This affected four residents (Residents #4, #14, #20 and #32) of six residents reviewed for infection control. The facility census was 43.

Inspectors wroteBased on medical record review, interview, and facility policy preview, the facility failed to accurately identify and adequately treat a pressure wound. This affected one resident (Resident #36) of four residents reviewed for pressure injuries. The facility census was 43.

Inspectors wroteBased on closed medical record review, review of 911 communications, review of the American Heart Association (AHA) guidance for adult Cardiopulmonary Resuscitation (CPR), review of Ohio Revised Code related to pronouncement of death, facility policy review, and interview, the facility failed to ensure Resident #46, who had a Full Code status, received appropriate and timely emergency response (including CPR) consistent with the resident's advance directives, facility policy, professional standards of practice, and physician expectations. This resulted in Immediate Jeopardy and Actual Harm with subsequent death on [DATE] at 7:20 A.M. [...]

Inspectors wroteBased on medical record review, staff interview, resident interview, and facility procedure review, the facility failed to ensure medications were ordered and available in a timely manner for newly admitted residents. This affected one (Resident #41) of three residents reviewed for timely medication administration. The census was 42. Findings Include: Review of the medical record for Resident #41 revealed she was admitted to the facility on [DATE]. Her diagnoses were chronic kidney disease (stage IV), spinal stenosis, weakness, need for assistance with personal care, difficulty walking, obstructive and reflux uropathy, schizophrenia, spondylosis, migraine, schizoaffective disorder, and major depressive disorder. Review of Resident #41's progress note dated 12/11/24 revealed she was admitted to the facility on [DATE] at approximately 8:14 P.M. [...]

Inspectors wroteBased on observation, interview, record review and review of the facility policy, the facility failed to ensure Resident #30 had a comprehensive care plan regarding interventions to maintain her peripherally inserted central catheter (PICC) (a catheter inserted through the arm vein and passed through to larger veins near the heart) line and monitor her intravenous (IV) antibiotics. This affected one resident (#30) out of three residents reviewed for care plans. The facility census was 41.

Inspectors wroteBased on observation, interview, record review and review of the facility policy, the facility failed to ensure Resident #30's peripherally inserted central catheter (PICC) (a catheter inserted through the vein in the arm and passed through to larger veins near the heart) line dressing changes were changed as ordered, and failed to ensure physician's orders were obtained to maintain the PICC line, including flushing before and after intravenous (IV) antibiotic therapy and changing of IV tubing timely. This affected one resident (#30) out of one resident with an IV. The facility census was 41.

Inspectors wroteBased on observation, interview, record review, and facility policy review the facility failed to change Resident #38's PICC (peripheral inserted central catheter) line dressing as ordered. This affected one resident (#38) of three residents reviewed for PICC line dressings. The facility census was 41.

Inspectors wroteBased on record review and interview, the facility failed to ensure staffing data was submitted appropriately to the Centers for Medicare and Medicaid Services (CMS). This had the potential to affect all residents in the facility. The census was 36.

Inspectors wroteBased on record review and interview, the facility failed to ensure the drug regimen of each resident was reviewed at least once a month by a pharmacist and ensure pharmacy recommendations were acted upon. This affected four of five residents reviewed for unnecessary medications (Resident #26, #30, #13, and #33). The total census was 36.

Inspectors wroteBased on interview, observation, medical record review and policy review the facility did not ensure Resident #48 was free of a significant medication error. This affected one resident (Resident #48) out of one resident reviewed for insulin administration. This had the potential to affect eight residents (Resident #6, #10, #20, #18, #30, #33, #47, and #48) that had orders for insulin.

Inspectors wroteBased on interview, record review and review of facility policy the facility did not ensure State Tested Nursing Assistant (STNA) #602 received 12 hours of formal in service education within the last year. This affected one STNA out of three STNAs (#602, #604, and #605) whose personnel files were reviewed for formal education/training. This had the potential to affect 36 residents.

Inspectors wroteBased on review of the medical record, review of facility investigation, and interviews with facility staff and residents, the facility failed to ensure food served to the residents was free of mold. This affected one resident (Resident #24) of three residents reviewed for palatable food. The facility census was 45.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure call lights were within residents' reach. This affected two (Residents #35 and #36) of two residents reviewed for call lights. The facility census was 27 residents.

Inspectors wroteBased on interview and record review, the facility failed to notify the resident in writing of the reason the reason for transfer. This affected three (Residents #3, #41 and #43) of four residents reviewed for hospitalization. The facility census was 27 residents.

Inspectors wroteBased on interview and record review, the facility failed to provide bed hold notice for residents transferred to the hospital. This affected two (Resident #3, and #41) of four residents reviewed for hospitalization. The facility census was 27 residents.

Inspectors wroteBased on record review, observation, staff interview, and review of the facility policy, the facility failed to ensure Resident #18 received fluids in the consistency prescribed per physician's order. This affected one (Resident #18) of two residents that received thickened liquids. The facility census was 27 residents.

Inspectors wroteBased on record review and interview, the facility failed to ensure significant medication errors did not occur for the residents. This affected one (Resident #17) of one resident who received crushed medications on the 400 hallway. The facility census was 27 residents.

Inspectors wroteBased on observation, staff interview, and review of the facility's medication storage procedures, the facility failed to ensure medication storage procedures were followed. This had the potential to affect four (Residents #9, #23, #24 and #29) who had medications stored in the 400 hallway medication cart. The facility census was 27 residents.

Inspectors wroteBased on record review and interview the facility failed to maintain sufficient levels of nursing staff to ensure Resident #6 and Resident #11's call lights were answered timely. This affected two residents (#6 and #11) of 15 sampled residents reviewed for staffing.