Carecore at Mary Scott

Inspectors wroteBased on record review and staff and resident guardian interviews, the facility failed to follow a resident's legal guardian's requests to not allow the resident to go on unsupervised Leave of Absences (LOA's) from the facility. This affected one (#59) out of three reviewed for supervision. The facility census was 59.

Inspectors wroteBased on medical record review, staff interview, review of a facility document, review of email correspondence, and policy review, the facility failed to ensure timely assistance with a resident/family initiated request for discharge to another facility. This affected one (Resident #27) out of three residents reviewed for discharge. The facility census was 64. Findings Included:Review of the medical record revealed Resident #27 was admitted to the facility on [DATE]. Diagnoses included type two diabetes, dementia, nutritional deficiency, acute kidney failure, transient ischemic attack, and atherosclerotic heart disease. Review of the quarterly minimum data set (MDS) dated [DATE] revealed Resident #27 had a Brief Interview for Mental Status (BIMS) score of eight documented cognitive impairment. Resident #27 was set up or clean-up for oral care, and personal hygiene. [...]

Inspectors wroteBased on medical record review, observation, staff interview, and policy review, the facility failed to ensure weekly skin assessments and treatments were completed as ordered. This affected one (Resident #23) out of three residents reviewed for wounds. The facility census was 64. Findings Included:Review of the medical record for Resident #23 revealed an admission date of 08/27/22. Diagnoses included morbid obesity, anxiety disorder, nonpsychotic mental disorder, schizoaffective disorder, chronic pain syndrome, osteoarthritis, and major depression. Review of the minimum data set (MDS) assessment dated [DATE] revealed Resident #23 had Brief Interview of Mental Status (BIMS) score of 10 revealing she had moderate cognitive impairment. Resident #23 was bed bound and required staff assistance for activities of daily living (ADL). [...]

Inspectors wroteBased on interview, observation, record review, and facility policy review, the facility failed to date opened vials of insulin and failed to remove expired insulin from two of four medication carts observed. The facility census was 71.

Inspectors wroteBased on observation, interview, and facility document and policy review, the facility failed to ensure food was prepared and served in accordance with professional standards for food service safety. Specifically, the facility failed to ensure staff wore beard restraints during food preparation, and the facility failed to ensure chemical test strips used to check the concentrations of sanitizing solutions were not expired. This affected all residents who ate food prepared in the kitchen.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to allow a resident to determine their own treatment options. This affected one (#43) of two residents reviewed for exercising treatment options. The facility census was 71.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure a resident was provided with reasonable access to a telephone in a private setting. This affected one (#23) of two residents reviewed for privacy. The facility census was 71.

Inspectors wroteBased on facility policy review, record review, and interview, the facility failed to report allegations of abuse to the State Survey Agency (SSA). This affected three (#69, #43, and #78) of three residents reviewed for abuse. The facility census was 71.

Inspectors wroteBased on facility policy review, record review, facility document review, and interview, the facility failed to thoroughly investigate allegations of abuse. This affected three (#69, #43, and #78) of three residents reviewed for abuse. The facility census was 71.

Inspectors wroteBased on facility policy review, record review, and interview, the facility failed to document in the medical record any behaviors to support the reason for an emergency discharge as documented on an Emergency Discharge Notice of Discharge and Discharge Summary, and failed to assist with coordinating after discharge care as outlined in the physician's Discharge Summary. This affected one (#78) of two residents reviewed for discharge requirements. The facility census was 71.

Inspectors wroteBased on facility policy review, record review, and interview, the facility failed to ensure a resident's discharge was accurately and thoroughly documented in the medical record. This affected one (#78) of two residents reviewed for discharge requirements. The facility census was 71.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to develop individualized resident-centered care plans with measurable objectives for two (#3 and #61) of 49 residents whose care plans were reviewed. The facility census was 71.

Inspectors wroteBased on interview, observation, record review, and facility policy review, the facility failed to trim and clean the fingernails for one (#8) of three residents reviewed for activities of daily living (ADLs). The facility census was 71.

Inspectors wroteBased on interview, observation, record review, and facility policy review, the facility failed to place a splint or handroll into residents contracted hands as ordered by the physician. This affected two (#3 #8) of three residents reviewed for contractures. The facility census was 71.

Inspectors wroteBased on observation, interview, record review, facility policy review, and product operation manuals, the facility failed to ensure resident weight settings were correct on low air loss mattresses. This affected two (#2 and #57) of two residents reviewed for pressure ulcer management. The facility census was 71.

Inspectors wroteBased on facility policy review, record review, observation, and interview, the facility failed to ensure residents did not retain their own lighters according to the facility policy. This affected three (#61, #5, and #58) of four residents reviewed for smoking. The facility census was 71.

Inspectors wroteBased on manufacturer guidelines, observation, and interview, the facility failed to ensure staff sanitized a blood glucose monitor after checking a resident's blood sugar and before placing the blood glucose monitor into the medication cart for further use. This affected one (#8) of two residents observed who had their blood sugar checked during medication administration. The facility census was 71.

Inspectors wroteBased on medical record review, staff interviews, review of the Ohio Department of Health (ODH) Gateway Application, review of a facility timeline, review of a Narcotic Administration Sheet and policy review, the facility failed to report an allegation of misappropriation to the State Agency. This affected one (#79) out of three residents reviewed for misappropriation. The facility census was 77.

Inspectors wroteBased on medical record review, observations, staff interviews and policy review, the facility failed to ensure tracheostomy (trach) supplies were available in accordance with the care plan and facility policy. This affected one (#77) out of three residents reviewed for trach care and services. The facility census was 77.

Inspectors wroteBased on observation, staff interview and review of facility policy, the facility failed to ensure food items were properly stored. This had the potential to affect all residents, except two (#29 and #80) residents identified by the facility as receiving no nutrition from the kitchen. The facility census was 82.

Inspectors wroteBased on medical record review, review of a transportation communication log, resident and staff interviews, and facility policy review, the facility failed to provide proper and timely care/services to ensure a medical procedure was completed. This affected one (#9) of three residents reviewed for outside medical appointments. The census was 83. Findings Include: Resident #9 was admitted to the facility on [DATE]. His diagnoses were rhabdomylosis, congestive heart failure, alcohol dependence, alcoholic hepatitis, alcohol abuse, hepatic encephalopathy, dementia, depression, hypertension, and tobacco use. Review of Resident #9's minimum data set (MDS) assessment, dated 10/29/24, revealed he had a mild cognitive impairment. Review of Resident #9's Central Appointment Communication Sheet, dated 10/18/24, revealed he was to have an orthopedic appointment on 11/20/24. [...]

Inspectors wroteBased on medical record review, review of a transportation communication log and staff interview, the facility failed to maintain complete resident medical records regarding outside medical appointments. This affected three (#9, #20, and #35) of three residents reviewed for outside medical appointments. The census was 83. Findings Include: 1. Resident #9 was admitted to the facility on [DATE]. His diagnoses were rhabdomylosis, congestive heart failure, alcohol dependence, alcoholic hepatitis, alcohol abuse, hepatic encephalopathy, dementia, depression, hypertension, and tobacco use. Review of Resident #9's minimum data set (MDS) assessment, dated 10/29/24, revealed he had a mild cognitive impairment. Review of Resident #9's Central Appointment Communication Sheet, dated 10/18/24, revealed he was to have an orthopedic appointment on 11/20/24. [...]

Inspectors wroteBased on medical record review and staff interview, the facility failed to administer a medication as ordered. This affected one (#3) of three residents reviewed for medication administration. The census was 75.

Inspectors wroteBased on medical record review, staff interview, and review of the facility policy, the facility failed to ensure residents received their medications as ordered. This affected one (Resident #64) of three residents reviewed for medication administration. The facility census was 61.

Inspectors wroteBased on medical record review, review of hospital documentation, observation, interviews with staff, Certified Nurse Practitioner (CNP) #250 and family, review of facility policy, and review of medication information from Medscape, the facility failed to ensure residents were free from unnecessary medications when the facility failed to adequately monitor Resident #21's blood glucose level before administering insulin. This resulted in Actual Harm when staff administered insulin to Resident #21 without monitoring the residents blood glucose levels and the resident was subsequently found unresponsive by staff and was admitted to a local hospital for hypoglycemia. This affected one (#21) of five residents reviewed for unnecessary medications. The census was 66.

Inspectors wroteBased on observation, staff interview and review of facility policy the facility failed to discard expired medications. This affected one (first floor) of two medication rooms observed during the survey and had the potential to affect all residents residing in the facility. The facility failed to ensure medication were labeled, dated and stored appropriately in the medication carts. This affected one (200 hall) of two medication carts reviewed. Facility census was 66.

Inspectors wrote3. Observation of staff members upon entrance to the facility on [DATE] at 8:00 A.M. revealed no staff members were wearing eye protection while in resident care areas. Interview with Licensed Practical Nurse (LPN) #240 on 07/11/22 at 8:36 A.M. confirmed she was not wearing any eye protection while caring for residents. LPN #240 stated she was told she was not required to wear any. Interview with State Tested Nursing Assistant (STNA) #152 on 07/11/22 at 10:07 A.M. confirmed she was not wearing any eye protection. STNA #152 stated eye protection was not required, just facemask's. During in interview on 07/11/22 at 10:48 A.M. Regional Director of Clinical Services (RDCS) #250 confirmed staff members were not currently wearing any eye protection in the facility. [...]

Inspectors wroteBased on record review, observations, staff and family interviews and policy review, facility failed to inform resident's, their representatives and families of positive Coronavirus Disease 2019 (COVID-19) cases in the facility. This had the potential to affect all 66 residents residing in the facility. Facility census was 66.

Inspectors wroteBased on observations, staff interview, and policy review, the facility failed to ensure all items stored in the refrigerator and freezer were properly labeled. This had the potential to affect 64 out of 66 residents residing in the facility as two residents (#32 and #60) do not consume food from the kitchen. The facility census was 66.

Inspectors wroteBased on medical record review, staff interview and policy review, facility failed to ensure the influenza (flu) and pneumonia vaccinations were offered and provided to residents. This affected four (#14, #21, #52, and #54) of five residents reviewed for immunizations. Facility census was 66.

Inspectors wroteBased on medical record review, staff, resident and representative interviews and policy review, the facility failed to ensure residents and families were invited to attend interdisciplinary care conferences. This affected one (#53) of five residents reviewed for care plans and care conferences. Facility census was 66.

Inspectors wroteBased on medical record review, review of Medicare beneficiary notice letters, and staff interview, the facility failed to issue the Skilled Nursing Facility Advance Beneficiary Notices (SNFABN), as required to residents when their Medicare Part A Services were ending. This affected two (#11 and #365) of three residents reviewed for Medicare beneficiary notice letters. The census was 66.

Inspectors wroteBased on medical record review, observation, and staff and resident interview, the facility failed to ensure a resident's bathroom and shower were in good condition. This affected one (#364) out of 19 resident reviewed in the sample. The census was 66.

Inspectors wroteBased on medical record review, staff interview, and policy review, the facility failed to ensure a resident on dialysis was monitored for signs and symptoms of infection. This affected one (#22) of one residents reviewed for dialysis. The facility census was 66.

Inspectors wroteBased on medical record review and staff and Physician #210 interviews, the facility failed to ensure physician ordered laboratory (lab) values were obtained as physician ordered. This affected one (#4) of one residents reviewed for labs services. Facility census was 66.

Inspectors wroteBased on medical record review, review of electronic mail (email) communication, staff interviews, and policy review, the facility failed to ensure residents had dental services arranged in a timely manner. This affected two (#43 and #44) out of three residents reviewed for dental services. The facility census was 66.

Inspectors wroteBased on medical record review, staff interview and policy review, the facility failed to ensure Coronavirus Disease 2019 (COVID-19) vaccinations were offered and provided to residents. This affected three (#14, #31, and #52) of five residents reviewed for immunization. Facility census was 66.

Inspectors wroteBased on review of the facility's Water Management Plan and staff interview, the facility failed to implement it's Legionella prevention plan. This had the potential to affect all the residents of the facility. The census was 79.

Inspectors wroteBased on resident council meeting, resident and staff interviews, review of the local post office business hours, and facility policy review the facility failed to ensure mail was delivered on Saturdays. This affected six (#14, #15, #28, #41, #47, and #61) of six residents interviewed during resident council meeting and had the potential to affect all 79 residents in the facility. Facility census was 79.

Inspectors wroteBased on observation, resident and staff interviews, and review of facility policy the facility failed to maintain residents' room environment in a safe and comfortable manner. This affected 10 rooms (100, 101, 102, 103, 104, 106, 108, 113, 114, and 115) out of 13 rooms on the 100 Hall. Facility census was 79.

Inspectors wroteBased on medical record review and staff interview, the facility failed to accurately complete Minimum Data Set (MDS) assessments. This affected two (#13 and #77) of 18 residents reviewed during the investigation stage of the annual survey. The facility census was 79.

Inspectors wroteBased on medical record review, and staff interview, the facility failed to have resident's medication and/or treatment orders reviewed and signed by the physician. This affected three Resident's (#19, #38 and #42) reviewed during the investigation stage of the annual survey. The facility census was 79.

Inspectors wroteBased on observation, staff interview, and review of facility policy, the facility failed to securely store medications and/or dispose of outdated/undated medication. This had the potential to affect all 79 residents residing in the facility.

Inspectors wroteBased on observation and staff interview, the facility failed to maintain resident call lights in working order. This affected six Rooms # (301, 303, 304, 306, 308, and 310) of 13 rooms on the 300 hall. The facility census was 79.

Inspectors wroteBased on medical record review, observation and staff interviews, the facility failed to treat a resident in a dignified manner. This affected one Resident (#55) of two reviewed for dignity during the investigation stage of the annual survey. The facility census was 79.

Inspectors wroteBased on medical record review, observation, staff interviews and review of the facility policy, the facility failed to assess, monitor, and/or obtain orders for a resident's seatbelt. This affected one resident (#33) of one reviewed for restraints during the investigation stage of the annual survey. The facility census was 79.

Inspectors wroteBased on medical record review, observation, and interview, the facility failed to update a resident's care plan. This affected one Resident (#64) of two reviewed for urinary catheters. The census was 79.

Inspectors wroteBased on medical record review, observation, and resident and staff interviews, the facility failed to provide bathing assistance to residents who required assistance. This affected one (#127) of two residents reviewed for activities of daily living (ADL). The census was 79.

Inspectors wroteBased on medical record review, observation, and staff interviews, the facility failed to assess and/or monitor for continued use of a urinary catheter. This affected one Resident (#3) of two residents reviewed for urinary catheters during the investigation stage of the annual survey. The facility census was 79.

Inspectors wroteBased on medical record review, observation, and staff interview the facility failed to obtain a chest X-ray as ordered by a physician. This affected one Resident (#19) of one reviewed for respiratory care. The census was 79.

Inspectors wroteBased on medical record review, observation, and interview, the facility failed to appropriately assess a Resident #64's dialysis access. This affected one Resident (#64)of one reviewed for dialysis. The census was 79.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure residents were was free of unnecessary medications. This affected two Residents (#11 and #42) of five residents reviewed for unnecessary medications. The facility census was 79.

Inspectors wroteBased on medical record review, staff interview, and review of facility policy, the facility failed to obtain physician ordered labs for residents. This affected one Resident (#42) of five reviewed for unnecessary medications during the investigation stage of the annual survey. The facility census was 79.