Concordia at Sumner

Inspectors wroteBased on observation and interview, the facility failed to prepare food in a sanitary manner. This had the potential to affect all 43 residents who received meals from the kitchen. The census was 43.

Inspectors wroteBased on record reviews, observations and interviews with staff the facility failed to prevent Resident #28 from eloping from the facility without staff knowledge. This affected one resident (Resident #28) of four residents reviewed for elopements. The census was 42.

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to ensure infection control protocols were maintained during incontinence care and Hoyer (mechanical) lift transfers. This affected one resident (#8) out of one resident observed for incontinence care and Hoyer lift transfers. The facility census was 42.

Inspectors wroteBased on observations, interview, and policy review the facility failed to serve food in a sanitary manner. This had the potential to affect all residents who ate meals prepared in the kitchen. The census was 43.

Inspectors wroteBased on observation, interviews, and policy review the facility failed to serve food at an appropriate temperature. This affected the 22 residents observed for lunch service, Residents #22, #23, #24, #25, #26, #27, #28, #29, #30, #31, #32, #33, #34, #35, #36, #37, #38, #39, #40, #41, #42, and #43. Census was 43.

Inspectors wroteBased on record review, interview and facility policy review, the facility failed to ensure Resident #45's funds were disbursed timely after discharge. This affected one resident (#45) of three residents reviewed for resident funds. Facility census was 44.

Inspectors wroteBased on observations, interview, and facility policy review, the facility failed to ensure the kitchen was clean and sanitary. This had the potential to affect 35 residents that received meals from the facility. No residents were identified as receiving nothing by mouth. Findings Include: A tour of the kitchen on 02/20/24 from 8:00 A.M. to 8:15 A.M. revealed the reach-in refrigerator had dried milk on the bottom of it and a container of gravy was not labeled or dated and had a plastic spoon in it, the microwave had dried food splatter inside, the steam table had food splatter on it, the reach-in freezer had a bag of chicken not labeled or dated and stuck to the bottom of the freezer. This was verified by the Administrator on 02/20/24 at 8:17 A.M. Interview on 02/22/24 at 10:27 A.M. with Registered Dietitian (RD) #264 revealed that she does not inspect the kitchen. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure the facility assessment was accurate and thorough regarding facility staffing. This had the potential to affect all 35 residents in the facility. Findings Include: Review of the facility assessment dated [DATE] revealed staffing was sufficient regarding the current amount of staff needed to care for the number and acuity of residents. There was no indication of the type and number of staff needed to provide care and services. Interview on 02/21/24 at 11:09 A.M. with Corporate Registered Nurse (RN) #298 confirmed the facility assessment was not thorough and accurate.

Inspectors wroteBased on record review, staff interview, and facility policy review the facility failed to ensure non-pharmacological interventions were attempted prior to the administration of the pain medication for Residents #9, #10, #16, and #341 and did not ensure as needed (PRN) pain medications and failed to ensure parameters were in place for Resident #10's PRN pain medication. In addition, the facility failed to ensure PRN antianxiety were not used for longer than 14 days without rationale or review for Resident #16. This affected four residents (#9, #10, #16, and #341) of five residents reviewed for unnecessary medications. The facility census was 35.

Inspectors wroteBased on observations, interviews, record review, and facility policy review the facility failed to ensure Resident #5 and Resident #292 received assistance with activities of daily living (ADL). This affected two residents (#5 and #292) of 35 residents reviewed for ADL care. The facility census was 35. Findings Include: 1. Review of the medical record for Resident #5 revealed an admission date on 03/04/16. Diagnoses include multiple sclerosis and muscle weakness. Review of quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #5 was dependent for personal hygiene, toileting, and showers. Review of the plan of care dated 11/21/22 for ADL due to multiple sclerosis revealed inventions included assist Resident #5 with ADL completion as needed, and resident will participate in activities as ordered. Showers were to be given Tuesdays and Fridays. Interview on 02/20/24 at 11:54 A.M. [...]

Inspectors wroteBased on observations, interview, and record review the facility did not ensure Resident #10 had her wound dressing changed as ordered by the physician. This affected one resident (#10) of one resident reviewed for wound care. The facility census was 35. Findings Include: Review of the medical record revealed an admission date of 08/24/22. Diagnoses included dementia, depression, stage four pressure ulcer of the sacral region and acute kidney failure. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was severely cognitively impaired. She was totally dependent on staff for oral hygiene, showering or bathing, personal hygiene, and toileting. [...]

Inspectors wroteBased on observation, interview, record review, and review of manufacture guidelines for urinary drainage bag the facility failed to ensure proper infection control practices for Resident #4 when his indwelling Foley catheter bag was lying on the floor. This affected one resident (#4) of one resident reviewed for indwelling Foley catheter care. The facility census was 35. Findings Include: Review of the medical record for Resident #4 revealed an admission date of 08/19/22 with diagnosis including neuromuscular dysfunction of bladder and diabetes mellitus. Review of the physician orders for February 2024 revealed an order for an indwelling Foley catheter care every shift. Review of the plan of care 01/18/24 for indwelling Foley catheter due to urinary obstruction. Intervention included staff will keep the indwelling Foley catheter drainage bag off the floor and below bladder level. [...]

Inspectors wroteBased on observation, staff interview, and review of facility policy the facility failed to ensure kitchen staff wore appropriate hair coverings. This had the potential to affect 39 residents who received food from the kitchen. The facility census was 39.

Inspectors wroteBased on observation, record review and interview the facility failed to properly prevent the potential spread of infections such as COVID-19 as evidenced by failing to ensure all staff and visitors were consistently screened for COVID-19 when entering the facility. This had the potential to affect all 39 residents currently residing in the facility.

Inspectors wroteBased on observation, record review and interview the facility failed to implement their vaccination policy and monitor staff members, contract employees and visitors to ensure that 100% (percent) of staff have received at least one dose of a COVID-19 vaccine, have a pending request for exemption, or have been identified as appropriate for a temporary delay per Centers for Disease Control (CDC) guidance. The vaccination rate for the facility was calculated at 97.3%. This had the potential to affect all 39 residents currently residing in the facility.

Inspectors wroteBased on personnel file review and interview the facility failed to ensure all new employees were checked against the State of Ohio Nurse Aide Registry. This affected seven of twelve staff reviewed and 39 residents in the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to develop and implement an individualized care plan related to the hygiene and application of a palm guard for Resident #12 regarding bilateral hand contractures. This affected one of three residents reviewed for activities of daily living (#12, #16, #40 and #398) and one resident (#12) reviewed for position and mobility.

Inspectors wroteBased on observation, interview and record review the facility failed to provide adequate hand hygiene and apply a palm guard as ordered for Resident #12 who was dependent for activities of daily living care. This affected one (Resident #12) of four residents (#12, #16, #40 and #398) reviewed for activities of daily living.