Edgewood Manor of Lucasville II

Inspectors wroteBased on resident record review, staff interview, review of the facility Self-Reported Incident (SRI) and investigation, and review of facility policy, the facility failed to timely report an Injury of Unknown Origin (IUO). This affected one resident (#14) out of the three residents reviewed for abuse. The facility census was 70.

Inspectors wroteBased on closed record review, interview and policy review, the facility failed to allow Resident #22 to return to the facility following a discharge to jail and subsequent hospitalization due to the inability to find a safe discharge location. The facility also failed to assist the resident with appropriate and necessary discharge planning to ensure the resident's total care needs were met. This affected one resident (#22) of three residents reviewed for discharge and transfers. The facility census was 68.

Inspectors wroteBased on observations, staff interviews, and review of facility policy, the facility failed to ensure privacy curtains were in place around commodes in the communal bathroom for residents to utilize for privacy when toileting. This had the potential to affect the 22 residents (#1, #2, #5, #6, #9, #14, #17, #18, #19, #22, #26, #27, #33, #34, #35, #36, #38, #39, #45, #54, #59, and #64) who resided on the 300 hall and 400 hall and were identified by the facility as utilizing the communal bathrooms. The facility census was 67.

Inspectors wroteBased on record review and staff interview, the facility failed to complete a gradual dose reduction (GDR) or documentation of a clinical contraindication for not attempting a GDR for a resident on two antipsychotics. This affected one (Resident #16) of five residents reviewed for unnecessary medications. The facility census was 67.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure a resident who had abnormal heart rate received timely care and services. This affected one (Resident #37) of two residents reviewed for change of condition. The facility census was 67.

Inspectors wroteBased on medical record review, review of facility Self-Reported Incidents (SRIs), and review of the facility policy, the facility failed to timely report an allegation of staff to resident physical abuse. This affected one (Resident #9) of three residents reviewed for abuse. The facility census was 65 residents.

Inspectors wroteBased on medical record review, review of facility Self-Reported Incidents (SRIs), and review of the facility policy, the facility failed to ensure residents were protected from further possible abuse during an abuse investigation. This affected one (Resident #9) of three residents reviewed for abuse. The facility census was 65 residents.

Inspectors wroteBased on staff interview and record review the facility failed to have accurate advance directives in the electronic and medical record. This affected one (Resident #14) of one resident reviewed for advanced directives. The facility census was 64.

Inspectors wroteBased on record review and interview, the facility failed to notify one resident's (#218) physician of a change in condition. This affected one (Resident #218) of four residents reviewed for accidents. The census was 64. Findings Include: [...]

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure one resident (#55) was free from physical restraints. This affected one (Resident #55) of three residents reviewed for restraints. The facility census was 64. Findings Include Review of the medical record for Resident #55 revealed an initial admission date of 04/07/22 with the latest readmission of 05/13/23 with diagnoses including sepsis, anterior displaced type II dens fracture with delayed healing, chronic viral hepatitis, insomnia, tobacco use, Alzheimer's disease, generalized muscle weakness, shortness of breath, difficulty in walking, unsteadiness, dysphagia, dementia with behavioral disturbances, disorders of bladder, neurogenic bladder, hypertension and atrial fibrillation. [...]

Inspectors wroteBased on record review, review of facilities Self Reported Incident (SRI), review of facility policy titled Abuse, Investigation and Reporting and interviews the facility failed to appropriately identify and report a resident to resident abuse. This affected one resident (Resident #39) out of four residents screened for abuse. The facility policy was 64.

Inspectors wroteBased on record review, review of facilities Self Reported Incident (SRI), review of facility policy titled Abuse, Investigation and Reporting and interviews, the facility failed to appropriately report a resident to resident abuse. This affected one resident (Resident #39) out of four residents screened for abuse. The facility policy was 64.

Inspectors wroteBased on record review, and staff interview the facility failed to ensure a new Pre-admission Screen and Resident Review (PASARR) was completed following a new mental health diagnosis. This affected two (Resident #1 and #42) residents of four residents reviewed for PASARR. The facility census was 64.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure Resident #15, #17, and #55 who required assistance with activities of daily living (ADL) received shaving assistance. This affected three (Resident #15,#17, and #55) of four residents reviewed for ADL. The facility census was 64. Findings Include: 1. Review of the medical record for Resident #15 revealed an initial admission date of 09/08/11 with the latest readmission of 04/17/16 with the diagnoses including major depressive disorder, anxiety disorder, insomnia, palliative care, dementia with behavioral disturbance, undifferentiated schizophrenia, dysphagia, psychosis, hypertension, pain, contracture of right ankle, contracture of left ankle, anemia, restlessness and agitation, retention of urine, viral hepatitis C, convulsions, delusional disorder and personal history of traumatic brain injury. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure one resident (#65) who received antihypertensive medications with parameters for blood pressure (BP) was obtained prior to administration. This affected one (Resident #65) of five residents reviewed for unnecessary medications. The facility census was 64. Findings Include: Review of the medical record for Resident #65 revealed an initial admission date of 04/12/23 with the admitting diagnoses including chronic obstructive pulmonary disease (COPD), dementia, low back pain, dysphagia, major depressive disorder, benign prostatic hyperplasia, neutropenia, psychosis, gastro-esophageal reflux disease, malignant neoplasm of pharynx, hypertension, convulsions and type I diabetes mellitus. Review of the resident's plan of care revealed no care plan addressing the resident's diagnosis of hypertension. [...]

Inspectors wroteBased on observation and staff interview the facility failed to provide a safe, comfortable environment for Resident #18 when his wall was cracked and the heater was rusted and for Resident #42 when his room walls needed painted and patched. This affected two Residents (Resident #18 and #42) of five residents reviewed for environment. The facility census was 64.

Inspectors wroteBased on observation, record review, facility policy and procedure review and interview the facility failed to ensure treatment for a non-pressure related skin impairment was completed as ordered by the physician for Resident #65 and failed to appropriately assess and treat a cigarette burn on Resident #59's thumb following the injury. Actual harm occurred on 06/16/21 when Resident #65 was admitted to the hospital and diagnosed with osteomyelitis (inflammation of bone or bone marrow, usually due to infection) of the second left toe had to have the second left toe amputated. Treatment for non-pressure related skin impairment to the toe area was not completed as ordered after 05/13/21. This affected two residents (#59 and #65) of three residents reviewed for hospitalization and/or skin conditions. Findings Include: 1. [...]

Inspectors wroteBased on observation, record review and interview the facility failed to provide nutritional interventions, including timely and adequate assistance with meals to Resident #65 to prevent weight loss. Actual harm occurred when Resident #65, who was dependent on staff for eating and assessed to sustain a 20.9% severe weight loss in 180 days (on 02/12/21 the resident weighed 240.6 pounds and on 08/10/21 the resident weighed 190.2 pounds loss of 50.4 pounds in 180 days) did not receive adequate or timely assistance with meals on 08/30/21 and 09/01/21. This affected one resident (#65) of four residents reviewed for weight loss.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure timely dental services were provided for Resident #9 and Resident #65. Actual harm occurred on 09/02/21 when Resident #65, who had been referred for tooth extraction (on 04/27/21) was assessed to have an infected tooth which required antibiotic treatment. The facility failed to ensure a follow up appointment for the extraction was completed timely after the need for the extraction was identified on 04/27/21 resulting in the resident developing an infection. This affected two residents (#9 and #65) of the three residents reviewed for dental services. Findings Include: 1. [...]

Inspectors wroteBased on observation, record review and interview the facility failed to ensure the correct diet that met resident needs was provided when whole broccoli florets were given to residents on a dysphagia advanced diet instead of chopped broccoli. This had the potential to affect 18 residents (#5, #8, #14, #16, #17, #28, #33, #37, #38, #39, #44, #45, #48, #54, #58, #60, #63 and #268) of 18 residents identified to have orders for a dysphagia advanced diet. The facility census was 69. Findings Include: On 08/31/21 from 11:25 A.M. to 12:10 P.M. observation of the lunch meal service revealed two available vegetable options puree broccoli and regular broccoli florets. Further observation revealed 14 residents, Resident #5, #8, #14, #16, #17, #33, #39, #45, #48, #54, #58, #60, #63 and #268 on a dysphagia advanced diet were served regular broccoli florets. [...]

Inspectors wroteBased on observation, record review and interview the facility failed to ensure resident refrigerators were maintained at appropriate temperatures and were clean and free from expired food items. This affected four residents (#2, #20, #26, and #28) who resided on the 400 unit and had refrigerators in their rooms. The facility census was 69. Findings Include: 1. Observation on 09/01/21 at 8:30 A.M. of the refrigerator in Resident #28's room revealed the shelves had a sticky substance adhered to them and the refrigerator did not have a thermometer inside it. Review of a refrigerator temperature log located on the side of the refrigerator was dated 07/2021 and contained documentation only for 07/28/21 which stated No thermometer. Interview with Licensed Practical Nurse (LPN) #999 on 09/01/21 at 8:30 A.M. [...]

Inspectors wrote3. Review of Resident #9's medical record revealed an admission date of 05/07/21 with admitting diagnoses of chronic obstructive pulmonary disease, vascular dementia, diabetes mellitus, gastrostomy, protein-calorie malnutrition, dysphagia, anemia, metabolic encephalopathy, anxiety disorder, major depressive disorder, constipation, insomnia and hypertension. Review of the resident's comprehensive MDS 3.0 assessment, dated 05/14/21 revealed the resident had clear speech, understood others, made himself understood and had a moderate cognitive deficit as indicated by a Brief Interview for Mental Status (BIMS) score of nine. [...]

Inspectors wroteBased on observation, medical record review, interview and facility policy review the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility failed to ensure staff provided meal assistance to Resident #9 in a dignified and respectful manner and failed to ensure Resident #65 was provided clothing to promote the resident's dignity and individuality. This affected two residents (#9 and #65) of two residents reviewed for dignity. Findings Include: 1. [...]

Inspectors wroteBased on record review, staff interview and facility policy review the facility failed to ensure Resident #9's family/responsible party was notified of falls sustained by the resident and failed to ensure Resident #32's family/responsible party was notified of weight loss. This affected two residents (#9 and #32) of 19 sampled residents. Findings Include: 1. Review of Resident #9's medical record revealed an admission date of 05/07/21 with admitting diagnoses of chronic obstructive pulmonary disease, vascular dementia, diabetes mellitus, gastrostomy, protein-calorie malnutrition, dysphagia, anemia, metabolic encephalopathy, anxiety disorder, major depressive disorder, constipation, insomnia and hypertension. [...]

Inspectors wroteBased on observation, record review, facility policy and procedure review and interview the facility failed to ensure comprehensive care plans were developed for all residents. The facility failed to develop a plan of care for Resident #9 related to dental/oral needs, for Resident #32 related to insomnia and for Resident #31 related to anticoagulant medication use. This affected three residents (#9, #31 and #32) of 19 sampled residents who care plans were reviewed. Findings Include: 1. Review of Resident #9's medical record revealed an admission date of 05/07/21 with admitting diagnoses of chronic obstructive pulmonary disease, vascular dementia, diabetes mellitus, gastrostomy, protein-calorie malnutrition, dysphagia, anemia, metabolic encephalopathy, anxiety disorder, major depressive disorder, constipation, insomnia and hypertension. [...]

Inspectors wroteBased on observation, record review and interview the facility failed to ensure Resident #3, #15 and #52, who required staff assistance with activities of daily living (ADLs) received timely and adequate assistance with meals to promote proper nutrition. This affected three residents (#3, #15 and #52) of four residents reviewed for ADL care/nutrition. The facility identified all 69 residents residing in the facility required assistance with meals. Findings Include: 1. Review of the medical record for Resident #3 revealed an admission date of 03/27/14 with diagnoses including unspecified dementia with behavioral disturbance, dysphagia, unspecified open-angle glaucoma, schizophrenia and diabetes mellitus. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment, dated 06/01/21 revealed Resident #3 had impaired cognition and was totally dependent on one staff member for eating. [...]

Inspectors wroteBased on observation, record review and interview the facility failed to provide intervention/adaptive equipment as ordered for Resident #15 and Resident #52 who were assessed to have limitation in range of motion. This affected two residents (#15 and #52) of two residents reviewed for range of motion. Findings Include: 1. Review of the medical record for Resident #52 revealed an admission date of 02/21/17 with diagnoses including unspecified dementia with behavioral disturbance, hypertension, contractures of the right hip, right knee, and left hip, dysphagia, schizophrenia and adult failure to thrive. Review of the physical therapy and occupational therapy functional maintenance program, dated 01/06/20 revealed the resident was to have a hip abductor pillow daily from 8:00 A.M. to 2:00 P.M. [...]

Inspectors wroteBased on observation, record review, staff interview and facility policy review the facility failed to fall/safety interventions were in place as ordered for Resident #9. This affected one resident (#9) of three residents reviewed for falls. Findings Include: Review of Resident #9's medical record revealed an admission date of 05/07/21 with admitting diagnoses of chronic obstructive pulmonary disease, vascular dementia, diabetes mellitus, gastrostomy, protein-calorie malnutrition, dysphagia, anemia, metabolic encephalopathy, anxiety disorder, major depressive disorder, constipation, insomnia and hypertension. Review of the fall evaluation, dated 05/07/21 revealed a score of 20 indicating Resident #9 was at a high risk for falls. [...]

Inspectors wroteBased on observation, record review and staff interview the facility failed to ensure Resident #32's enteral feeding was labeled with the solution, date and time the enteral feeding was initiated/started to prevent the risk of complication(s) from the enteral feeding. This affected one resident (#32) of one resident reviewed for enteral feeding. Findings Include: Review of Resident #32's medical record revealed an original admission date of 03/31/15 with the latest readmission of 03/26/21. Resident #32 had diagnoses including dementia, anxiety disorder, dysphagia, diabetes mellitus, insomnia, gastrostomy, encephalopathy, constipation, mood disorder, major depressive disorder, chronic pain, urine retention, psychosis and hypertension. [...]

Inspectors wroteBased on record review and staff interview the facility failed to ensure pharmacy recommendations were addressed by the physician in a timely manner. This affected two residents (#9 and #32) of five residents reviewed for unnecessary medication use. Findings Include: 1. Review of Resident #9's medical record revealed an admission date of 05/07/21 with admitting diagnoses of chronic obstructive pulmonary disease, vascular dementia, diabetes mellitus, gastrostomy, protein-calorie malnutrition, dysphagia, anemia, metabolic encephalopathy, anxiety disorder, major depressive disorder, constipation, insomnia and hypertension. Review of a pharmacy recommendation, dated 05/28/21 revealed the pharmacist recommended to add a Vitamin B12 supplement. The physician agreed with the recommendation but did not date when the review was completed. [...]

Inspectors wroteBased on observation, record review and interview the facility failed to monitor residents for side effects of medication, prevent unnecessary medications and follow pharmacy recommendations when Resident #31 received an anticoagulant past the prescribed end date and was not monitored for side effects related to the medication, Resident #9's blood pressure was not obtained as ordered to monitor an antihypertensive medication and Resident #43's Aspirin dose was not changed following a pharmacy recommendation. This affected three residents (#31, #9 and #43) of five residents reviewed for unnecessary medication use. Findings Include: 1. Review of Resident #31's medical record revealed an admission date of 07/31/20 with diagnoses including schizophrenia, vascular dementia with behavioral disturbance, chronic viral hepatitis C, dysphagia and hypertension. [...]

Inspectors wroteBased on observation, record review and interview the facility failed to maintain an effective pest control program to prevent the presence of gnats/flies in the resident environment. This affected two residents (#9 and #65) of 19 sampled residents. Findings Include: 1. Review of Resident #9's medical record revealed an admission date of 05/07/21 with admitting diagnoses of chronic obstructive pulmonary disease, vascular dementia, diabetes mellitus, gastrostomy, protein-calorie malnutrition, dysphagia, anemia, metabolic encephalopathy, anxiety disorder, major depressive disorder, constipation, insomnia and hypertension. [...]