Harrison Pavilion Care Center

Inspectors wroteBased on record review, observations, staff interviews, policy review, and review of the guidelines from the National Pressure Injury Advisory Panel (NPIAP), the facility failed to adequately assess Resident #09's skin, failed to timely identify the resident's pressure ulcer (a pressure ulcer is a localized injury of the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction), until it had reached an advanced stage and failed to timely implement provider ordered interventions to prevent the development of pressure ulcers and/or aid in the healing of existing pressure ulcers. This resulted in Actual Harm to Resident #09, who was admitted without pressure ulcers but was at risk for the development of pressures and subsequently developed an avoidable, facility acquired pressure ulcer. [...]

Inspectors wroteBased on record review, staff interviews and policy review, the facility failed to ensure Resident #03's power-of-attorney (POA) was notified of the resident's change in condition status and transfer to the hospital. This affected one (Resident #03) of three records reviewed for notification. The facility census was 78.

Inspectors wroteBased on record review, staff interviews, review of pharmacy records, and policy review, the facility failed to ensure residents were free from significant medication errors. This affected one (Resident #45) of three resident reviewed for medication administration. The facility census was 78.

Inspectors wroteBased on observations, staff interviews, and policy review, the facility failed to ensure dishware was clean prior to serving pureed meal service. This affected one (Resident #11) of one resident who the facility identified as receiving pureed diets. The facility census was 78.

Inspectors wroteBased on record review, observations, staff interviews, and policy review, the facility failed to ensure infection control measures were implemented during wound care. This affected one (Resident #09) of three residents reviewed for wound care. The facility census was 78.

Inspectors wroteBased on observation, staff interview, and review of the facility policy, the facility failed to ensure medications were stored appropriately and failed to discard expired medications. This had the potential to affect 35 facility-identified residents who receive medications from medication cart number two/back east, from medication cart short front, and from medication cart short back hall. The facility also failed to discard expired medications and supplies stored in the medication room. This had the potential to affect all of the residents residing in the facility. The facility census was 79 residents.

Inspectors wroteBased on observation, staff interview, and review of the facility policy, the facility failed to ensure food items were stored properly and the kitchen was maintained in clean, sanitary manner. This had the potential to affect all the residents receiving food from the facility. The facility census was 79 residents.

Inspectors wroteBased on medical record review and staff interview, the facility failed to complete a significant change Pre-admission Screening and Resident Review (PASARR) assessment after residents received new diagnoses for psychiatric disorders. This affected two (Residents #7 and #76) of four residents sampled for PASARR. The facility census was 79 residents.

Inspectors wroteBased on medical record review, resident interview, and staff interview, the facility failed to ensure residents received timely treatment for respiratory infections. This affected one (Resident #7) of seven residents sampled for respiratory infections. The facility census was 79 residents.

Inspectors wroteBased on medical record review, staff interview, and review of the facility policy, the facility failed to complete root cause analysis following resident falls. This affected one (Resident #39) of three residents reviewed for falls. The facility census was 79 residents.

Inspectors wroteBased on medical record review, observation, staff interview, and review of the facility policy, the facility failed to ensure the medication error rate was less than five percent (%). The facility had three medication errors per 25 medication opportunities with a medication error rate of 12 %. This affected two (Residents #2 and #44) of three residents observed for medication administration. The facility census was 79 residents.

Inspectors wroteBased on review of the medical record review, observation, staff interview, and review of manufacturer's instructions, the facility failed to prime an insulin pen prior to administration. This affected one (Resident #44) of one observed for insulin administration and had the potential to affect two residents on medication cart one on the east hall with physician orders for insulin. The facility census was 79 residentsFindings include:Review of the medical record for Resident #44 revealed an admission date of 10/31/24 with diagnoses including chronic obstructive pulmonary disease (COPD), type two diabetes mellitus, and depression. [...]

Inspectors wroteBased on observation, staff interview, and review of the facility policy, the facility failed to measure correct portion sizes to meet resident nutritional needs. This affected one (Resident #73) of one resident with physician's orders for a pureed diet. The facility census was 79 residents.

Inspectors wroteBased on medical record review, observation, resident interview, staff interview, and review of the facility policy, the facility failed to ensure staff maintained sterile technique during tracheostomy care. This affected one (Resident #11) of one resident sampled for tracheostomy care. The facility also failed to ensure staff wore the appropriate personal protective equipment (PPE) for residents on Enhanced Barrier Precautions (EBP). This affected one (Resident #12) of 13 residents reviewed for EBP. The facility census was 79 residents.

Inspectors wroteBased on staff interviews and record review, the facility failed to allow residents who were cognitively intact and were their own persons, the ability to independently sign out of the facility. This affected four Residents (#16, #69, #100 and #400) of the four residents reviewed for resident rights. The facility identified 63 Residents (#02, #05, #06, #09, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #22, #23, #24, #26, #27, #28, #29, #30, #31, #33, #35, #37, #38, #39, #40, #41, #42, #43, #45, #48, #49, #50, #52, #53, #54, #55, #56, #57, #58, #60, #61, #62, #63, #65, #66, #67, #68, #69, #70, #71, #72, #73, #75, #76, #78, #79, #80 and #81) as being their own person without a guardian at the facility and was able to sign themselves out of the facility if desired. The facility census was 78.

Inspectors wroteBased on staff interview, record review, and review of discharge notices, the facility failed to permit a resident to remain in the facility and not transfer or discharge from the facility without the proper documentation regarding the need for discharge from the facility or the physician. This affected one Resident (#400) of the three residents reviewed for transfers. The facility also failed to allow a resident to remain in the facility for the duration of their discharge notice. This affected one Resident (#100) out of three residents reviewed for transfer or discharge. The facility census was 78.

Inspectors wroteBased on staff interview and record review, the facility failed to ensure a resident's discharge summary included a recapitulation of the resident's stay. This affected one Resident (#400) out of three residents reviewed for transfer or discharge summaries. The facility census was 78.

Inspectors wroteBased on staff and resident interviews, medical record review, review of Self-Reported Incident (SRI), review of police report, and policy review, the facility failed to ensure a resident was free from abuse. This affected one (#34) resident out of four residents reviewed for abuse. The facility census was 80.

Inspectors wroteBased on medical record review and staff and pain specialist staff interviews, the facility failed to ensure a pain specialist appointment was scheduled and failed to effectively manage a resident's pain. This affected one (#84) resident out of three residents reviewed for pain management. The facility census was 80.

Inspectors wroteBased on medical record review, observation, staff interview, and review of facility policies, the facility failed to follow infection control guidelines when administering medications. This affected one (#70) out of three residents reviewed for medication administration. The facility census was 80.

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, review of the State of Ohio Board of Pharmacy Terminal Distributor Licensure of Prescriber Practices, and staff interview, the facility failed to ensure medications administered intravenously (IV) were obtained from a source with a Terminal Distributor of Dangerous Drugs (TDDD) license (which allows a business entity to purchase, possess, and/or distribute dangerous drugs at a specific location) specific to the State of Ohio. This deficiency affected four (Residents #3, #25, #37, and #42) of four residents reviewed for medications administered by a contracted ancillary provider. [...]

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, review of the State of Ohio Board of Pharmacy Terminal Distributor Licensure of Prescriber Practices, and staff interview, the facility failed to ensure medications were obtained from a source with a Terminal Distributor of Dangerous Drugs (TDDD) license (which allows a business entity to purchase, possess, and/or distribute dangerous drugs at a specific location) specific to the State of Ohio. This deficiency affected four (Residents #3, #25, #37, and #42) of four residents reviewed for medications administered by a contracted ancillary provider. [...]

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, review of the State of Ohio Board of Pharmacy Terminal Distributor Licensure of Prescriber Practices,, and interview, the facility failed to ensure a contracted entity had appropriate State of Ohio required credentials for provision of services for residents. This deficiency affected four (Residents #3, #25, #37, and #42) of four residents reviewed for medications administered by a contracted ancillary provider. [...]

Inspectors wroteBased on observation, interview, and policy review, the facility failed to store and prepare food in a safe manner. This had the potential to affect 82 residents who received food from the kitchen. The facility census was 83.

Inspectors wroteBased on observation, resident interview, staff interview and policy review, the facility failed to ensure residents were provided a dining room to eat their meals. This had the potential to affect 82 of 82 residents that receive meals from the dining room. The facility identified one (Resident #19) who did not receive his meals from the kitchen. The facility census was 83.

Inspectors wroteBased on record review, staff interview, resident interview, and review of the policy, the facility failed to ensure residents were invited to their care plan meetings. This affected four (#18, #28, #47, and #233) of four residents reviewed for care conferences. The facility census was 83.

Inspectors wroteBased on observation, resident interviews, staff interviews, record review, and policy review, the facility failed to provide a home like environment in maintaining resident's rooms in good condition. This affected four (#03, #21, #36, and #233) of 83 residents residing in the facility. The facility census was 83.

Inspectors wroteBased on observations, grievance report review, spread sheet review, email communication review, policy review, resident interviews, staff interviews, Registered Dietician interview, the facility failed to ensure residents were provided with adequate portion sizes and substitutes according to the approved menus/spreadsheets. This had the potential to affect 82 of 82 residents who were served food from the kitchen. The facility identified one resident (#19) did not receive food from the facility kitchen. The facility census was 83.

Inspectors wroteBased on observation, staff interview, and policy review, the facility failed to provide a home like environment by maintaining shower rooms and ensuring there was enough plates and silverware to serve meals. This had the potential to affect up to 50 of 83 residents who reside in the faciltiy. Excluding Resident #19, who does not receive food and a total of 59 residents who do not utilize the shower rooms. The facility census was 83.

Inspectors wroteBased on record review, observation, resident interview, and staff interview, the facility failed to ensure a resident was provided the assistance to obtain a pair of shoes. This affected one (#64) of 24 residents sampled during the annual survey. The facility census was 83.

Inspectors wroteBased on record review, and staff interview, the facility failed to complete a Significant Change Pre-admission Resident Review (PASARR) for Resident #24. The facility failed to complete a PASARR review for Resident #63 in a timely manner following the expiration of the Hospital Exemption Notification System ([NAME]) approved stay at the facility. The facility failed to ensure Resident #70's PASARR was completed correctly by failing to identify mental health diagnoses. This affected three (#24, #63 and #70) of three residents reviewed for PASARR. The facility census was 83.

Inspectors wroteBased on record review, resident interview, staff interview, and policy review, the facility failed to complete a thorough investigation to identify the root cause of the fall during a Hoyer lift transfer. This affected one (#47) of three residents reviewed for falls. The facility census is 83.

Inspectors wroteBased on record review, resident interview, staff interview and observations, revealed the facility failed to ensure pain medications were available and provided timely to a resident to maintain pain management. This affected one (#1) of one resident reviewed for pain management. The facility census was 83.

Inspectors wroteBased on observation, interview and policy review, the facility failed to ensure the facility was free of gnats. This affected the kitchen area. The facility census was 83.

Inspectors wroteBased on record review, observations, staff interviews, review of facility policy, and review of online guidance per the Centers for Disease Control (CDC), the facility failed to ensure staff wore proper personal protective equipment (PPE) to prevent the spread of Coronavirus Disease 2019 (COVID-19). This affected four (#39, #58, #61 and #80) of five residents reviewed for infection control. The facility census was 81.

Inspectors wroteBased on interviews with facility staff, the Medical Director, and Non-Physician Practitioners (NPPs), medical record review, review of the pre-admission screening form, review of hospital records, review of Emergency Medical Services (EMS) run report, review of the coroner ' s report, review of facility e-mails, review of the facility timeline investigation, review of the police report, and review of facility policies, the facility failed to provide adequate behavioral health services for one resident (#231) with a known history of suicidal ideations, paranoia, delusions, and who had a recent hospitalization for suicide ideations. This resulted in Immediate Jeopardy and life-threatening serious injuries and ultimate death when Resident #231 placed an upright dresser on his neck and committed suicide on [DATE]. [...]

Inspectors wroteBased on observation, record review, staff and resident interview, and review of facility policy, the facility failed to provide each resident with a therapeutic diet as ordered by the physician, and planned by the Registered Dietitian, and/or receive interventions per the plan of care to ensure the resident maintained acceptable parameters of nutritional status including body weight. This resulted in actual harm for three residents (#22, #40, #74) who experienced avoidable, unplanned significant to severe weight loss and/or failed to maintain their weight or improve weight status per the plan of care. Additionally, the facility failed to provide a therapeutic diet as ordered by the physician for one resident (#05) out of eight residents reviewed for Nutrition. The facility census was 79.

Inspectors wroteBased on staff interview, review of facility assessment, and review of facility policy, the facility failed to complete and update the facility assessment. This affected all 79 residents who resided in the facility.

Inspectors wroteBased on staff interview and record review, the facility failed to ensure the Activities Director was properly certified. This affected all residents who resided in the facility. Facility census was 79.

Inspectors wroteBased on observation, record review, interview, policy review, and review of online resources per the Center for Medicare and Medicaid Studies (CMS) and the Centers for Disease Control (CDC) the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent spread of infectious diseases including the Coronavirus 2019 (Covid -19) virus. This had the potential to affect all 79 residents. Furthermore, the facility failed to ensure staff wore personal protective equipment properly to prevent the spread of Coronavirus (COVID-19) and failed to ensure contracted staff had temperature taken and completed a signs and symptom screen for COVID-19 prior to entering the resident area. [...]

Inspectors wroteBased on observation, staff and resident interview, and review of facility policy, the facility failed to provide dining services for residents in a dignified manner which enhanced their quality of life. This affected seven Residents (#45, #40, #75, #65, #9, #14, #36) out of a total facility census of 79.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure that when a resident formulated an advanced directive the resident's advanced directive was accurately recorded in all locations of the medical record to ensure the resident's wishes would be followed as directed in the event of an emergency. This affected four residents (#22, #40, #74, and #5) of six residents reviewed for Advance Directives. The facility census was 79.

Inspectors wroteBased on staff interview, review of facility investigation, review of facilities self-reported incidents (SRIs), review of medical records, and review of facilities Abuse Investigating and Reporting Policy, the facility failed to prevent potential further neglect during their investigation with ( Resident #231) when he had committed suicide in the facility. This had the potential to affect 49 Residents (#01, #02, #03, #04, #05, #06, #08, #09, #15, #18, #19, #20, #21, #22, #23, #25, #28, #32, #34, #36, #38, #39, #40, #41, #43, #44, #45, #47, #48, #49, #52, #53, #55, #58, #61, #64, #65, #69, #76, #85, #86, #87, #88, #89, #90, #91, #92, #93, and #94) whom the facility identified as having a history of suicidal ideations/attempts after the suicidal incident [DATE]. The facility census was 79.

Inspectors wroteBased on record review and interview, the facility failed to ensure a valid Pre admission Screen and Resident Review (PASRR) was in place for three Residents (#24, #29, and #231) out of three residents reviewed for PASRR screenings. The facility census was 79.

Inspectors wroteBased on chart review, interview, and policy review, the facility failed to provide baseline care plans upon admission. This affected two Residents (#27 and #71) . Furthermore, the facility failed to complete a baseline careplan accurately for one Resident (#231) out of 21 residents reviewed for baseline care plans. The in-house facility census was 79.

Inspectors wrote5. Record Review of Resident #77 revealed she admitted to the facility on [DATE]. Her diagnoses included, acute kidney failure, cognitive communication deficit, dysphagia, history of coronavirus (COVID) 19, and acute respiratory failure. Review of her 5-day admission MDS assessment, dated 11/08/21 revealed Resident #77 was cognitively intact and she required supervision assistance from staff with bed mobility, transfers, and supervision assistance with personal hygiene, toilet use, eating, and dressing. Review of the nursing progress notes dated 10/11/21 for Resident #77 had a fall and new fall were listed as bed at lower position and floor mats at bedside. [...]

Inspectors wroteBased on record review, observation, and interview the facility failed to ensure residents were smoking safely. This affected six Residents (#11, #31, #53, #57, #73, and #230) out of 29 residents identified by the facility as smokers. The facility failed to ensure resident safety while moving around in wheelchair affecting one Resident #77, and failed to put non-skid strips in bathroom to prevent falls affecting Resident #29. The in-house facility census was 79.

Inspectors wroteBased on staff interview, medical record review and review of facility policy, the facility failed to ensure the physician personally approved in writing a recommendation for residents being admitted . This affected 21 residents (#12, #14, #15, #17, #22, #24, #27, #29, #33, #37, #40, #42, #71, #74, #76, #77, #78, #81, #229, #231, and #328) of the 31 sampled residents. The facility census was 79.

Inspectors wroteBased on staff interview and interview with facility Medical Director (MD), medical record review and review of facility policy, the facility failed to ensure the physician and Non-Physician Providers (NPP) wrote, signed, and dated progress note at each visit. This affected 25 Residents (#05, #12, #14, #15, #17, #19, #22, #24, #29, #30, #34, #36, #37, #40, #48, #53, #71, #76, #77, #79, #81, #82, #229, #231, and #328) of the 31 sampled residents. Facility census was 79.

Inspectors wroteBased on observation, interview, and policy review the facility failed to ensure expired medications were properly disposed. This affected one medication room, and four medication carts out of six medication carts reviewed for medication storage. The in-house census was 79.

Inspectors wroteBased on observation, staff interview, review of nutrition services agreement, and review of personnel records, the facility failed to employ sufficient staff with appropriate skills and competencies necessary to carry out the function of the dietary department related to food and nutrition services. This had the potential to affect 77 of 79 residents of the facility , excluding residents #16 and #19 who received enteral feedings and nothing by mouth. The facility census was 79.

Inspectors wroteBased on observation, staff and resident interview, review of the dietary staffing schedule, and review of the facility mealtime cart schedule revealed the facility failed to employ sufficient staff with appropriate competencies to effectively carry out the functions of the food and nutrition service department. This had the potential to affect 77 of 79 residents of the facility, excluding residents #16 and #19 who received enteral feedings and nothing by mouth. The facility census was 79.

Inspectors wroteBased on observation, staff and resident interview, and review of planned menus, the facility failed to follow the planned menus as approved by the Registered Dietitian for residents on mechanical soft and pureed diets, resulting in resident's not receiving all planned menu items necessary to meet their nutritional needs. This directly affected four Residents (#22, #71, #48, and #43) who were on texture modified diets, and had the potential to affect six additional Residents ( #72, #77, #62, #38, #40, #64) with physician's order for texture modified diets; mechanical soft or pureed. The facility census was 79.

Inspectors wroteBased on observation, staff and resident interview, review of planned menus, and review of facility policy, the facility failed to provide food that was served at a safe and appetizing temperature. This affected seven Residents (#30, #40, #9, #14, #36, #45, and #75) and had the potential to affect a total of 77 of 79 residents, excluding residents #16 and #19 who received enteral feedings and nothing by mouth. The facility census was 79.

Inspectors wroteBased on observation, staff and resident interview, and review of planned menus, the facility failed to prepare the planned menus as approved by the Registered Dietitian for residents on mechanical soft and pureed diets, to ensure residents received food prepared in a form designed to meet their individual needs per physician orders and the comprehensive plan of care. This directly affected five Residents (#22, #48, #43, #40, and #71) who had physician orders for texture modified diets, and had the potential to affect five additional residents ( #72, #77, #62, #38, and #64) with physician's orders for texture modified diets; mechanical soft or pureed. The facility census was 79.

Inspectors wroteBased on observation, staff interview, and review of facility policy, the facility failed to ensure that food was stored, prepared, and served in accordance with professional standards for food service safety. This had the potential to affect 77 of 79 residents of the facility , excluding Residents #16 and #19 who received enteral feedings and nothing by mouth. The facility census was 79.

Inspectors wroteBased on observation, record review, staff and family/representative interview, and review of facility policy, the facility failed to notify each resident's family/representative when the resident experienced an unplanned significant weight loss. This affected one resident (#78) of 31 residents reviewed. The facility census was 79.

Inspectors wroteBased on staff interview, review of facility investigation, review of facilities self-reported incidents (SRIs), review of medical records, and review of facilities Abuse Investigating and Reporting Policy, the facility failed to report an incident of possible neglect to the State Agency when a resident was found on the floor with a dresser on neck and determined deceased by emergency medical services (EMS). This affected one Resident (#231) of the 31 sampled residents. Facility census was 79.

Inspectors wroteBased on staff interview and record review, the facility failed to properly notify the Ombudsman program of resident hospitalizations. This affected two Residents (#03 and #29) out of five residents reviewed for hospitalization. The facility census was 79.

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to conduct initial or periodic assessments of each resident's activity interests. This affected one Resident (#22) of three residents reviewed for Activities. The facility census was 79.

Inspectors wroteBased on staff interview, record review and review of facility policy, the facility failed to ensure residents comprehensive care plans were reviewed and revised. This affected two Residents (#77 and #29) of the 31 residents sampled. The facility census was 79.

Inspectors wroteBased on record review, observation, and interview the facility failed to provide professional services while administering medications to residents on therapeutic diet. This affected one Resident #71 out of one resident identified by the facility on thickened liquids. The in-house facility census was 79.

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to provide each resident an ongoing program of activities designed to support their physical, mental, and psychosocial well-being. This affected one Resident (#22) of three residents reviewed for Activities. The facility census was 79.

Inspectors wroteBased on record review, observation, resident interview, staff interview, and review of facility policy the facility failed to conduct consistent assessments of resident's skin condition per a licensed nurse. This affected three (#40, #70, #78) of three residents reviewed for skin integrity. The facility also failed to conduct regular pressure ulcer risk assessments which affected two (Residents #40 and #70) of three residents reviewed for skin integrity. The facility failed to document a description of impaired skin integrity which required intervention per physician's order which affected one (Resident #78) of three residents reviewed for skin integrity. The facility census was 79.

Inspectors wroteBased on medical record review, observation, staff interview, and review of facility policy, the facility failed to ensure each resident's oxygen tubing was dated, documented, and changed weekly per facility policy. This affected one Resident (#30) reviewed for respiratory care, out of 10 residents identified by the facility as receiving oxygen therapy. The facility census was 79.

Inspectors wroteBased on staff interview, record review and review of facility policy, the facility failed to ensure residents medical records were complete and accurately documented. This affected two Residents (#03 and #231) of the 31 sampled residents. Facility census was 79.

Inspectors wroteBased on observation, resident and staff interview, record review, and review of facility policy revealed the facility failed to provide each resident with a safe, functional, and sanitary environment which was clean and in good repair. This affected five Residents (#74, #30, #40, #24, and #77) out of 31 sampled residents. The facility census was 79. 1. Observation of the resident sleeping room and bathroom occupied by Resident's #30 and #40 on 11/15/21 at 9:56 A.M. revealed the cover to the baseboard heater in front of the toilet was missing exposing sharp edges of the heating element and there were multiple gnats in the bathroom. The floor behind the head of Resident #30's bed was heavily soiled with food and other debris and his privacy curtain was stained and soiled with a large dark grayish/black in area near the resident's head. [...]