Heritage Healthcare of Euclid

Inspectors wroteBased on observation, interview, and review of the facility policy and procedure, the facility failed to ensure a homelike environment. This affected six residents (#1, #4, #14, #16, #41, and #54) of six residents reviewed for environment and had the potential to affect all 68 residents residing in thee facility. The facility census was 68.

Inspectors wroteBased on observation, interview, record review and review of the facility policy the facility failed to ensure Resident #29 received timely incontinence care and was free from skin breakdown. This affected one resident (Resident #29) out of three residents reviewed for incontinence care. The facility census was 66.

Inspectors wroteBased on record review, staff interview, and review of the Centers for Disease Control and Prevention (CDC) guidance for water management, the facility failed to provide evidence of water testing conducted to monitor and prevent the growth of Legionella (a bacteria that causes Legionnaire's disease) in the building water system. This had the potential to affect all 65 residents in the facility. The census was 65. Findings Include: During the entrance conference, the facility was asked to provide a copy of the Legionella water management program and evidence of water testing being conducted. The facility provided the policy titled, Legionella Water Management Program, revised September 2022; however, the facility had no evidence to support that regular testing for Legionella was being done in the building. Interview on 06/27/24 at 12:50 P.M. [...]

Inspectors wroteBased on observation, staff interview, review of a State Fire Marshal report, and policy review, the facility failed to maintain a safe, clean, sanitary, and well maintained environment and equipment. This had the potential to affect all 65 residents residing in the facility. The facility census was 65. Findings Include: 1. An environmental tour was conducted on 06/26/24 between 9:30 A.M. and 9:45 A.M. with Maintenance Director (MD) #915. Observation of the carpeting throughout the facility was significant discolored and stained. The ceiling in the 400 hall dining room area was completely ripped off and plastic sheeting was covering the ceiling to prevent debris from falling. One of the walls of the dinning room was completely taken down to the wooden studs. Observation of the 300 and 400 Hall tub room had drilled out holes in the shower room that were directly in front of the room. [...]

Inspectors wroteBased on observation, staff interview, and policy review, the facility failed to ensure insulin was dated when opened, was stored in the container for the resident it was ordered for, and was disposed of once expired. This affected five (#13, #15, #26, #33, and #40) of thirteen residents who receive insulin. The census was 65.

Inspectors wroteBased on observation, staff interview, and policy review, the facility failed to store food in a safe and sanitary manner. This affected six (#3, #10, #44, #48, and #172) of 31 residents residing on the 300 and 400 units. The census was 65.

Inspectors wroteBased on observation, staff interview, and medical record review, the facility failed to treat residents with dignity while feeding. This affected one resident (#48) of three residents who were provided assistance with feeding. The facility census was 65. Findings Include: Review of the medical record for Resident #48 revealed an admission date of 12/18/20. Diagnoses included cerebral infarction, seizures, dementia, and dysphasia. Review of the quarterly Minimum Data Set (MDS) assessment, dated 06/17/24, revealed Resident #48 had severely impaired cognition. Review of Resident #48's physician orders for June 2024 revealed an order for feeding assist with all meals on 01/24/24 and the resident was ordered a dysphasia puree texture diet on 04/22/24. Observation on 06/25/24 at 12:29 P.M. [...]

Inspectors wroteBased on medical record review, review of resident funds accounts, and staff interview, the facility failed to make final dispersal of resident funds within 30 days of a resident's death. This affected one (#219) of one residents reviewed for final dispersal of resident funds. The facility census was 65. Findings Include: Review of Resident #219's medical record revealed the resident was admitted to the facility on [DATE] and expired on [DATE]. Review of Resident #219's resident funds account revealed a check dated [DATE] for $90.56 was sent to the Attorney General and a check dated [DATE] for $1,768.00 was sent to to cover the balance due on the resident's account. Interview on [DATE] at 2:25 P.M. with the Administrator verified Resident #219's personal funds were not disbursed within 30 days after the resident's death as required. [...]

Inspectors wroteBased on medical record review, review of self-reported incidents, staff interview, and review of a facility policy, the facility failed to report an allegation of abuse, neglect, or injury of unknown origin to the State Survey Agency as required. This affected one (#67) of two residents reviewed for abuse. The facility census was 65. Findings Included: Review of the medical record revealed Resident #67 was admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (COPD), congestive heart failure, high blood pressure, and nicotine dependence. Resident #67 discharged from the facility against medical advice (AMA) on 04/17/24. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #67 was cognitively intact and required one person physical assistance for completing activities of daily living. [...]

Inspectors wroteBased on medical record review and staff interview, the facility failed to electronically transmit encoded, accurate, and complete Minimum Data Set (MDS) assessment data to the Centers for Medicare and Medicaid (CMS) system within 14 days of completing the assessment. This affected one (#2) of three residents reviewed for discharge. The facility census was 65.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure a Preadmission Screening and Resident Review (PASARR) Level I screen was completed after a resident remained in the facility longer than 30 days as required. This affected one (#13) of two residents reviewed for PASARR. The facility census was 65. Findings Include: Review of the medical record revealed Resident #13 was admitted to the facility on [DATE] with diagnoses that included schizophrenia, chronic obstructive pulmonary disease, and high blood pressure. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #13 was cognitively intact and required minimum assistance for completing his activities of daily living. Review of the medical record revealed a PASARR was completed for Resident #13's stay in the facility on 04/09/24. [...]

Inspectors wroteBased on medical record review and staff interview, the facility failed to timely act upon pharmacist recommendations to address any medication irregularities in the medical record. This affect one (#40) of five residents reviewed for unnecessary medications. The facility census was 65. Findings Include: Review of the medical record revealed Resident #40 was admitted to the facility on [DATE] with diagnoses that included visual hallucinations, repeated falls, and bipolar disorder. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #40 was moderately cognitively impaired and required the assistance of one staff person for completing her activities of daily living. [...]

Inspectors wroteBased on medical record review, staff interview, and review of a facility policy, the facility failed to adequate monitoring was completed as ordered prior to the administration of a medication. This affected one (#40) of five residents reviewed for unnecessary medications. The facility census was 65. Findings Include: Review of the medical record revealed Resident #40 was admitted to the facility on [DATE] with diagnoses that included visual hallucinations, repeated falls, and bipolar disorder. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #40 was moderately cognitively impaired and required the assistance of one staff person for completing her activities of daily living. [...]

Inspectors wroteBased on observation and staff interview, the facility failed to ensure all required postings were on displaying in the facility in a manner that was accessible and understandable. This had the potential to affect all 65 residents residing in the facility. The facility census was 65. Findings Include: Observation of the facility on 06/26/24 between 2:45 P.M. and 3:00 P.M. revealed no evidence of posted contact information for the State Survey Agency and other pertinent agencies and advocacy groups, including the State licensure office, adult protective services, the Office of the State Long-Term Care Ombudsman program, the protection and advocacy network, home and community based service programs, and the Medicaid Fraud Control Unit, were accessible to residents and resident representatives. [...]

Inspectors wroteBased on observation and staff interview, the facility failed to ensure daily nursing staffing information was up-to-date and posted in a prominent place readily accessible to residents and visitors. This had the potential to affect all 65 residents residing in the facility. The facility census was 65. Findings Include: Observation of the posted nursing staff information on 06/24/24 at 8:45 A.M. revealed the posted nursing staff information was located on a bulletin board inside a staffing information area near the front desk that was not visible to residents and visitors. Further observation revealed the posted nursing staffing information was dated 06/14/24. Receptionist #955 verified the posted nursing staffing information was not current and not visible to residents or visitors in the facility during an interview on 06/24/24 at approximately 8:45 A.M.

Inspectors wroteBased on observation, interview, record review, and review of the facility policy the facility failed to ensure individualized care planned interventions were developed and followed to prevent Resident #17 from developing pressure ulcers, and failed to ensure the pressure ulcers were timely identified, properly treated, and interventions were initiated to promote healing. Actual Harm occurred on 01/06/24 when Resident #17 who was cognitively impaired, at risk for pressure ulcer development, and required assistance with bed mobility, developed new, in-house acquired bilateral heel pressure ulcers that were first assessed to be unstageable (a type of bed sore that occurred due to prolonged pressure on a specific area of the skin, resulting in the lack of blood flow and oxygen to the tissue. [...]

Inspectors wroteBased on observation, interview, record review and review of the facility policy, the facility failed to ensure Resident's #1, #24 and #55 received proper, timely incontinence care. This affected three resident's (Resident's #1, #24 and #55) out of four resident's reviewed for incontinence care.

Inspectors wroteBased on observation, interview, record review and review of the facility policy, the facility failed to ensure Resident #45 had an individualized care plan with appropriate interventions in place to manage symptoms of dementia to prevent wandering in other residents rooms. This affected one resident (Resident #45) out of three resident reviewed for dementia care. The facility census was 67.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure physician orders were in place for care or treatment of a peripherally inserted central catheter (PICC) line. This affected one (Resident #11) of one facility-identified residents with a PICC line. The facility census was 65.

Inspectors wroteBased on medical record review, staff interview and review of the facility policy, the facility failed to ensure resident safety during a two-staff assisted transfer. This affected one (Resident #30) of three reviewed for safe transfers. The facility census was 65.

Inspectors wroteBased on record review, resident interview, and staff interview the facility failed to ensure it was sufficiently staffed to meet the needs of the residents. This had the potential to affect all 54 residents residing in the facility.

Inspectors wroteBased on observation, interview, record review and review of the Facility Assessment, the facility failed to ensure sufficient dietary staffing to provide residents with a dignified dining experience. This affected 52 of 54 residents who consumed meals in the facility. Two (Resident's #37 and #249) received nothing by mouth. The facility census was 54.

Inspectors wroteBased on observation and interview, the facility failed to maintain a clean, safe, and sanitary environment throughout the facility. This affected 26 (Residents #3, #7, #11, #12, #14, #16, #19, #20, #21, #22, #25, #27, #31, #32, #34, #35, #38, #41, #43, #44, #45, #46, #251, #252, #253 and #254) and had the potential to affect all 54 residents in the facility.

Inspectors wroteBased on observation, record review, and interview the facility failed to ensure call lights were within reach and accessible. This affected five (Resident's #20, #31, #34, #35 and #43) of 54 residents reviewed for call light placement. The facility census was 54.

Inspectors wroteBased on record review and staff interview the facility failed to ensure resident and/or responsible parties received quarterly statements of resident personal needs account activity as required. This affected seven (Resident's #8, #16, #17, #25, #29, #30 and #31) of seven residents reviewed for personal funds. This had the potential to affect 13 additional residents (Resident's #3, #6, #7, #9, #11, #12, #14, #15, #20, #27, #32, #33 and #47) who also had personal needs bank accounts at the facility. The facility census was 54.

Inspectors wroteBased on record review and staff interview the facilities failed to notify residents when their resident funds accounts were within $200.00 of the Medicaid resource limit as required. This affected four (Resident's #8, #29, #30 and #31) of six residents reviewed for personal funds. The facility census was 54.

Inspectors wroteBased on record review and staff interview the facility failed to ensure hospitalized residents on leave of absence from the facility were given copies of resident bed hold status as required. This affected four (Resident's #18, #34, #35 and #41) of four residents reviewed for hospitalization. The facility census was 54.

Inspectors wroteBased on record review and interview the facility failed to ensure care plans were developed timely and care plan interventions were implemented. This affected four (Resident's #20, #33, #35 and #248) of 32 residents whose care plans were reviewed. The facility census was 54.

Inspectors wroteBased on record review and interview, the facility failed to ensure shower/bed baths were given to residents. This affected four (Resident's #23, #38, #43, and #47) of five residents reviewed for showers. The facility census was 54. Findings Include: 1. Review of the medical record revealed Resident #38 was admitted to the facility on [DATE] with diagnoses including acute cystitis with hematuria, type II diabetes, heart failure, ileus, atrial fibrillation, and anxiety disorder. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #38 was alert and oriented times to person, place, and time. He required extensive assistance of two staff for transfers, dressing, toilet use, and personal hygiene. Review of the plan of care dated 07/21/21 revealed Resident #38 had an activities of daily living (ADL) self-care performance deficit related to impaired mobility. [...]

Inspectors wroteBased on observation, interview, record review, review of Centers for Medicare and Medicaid Services (CMS) memorandums, Food and Drug Administration (FDA) Warning about drawing insulin from pens, and manufacturer's instruction on how to use insulin pens, the facility failed to ensure nurses knew how to administer insulin using an insulin pen correctly. In addition, the facility failed to ensure non-licensed nursing staff demonstrated competencies in skills and techniques necessary to care for residents needs prior to providing care and services to residents. This had the potential to affect all 54 residents residing in the facility.

Inspectors wroteBased on observation and interview, the facility failed to ensure Insulin Kwik pens were dated when opened. This affected two (Resident's #3 and #29) of two residents reviewed for Lantus Kwik pens. In addition, the facility failed to ensure expired stock over-the-counter Colace and baby aspirin used for multiple residents were removed from the medication carts. This had the potential to affect six (Resident's #4, #5, #26, #32, #34 and #35) of six residents who received baby aspirin and five (Resident's #14, #31, #43, #47 and #198) of five residents who received Colace. The facility census was 54.

Inspectors wroteBased on record review and staff interview the facility failed to ensure accurate advanced directive information was present throughout the medical record. This affected one (Resident #11) of one resident reviewed for advanced directives. The facility census was 54.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a wheelchair was in good working order for Resident #8. This affected one (Resident #8) of one resident reviewed for wheelchair condition. The facility census was 54.

Inspectors wroteBased on record review and staff interview the facility failed to accurately and timely complete Minimum Data Set (MDS) 3.0 assessments. This affected two (Resident's #1 and #35) of 26 residents reviewed for resident assessments. The facility census was 54.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure assessments were completed accurately. This affected three (Resident's (#250, #19 and #248) of 26 residents reviewed for accurate assessments and had the potential to affect all 54 residents residing in the facility.

Inspectors wroteBased on record review and staff interview the facility failed to ensure level one screening for mental illness and a Pre-admission Screen and Resident Review (PASARR) for residents were completed as required. This affected three (Resident's #24, #37 and #40) of four residents reviewed for PASARR status. The facility census was 54.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure insulin was administered according to the physician's orders. This affected one (Resident #19) of three residents reviewed during medication administration. The facility census was 54.

Inspectors wroteBased on record review, observation, and interview the facility failed to ensure physician's orders for urinary catheter care and failed to ensure routine urinary catheter care was administered. This affected one (Resident #35) of two residents reviewed for urinary catheters. The facility census was 54.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure Resident #47 was provided fresh water daily. This affected one (Resident #47) of three residents reviewed for hydration. The facility census was 54.

Inspectors wroteBased on interview, and record review, the facility failed to ensure insulin orders for residents were written with the correct method of administration. This affected three residents (Resident's #19, #37 and #98) of three residents reviewed for insulin administration. The facility census was 54.

Inspectors wroteBased on observation, medical record review, and staff interviews the facility failed to ensure residents were provided with eating equipment to maintain independence while eating. This affected two (Resident's #26 and #40) of two residents reviewed for adaptive eating equipment. The facility census was 54.

Inspectors wroteBased on record review and interview the facility failed to ensure a complete and accurate medical record for two (Resident's #41 and #11) of 28 residents reviewed for the annual survey. The facility census was 54.

Inspectors wroteBased on record review and staff interview the facility failed to ensure the most recent state survey results were readily available to staff and the public. This had the potential to affect all 54 residents residing in the facility.

Inspectors wroteBased on observation and staff interview the facility failed to ensure its posted nursing staff information was up to date as required. This had the potential to affect all residents. The facility census was 54.

Inspectors wroteBased on record review, observation and interview the facility failed to ensure foods were stored under sanitary conditions in unit refrigerators. This had the potential to affect 48 of 49 residents currently residing in the facility who received foods from the kitchen. The facility identified Resident #35 as not taking anything by mouth.

Inspectors wroteBased on record review, observation and interview the facility failed to ensure a clean and safe environment for Resident #35 and Resident #9. This affected two of 49 residents sampled residents. The facility census was 49.

Inspectors wroteBased on record review and interview the facility failed to ensure Resident #46's meal intakes were consistently monitored per her care plan for nutrition and failed to ensure Resident #46's care plan for the use of an indwelling urinary catheter included ordered catheter care. This affected one resident (Resident #46) out of four residents reviewed for nutrition and one resident (Resident #46) of one resident reviewed for the use of a urinary catheter.

Inspectors wroteBased on record review and interview the facility failed to ensure the state Ombudsman was notified when Residents #40, #204, and #46 were discharged to an acute care facility. This affected three of four residents reviewed for hospitalization. The facility census was 49.