Heritage Healthcare of Lyndhurst

Inspectors wroteBased on observation, review of the food temperature log, review of food committee meeting minutes, review of the Food Drug Administration (FDA) Food Code 2022, policy review, and interview, the facility failed to serve food at a safe, appetizing and palatable temperature. This affected all residents who received meals from the kitchen (except Resident #60 and Resident #90 who were ordered nothing by mouth (NPO). The census was 94.

Inspectors wroteBased on observation, interview, medical record review, review of hospice notes, and facility policy review, the facility failed to ensure care and services were provided to facilitate resident preference, comfort and hydration. Actual Harm occurred on 03/24/25 at 10:04 A.M. when Resident #58, a resident who was receiving end-of-life hospice care who staff believed was actively dying, was left alone behind a closed door, thirsty, in severe pain, and unable to call for assistance. Resident #58 was dependent on all aspects of care and unable to call for help, was denied hydration measures, and had minimal pain control for 2 days. This affected one resident (#58) of three residents reviewed for quality of care and treatment. The facility census was 81.

Inspectors wroteBased on review of facility documentation and interview with the Administrator, the facility failed to provide a complete and detailed Facility Assessment. This had the potential to affect all 81 residents residing in the facility.

Inspectors wroteBased on observation, interview, record review, and review of the facility policy, the facility failed to provide hygiene and grooming as scheduled and as needed for three residents (#13, #28, and #60) of three residents reviewed for hygiene. The facility census was 81.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received meals compatible with their likes and dislikes. This affected one resident (Resident #22) and had the potential to affect 76 of 81 residents receiving food from the kitchen as five residents (Resident #17, #35, #44, #52, and #62) received nothing by mouth (NPO). The facility census was 81.

Inspectors wroteBased on record review, interview, and review of the facility policy, the facility failed to offer the flu and or pneumonia vaccine for all residents. This affected four residents (Resident #9, #10, #13, and #21) of five residents reviewed for immunizations. The facility census was 81.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure a resident's request to go to bed and receive timely care was respected and the resident was timely assisted in a dignified manner. This affected one resident (#28) of three residents reviewed for dignity. The facility census was 81.

Inspectors wroteBased on observations, record review and interview, the facility failed to ensure residents had access to their personal property in a timely manner. This affected one resident (#40) of one resident reviewed for personal property. The facility census was 81.

Inspectors wrote2. Review of the medical record for Resident #5 revealed an admission date of 01/29/25. Diagnoses included cerebrovascular disease, dementia, psychotic disturbance, mood disturbance and anxiety, and dysphagia (difficulty swallowing). Review of the MDS assessment dated [DATE] revealed Resident #5 had moderate cognitive impairment and was dependent on staff for personal hygiene and transfers. Observation on 03/24/25 at 11:05 A.M revealed Resident #5 was lying in bed and his left arm was constricted. The call light was wrapped around the right-side bed rail. Interview at this time with Resident #5 stated he was unable to reach his call light. Interview on 03/24/25 at 11:10 A.M. with Housekeeper #242 verified the call light was not within reach for Resident #5. [...]

Inspectors wroteBased on observation, interview, record review, and review of the facility policy, the facility failed to respect and promote resident self-determination. This affected two resident (#9 and #60) of three residents reviewed for the ability for residents to choose important facets of their lives. The facility census was 81.

Inspectors wroteBased on record review and interview, the facility failed to ensure a completed code status form was completed for Resident #40. This affected one resident (#40) of one resident reviewed for advanced directives. The facility census was 81.

Inspectors wroteBased on record review, interview and facility policy review, the facility failed to ensure notification of significant weight loss to the resident's physician and/or the resident representative. This affected one resident (#45) of seven residents reviewed for nutrition and one resident (#35) of one resident reviewed for tube feeding. The facility census was 81.

Inspectors wroteBased on review of Notice of Medicare Non-Coverage (NOMNC) letters and staff interview, the facility failed to provide residents with the correct last covered day (LCD). This affected five (Resident #60, Resident #63, Resident #73, Resident #79, and Resident #80) of eleven residents reviewed for liability notices. The census was 81.

Inspectors wrote2. Review of the medical record for Resident #5 revealed an admission date of 01/29/25. Diagnoses included cerebrovascular disease, dementia, psychotic disturbance, mood disturbance and anxiety, and dysphagia (difficulty swallowing). Review of the MDS assessment dated [DATE] revealed Resident #5 had moderate cognitive impairment and was dependent on staff for personal hygiene and transfers. Observation on 03/24/25 at 11:05 A.M, revealed Resident #5 was lying in bed. The resident had a floor mat to the right side of the bed. The mat was covered with a dried white substance. The carpeted next to the mat had large areas with a dried white substance. Interview 03/24/25 at 11:10 A.M. with Housekeeper #242 verified the dirty floor mat and spillage on the carpet. Housekeeper #242 stated she did not get to clean Resident #5 room today. [...]

Inspectors wroteBased on record review, observation, interview, and review of the facility policy, the facility failed to ensure quarterly care plan meetings were offered/completed for Resident #13. This affected one resident (#13) of one resident reviewed for quarterly care plan timing. The facility census was 81.

Inspectors wrote2. Review of the medical record for Resident #42 revealed an admission date of 03/06/25. Diagnoses included sepsis, osteomyelitis, heart failure, dementia, and peripheral vascular disease. Review of the laboratory service report dated 03/06/25 at 10:11 A.M. revealed the urine culture resulted Escherichia coli and extended spectrum beta lactamase (ESBL) producing organism. The report revealed the organism was resistant to ciprofloxacin and sensitive to Macrobid. Review of the admitting medications reconciliation dated 03/06/25 revealed ciprofloxacin 250 milligram (mg) twice daily was crossed off not to be administered. Review of Resident #42's physician orders dated 03/06/25 at 6:13 P.M. revealed an order dated 03/08/25 for Macrobid 100 milligrams, an antibiotic, two times a day to treat urinary tract infection. [...]

Inspectors wroteBased on record review and interview, the facility failed to apply Resident #179's Automatic Positive Airway Pressure (auto-PAP) machine as ordered. This affected one resident (#179) of four residents reviewed for respiratory care. The facility census was 81.

Inspectors wrote3. Review of the medical record for Resident #42 revealed an admission date of 03/06/25. Diagnoses included sepsis, osteomyelitis, heart failure, dementia, and peripheral vascular disease. Review of the comprehensive Minimum Data Set 3.0 dated 03/12/25 revealed the resident had moderate cognitive impairment and was dependent on staff for toileting, transfers and ambulation. The assessment indicated the resident received and antibiotic and antiplatelet. Review of Resident #42's physician orders revealed an order dated 03/08/25 for Macrobid 100 milligrams (mg), an antibiotic, administered two times a day to treat urinary tract infection (UTI). Review of progress note dated 03/08/25 at 6:30 P.M. revealed a new order was placed for Macrobid 100 mg to be administered twice daily for a duration of ten days to treat a UTI. [...]

Inspectors wroteBased on record review and interview the facility failed to ensure accurate documentation in the medical record. This affected two residents (Resident #42 and #179) of two residents reviewed for accuracy of medical records. The facility census was 81.

Inspectors wroteBased on record review, interview and review of the facility policy, the facility failed to ensure the resident, resident representative, and Ombudsman were notified in writing of the transfer to the hospital. This affected one resident, (Resident #41) of one resident reviewed for hospital transfers and had the potential to affect 11 additional residents (Residents #4, #64, #179, #186, #187, #188, #189, #190, #191, #192, and #193) identified by the facility as having a hospital transfer from 09/01/24 through 02/28/25. The facility census was 81.

Inspectors wrote2. Review of Resident #179's medical record revealed an admission date of 06/14/22 with diagnoses including Respiratory failure, chronic obstructive pulmonary disease (COPD), obesity, and emphysema. Resident #179 was discharged on 02/21/25. Review of the admission assessment dated [DATE] revealed Resident #179 was alert and orientated to person, place, time and date. The resident was independent with activities of daily living (ADL). Review of the progress note dated 02/11/25 at 11:00 P.M. revealed Resident #179 had diminished lung sounds and difficulty breathing. The Nurse Practitioner (NP) ordered to send Resident #179 to the emergency room (ER). Review of the progress note dated 02/21/25 at 10:00 A.M. revealed Resident #179 was unresponsive and sent to the ER for further evaluation. [...]

Inspectors wroteBased on observations, interviews, and review of the facility policy and procedures the facility failed to ensure proper storage of food items and failed to maintain a clean and sanitary kitchen and nursing unit refrigerators. This had the potential to affect 76 of 81 residents in the facility as five residents (Resident #17, #35, #44, #52, and #62) received nothing by mouth. The facility census was 81.

Inspectors wrote4. Review of the medical record for Resident #9 revealed an admittance date of 03/13/23 with diagnoses including spinal injury at T7 through T10, paraplegia, spinal stenosis, hypertension, depression, and heart failure. Review of Resident #9's physician orders for March 2025 revealed morning medications that included Allopurinol 100 milligram (mg), 0.6 mg Colchicine 0.6 mg. Furosemide 40 mg, multivitamin, potassium 20 milliequivalents (meq), vitamin B12, Vyvanse 40 mg, Flomax 0.4. and Gabapentin 800 mg. Observation on 03/26/25 at 7:57 A.M. of medication administration with Registered Nurse (RN) #310 revealed the nurse prepared Resident #9's morning medications and administered the medications. There was no hand sanitizer on the medication cart. RN #310 did not sanitize or wash hands prior to preparing medication Resident #9 medications or after administering the medications. [...]

Inspectors wroteBased on medical record review and staff interview the facility failed to ensure an environment free of accidents hazards when smoking materials were not secured to prevent Resident #1 from smoking in his room. This affected one (#1) of three residents reviewed with a diagnosis of dementia on the locked nursing unit and the 24 (#2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #17, #18, #19, #20, #21, #22, #23, #24 and #25)additional residents residing on the locked memory care nursing unit. Facility census was 72.

Inspectors wroteBased on observation, interview, medical record review, and policy review, the facility failed to ensure Resident #17, who had chronic pain syndrome and received routine and as needed medication to treat pain, was provided pain medication as requested to effectively manage her chronic pain. This affected one resident (#17) of three residents reviewed for pain management. The facility census was 66. Findings Include: Review of the medical record revealed Resident #17 was admitted to the facility on [DATE] with diagnoses including Amyotrophic Lateral Sclerosis (ALS), fibromyalgia, chronic pain syndrome, major depression disorder, anxiety disorder, and insomnia. Review of the physician's orders for Resident #17 revealed on 02/27/24 the resident was admitted to hospice for the diagnosis of ALS. She was receiving Ambien (a hypnotic medication for sleep) 10 milligrams (mg) between 11:30 P.M. [...]

Inspectors wroteBased on record review, review of a facility fall investigation, review of staff disciplinary forms, review of a facility procedure and interview, the facility failed to provide adequate assistance to Resident #35 during incontinence care to prevent a fall with injury. This affected one resident (#35) of three residents reviewed for incontinence care. The facility census was 68. Actual harm occurred on 08/05/24 when Resident #35, who was severely cognitively impaired, required two staff assistance for bed mobility and was incontinent, sustained a fall out of bed when staff were providing incontinence care. At the time of the incident, the staff failed to maintain the resident's safety in bed. The resident exhibited pain to the left side of the head with swelling and bruising to the left cheek and eye and pain with range of motion to the left elbow. [...]

Inspectors wroteBased on observation, interview, record review, and facility policy review the facility failed to provide feeding assist for Residents #5 and #6 and personal care assist with a mechanical lift for Resident #35 in a dignified and respectful manner. This affected three residents (#5, #6 and #35) of three residents reviewed for dignity and respect. The facility census was 68.

Inspectors wroteBased on review of facilities self reported incidents (SRIs), medical record review, policy review, family interview, staff interview, and facilities policy review, the facility failed to ensure residents responsible parties and medical practioners were notified of an instance of potential sexual abuse. This affected two (Residents #100 and #101) of three residents reviewed for notification of change. The facility census was 60. Findings Include: Resident #100 was admitted to the facility on [DATE] with diagnoses that included epilepsy, major depressive disorder, anxiety disorder and [NAME]-[NAME] syndrome. Review of the most recent quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #100 was moderately cognitively impaired and required extensive assistance of two staff persons for completing her activities of daily living (ADLs). [...]

Inspectors wroteBased on review of self-reported incidents (SRIs), medical record review, policy review, police report review, family interview and staff interview, the facility failed to ensure Resident #100 was free from sexual abuse. This affected one of three residents reviewed for abuse. The facility census was 60. Findings Include: Resident #100 was admitted to the facility on [DATE] with diagnoses that included epilepsy, major depressive disorder, anxiety disorder and [NAME]-[NAME] syndrome. Review of the most recent quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #100 was moderately cognitively impaired and required extensive assistance of two staff persons for completing her activities of daily living (ADLs). [...]

Inspectors wroteBased on record review,staff interview, and facility policy review, the facility failed to ensure it implemented its abuse policy related to an incident of potential sexual abuse against Resident #100. This affected one (Resident #100) of three residents reviewed for abuse. This had the potential to affect all residents. The facility census was 60. Findings Include: Resident #100 was admitted to the facility on [DATE] with diagnoses that included epilepsy, major depressive disorder, anxiety disorder and [NAME]-[NAME] syndrome. Review of the most recent quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #100 was moderately cognitively impaired and required extensive assistance of two staff persons for completing her activities of daily living (ADLs). [...]

Inspectors wroteBased on review of facility self-reported incidents (SRIs) ,medical record review and staff interview the facility failed to ensure a complete and accurate medical record for residents. This affected two (Residents #100 and #101) of three residents reviewed for accuracy of medical records. The facility census was 60. Findings Include: Resident #100 was admitted to the facility on [DATE] with diagnoses that included epilepsy, major depressive disorder, anxiety disorder and [NAME]-[NAME] syndrome. Review of the most recent quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #100 was moderately cognitively impaired and required extensive assistance of two staff persons for completing her activities of daily living (ADLs). [...]

Inspectors wroteBased on observation, interview and policy review, the facility failed to ensure a clean and sanitary kitchen environment including labeling and dating food, discarding expired food and appropriate monitoring of the low-temperature dish machine. This had the potential to affect 53 residents receiving food from the kitchen as four residents (Residents #2, #7, #47 and #54) received nothing-by-mouth (NPO). Facility census was 57.

Inspectors wroteBased on observation, interview and facility policy review, the facility failed to ensure trash including biohazardous waste was collected and stored appropriately. This had the potential to affect all 57 residents residing in the facility.

Inspectors wroteBased on observation, interview, record review and facility document review, the facility failed to ensure washing machines hit minimum required temperatures for hot water processing. These findings had the potential to affect all 57 residents within the facility.

Inspectors wroteBased on observation, interview and review of the menu and spreadsheet, the facility failed to ensure foods were served in appropriate quantities. This affected 49 residents receiving food from the kitchen as four residents (#2, #7, #47, #54) were ordered nothing-by-mouth (NPO) and four additional residents (#12, #31, #43 and #56) were scheduled to receive a different entree at the meal as they were on a regular No Added Salt (NAS) diet. Facility census was 57.

Inspectors wroteBased on record review and interview, the facility failed to ensure an allegation of misappropriation of property was reported to the State agency. This affected one (Resident #6) of five residents reviewed for abuse and misappropriation. The facility census was 57.

Inspectors wroteBased on review of personnel files, review of facility policy and interviews with staff, the facility did not ensure all employees were checked against the nurse aide registry (NAR) and had evidence of Bureau of Criminal Investigation (BCI) checks. This had the potential to affect all 61 residents residing in the facility. The facility census was 61. Findings Include: Review of employee personnel files revealed the following: Review of the personnel file for Dietary Manager (DM) #601, hire date of 01/02/24, revealed no evidence of a check against the nurse aide registry (NAR). Review of the online Ohio NAR for DM #601 revealed no findings for DM #601. Review of the personnel file for Employee #834, hired in December 2023 into the position of nurse, revealed no evidence of a criminal background check. [...]

Inspectors wroteBased on observations, resident interviews, staff interviews, review of the activity calendars and facility policy, the facility failed to ensure an adequate number and variety of therapeutic activities were being provided to meet the needs and preferences of the residents. This had the potential to affect all 61 residents residing in the facility. The facility census was 61.

Inspectors wroteBased on personnel record review, staff interview and review of the facility activity director job description, the facility failed to ensure a qualified professional was in place to act as the activity director and direct the facility's activity program. This had the potential to affect all 61 residents residing in the facility. The facility census was 61.

Inspectors wroteBased on observation of a test meal tray, resident interviews, staff interviews and facility policy review, the facility failed to serve hot, palatable, and visibly pleasing foods. This had the potential to affect all residents, except Residents #2, #8, #11, #49, and #60, who were identified by the facility a consuming nothing by mouth (NPO). The facility census was 61.

Inspectors wroteBased on personnel record review, review of the job description for social services director and staff interview the facility failed to employ a full-time Licensed Social Worker (LSW). This had the potential to affect all residents residing in the facility. The facility census was 61.

Inspectors wroteBased on observation, staff interviews, and review of a police report, the facility failed to ensure all door locks in the facility kitchen properly worked to maintain a safe and secure environment at all times. This affected all 61 residents residing in the facility. The facility census was 61.

Inspectors wroteBased on observation, resident interviews, staff interviews, and facility policy review, the facility failed to maintain a safe, clean, comfortable and sanitary environment in resident rooms affecting 17 Residents (#16, #39, #55, #25, #44, #51, #21, #3, #4, #6, #8, #9, #49, #58, #17, #57 and #56), and failed to maintain the second floor shower room in a safe, clean and sanitary manner which had the potential to affect an additional 21 residents living on the second floor (#1, #2, #5, #7, #10, #11, #13, #14, #18, #19, #22, #23, #24, #27, #28, #29, #30, #33, #38, #40, and #48.). The facility census was 61.

Inspectors wroteBased on observation, staff interview, and record review, the facility failed to ensure urinary catheter drainage bags were covered for privacy and did not eminate a strong odor of urine that could be smelled in the room and into the hallway and therefore traced to Resident #2's room. This affected one resident (#2) of one resident reviewed for urinary catheters.

Inspectors wroteBased on record review, review of the facility policy and staff interview, the facility failed to ensure Resident #17's care plan was revised to reflect accurate advanced directives ordered by the physician as decided by the resident representatives. This affected one resident (#17) of three residents reviewed for accurate care plans. The facility census was 61.

Inspectors wroteBased on record review, observation and interview, the facility did not ensure Resident #14 was appropriately supervised by two staff while being transferred using a mechanical lift. This affected one resident (#14) of three residents reviewed for hazard risks. The facility census was 61.

Inspectors wroteBased on resident record review, family interview, staff interviews, and review of the facility hospice contract, the facility failed to ensure hospice services were implemented in a timely manner. This affected one resident (#43) of three residents reviewed for hospice services. The facility census was 61.

Inspectors wroteBased on observation, staff interview, and record review, the facility failed to ensure the urinary cathetar drainage bag for Resident #2 was not sitting uncovered and directly on the floor exposing the bag to a source of contamination and potential infection. This affected one resident (#2) of one resident reviewed for urinary catheters. The facility census was 61.

Inspectors wroteBased on record review and interview the facility failed to ensure accurate advance directives for Resident #35. This affected one resident (#35) of two residents reviewed for advanced directives. The facility census was 60.

Inspectors wroteBased on record review and interview, the facility failed to provide the hospital with information on Resident #115's background and current condition. This affected one resident (#115) of three residents reviewed for hospitalization. The facility census was 60.

Inspectors wroteBased on record review and interview, the facility failed to ensure Resident #115's care plan was updated to include accurate information. This affected one resident (#115) of three residents reviewed for care plans. The facility census was 60.

Inspectors wroteBased on observation, record review, interview, and facility policy review the facility failed to ensure Resident #15's oxygen was administered as ordered. This affected one (#15) of three residents reviewed for physician's orders. The facility census was 60.

Inspectors wroteBased on record review and interview, the facility failed to ensure behaviors were monitored in conjunction with the use of psychotropic medications. This affected one resident (#49) of five residents reviewed for unnecessary medications. The facility census was 60.

Inspectors wroteBased on observation and interview, the facility failed to maintain a homelike physical environment. This had the potential to affect all residents residing in the facility. The facility census was 62.

Inspectors wroteBased on closed record review, review of a facility fall investigation, hospital record review, facility policy and procedure review and interviews, the facility failed to provide Resident #06 with necessary and an appropriate level of assistance with bed mobility during incontinence care resulting in the resident falling out of bed. In addition, the facility failed to thoroughly investigate the fall to determine the root cause to identify potential hazards to reduce and/or eliminate falls with major injury. Actual Harm occurred on 08/28/23 when State Tested Nursing Assistant (STNA) #400 was providing incontinence care to Resident #06 without the appropriate level of assistance, the resident rolled out of bed and fell to the floor. Following the incident, the resident was transported to the hospital and diagnosed with a right distal femur fracture which required surgical intervention. [...]

Inspectors wroteBased on observation, resident interview, staff interview, record review, and review of the facility policy, the facility failed to ensure an indwelling urinary catheter was stabilized and maintained in a manner to prevent urinary tract infection (UTI). This affected one resident (#3) of one resident reviewed for an indwelling urinary catheter. The facility census was 61.

Inspectors wroteBased on medical record review, observation, resident interview, staff interview, and review of the policy, the facility failed to ensure infection control was maintained for oxygen tubing, by storing nasal cannula's and tubing to prevent contamination and changing oxygen tubing as needed. In addition, the facility failed to ensure a physician's order was in place prior to administering oxygen. This affected one (#3) of one resident reviewed for oxygen. The facility census was 61.

Inspectors wroteBased on observation, record review and interview, the facility did not ensure sufficient staff to meet the needs of all residents during dining. This finding affected nine residents (Residents #12, #13, #59, #62, #73, #112, #114, #130 and #146) and had the potential to affect all 140 residents currently residing in the facility.

Inspectors wroteBased on observation, record review, test tray, and interview the facility failed to serve food at appropriate and palatable temperatures and taste for Resident #13, #58, #73 and Resident #130. This affected four residents and had the potential to affect all 140 residents residing in the facility receiving meals/food from the kitchen.

Inspectors wroteBased on record review, observation and interview the facility failed to ensure Resident #62 was treated with dignity/respect after her morning meal. This affected one of two residents reviewed for dignity and respect.

Inspectors wroteBased on interview and record review, the facility failed to ensure Resident #34 received timely and appropriate notice of non-coverage when skilled Medicare services ended. This affected one of three residents reviewed for beneficiary protection notification.

Inspectors wroteBased on record review and interview, the facility failed to ensure comprehensive assessments were accurate for Resident #45, Resident #73 and Resident #140. This affected three of 35 residents reviewed for accurate assessments.

Inspectors wroteBased on observation, interview and record review the facility failed to provide timely assistance for Resident #13 and Resident #130, who were dependent on staff to eat meals. This affected two of two residents reviewed for Activities of Daily Living (ADL) assistance. The facility census was 141.

Inspectors wroteBased on observation, record review and interview, the facility failed to assess and monitor Resident #73's head laceration (cut). This finding affected one (Resident #73) of three residents reviewed for accidents.

Inspectors wroteBased on record review and interview, the facility failed to ensure Resident #31's pressure wound care was completed as ordered by the physician. This finding affected one of four residents reviewed for pressure ulcers.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents and/or the resident's representative were properly notified in writing when a resident was discharged to the hospital in an easily understandable language. This affected four residents (Resident #1, Resident #20, Resident #31, and Resident #146) out of four residents reviewed for hospitalization.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents and/or the resident representatives were notified in writing of the facility bed hold policy. This finding affected four residents (Resident #1, Resident #20, Resident #31, and Resident #146) out of four residents reviewed for hospitalization.