Inniswood Health and Rehabilitation

Inspectors wroteBased on observation, resident interview, and staff interview, the facility failed to ensure hot water temperatures were provided to residents to maintain a homelike environment. This affected seven (#8, #21, #25, #64, #70, #85, and #90) of seven residents observed for water temperatures on the 400 and 500 hallway. The census was 86.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to timely report an allegation of involuntary seclusion. This affected one, (Resident #94) of one resident reviewed for abuse. The facility census was 87.

Inspectors wroteBased on observation, record review, and staff interview, and facility policy review, the facility failed to ensure appropriate transmission based precautions (TBP) were maintained for Residents #28 and #14. This had the potential to affect all 17 residents residing on the 100 hall. Additionally, the facility failed to ensure acceptable infection control practices were maintained while administering medications to Resident #36. This affected one resident (#36) of four residents reviewed for medication administration. The facility census was 74.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Resident #52 was appropriately covered to maintain dignity and privacy. This affected one Resident (#52) of three residents reviewed for dignity. The facility census was 74.

Inspectors wroteBased on observation, resident interview, staff interview and record review, the facility failed to place a call light button in a location where Resident #16 was able to utilize the call light. This affected one resident (#16) out of seven residents reviewed for call light placement. The facility census was 74.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide nail care for one resident (#32) out of four residents reviewed for activities of daily living (ADLs). The facility census was 74.

Inspectors wroteBased on observation, interview, record review, review of facility policy, and review of the National Pressure Injury Advisory Panel recommendations, the facility failed to ensure interventions to prevent the development or decline of pressure ulcers were in place. This affected two residents (#16 and #228) out of three residents reviewed for pressure ulcers during the annual survey. The facility census was 74.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure care and services to prevent the worsening of contractures were provided. This affected one resident (#23) out of four residents reviewed for limited range of motion. The facility census was 74.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure tube feeding solution was administered at the rate ordered by the physician and failed to ensure placement and residual were verified prior to using Resident #228's gastrostomy tube. This affected one resident (#228) out of one resident reviewed for gastrostomy tubes. The facility census was 74.

Inspectors wroteBased on medical record review, observation, and staff interview, the facility failed to ensure the medication error rate did not exceed five percent (%). The facility had seven errors out of 37 opportunities for a medication error rate of 18.9%. This affected one resident (#228) of four residents reviewed for medication administration. The facility census was 74.

Inspectors wroteBased on record review, staff interview, and facility policy review, the facility failed to ensure antibiotics were not administered unnecessarily for two residents (#17 and #26) out of three residents reviewed for urinary tract infections. The facility census was 74.

Inspectors wroteBased on observations and interviews, the facility failed to ensure daily staffing information was posted for residents and visitors to view. This had the potential to affect all residents residing in the facility. The facility census was 74.

Inspectors wroteBased on staff interview, review of facility self-reported incidents (SRI's), medical record review and review of facility policy, the facility failed to ensure an incident of potential sexual abuse was timely reported to the Administrator and to the state agency. This affected two residents (#36 and #67) of three residents reviewed for abuse. The facility census was 72.

Inspectors wroteBased on staff interview, review of facility self-reported incidents (SRI's), medical record review, and review of facility policy, the facility failed to ensure an incident of potential sexual abuse was thoroughly investigated. This affected two residents (#36 and #67) of three residents reviewed for abuse. The facility census was 72.

Inspectors wroteBased on observations, staff interview, and facility policy review, this facility failed to ensure medication carts were locked at all times unless in use and under direct observation of the medication administration personnel. This had the potential to affect all 26 residents who were noted to be mobile on the 300 and 500 unit. The facility census was 74.

Inspectors wroteBased on medical record review, medication administration observation, staff interviews, and medication administration policy review, the facility failed to ensure an medication error rate of 5% or less when medication that was noted to be delayed release was crushed, or capsule were opened during administration. Medication error rate was 9%. This affected two residents (Resident #6, and #32) of the four residents reviewed for medication administration. The facility census was 74.

Inspectors wroteBased on medication administration observation, staff interview and facility policy review, this facility failed to ensure infection control measures were maintained during medication administration. This affected two residents (Resident #32 and #42) out of the four residents observed during medication administration. The facility census was 74.

Inspectors wroteBased on observation, medical record review, hospital record review, staff, physician and Registered Dietician (RD) interview, review of the Ohio Board of Dietetics (OBD) Standards of Practice in Nutrition Care, contract reviews, and facility policy review, the facility failed to ensure Resident #32, who was identified at nutritional risk, was provided a comprehensive and individualized nutritional plan to include monitoring weights and nutritional status, physician and dietitian notification for weight loss and implementation of nutrition interventions to prevent severe weight loss. This resulted in Immediate Jeopardy and actual harm for Resident #32, who experienced severe weight loss from 09/07/23 to 10/04/23 when she lost 19.9 pounds, representing a weight loss of 10.05% in one month (September to October 2023); [...]

Inspectors wroteBased on observation, medical record review, interviews and facility policy review, the facility failed to implement adequate skin risk interventions for Resident #32 to prevent the development of a pressure ulcer. Actual harm occurred on 08/24/23 when Resident #32, who was re-admitted to the facility on [DATE] with a displaced subtrochanteric fracture of right the femur with surgical repair and required extensive assistance with bed mobility for turning and repositioning developed a deep tissue injury (DTI) (A purple or maroon area of discolored intact skin due to damage of underlying soft tissue. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer, or cooler as compared to adjacent tissue.) to the right heel. The resident reported an increased amount of pain due to the development of the pressure ulcer. [...]

Inspectors wroteBased on record review, staff interview, hospital records review, Hoyer Lift user manual review and facility policy review, the facility failed to ensure Resident #87 was transferred in a safe manner using a mechanical (Hoyer) lift (a mechanical device with a sling used to transfer residents from one place to another). Actual Harm occurred on 10/18/23 when Resident #87, who was dependent on two staff for transfers using a Hoyer lift, sustained a fall out of the lift resulting in a hospitalization and diagnosis of cervicalgia (pain in the neck and shoulders that varies in intensity, and may feel achy or like an electric shock from the neck to the arm) with an order for a cervical collar to be worn at all times for four weeks. The fall occurred as a result of the legs of the lift not being in proper position to accommodate a shift in the resident's weight during the transfer. [...]

Inspectors wroteBased on record review, interviews and facility policy review, the facility failed to provide adequate pain management for Resident #32 following an unwitnessed fall with pain to the right hip. Actual harm occurred on 07/31/23 when Resident #32 who was noted to have chronic hip pain and received scheduled Tylenol, was found on the floor screaming and pointing to her right leg at 4:30 A.M. The resident was assisted back into bed and continued to scream and point to her right leg for an additional two hours before Physician #502 was notified and an order was obtained for an x-ray. Additionally, the resident rated her pain as 7 out of 10 (zero being no pain and 10 being the worst pain possible) and was not given any pain medication until her scheduled Tylenol at 8:00 A.M. [...]

Inspectors wroteBased on observation, record review and staff interview the facility failed to maintain effective pest management. This had the potential to affect all 83 residents.

Inspectors wroteBased on medical record review and staff interview the facility failed to ensure Minimum Data Set (MDS) assessments were accurate to reflect resident care needs. This affected two (Resident #23 and #42) of 21 residents reviewed for accurate MDS assessments. The facility census was 83.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure Pre-admission Screening and Resident Review (PASARR) were accurate regarding resident mental health diagnoses. This affected one (Resident #61) of two residents reviewed for PASARR. The facility census was 83. Findings Include: Review of the medical record for Resident #61 revealed an initial admission date of 09/26/18 with the diagnoses including starvation, psychosis, adult failure to thrive, congestive heart failure (CHF), non-compliance with medical treatment regimen, dementia with behavioral disturbances, delusional disorder, paranoid personality disorder, altered mental status, gastro-esophageal reflux disease (GERD), visual hallucinations, hypertension, vitamin B deficiency, anxiety disorder, restlessness and agitation, glaucoma, auditory hallucinations, constipation and insomnia. [...]

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure the preadmission screening and record review (PASRR) assessment and referral for level II services were completed. This affected one (Resident #81) of two residents reviewed for PASRR documents. The census was 83. Findings Include: Resident #81 was admitted to the facility on [DATE]. His diagnoses were spinal stenosis, muscle weakness, cervical disc disorder, adjustment disorder with mixed anxiety and depressed mood, generalized anxiety disorder, schizoaffective disorder, osteoarthritis, hypertension, hyperlipidemia, deaf nonspeaking, legal blindness, chronic kidney disease, depression, and insomnia. Review of his Minimum Data Set (MDS) assessment, dated 10/25/23, revealed he had a severe cognitive impairment. [...]

Inspectors wroteBased on medical record review and staff interview, the facility failed to notify the state mental health agency of significant changes in a resident's mental/physical health condition. This affected one (Resident #61) of two Pre-admission Screening and Resident Review (PASARR) documents reviewed. The census was 83. Findings Include: [...]

Inspectors wroteBased on observation, record review and interview the facility failed to ensure a self-releasing wheelchair seatbelt was only used during transportation to workshop for Resident #1. This affected one resident (Resident #1) of one residents reviewed for transportation devices. Findings Include: Review of Resident #1's medical record revealed Resident #1 was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident #1's admitting diagnoses included intellectual disabilities, type two diabetes, and impaired communication. Further review revealed Resident #1 required assistance from staff for activities of daily living (ADL) tasks. Review of Resident #1's signed physician orders revealed Resident #1 may attend workshop on Mondays and Wednesdays. [...]

Inspectors wroteBased on record review and interview the facility failed to follow a physician ordered fluid restriction for Resident #55, who received hemodialysis to promote optimal cardiac and renal outcomes for the resident. The facility also failed to ensure dialysis communication forms were accessible to facility staff for review and reference. This affected one resident (#55) of one resident reviewed for hemodialysis/hydration. The facility census was 83. Findings Include: Review of the medical record for Resident #55 revealed an initial admission date of 03/24/23 and a re-entry date of 11/10/2023. Diagnosis included end stage renal disease, dependence on renal dialysis, and heart disease. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure medication monitoring was completed for the use of antipsychotic medications. This affected one resident (Residents #70) of five residents reviewed for unnecessary medications. The facility census was 83.

Inspectors wroteBased on record review, interviews and facility policy review, the facility failed to ensure one resident's (#32) physician ordered laboratory tests were completed as ordered. This affected one of 11 residents reviewed for nutrition. The facility census was 83. Findings Include: Review of Resident #32's medical record revealed the resident was admitted to the facility on [DATE] with the latest readmission of 08/18/23. Her diagnoses included encephalopathy, need for assistance with personal care, displaced subtrochanteric fracture of right femur, vitamin D deficiency, major depressive disorder, deaf nonspeaking, type II diabetes, mild intellectual disabilities, secondary malignant neoplasm of the breast, acquired absence of left breast and nipple and anxiety disorder. [...]

Inspectors wroteBased on observation and staff interviews, the facility failed to ensure residents were not served food past the use-by date. This had the potential to affect 82 of 82 residents who receive food from the facility kitchen. One resident (Resident #23) receives nothing by mouth. The census was 83.

Inspectors wroteBased on medical record review and staff interview, the facility failed to maintain hospice documentation on-site for resident care. This affected one resident (Resident #2) of one resident reviewed for hospice services. The facility census was 83. Findings Include: Resident #2 was admitted to the facility on [DATE]. Her diagnoses were chronic kidney disease, diabetes, hypertension, hyperkalemia, depression, anxiety disorder, lumbar spina bifida, acquired absence of right and left leg above knee, and glaucoma. Review of her minimum data set (MDS) assessment, dated 12/14/23, revealed she had a significant cognitive impairment. Review of Resident #2's medical records revealed the facility had no hospice notes or orders on site for her. [...]

Inspectors wroteBased on record review and interview, the facility failed to provide evidence of education and administration of pneumonia immunizations. This affected two residents (Resident #35 and #84) of five residents reviewed for immunizations. The facility census was 83. 1. Review of Resident #35's medical record revealed Resident #35 was admitted to the facility on [DATE] with admitting diagnoses including asthma, chronic obstructive pulmonary disease (COPD), depression, high blood pressure, and chronic venous ulcer to lower left leg. Resident #35 required assistance from staff for activities of daily living (ADL) tasks. Review of Resident #35's immunization record revealed Resident #35 declined the Covid-19 immunization, the influenza immunization, and the annual Tuberculosis health questionnaire on 10/04/23. Interview on 01/08/24 at 11:30 A.M. [...]