King David Post Acute Nursing & Rehabilitation LLC

Inspectors wroteBased on observation and interview, the facility failed to maintain a safe physical environment by using unapproved electric coiled space heaters for heating. This had the potential to affect an unidentified number of residents residing on eight resident units who utilized the exit corridors, dining areas and nurses' workstations. The facility census was 267.

Inspectors wroteBased on observation, interview, record review, drug package insert review, prescribing information review and review of the facility policy, the facility did not ensure residents were administered medications free of medication error rate of five percent or less. This affected two (Residents #171 and #173) out of six residents observed for medication administration. The facility census was 243.

Inspectors wroteBased on closed record review, review of emergency medical services (EMS) run report, review of a facility incident report, staff interviews, and facility policy review, the facility to ensure cardiopulmonary resuscitation (CPR) was initiated immediately and performed appropriately following Resident #271, a resident with a Full code status (indication for healthcare providers to perform all possible life saving measures in the event of a cardiac or respiratory arrest) was found unresponsive. This affected one resident (#271) of three residents reviewed for advance directives. The facility identified 178 residents who had an advance directive of a full code. The facility census was 270.

Inspectors wroteBased on observation, test tray and interviews, the facility failed to ensure meals were served at a safe and palatable temperature. This had the potential to affect all residents who received meals from the facility except for six residents (#1, #2, #101, #212, #240, and #261) identified by the facility as having orders for nothing by mouth (NPO). The facility census was 259.

Inspectors wroteBased on record review, observation, interview and facility policy review, the facility failed to ensure the call light was within reach for Resident #173. This affected one resident (#173) of 15 residents on the 200-hall of the Beachwood unit and had the potential to affect all 259 residents residing in the facility.

Inspectors wroteBased on record review, interview, self-reported incident (SRI) review and facility policy review, the facility failed to ensure Resident #286 was free from physical abuse by Residents #259 and #201 and failed to ensure Resident #106 was free from physical abuse by Resident #275. This affected two (Residents #286 and #106) of eight residents reviewed for abuse and had the potential to affect all residents. The facility census was 259.

Inspectors wroteBased on record review, interview, self-reported incident (SRI) review and facility policy review, the facility failed to ensure allegations of resident-to-resident physical abuse were reported to the State Agency within two hours as required. This affected four (Residents #106, #259, #275 and #286) of eight reviewed for abuse and had the potential to affect all residents. The facility census was 259.

Inspectors wroteBased on record review, interview, self-reported incident (SRI) review and facility policy review, the facility failed to ensure incidents of resident-to-resident incident physical abuse were thoroughly investigated. This affected four (Residents #106, #259, #275 and #286) of eight residents reviewed for abuse and had the potential to affect all residents. The facility census was 259.

Inspectors wroteBased on record review, observation, interview and review of the facility policy, the facility failed to ensure residents dependent on staff for activities of daily living (ADL) received assistance for feeding and showers as ordered, recommended per therapy and/or per preference. This affected two residents (#8 and #195) out of four residents reviewed for resident's dependent on ADL care on the [NAME] unit. This had the potential to affect four residents (#91, #107, #185, and #195) that required feeding assistance, and all 31 residents (#8, #33, #45, #61, #89, #91, #93, #102, #104, #107, #143, #146, #155, #181, #185, #187, #192, #194, #195, #198, #199, #200, #203, #213, #229, #231, #233, #249, #252, #267, and #292) that the facility identified requiring assistance with showers on the [NAME] unit. The facility census was 259.

Inspectors wroteBased on record review, observation and interview, the facility failed to ensure Resident #201 was offered activities to meet her preferences. This affected one resident (#201) of three residents reviewed for activities. The facility census was 259.

Inspectors wroteBased on record review and interview, the facility failed to ensure a change in condition was thoroughly addressed and vital signs were obtained as ordered. This affected two residents (#93 and #278) of three residents reviewed for change in condition. The facility census was 259.

Inspectors wroteBased on record review, observation, interview and facility policy review, the facility failed to ensure fall interventions were in place and falls were thoroughly investigated. This affected one resident (Resident #259) of three reviewed for falls and orders. The facility census was 259.

Inspectors wroteBased on record review, observation, interview and review of facility policy, the facility failed to ensure oxygen tubing was dated when changed and proper signage on the entrance to a resident's rooms indicating oxygen was in use. This affected two residents (#45 and #93) out of two residents reviewed for respiratory needs. This had the potential to affect 16 additional residents (#2, #13, #27, #60, #79, #85, #101, #105, #122, #170, #177, #185, #193, #231, #242, and #272) identified by the facility as using oxygen. The facility census was 259.

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on interview and record review the facility failed to ensure Resident #7 was provided with reliable transportation to and from dialysis. This affected one resident (#7) of two residents reviewed for transportation. The facility census was 295.

Inspectors wroteBased on record review, interviews and facility policy review, the facility failed to adequately provide trauma-informed care to Residents #8 and #74. This affected two residents (#8 and #74) out of two residents reviewed for trauma-informed care. This had the potential to affect four residents (#8, #74, #81, and #157) identified by the facility with a diagnosis of post-traumatic stress disorder (PTSD). The facility census was 259.

Inspectors wroteBased on record review, interview, observation and review of facility policy, the facility failed to ensure medical records were accurate and/or legible. This affected two residents (#8 and #91) out of 44 resident records reviewed for accuracy and/or identifiable information. The facility census was 259.

Inspectors wroteBased on closed record review, and interview, the facility failed to ensure Resident #284 was permitted to return to the facility after being transferred to the emergency room due to an acute change in condition. This affected one resident (#284) of one resident reviewed for hospitalization. The facility census was 283.

Inspectors wroteBased on observation, interview, record review, review of the label directions on the cleaning wipes and review of the facility policy, the facility failed to ensure proper cleaning of a blood glucose meter while checking resident blood sugar levels. This affected two residents (Resident #127 and #271) and had the potential to affect an additional 28 residents (Resident #5, #31, #36, #46, #49, #51, #58, #61, #81, #85, #92, #116, #124, #145, #148, #152, #163, #186, #195, #230, #242, #245, #254, #261, #272, #273, #275, and #276) who received blood glucose level checks via a glucometer. The facility census was 277.

Inspectors wroteBased on interview, record review, and review of the facility policy, the facility failed to ensure Resident #138's physician and responsible party was notified of a change in condition. This affected one resident (Resident #138) of three residents reviewed for a change in condition. The facility census was 277.

Inspectors wroteBased on observation, interview, record review, and review of the facility policy, the facility failed to timely assess and provide wound care for Resident #138. This affected one resident (Resident #138) of three residents reviewed for incontinence care. The facility census was 277.

Inspectors wroteBased on medical record review, interview, review of a video recording, review of the facility investigation report, and review of the facility policy, the facility failed to administer Resident #85 and Resident #155's medications per physician orders. This affected two residents (Resident #155 and #85) of three residents reviewed for pharmacy services. The facility census was 277.

Inspectors wroteBased on medical record review, observation, staff interview, and review of the facility policy, the facility failed physician orders were followed and the medication error rate did not exceed five percent (%). The facility had four medication errors of 30 opportunities for an error rate of 13.33%. This affected three residents (Resident #8, Resident #127, and Resident #271) of nine residents observed for medication administration. The facility census was 277 residents.

Inspectors wroteBased on observation, interview and policy review, the facility failed to ensure resident meals were palatable. This had the potential to affect 261 of 261 residents who received meal trays from the kitchen with the exception of three residents (#99, #182, #204) who the facility identified as receiving no food by mouth (NPO). The facility census was 264.

Inspectors wroteBased on observation, review of the job descriptions, review of the employee handbook, and interviews, the facility failed to have systems in place to ensure it was administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Administrative staff failed to ensure staff did not sleep while on duty, failed to ensure staff did not have and/or utilize phones for personal use in resident care areas of the facility and failed to ensure the kitchen dishwasher was utilized timely after repairs to ensure meals were not served on disposable plates resulting in food being served from the kitchen that was not palatable. [...]

Inspectors wroteBased on observations, staff interviews, and review of the employee handbook, the facility failed to ensure residents were free from potential neglect when staff were sleeping while on duty. This had the potential to affect all 35 residents (#17, #27, #35, #47, #56, #62, #70, #76, #83, #92, #98, #102, #109, #120, #129, #131, #142, #143, #147, #150, #151, #161, #163, #165, #198, #213, #219, #221, #229, #231, #232, #233, #236, #246, #250) residing on the Beachwood Pavilion unit and the potential to affect all 55 residents (#3, #4, #11, #13, #18, #19, #20, #34, #36, #37, #42, #46, #54 #63, #66, #84, #86, #91, #94, #95, #99, #101, #103, #110, #113, #119, #123, #124, #126, #128, #133, #154, #156, #158, #160, #166, #168, #169, #172, #179, #181, #185, #187, #194, #199, #201, #202, #205, #210, #218, #227, #234, #238, #252, #262) residing on the Euclid Pavilion Unit. The facility census was 264.

Inspectors wroteBased on observation, record review, review of the facility policy, review of the Centers for Medicare and Medicaid (CMS) directive related to Enhanced Barrier Precautions (EBP) and interview, the facility failed to develop and implement an effective infection control program to ensure enhanced barrier precautions (EBP) were maintained while wound care was performed for Resident #67. This affected one resident (#67) of three residents reviewed for wound care. The facility census was 264.

Inspectors wroteBased on closed medical record review, review of a facility fall investigation, hospice staff interview, review of a hospice electronic mail (e-mail) correspondence, staff interview and review of facility policy, the facility failed to ensure physician ordered fall interventions were implemented and further failed to accurately report assessment findings and timely notify the attending physician and resident representative following a fall. Actual harm occurred on 09/15/24 at 11:00 P.M. when Resident #280, who was assessed to be at high risk for falls, sustained a fall from bed onto the floor without a physician ordered fall mat in place sustaining a fractured right clavicle (collarbone) and fracture at the sixth and seventh ribs. At the time of the fall, nursing staff assessed the resident and identified Resident #280 had limited range of motion (ROM) to her upper extremities and pain. [...]

Inspectors wroteBased on observation, staff interview and review of facility policy, the facility failed to ensure the nursing unit kitchenettes were maintained in a clean and sanitary manner. This had the potential to affect all residents except two (#105 and #193) who received nothing by mouth and 34 residents (#2, #8, #24, #30, #40, #46, #54, #64, #76, #78, #111, #116, #131, #132, #136, #138, #140, #150, #154, #155, #159, #177, #185, #195, #216, #221, #222, #225, #226, #232, #249, #255, #265 and #269) who resided on the [NAME] nursing unit. The facility census was 276.

Inspectors wroteBased on observation, staff interview, review of the dishwasher temperature log, service manager interview, and review of the manufacturer's brochure for the facility's dishwasher, the facility failed to ensure the dishwasher reached the minimum required temperature for proper dish sanitization. This had the potential to affect all but three residents (Residents #113, #203, and #293) who received meals prepared and served by the facility. The facility census was 288.

Inspectors wroteBased on observation, resident interview, staff interview, and review of the employee handbook, the facility failed to ensure staff did have personal conversations, which included yelling into their phones, in resident rooms. not talk on their phone in resident care areas of the facility. This affected one (#294) out of four residents observed for staff -to-resident interactions. The facility census was 288.

Inspectors wroteBased on medical record review, observation and staff interview, the facility failed to maintain wheelchairs and durable medical equipment in a clean and sanitary manner one (#120) out of three residents who used a wheelchair for mobility. The facility census was 288.

Inspectors wroteBased on observation, record review, staff interview, resident interview and review of facility policy, the facility failed to ensure pressure ulcer treatments were provided as ordered for one (#105) out of three residents reviewed for wounds. The facility census was 288.

Inspectors wroteBased on observation, interview, record review, and facility policy review the facility failed to ensure staff treated Residents #68 and #126 with respect and dignity. This affected two residents (#68 and #24) of ten residents reviewed for dignity and respect. The facility census was 276.

Inspectors wroteBased on interview and record review the facility failed to notify Resident #281 or the resident's representative before a transfer to another room. This affected one resident (#281) of three residents reviewed for room changes. The facility census was 276.

Inspectors wroteBased on record review, interview, and observation the facility failed to provide wound care according to physician's orders for Resident #68. This affected one resident (#68) of three residents reviewed for wound management. The facility census was 276.

Inspectors wroteBased on observation, record review, interview, and facility policy review the facility failed to provide routine indwelling urinary catheter care and failed to have indwelling urinary catheter care orders in place for Resident #68. This affected one resident (#68) of three residents reviewed for indwelling urinary catheters. The facility census was 276.

Inspectors wroteBased on record review, interview, and facility policy review the facility failed prevent a significant medication error when Resident #38, who was being treated for chronic pain, did not receive pain medication as ordered by the physician. This affected one resident (#38) of four residents reviewed for medication administration. The facility census was 276.

Inspectors wroteBased on observation, record review, interview, and facility policy review the facility failed to ensure medications were always secure form unauthorized access. This affected one resident (#162) of 29 residents identified to receive medications on the involved nurse's assignment. The facility census was 276.

Inspectors wroteBased on observation, staff interview, resident interview, and review of the facility policy, the facility failed to ensure residents received clean silverware with meals. This affected five (Residents #42, #183, #215, #261, and #261) of five residents observed for meal service. The facility census was 266 residents.

Inspectors wroteBased on observation, interview, record review and review of facility policy the facility failed to ensure call lights were answered in a timely manner and failed to ensure staff was not taking personal phone calls while a resident was waiting for assistance. This affected three residents (#285, #116, and #139) out of five residents reviewed for call light response and had the potential to affect all residents residing in the facility. The facility census was 285.

Inspectors wroteBased on record review, staff interview, and facility policy review the facility failed to ensure to obtain Pedialyte (oral electrolytes) ordered by the physician for Resident #226's resulting in nursing staff having to pay for the product with their own money. In addition, the facility failed to notify the physician when Pedialyte was unavailable, and staff were substituting it with Powerade. This affected one resident (#226) of five residents reviewed for dietary services. The facility census was 285.

Inspectors wroteBased on interview, observation, record review, review of manufacture guidelines, facility policy review, and review of the facility Caregiver Safety Tips for use of a mechanical lift (device used to move a resident from one place to another)/ sling revealed the facility failed to ensure Resident #280's mechanical lift sling was properly examined prior to transferring resulting in the sling strap breaking and Resident #280 falling to the floor. The facility also failed to complete a thorough nursing assessment prior to Resident #280 being transferred back to bed, the mechanical lift slings were properly laundered, and a thorough investigation was completed of the incident. This affected one resident (#280) of three residents reviewed for falls. The facility census was 285.

Inspectors wroteBased on observation, interview, record review, and review of facility policy revealed the facility failed to ensure Resident #285's incontinence care was completed in a timely manner, did not place soiled linen and incontinence briefs (a product that holds urine or bowel movement) on the floor and that Resident #285 did not have two incontinence briefs applied at once. This affected one resident (#285) out of three residents reviewed for incontinence care. This had the potential to affect 50 residents (#20, #23, #26, #37, #38, #47, #48, #57, #60, #67, #72, #89, #91, #95, #119, #133, #135, #136 #138, #143, #150, #151, #155, #160, #169, #171, #189, #193, #195, #210, #213, #216, #217, #219, #221, #222, #233, #238, #246, #247, #248, #254, #257, #264, #274, #275, #278, #280, #282, and #285) on the Fairmount Unit that were identified as incontinent. The facility census was 285.

Inspectors wroteBased on observation, interview, record review, and review of facility policy the facility failed to ensure oxygen cylinders was secured safely and failed to ensure residents had oxygen signs indicating oxygen was in use upon entrance to their rooms. This affected three residents (#51, #193, and #262) out of four residents reviewed for oxygen use. This had the potential to affect 38 residents (#1, #6, #10, #17, #19, #25, #35, #38, #44, #71, #83, #99, #105, #115, #117, #130, #140, #148, #150, #155, #193, #194, #195, #199, #200, #205, #210, #211, #213, #219, #225, #241, #242, #243, #258, #261, #262, and #283) with orders for oxygen. The facility census was 285.

Inspectors wroteBased on observation, interview, record review, review of facility policy and clinical pharmacology guidelines and manufacture insulin pen guidelines, the facility failed to ensure Resident #264's insulin by route of insulin pen (an injection device that can use to deliver a preloaded insulin subcutaneously (under the skin)) was administered in a safe manner according to the guidelines. This affected one resident (#264) out of three residents observed for insulin administration. This had the potential to affect 47 Residents (#4, #5, #14, #17, #34, #55, #57, #65, #66, #68, #75, #87, #89, #91, #93, #101, #102, #107, #117, #122, #123, #128, #136, #138, #144, #147, #156, #160, #177, #183, #187, #188, #189, #203, #206, #212, #224, #228, #234, #253, #255, #264, #274, #277, #279, #284, and #285) that had physician orders for insulin. The facility census was 285.

Inspectors wroteBased on record review and interview, the facility failed to ensure assessments were accurately completed. This affected four (Residents #77, #110, #217 and #281) of 42 residents reviewed for Minimum Data Set (MDS) 3.0 assessments. The facility census was 318.

Inspectors wroteBased on record review, interview, and policy review the facility failed to ensure medical records were accurate and complete. This affected four residents (#28, #43, #179 and #317) of 42 residents reviewed for accurate medical records. The facility census was 318.

Inspectors wroteBased on observation, interview, record review, and policy review the facility failed to ensure Resident #764's call light was within reach and Resident #666's bed was of a comfortable length. This affected two of three residents reviewed for accommodation of needs, Residents #764 and #666. The facility census was 318.

Inspectors wroteBased on interview, record review, and policy review the facility failed to report an allegation of misappropriation to the state survey agency in a timely manner. This affected one resident (Resident #21) of three residents investigated for concerns related to abuse (Resident #21, Resident #110 and Resident #217) The facility census was 318.

Inspectors wroteBased on interview, record review, and policy review the facility failed to thoroughly investigate an allegation of misappropriation. This affected one resident (Resident #21) of three residents investigated for concerns related to abuse (Resident #21, Resident #110 and Resident #217) The facility census was 318.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure proper infection control measures were maintained throughout a wound care dressing change to promote healing of the wound. This affected one resident (Resident #296) out of eight residents reviewed for wound care. The facility census was 306.

Inspectors wroteBased on observation, interview and review of the facility policy the facility failed to ensure residents performed hand hygiene to prevent cross contamination of germs during Resident #16's and Resident #17's medication administration, Resident #23's perineal care and Resident #31's mechanical lift transfer. This affected two residents (Resident #16 and #17) out of six residents observed for medication administration, one resident (Resident #23) out of two residents observed for perineal care and one resident (Resident #31) out of one resident observed for mechanical lift transfer. The facility census was 317.

Inspectors wroteThe facility failed to ensure Resident #34's skin treatment was applied to prevent development of skin breakdown. This affected one resident (Resident #34) out of two residents observed for incontinence care. The facility census was 317.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure staff secured Resident #24's, Resident #29's, and Resident #33's medications. This affected three residents (Resident #24, Resident #29, Resident #33) out of six residents observed for medication administration.

Inspectors wroteBased on observation, staff interview, and facility policy review the facility failed to ensure the kitchen was clean and sanitary, food items were dated when opened, there were internal thermometers for reach in freezers and refrigerators, microwaves in the kitchenettes were clean, and cross contamination did not occur when taking the temperatures of food items or when placing lids over the plates of food. This had the potential to affect all residents receiving food from the facility kitchen. The facility identified five residents (#111, #142, #209, #657, and #663) that received no food by mouth. The facility census was 309.

Inspectors wroteBased on observations, interview, and record review the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. This affected one resident (#33) of one resident reviewed for choices. The facility census was 309.

Inspectors wroteBased on interviews, record review, and facility policy review the facility failed to ensure fluid restrictions were being monitored for four residents (#98, #232, #233, and #270) out of four residents reviewed for fluid restriction. The facility identified eleven residents (#98, #161, #232, #233, #256, #259, #266, #270, #307, #631, and #651) on a fluid restriction. The facility census was 309.

Inspectors wroteBased on record review and staff interview the facility failed to notify the appropriate state agency (The Ohio Department of Mental Health) of a significant change in a resident's mental health condition as required. This affected one resident (#91) of one resident reviewed for preadmission screening and resident review (PASARR). The facility census was 309. Findings Include: Medical record review revealed Resident #91 was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (COPD), rheumatoid arthritis, hypertension (high blood pressure), and major depressive disorder. Review of the psychiatric consult note for Resident #74, dated 11/02/22, revealed Resident #91 was given a diagnosis of schizoaffective disorder. This diagnosis was reflected and dated as such throughout Resident #91's medical record. [...]

Inspectors wroteBased on observation, interview, record review, and facility policy review the facility failed to date or change oxygen tubing for Residents #188 and #255 and failed to have a physician order for oxygen administration for Resident #188. This affected two residents (#188 and #255) of two residents reviewed for oxygen therapy. The facility census was 309.

Inspectors wroteBased on record review, interview, and facility policy review the facility failed to ensure Resident #270 was assessed and monitored for complications after hemodialysis treatments and failed to provide proof of ongoing communication and collaboration with the dialysis facility. This affected one resident (#270) of one resident reviewed for hemodialysis. The facility census was 309.

Inspectors wroteBased on record review, interview, and facility policy review the facility failed to ensure medical records were complete and accurate. This affected one resident (#278) of three reviewed for accurate medical records. The facility census was 309.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure staff used appropriate infection control practices, including hand washing and use of gloves during wound care for Resident #61 and intravenous medication administration for Resident #641. This affected one resident (#61) of six residents reviewed for wounds, and one resident (#641) of two residents reviewed for intravenous medication administration. The census was 309.