Kirtland Woods of Journey

Inspectors wroteBased on a review of personnel files, the Social Services Director job description, the Facility Assessment, and staff interviews, the facility failed to employ a qualified full time licensed social worker (LSW) as required. This deficiency had the potential to affect all 58 residents living in the facility.

Inspectors wroteBased on record review and staff interview, the facility failed to notify residents or their responsible parties when resident personal fund accounts reached within $200 of the Medicaid resource limit, as required by regulation. This failure affected four of the six residents reviewed for personal funds (Residents #1, #22, #50, and #59). The facility census was 58.

Inspectors wroteBased on observations, review of the Housekeeping Daily Checklists, staff and resident interviews, and review of facility policies, the facility failed to provide residents with a clean, safe, sanitary, and homelike environment as required. The facility did not ensure Resident #36's room was maintained in a clean condition, as evidenced by a stained window curtain that remained unaddressed despite multiple resident requests and observations by staff. Additionally, the memory care unit dining and common areas were kept clean, sanitary, and properly maintained. This affected one resident (#36) being directly affected out of seven residents reviewed for physical environment and had the potential to impact all 23 residents (#4, #6, #7, #10, #12, #13, #15, #16, #18, #22, #23, #25, #26, #28, #32, #33, #43, #46, #50, #52, #54, #55, and #58) in the memory care unit. The facility census was 58.

Inspectors wroteBased on interviews, record review and facility policy, the facility failed to ensure routine care plan conferences were conducted. This affected six residents (#11, #13, #14, #22, #32, #49) out of 25 sampled residents. The facility census was 58.

Inspectors wroteBased on record review, review of the Social Services Director job description and interviews, the facility failed to provide medically related social services necessary for residents to attain or maintain their highest practicable physical, mental, and psychosocial well being. The facility had no Licensed Social Worker (LSW) providing or overseeing required social services for more than five months, resulting in missed care conferences, absence of required resident and representative involvement in care planning and failure to notify residents or representatives when personal fund accounts exceeded Medicaid limits. This affected nine residents (#13, #14, #22, #32, #49, #11, #1, #50, and #59) of 25 sampled residents and had the potential to affect all 58 residents in the facility. The facility's census was 58.

Inspectors wroteBased on observation, record review, policy review, and interview, the facility failed to ensure residents were fed in a dignified manner. This affected one resident (#19) of four residents who were identified as needing assistance with meal intake. The facility census was 58.

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.Based on record review, interview, review the Ohio Department of Health (ODH) Certification, Licensure and Survey System (CALS) website, and review of a facility self-reported incident (SRI) and policy review, the facility failed to prevent staff to resident verbal abuse. This affected one resident (Resident #6) of six residents who were reviewed for abuse. The facility census was 58.

Inspectors wroteBased on record review, observation, interviews and facility policy review, the facility failed to ensure physician orders were followed and dressing changes were performed. This affected one (Resident #35) out of four residents reviewed for pressure and non-pressure skin conditions. The facility census was 58.

Inspectors wroteBased on record review and interview, the facility failed to identify and document individualized trauma triggers and coping mechanisms for a resident with a diagnosed trauma related disorder. This affected one resident (#3) of two residents reviewed for mood/behavior. The facility census was 58.

Inspectors wroteBased on observation, interview, and facility policy review the facility failed to appropriately dispose of biohazardous materials and handle clean and soiled linen to prevent the spread of infection. This affected eight residents (#1, #8, #13, #24, #40, #58, #73 and #77) and had the potential to affect all 103 residents residing in the facility.

Inspectors wroteBased on observation, interview, and facility policy review the facility failed to provide a safe, sanitary, and homelike environment. This affected 48 residents (#3, #6, #7, #8, #13, #15, #16, #17, #19, #21, #23, #24, #27, #31, #32, #34, #35, #37, #38, #39, #42, #44, #46, #47, #49, #51, #55, #58, #59, #74, #75, #76, #77, #78, #79, #80, #81, #82, #83, #84, #88, #89, #92, #93, #95, #97, #100 and #102) and had the potential to affect all 103 residents residing in the facility.

Inspectors wroteBased on observation and interview, the facility failed to provide a private closet space separate from roommates' clothing. This affected 46 residents (#1, #2, #4, #6, #7, #8, #11, #13, #16, #20, #22, #23, #27, #31, #34, #35, #41, #42, #44, #47, #50, #51, #58, #59, #61, #64, #69, #73, #77, #78, #79, #80, #81, #82, #83, #84, #86, #88, #92, #93, #94, #97, #98, #100, #102 and #103) out of 103 resident rooms reviewed for closet space. The facility census was 103.

Inspectors wroteBased on record review, facility self-reported incident (SRI) review, and interview the facility failed to prevent resident-to-resident abuse for residents #41 and #104. This affected two residents (#41 and #104) of three residents reviewed for abuse. The facility census was 103.

Inspectors wroteBased on observation, interview and record review, the facility failed to accurately document fall interventions for Resident #62 and make vaccination documentation readily accessible in the medical record for Residents #97 and #102. This affected three residents (#62, #97 and #102) of 23 medical records reviewed. The facility census was 103.

Inspectors wroteBased on observation and interview, the facility failed to provide an adequate bathroom door for privacy for Resident #25. This affected one resident (#25) of 103 residents whose rooms were observed for privacy. The facility census was 103.

Inspectors wroteBased on observation, interview, and facility policy and procedure review, the facility failed to ensure a clean, sanitary, and homelike environment. This had the potential to affect all 110 residents residing in the facility.

Inspectors wroteBased on observation and interview the facility failed to ensure call lights were within reach at all times. This affected one (Resident #86) of five sampled residents. The facility census was 110.

Inspectors wroteBased on observation, interview and review of facility policy, the facility failed to ensure choices were honored for one (Resident #86) of five residents reviewed for choices. The facility census was 110.

Inspectors wroteBased on observation, interview, and review of the National Weather Service website (forcast.weather.gov) the facility failed to ensure a comfortable and safe ambient temperature for all residents. This affected one of five sampled residents, Resident #73.

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide comprehensive, individualized, and sufficient eye care for Resident #104. This affected one resident (#104) of three residents reviewed for activities of daily living. The facility census was 120. Actual Harm occurred on 04/22/24 when Resident #104, who was admitted on [DATE] with severe cognitive impairment and was known to use contact lenses, developed right eye redness and pain and was diagnosed with conjunctivitis (pink eye) which required antibiotic treatment due to a lack of routine eye care for the resident.

Inspectors wroteBased on observation, record review, policy review and interview the facility failed to provide adequate assistance, supervision and/or assistive devices to prevent falls and consistently implement fall interventions for Resident #57 and Resident #101. Actual harm occurred on 04/14/24 when Resident #57, who was moderately cognitively impaired and required two staff assist with bed mobility, sustained a fall out of bed when being provided hands on care by only one staff member. The resident sustained a right shoulder fracture as a result of the fall. This affected two residents (#57 and #101) of three residents reviewed for falls. The facility census was 120. Findings Include: 1. [...]

Inspectors wroteBased on interview, record review and facility policy review, the facility failed to complete annual nurse aide performance evaluations as required. This had the potential to affect all 120 residents residing in the facility.

Inspectors wroteBased on observation, interview, record review and facility policy review, the facility failed to properly store injectable pharmaceuticals by dating opened containers and failed to maintain clean medication storage refrigerators. This was identified in two of four medication rooms and one of six medication carts which affected one resident (#61) and had the potential to affect all 120 residents residing in the facility.

Inspectors wroteBased on observation and interview, the facility failed to ensure meals were served at palatable temperatures. This affected four residents (#37, #59, #63, and #107) and had the potential to affect all residents receiving food from the kitchen. The facility census was 120.

Inspectors wroteBased on observation, interview and review of the facility policy and procedure, the facility failed to ensure a clean and sanitary kitchen and nursing unit refrigerators. This had the potential to affect all residents. The facility census was 120.

Inspectors wroteBased on record review, staff interview, Centers for Disease Control and Prevention review and facility policy review, the facility failed to complete admission testing for tuberculosis (TB) for Resident #419. This affected one resident (#419) of seventeen residents reviewed for new admissions. In addition, the facility failed to accurately complete the new hire testing for TB on five new employee (Maintenance Director #594, Licensed Practical Nurse (LPN) #591, LPN #571, Human Resource Business Partner (HRBP) #560, and Assistant Director of Nursing (ADON) #504) of 11 new hire personnel files reviewed. This had the potential to affect all 120 residents residing in the facility.

Inspectors wroteBased on observation, interview, and review of the contracted quotes, the facility failed to ensure the washers and dryers were in good repair. This had the potential to affect all residents. The facility census was 120.

Inspectors wroteBased on observation, interview, record review and facility policy and procedure review, the facility failed to ensure a clean, sanitary, and homelike environment. This had the potential to affect all 120 residents residing in the facility.

Inspectors wroteBased on observation and interview, the facility failed to ensure handrails were in good repair. This had the potential to affect all residents. The facility census was 120.

Inspectors wroteBased on record review, interview and facility policy review, the facility failed to complete the required 12 hours of annual training for nurse aides. This had the potential to affect all 120 residents residing in the facility.

Inspectors wroteBased on record review and interview the facility did not ensure Resident Fund Authorizations were witnessed. This affected six of six residents (#41, #63, #76, #83, and #220) whose fund accounts were reviewed. The facility census was 120.

Inspectors wroteBased on observation, interview, record review and review of the Minimum Data Set (MDS) 3.0 Resident Assessment Instrument User's Manual, the facility failed to ensure assessments were completed accurately for Residents #3, #8, #9, #14, #15, #20, #33, #36, #37, #39, #40, #48, #52, #53, #55, #62, #65, #68, #73, #76, #78, #80, #82, #85, #88, #91, #93, #95, #97, #98, #99, #103, #104, #105, #107, #108, #112, #114, #317, #319 and #1070. This affected 41 residents (#3, #8, #9, #14, #15, #20, #33, #36, #37, #39, #40, #48, #52, #53, #55, #62, #65, #68, #73, #76, #78, #80, #82, #85, #88, #91, #93, #95, #97, #98, #99, #103, #104, #105, #107, #108, #112, #114, #317, #319 and #1070) of 42 residents reviewed for resident assessments. The facility census was 102.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to provide residents with a summary of their baseline care plan within 48 hours of admission. This affected four residents (#105, #114, #418, and #419) of 32 residents reviewed for care plans. The facility census was 120.

Inspectors wroteBased on immunization reviews, staff interview, and education review, the facility failed to offer COVID-19 education and vaccination opportunities for five staff members (State Tested Nursing Assistant [STNA] #509, [NAME] #548, Licensed Practical Nurse [LPN] #588, LPN #590, and Registered Nurse [RN] #599) of five staff members reviewed for COVID-19 immunizations. The facility census was 120. Findings Include: 1. STNA #509's date of hire was 08/25/21. COVID-19 immunization dates were 11/18/21 and 12/22/21. No evidence was provided regarding education being provided or if the vaccine was offered when booster doses became available. The status of the immunization was listed as past due. 2. [NAME] #548's date of hire was 03/21/23. No information was provided regarding if the employee had been educated and offered the COVID-19 vaccination. [...]

Inspectors wroteBased on interview, record review and facility policy review, the facility failed to formulate comprehensive care plans to include all necessary goals of care for Residents #21, #37 and #104. This affected three residents (#21, #37 and #104) of 29 residents reviewed for comprehensive care plans. The facility census was 120.

Inspectors wroteBased on staff interview and record review the facility failed to revise Resident #62's care plan in a timely manner. This affected one resident (#62) of 32 residents reviewed for care plans. The facility census was 120.

Inspectors wroteBased on observation, interview, review of the activity log, activity evaluation, and review of the facility policy and procedure, the facility failed to ensure activities were provided consistently according to the care plan and resident preferences for Resident #70. This affected one resident (#70) of three residents reviewed for activities. The facility census was 120.

Inspectors wroteBased on observation, interview, and review of the menu, the facility failed to ensure Resident #70 was served finger food items per physician's orders. This affected one resident (#70) of three residents reviewed for nutrition. The facility census was 120.

Inspectors wroteBased on staff interview, record review and facility policy review, the facility failed to assess residents for influenza or pneumonia immunization status upon admission to the facility. This affected two residents (#104 and #105) of 17 residents reviewed for new admission to the facility. The facility census was 120.

Inspectors wroteBased on interview, record review and facility policy review, the facility failed to implement policy and procedure for the prevention of abuse by not completing job reference checks and documenting timely state nurse aide registry (NAR) checks for new employees. This had the potential affect all 120 residents residing in the facility.

Inspectors wroteBased on observation, record review, interview, facility policy and procedure review, Self-Reported Incident (SRI) review and facility investigation review, the facility failed to ensure residents were properly transferred, as per their plan of care and/or physician's order to prevent actual injury and/or potential injury. Actual Harm occurred on [DATE] when Resident #125 who was dependent on staff for activities of daily living (ADL) and required a mechanical lift (device used to transfer a person from one place to another) of two staff assist for transfers was transferred by only one staff, State Tested Nursing Assistant (STNA) #614 without a mechanical lift from his bed to his wheelchair. The resident was again transferred on [DATE] by STNA #680 and STNA #685 without a mechanical lift from his wheelchair to his bed. [...]

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on observation, record review, review of a facility self-reported incident (SRI), facility policy review and interview, the facility failed to ensure Resident #17 was free from an incident of staff to resident abuse. This affected one resident (#17) of three residents reviewed for abuse prohibition. The total census was 125.

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, review of a facility self-reported incident, facility policy review and interview, the facility failed to effectively implement their abuse policy to prevent and timely report an incident of abuse involving Resident #17. This affected one resident (#17) of three residents reviewed for abuse prohibition. The total census was 125.

Inspectors wroteBased on observation, interview, and facility policy review the facility failed to serve meals at a palatable temperature. This had the potential to affect all residents in the facility. The facility census was 117.

Inspectors wroteBased on interview and record review, the facility failed to have a building-specific legionella assessment in place. This had the potential to affect all 117 residents in the facility.

Inspectors wroteBased on observation, record review, and interview the facility failed to ensure resident rooms were maintained in a sanitary condition and in good repair and failed to ensure the common bathroom on the secured memory care unit (SMCU) was maintained in a sanitary condition. This finding affected one resident (#88) and had the potential to affect an additional 42 residents who reside on the SMCU including Residents #4, #6, #7, #8, #11, #12, #17, #20, #29, #30, #32, #36, #37, #38, #41, #48, #50, #52, #53, #55, #64, #68, #69, #70, #76, #77, #78, #80, #83, #85, #89, #91, #93, #95, #97, #99, #102, #105, #106, #109, #162 and #163.

Inspectors wroteBased on record review, interview, and facility policy review the facility failed to ensure Resident #162 was transferred according to the physician's order and failed to ensure Resident #107's fall investigations were completed to ensure fall prevention interventions were in place as well as new interventions implemented. This finding affected two residents (#107 and #162) of three residents reviewed for transfers and falls. The facility census was 117.

Inspectors wroteBased on observation, record review, interview, and policy review the facility failed to ensure adequate staffing to meet the needs of the residents. This finding affected Residents #99 and #162 and had the potential to affect all 43 residents residing on the secured memory care unit (SMCU) including Residents #4, #6, #7, #8, #11, #12, #17, #20, #29, #30, #32, #36, #37, #38, #41, #48, #50, #52, #53, #55, #64, #68, #69, #70, #76, #77, #78, #80, #83, #85, #88, #89, #91, #93, #95, #97, #99, #102, #105, #106, #109, #162 and #163.

Inspectors wroteBased on observation, record review, and interview the facility failed to provide appropriate oral care for Resident #71 and failed to document refusals. This affected one resident (#71) of three residents reviewed for activities of daily living. The census was 117.

Inspectors wroteBased on observation, record review, interview, and facility policy review the facility failed to ensure Resident #99 was provided timely care. This finding affected one resident (#99) of three residents reviewed for incontinence care.