Medina Center for Rehabilitation and Nursing

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Residents #46 and #68, on the secured dementia unit, were provided activities to meet their interests and psychosocial needs. This affected two residents (#46 and #68) and had the potential to affect 12 additional residents (#3, #14, #19, #21, #22, #28, #32, #40, #41, #43, #53, and #71) who resided on the memory care unit. The facility census was 71.

Inspectors wroteBased on record review, review of an emergency squad run report, review of hospital records, facility policy and procedure review, review of the information contained on the Medscape website, resident and staff interviews, resident representative interview, and interview with pharmacy staff, the facility failed to ensure Resident #63 was free from significant medication errors, when Resident #63 who had a seizure diagnosis was not administered the anti-convulsant medication (Vimpat) as ordered by the physician. [...]

Inspectors wroteBased on record review, observation, resident interview, staff interview and review of facility policy, the facility failed to ensure resident meals were palatable and at a safe, appetizing temperature. This had the potential to affect all residents residing at the facility except for two residents, Resident #1 and #3 identified by the facility to receive nothing by mouth (NPO). The facility census was 70.

Inspectors wroteBased on observation, record review, facility policy review and resident and staff interview, the facility failed to ensure residents had comfortable water temperatures to bathe in, and maintain resident rooms in a clean and sanitary manner with adequate lighting. This affected two residents (#10 and #20) and had the potential to affect 18 additional residents (#2, #4, #7, #9, #15, #28, #30, #32, #37, #41, #45, #51, #56, #57, #64, #66, #69, and #71) who received a shower in the west shower room. The facility census was 70.

Inspectors wroteBased on resident and staff interviews, and review of the facility policy, the facility failed to honor residents' drink preferences to include caffeinated coffee. This had the potential to affect all residents residing at the facility except for two residents (#1 and #3) identified by the facility as being nothing by mouth (NPO). The facility census was 70.

Inspectors wroteBased on record review, facility policy review and interview, the facility failed to timely fix a broken water mixing valve to ensure residents who utilized the west shower room were provided water at a comfortable temperature for showering/bathing. This affected one resident (#10) and had the potential to affect 19 additional residents, Resident #2, #4, #7, #9, #15, #20, #28, #30, #32, #37, #41, #45, #51, #56, #57, #64, #66, #69, and #71 who received a shower in the west shower room. The facility census was 70.

Inspectors wroteBased on resident and staff interview, record review, and review of the facility policy, the facility failed to ensure residents were treated with respect and dignity. This affected one resident (#37) of three residents reviewed for respect and dignity. The facility census was 70.

Inspectors wroteBased on observation, record review, facility policy review and interview, the facility failed to ensure Resident #59 was free from an incident of neglect. This affected one resident (#59) of three residents reviewed for abuse/neglect. The facility census was 70.

Inspectors wroteBased on observation, record review, facility policy review and interview, the facility failed to ensure residents received timely, adequate and necessary staff assistance with activities of daily living (ADLs) to maintain proper grooming and hygiene. This affected three residents (#25, #15, and #39) of four residents reviewed for ADL care. The facility census was 70.

Inspectors wroteBased on observation, record review, facility policy review and interview, the facility failed to develop and implement a comprehensive and individualized plan of care for Resident #15 related to the presence of bilateral hand contractures to prevent skin impairment. This affected one resident (#15) of three residents reviewed for quality of care and treatment. The facility census was 70.

Inspectors wroteBased on observation, record review, review of Centers for Disease Control and Prevention (CDC) guidance, facility policy review and interview, the facility failed to ensure staff maintained infection control practices including appropriate hand washing and the use of personal protective equipment (PPE) when required. This affected three residents (#44, #68, and #74) of 70 residents residing in the facility.

Inspectors wroteBased on observation, record review, facility policy review and interview, the facility failed to ensure Resident #24, a resident dependent on staff, was safely secured in the wheelchair in the facility bus when transporting to outside appointments to prevent a fall with injury. Actual harm occurred on 12/12/24 when Bus Driver (BD) #118 failed to properly secure Resident #24 in her wheelchair during a facility bus transport resulting in the resident being propelled out of her chair approximately three feet, onto the bus floor when Bus Driver #118 stopped abruptly. The resident sustained a right humerus (arm) fracture as a result of the incident. This affected one resident (#24) of three residents reviewed for accidents. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to timely address and respond to voiced concerns regarding resident care and life in the facility identified by residents in resident council and food committee meetings. This had the potential to affect all residents residing in the facility. The facility census was 73.

Inspectors wroteBased on record review, resident interview, staff interview, review of the resident council meeting minutes, review of the grievance log, and facility policy review, the failed to be adequately staffed to meet the needs of its residents. This had the potential to affect all residents. The facility census was 73.

Inspectors wroteBased on record review and staff interview the facility failed to ensure the service of a Registered Nurse (RN) for at least eight hours a day seven days a week as required. This had the potential to affect all residents. The facility census was 73.

Inspectors wroteBased on observation, resident interview, and record review revealed the facility failed to provide palatable food to residents. This had the potential to affect all residents residing in the facility. The facility census was 73.

Inspectors wroteBased on observation, interview, and review of facility policy, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner. This had the potential to affect all 73 residents.

Inspectors wroteBased on observation and staff interview, the facility failed to maintain its garbage disposal area in a clean and sanitary condition. This had the potential to affect all 73 residents in the building.

Inspectors wroteBased on observation, interview, record review, and review of facility policy, the facility failed to maintain an infection prevention program to prevent, recognize, and control transmission of communicable disease. This affected two residents (#32 and #33) of four residents sampled and had the potential to affect all facility residents. The facility census was 73.

Inspectors wroteBased on record review, interview, and review of facility policy, the facility failed to designate a certified infection preventionist responsible for the infection control and prevention program. This affected one resident (Resident #32) of four residents sampled and had the potential to affect all facility residents. Facility census was 73.

Inspectors wroteBased on record review, observations and interview, the facility failed to maintain a safe and sanitary resident environment. This affected one (Resident #23) of 18 residents observed for environment.

Inspectors wroteBased on observation, interview, and policy review the facility failed to secure protected health information from the public and failed to protect the resident right to privacy. This affected one resident (#45) of four residents reviewed for privacy. The facility census was 73.

Inspectors wroteBased on record review, interview, and policy review the facility failed to create a plan of care for a resident who had a significant change in condition following an injury. This affected one (Resident #24) of five residents reviewed for care planning. The facility census was 73.

Inspectors wroteBased on record review, interview, and facility policy review, the facility failed to complete routine oral care for residents who required assistance. This affected one resident (#47) of five residents reviewed for activities of daily living. The facility census was 73.

Inspectors wroteBased on staff interviews and record review, the facility failed to arrange for transportation to outside medical appointments. This affected one (Resident #46) resident out of three residents reviewed for transportation to outside appointments. The facility census was 73.

Inspectors wroteBased on record review, observation and interview, the facility failed to ensure medications were properly secured. This affected two residents (#11 and #52) of six residents observed for medication administration. The facility census was 73.

Inspectors wroteBased on observation and interview, the facility failed to ensure residents had a functional call light. This affected one (Resident #46) of 25 sampled residents. The facility census was 75.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure staff approved to drive the facility bus were appropriately trained on safety mechanisms in the facility bus upon hire and annually. This affected one resident (#24) of three residents reviewed for accidents. The facility census was 73.

Inspectors wroteBased on review of the facility assessment and staff interview, the facility failed to ensure the facility assessment contained all required information. This had the potential to affect all 73 residents residing in the facility. The facility census was 73. Findings Include: Review the facility assessment dated [DATE] revealed the assessment did not contain evidence of direct input into the assessment from direct care staff (including but not limited to input from Registered Nurses (RN), Licensed Practical Nurses (LPNs), Certified Nursing Assistants (CNAs)) and a plan to maximize recruitment and retention of direct care staff. Interview on 02/20/25 at 11:11 A.M. with Regional Administrator (RA) #206 verified the assessment did not contain all required information.

Inspectors wroteBased on observation, interview, record review and facility policy review, the facility failed to ensure oxygen tubing was changed as ordered for residents #21 and #40. This affected two residents (#21 and #40) of four residents observed for respiratory care. The facility census was 66.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure therapeutic diets were provided as ordered by the physician for Residents #25 and #39. This affected two residents (#25 and #39) of four residents observed for therapeutic diets. The facility census was 66.

Inspectors wroteBased on observation and interview, the facility failed to ensure crash carts contained the appropriate supplies. This had the potential to affect all residents residing in the facility. The facility census was 66.

Inspectors wroteBased on observation, medical record review, facility policy review and interviews with Resident #02, facility staff and the Physician Assistant (PA), the facility failed to provide adequate monitoring, appropriate treatment and follow-up for a non-functioning suprapubic catheter (a thin, flexible tube that drains urine from the bladder through a small incision in the lower abdomen) for Resident #02. Actual Harm occurred beginning on 03/05/24 when staff documented Resident #02 had no output from her suprapubic catheter. Documentation between 03/05/24 and 10/02/24 noted the suprapubic catheter continued to malfunction, resulting in decreased urinary output, urinary retention, and increased pain and discomfort during this time with no evidence of adequate follow-up or interventions. [...]

Inspectors wroteBased on personnel record review, review of the Bureau of Criminal Investigation (BCI) log, review of the Ohio Board of Nursing's website and review of facility policy, the facility failed to ensure implementation of their abuse prevention policy related to pre-employment background checks. This had the potential to affect all 60 residents in the facility. The facility census was 60.

Inspectors wroteBased on observation, staff interview, review of posted meal times and review of the dietary staff schedule, the facility failed to ensure sufficient dietary staff to provide resident meals in a timely manner. This affected all 60 residents in the facility. The facility census was 60.

Inspectors wroteBased on observation and staff interview, the facility failed to serve food in a manner that was palatable and attractive. This had the potential to affect all 60 residents in the facility. The facility census was 60.

Inspectors wroteBased on observation, review of the dishwasher temperature logs and staff interview, the facility failed to maintain dishwasher water temperatures at the manufacturer's minimum water temperature during the wash cycle. This had the potential to affect all 60 residents in the facility. The facility census was 60.

Inspectors wroteBased on observation, resident interview, medical record review, staff interview and review of facility policy, the facility failed to ensure smoking devices were secured. This affected one resident (#9) of one resident reviewed for smoking. Additionally, the facility failed to ensure thorough fall investigations were completed. This affected five residents (#20, #22, #38, #44 and #61) of five residents reviewed for falls. The facility census was 60.

Inspectors wroteBased on observation, medical record review, review of the production meal sheet and staff interview, the facility failed to ensure all pureed food items identified on the menu were provided. This affected six residents (#6, #16, #23, #35, #37 and #44) of six residents identified by the facility as having orders for puree food texture. The facility census was 60.

Inspectors wroteBased on observation, resident interview, medical record review and staff interview, the facility failed to provide adaptive equipment during meals for nine residents (#41, #37, #16, #6, #58, #25, #2, #50, and #29) of nine residents identified by the facility who utilized adaptive equipment. The facility census was 60.

Inspectors wroteBased on medical record review, review of facility self-reported incidents (SRI) and staff interview, the facility failed to ensure complete and accurate medical records. This affected five (#39, #49, #42, #25 and #55) of five residents reviewed for accurate medical records. The facility census was 60.

Inspectors wroteBased on personnel record review and staff interview, the facility failed to provide annual behavioral health/dementia education. This had the potential to affect 32 residents (#1, #4, #5, #6, #11, #12, #16, #18, #20, #22, #23, #26, #29, #32, #33, #34, #35, #36, #37, #38, #39, #40, #41, #43, #44, #46, #49, #53, #54, #55, #57 and #60) of 32 residents identified by the facility with a diagnosis of dementia. The facility census was 60.

Inspectors wroteBased on medical record review, staff interview and review of facility policy, the facility failed to notify the physician of allegations of sexual abuse. This affected one resident (#42) of one resident reviewed for physician notification. The facility census was 60.

Inspectors wroteBased on observation, resident interview, family interview, staff interview and medical record review, the facility failed to ensure a comfortable, homelike environment free from loud noises. This affected three residents (#42, #28 and #17) of three residents reviewed for a comfortable, homelike environment. The facility census was 60.

Inspectors wroteBased on resident interview, medical record review, review of Self-Reported Incidents (SRI), staff interview and review of facility policy, the facility failed to ensure residents were free from abuse. This affected two residents (#25 and #55) of three residents reviewed for abuse. The facility census was 60.

Inspectors wroteBased on observation, medical record review, staff interview, hospice staff interview and review of facility policy, the facility failed to ensure residents were free from misappropriation. This affected one resident (#57) of three residents reviewed for misappropriation, with the potential to affected three additional residents (#26, #36 and #44) who also received hospice services. The facility census was 60.

Inspectors wroteBased on observation, resident interview, family interview, medical record review, staff interview and review of facility policy, the facility failed to ensure residents were free from physical restraints. This affected one resident (#42) of one resident reviewed for restraints. The facility census was 60.

Inspectors wroteBased on staff interview, medical record review, review of Self-Reported Incidents (SRI), review of facility investigations and review of facility policy, the facility failed to accurately document and thoroughly investigate allegations of abuse. This affected three residents (#25, #55 and #49) of four residents reviewed for facility investigations. The facility census was 60.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure care plans were updated when new interventions were implemented. This affected two residents (#22 and #38) of two residents reviewed for care planning. The facility census was 60.

Inspectors wroteBased on observation, family interview, medical record review, review of shower schedules, review of shower/bath sheets, staff interview and review of facility policy, the facility failed to provide routine showers for residents dependent for care. This affected one resident (#46) of three residents reviewed for showers. The facility census was 60.

Inspectors wroteBased on resident interview, family interview, staff interview, medical record review, review of hospital documents and review of transportation service communication, the facility failed to ensure transportation was arranged for Resident #02's outside appointments. This affected one resident (#02) of two residents reviewed for transportation services. Additionally, the facility failed to ensure a physician ordered follow-up appointment was scheduled for Resident #42. This affected one resident (#42) of two residents reviewed for coordination of care. The facility census was 60.

Inspectors wroteBased on observation and staff interview, the facility failed to provide food items free of listed allergens for Resident #2. This affected one resident (#2) and had the potential to affect five additional residents (#11, #30, #39, #47, and #57) identified by the facility as having food allergies. The facility census was 60.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure daily staffing information was posted. This had the potential to affect all 60 residents in the facility. The facility census was 60.

Inspectors wroteBased on review of the Payroll Based Journal (PBJ) Staffing Data Report, review of staff schedules, review of staff time sheets and staff interview, the facility failed to accurately report staffing to the Centers for Medicare and Medicaid Services (CMS). This had to the potential to affect all 60 residents. The facility census was 60.

Inspectors wroteBased on observation, interview with fire marshall, review of diswasher temperature monitoring logs, review of the Food and Drug Administration (FDA) Food Code, and staff interview, the failed to maintain the range hood vents in a sanitary manner and failed to ensure the dishwasher washing temperature was maintained to properly sanitize the kitchen dishware, utensils and equipment. This had the potential to affect all the residents who ate their meals in the facility. The facility census was 69.

Inspectors wroteBased on observation, record review, staff interview, review of the facility policy, and review of the reference website Medscape.com, the facility failed to ensure staff administered medication with less than a five percent error rate. This affected one (#43) out of three residents observed for medication administration with a 8.69% error rate observed. The facility census was 69.

Inspectors wroteBased on observation, staff interview, and review ofreview of the reference website Medscape.com, the facility failed to ensure medications were administered without a significant error. This affected one (#43) out of three residents observed during medication administration. The facility census was 69.

Inspectors wroteBased on observation, record review, staff interview, and review of facility policy, the facility failed to ensure staff adhered to infection control standards during colostomy care. This affected one (#27) out of three residents reviewed for colostomy care. The facility census was 69.

Inspectors wroteBased on record review, review of facility policy and interviews, the facility failed to ensure advanced directives were readily available and followed during a medical emergency for Resident #66. This affected one resident (Resident #66) of three residents reviewed for advance directives. The facility census was 64.

Inspectors wroteBased on review of the medical record and interview with staff the facility failed to notify the physician when Resident #65 was not administered routine insulin according to the physician order. This affected one resident ( Resident #65) of three reviewed for insulin administration. The facility census was 64.

Inspectors wroteBased on record review and interview the facility did not ensure Resident #65 was administered insulin according to physician orders. This affected one resident ( Resident #65) of three residents reviewed for insulin administration. The facility census was 64.

Inspectors wroteBased on review of the medical record and interview with staff the facility failed to document the death of Resident #66 in the medical record. This affected one resident ( Resident #66) of three reviewed for complete medical record. The facility census was 64.

Inspectors wroteBased on interview and personnel file review the facility failed to complete state tested nurse aide registry verification prior to allowing an individual to serve as a STNA. This had the potential to affect all residents residing in the facility. The facility census was 63.

Inspectors wroteBased on interview, record review, staff statement review, police report review, and text message review the facility failed to ensure a nurse showing signs of potential impairment was evaluated to ensure she was competent to provide direct resident care and/or was removed from direct resident care following suspicions of impaired behaviors by co-workers. This had the potential to affect 32 residents (#17, #18, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30, #31, #32, #33, #34, #49, #50, #51, #52, #53, #54, #55, #56, #57, #58, #59, #60, #61, #62 and #63), who resided on the 300 and 400 units where the nurse was working. The facility census was 63.

Inspectors wroteBased on interview, record review, staff statement review, and text message review the administration failed to timely respond to reports of a nurse showing signs of potential impairment. This had the potential to affect 32 residents (#17, #18, #20, #21, #22, #23, #24, #25, #26, #27, #28, #29, #30, #31, #32, #33, #34, #49, #50, #51, #52, #53, #54, #55, #56, #57, #58, #59, #60, #61, #62 and #63), who resided on the 300 and 400 units where the nurse was working. The facility census was 63.

Inspectors wroteBased on observation and interview the facility failed to ensure incontinence care was provided in a timely manner. This affected one resident (#21) of three observed for incontinence care. The facility census was 63.

Inspectors wroteBased on record review, interview, and facility policy review the facility failed to ensure all parties were notified Resident #75's change of condition. This affected one resident (#75) of three residents reviewed for notification. The facility census was 63. Findings Include: Review of the closed medical record for Resident #75 revealed an admission date 01/10/23. Diagnosis included dementia, acute kidney failure, delirium, and failure to thrive. Review of the fall incident report dated 12/19/23 at 2:00 P.M. Resident #75 was found on the floor between the wall and bed. No injury was noted at the time of the fall. Resident #75 was sent to hospital for evaluation. There was no documented evidence of family notification of the fall and transfer to the hospital. Interview on 02/12/24 at 11:01 A.M. [...]

Inspectors wroteBased on interview and record review the facility failed to provide an environment that was free from accident hazards. This affected one resident (#75) of three residents reviewed for accidents. The facility census was 63. Findings Include: Review of the closed medical record for Resident #75 revealed an admission date 01/10/23. Diagnosis included dementia, acute kidney failure, delirium, and failure to thrive. Review of the plan of care dated 01/12/23 revealed Resident #75 was at risk for falls related to impaired balance, history of falls and intentionally climbs out of bed. Interventions included assisting and encouraging the resident to go to common areas when awake, for safety, assuring bed is locked, defined perimeter mattress, floor mat to left side of bed while in bed, and bed in low position. [...]

Inspectors wroteBased on record review, interview, and facility policy review the facility failed to ensure all residents with special dietary needs were given appropriate meals. This affected one resident (#75) of three residents reviewed for allergies. The facility census was 63. Findings Include: Review of the closed medical record for Resident #75 revealed an admission date 01/10/23. Diagnosis included dementia, acute kidney failure, delirium, and failure to thrive. The resident was allergic to shellfish. Review of the employee memorandum dated 12/20/23 revealed [NAME] #300 was given an oral warning for serving shellfish to a resident with allergies. Date of violation was 12/15/23. Resident #75 was served crab cakes despite the meal ticket stating allergy in multiply spots on the ticket. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure fall interventions were in place for Resident #20. This affected one resident (#20) out of three residents reviewed for falls. The facility census was 61.

Inspectors wroteBased on medical record review, observations, policy reviews, resident and staff interviews, the facility failed to ensure adequate supplies were provided to a resident with urinary retention that required straight catheterization; provide proper care and service to ensure self-catheterization was being completed as needed and implement physician orders to encourage fluid intake and straight catheterized as needed and implement measures to prevent urinary tract infections. This affected one (Resident #09) of one resident reviewed for straight catheterization supplies. The facility census was 59. [...]

Inspectors wroteBased on observation, resident interview, staff interview, resident council minute review, and observation of a test tray, the facility failed to serve food that was palatable. This had the potential to affect all 59 residents, The facility census was 59.

Inspectors wroteBased on observation, resident interview, staff interview, medical record review, and review of the policy, the facility failed to store medications in a safe manner. This had the potential to affect three (#09, #49 and #59) and the potential to affect four (#66, #58, #52, and #26) additional residents who were cognitively impaired and independently mobile. The facility census was 59.

Inspectors wroteBased on observation and staff interview, the facility failed to serve safe food products to residents. This had the potential to affect 48 (#1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, #14, #15, #16, #19, #20, #21, #22, #23, #25, #28, #30, #31, #32, #33, #34, #35, #36, #37, #39, #40, #41, #42, #43, #44, #45, #47, #48, #50, #51, #53, #54, #55, #56, #57, and #60) of 59 residents served from the kitchen. The facility census was 59.

Inspectors wroteBased on observation and staff interview, the facility failed to maintain infection control practices while passing the lunch trays. This affected 11 (17, #18, #27, #49, #52, #26, #58, #29, #5, #15 and #39) of 11 resident that staff assisted lunch trays. The facility census was 59.

Inspectors wroteBased on medical record review, resident interview, staff interview, review of resident council minutes, review of the Self-Reported Incident (SRI), and review of the policy, the facility failed to ensure an allegation of physical abuse/mistreatment was reported to the state agency as required. This affected one (#14) of three residents reviewed for staff treating residents with dignity and respect. The facility census was 59.

Inspectors wroteBased on medical record review, resident interview, staff interview, review of resident council minutes, review of the Self-Reported Incident (SRI), and review of the policy, the facility failed to ensure an allegation of physical abuse/mistreatment was investigated as required. This affected one (#14) of three residents reviewed for staff treating residents with dignity and respect. The facility census was 59.

Inspectors wroteBased on medical record review, interview, and review of the policy, the facility failed to ensure upon discharge to home, the resident's medications were returned to the resident. This affected one (#62) of three residents reviewed for discharge. The facility census was 59. Findings revealed: Review for Resident #62's medical record revealed an admission date of 06/17/23 and a discharge date of 07/01/23. Review of the discharge summary for Resident #62 dated 07/01/23 at 3:38 P.M., completed by Registered Nurse (RN) #296 revealed Resident #62 left the facility at 2:20 P.M., with his wife and daughter, medications returned to wife, drug summary given and signed. Left in private vehicle. [...]

Inspectors wroteBased on observation, staff interview, and record review, the facility failed to ensure a resident with a catheter had a care plan to address the care and treatment of the catheter to prevent infections. This affected one (#09) of three residents reviewed for care plans. The facility census was 59.

Inspectors wroteBased on observation, staff interview, medical record review, and review of medication Hydrofera Blue Wound Dressing user guide, the facility failed to provide wound care treatments per the physicians orders. This affected two (#09 and #03) of three residents reviewed for wound care. The facility census was 59.

Inspectors wroteBased on observation, resident interview, staff interview, medical record review, and review of medication Hydrofera Blue Wound Dressing user guide, the facility failed to ensure staff was trained to provide wound care treatments per the physicians orders. This affected two (#09 and #03) of three residents reviewed for wound care. The facility census was 59.

Inspectors wroteBased on interview and record review the facility failed to ensure State Tested Nursing Assistant's (STNA)'s #221, #231 #227 had annual performance evaluations. This affected three STNA's (#221, #231, and #227) out of four STNA's reviewed for performance evaluations and had the potential to affect all 68 residents in the facility.

Inspectors wroteBased on observation and interview, the facility failed to ensure food was stored and served in a clean sanitary manner, and failed to ensure all food was dated and labeled properly. This had the potential to affect all 68 residents who received food from the kitchen.

Inspectors wroteBased on interview and record review, the facility failed to ensure annual and 90 day performance evaluations were completed for Director of Nursing, Licensed Practical Nurse #206, Receptionist #228, and Housekeeper #264. This had the potential to affect all 68 residents in the facility.

Inspectors wroteBased on observation, interview, record review and review of facility policy, the facility failed to ensure Resident #1's antipsychotic medication was reviewed per pharmacy recommendations to reduce the dose and the facility failed to ensure Resident's #1, #13, #32, #44 and #63 who were administered antipsychotic medications were monitored for side effects. This affected five residents (Resident's #1, #13, #32, #44, and #63) out of five reviewed for antipsychotic medications.

Inspectors wroteBased on interview and chart review, the facility failed to ensure the power of attorney (POA) or the next of kin of a resident was contacted regarding a change in the resident. This affected one resident (Resident #28) out of three residents reviewed for notification of change.

Inspectors wroteBased on record review and interview, the facility failed to ensure Resident #24's catheter care plan intervention was implemented and followed by the nursing staff. This affected one resident (Resident #24) out of three residents reviewed for implementation of care plan interventions.

Inspectors wroteBased on interview and record review, the facility failed to ensure care plan meetings were held with the resident and/or the family. This affected two (Resident #28 and Resident #39) out of three residents reviewed for plan of care meetings.

Inspectors wroteBased on interview, observation, and record review, the facility failed to ensure high blood glucose levels were properly addressed for Resident #16. This affected one resident Resident #16) out three residents reviewed for insulin.

Inspectors wroteBased on observation, interview, record review, and review of facility policy, the facility failed to ensure Resident #10's red and purple colored pressure injury to the right buttock and sacral area was assessed, monitored, and treated timely. This affected one resident (Resident #10) out of three residents reviewed for pressure ulcer injury.

Inspectors wroteBased on observation, interview, record review and review of facility policy the facility failed to ensure incontinence care for Resident #40 was provided timely, and failed to ensure Resident #10's urinary tract infection was treated timely. This affected two residents (Resident's #10 and #40) out of three residents reviewed for incontinence care and urinary tract infections.

Inspectors wroteBased on observation, interview, record review and review of the facility policy the facility failed to ensure Resident's #1, #17 and #39 oxygen orders specified the oxygen flow to be administered in number of liters per minute and failed to specify how often oxygen saturations should be checked. This affected three residents (Resident's #1, #17 and #39) out of four residents reviewed for oxygen administration. The facility census was 68.

Inspectors wroteBased on interview, observation, record review and Centers for Disease Control (CDC) guidance, the facility failed to ensure Resident #12 and #16 were cared for under proper infection control precautions. This affected two residents (Resident #12 and Resident #16) out of five residents reviewed for infection control.

Inspectors wroteBased on observation and interview, the facility failed to ensure resident rooms were free from insects and maintained in a clean functioning manner This affected three residents (Resident #25, Resident #39 and Resident #59) out of three residents reviewed for physical environment.

Inspectors wroteBased on staff interview and facility policy review the facility failed to ensure comprehensive policy and procedures were developed and implemented for the antibiotic stewardship program. This had the potential to affect all 58 residents residing in the facility. The census was 58.

Inspectors wroteBased on observation and staff interview the facility failed to ensure intravenous solutions were not expired. This had to potential to affect 58 residents residing at the facility. The facility was 58. Finding Include: Observation on [DATE] at 1:30 P.M. of the main medication room with License Practical Nurse (LPN) #92 revealed the following expired intravenous solutions: One-liter bag of Dextrose 5% in water (D5W) expired [DATE] Three bags 50 milliliter (mls) of sodium chloride 0/9% in water expired [DATE] Two 500 mls bags of sodium chloride 0.9% in water expired [DATE]. Interview with LPN #92 at 1:35 P.M. verified the above finding.

Inspectors wroteBased on observation, staff interview, and review of the facility policy and procedure, the facility failed to ensure an anchoring device to attempt to prevent accidental trauma, pain or injury from excessive tension or removal of a Foley catheter was in place for one resident This affected one Resident (#22) of one reviewed for catheter care. The facility census was 58.

Inspectors wroteBased on record review, interview the facility failed to ensure the pharmacy recommendations were addressed by the physician in a timely manner. This affected two Residents (Residents#15 and #54) of five residents reviewed for unnecessary medications. The facility census was 58.

Inspectors wroteBased on record review and interview the facility failed to ensure as needed medication orders for psychotropic drugs were limited to 14 days. This affected one (Resident #7) of five residents reviewed for unnecessary medications. The facility census was 58. Finding Include: Review of Resident #7's medical record revealed an admission date of 03/08/19 with diagnoses including major depression, anxiety and heart failure. The quarterly Minimum Data Set (MDS) 3.0 dated 10/24/19 revealed the resident was cognitively intact, had mild depression, was verbal behavior towards other, had pain medication prescribed as needed (PRN). The medical record was absent of any documented reason to extend the use of as needed Xanax medication beyond 14 days. Review of the physician order dated 02/01/19 revealed the resident was to receive Xanax 0.5 milligram (mg) every 8 hours PRN for anxiety. [...]

Inspectors wroteBased on policy review and interview the facility also failed to ensure the Legionella policy had quality measures with specified testing protocols. This had the potential to affect all 58 residents currently residing in the facility. The facility census was 58. Finding Include: Review of the facility's policy titled Sanctuary Health Network Water Management Plan, undated revealed quality control measures for testing that included to monitor and log hot water temperatures, change aerators and shower wands when scale build-up becomes evident, flush fixtures weekly in areas not used often. The policy lacked acceptable ranges for control measures and corrective actions taken when control limits are not maintained. Interview on 02/10/10:30 A.M. with Corporate Maintenance #93 verified the Legionella policy lacked the quality control measures and protocols for specified testing.