Ohio Living Quaker Heights

Inspectors wroteBased on record review, staff interview, policy review, Emergency Medical Services (EMS) report, police report, online guidelines from American Heart Association (AHA) and review of staff witness statements, the facility failed to assess a resident for a pulse or vital signs and failed to immediately start Cardio-Pulmonary Resuscitation (CPR) for a resident who was a full code. This resulted in serious life-threatening harm and/or death on [DATE] when Resident #60 was found unresponsive. The facility staff did not check Resident #60 for a pulse and did not obtain vital signs. CPR was not started by facility staff. This affected one (Resident #60) of three residents reviewed for Full Code status and Change of Condition. The facility census was 58. On [DATE] at 12:47 P.M., the Administrator and Director of Nursing (DON) were notified that Immediate Jeopardy began on [DATE] at 12:22 A.M. [...]

Inspectors wroteBased on staff interview and record review, the facility failed to ensure residents received showers per their preference. This affected one (#46) out of three residents reviewed for activities of daily living. The facility census was 58.

Inspectors wroteBased on record review and interview, the facility failed to implement appropriate fall interventions and the facility failed to ensure a resident's fall intervention was in place. This affected one (#31) resident out of three residents reviewed for falls. The facility census was 58.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident's medical record was accurate and free from falsified information. This affected one (#60) of the three residents reviewed for accuracy of records. The facility census was 58Findings include: Review of medical record for Resident #60 revealed an admission date of 06/30/26. Diagnoses included multiple fractures of ribs left side, fall on or from other stairs and steps, acute respiratory failure with hypoxia, acute respiratory failure with hypercapnia, type two diabetes mellitus with diabetic peripheral angiopathy, congestive heart failure (CHF), peripheral vascular disease (PVD), unilateral primary osteoarthritis left knee, and atherosclerotic heart disease of native coronary artery without angina pectoris. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement and follow it's abuse policy. This affected one (Resident #1), out of nine residents reviewed for abuse. The facility census was 58 at the time of survey.

Inspectors wroteBased on interview and record review, the facility failed to report allegations of abuse in a timely manner. This affected one (Resident #1) out of nine residents reviewed for abuse. The facility census was 58 at the time of survey.

Inspectors wroteBased on observation and interview, the facility failed to maintain call lights within reach of residents. This affected two (Residents #4 and #9). The facility census was 58 at the time of survey.

Inspectors wroteBased on observation and interview, the facility failed to ensure infection control policies and procedures were followed. This affected Residents #5 and #8. The facility census was 58 at the time of survey.

Inspectors wroteBased on medical record review, observation, staff interview, physician interview, review of pharmacy delivery sheets, review of Controlled Drug Receipt/Records, and review of the facility policy, the facility failed to notify the physician when residents were not administered medications as ordered by the physician. This affected one (#75) out of the three residents reviewed for notification. The facility census was 61.

Inspectors wroteBased on medical record review, the facility staff interview, and facility policy review the facility failed to provide resident with showers. This affected one (#75) out of the three residents reviewed for showers. The facility census was 61.

Inspectors wroteBased on medical record review, observation, staff interview, physician interview, review of pharmacy delivery sheets, review of Controlled Drug Receipt/Records, and review of the facility policy, the facility failed to ensure residents were free of significant medication errors. This affected one (#75) of the three residents reviewed for medications. The census was 57.

Inspectors wroteBased on record review, observation and interview, the facility failed to store foods in accordance with professional standards for food service safety. This had the potential to affect 56 residents who received food from the kitchen. The facility census was 56.

Inspectors wroteBased on record review and interview, the facility failed to have clear documentation of advanced directives in the electronic medical record. This affected four (Residents #9, #10,#13 and #25) of five residents reviewed for advanced directives. The facility census was 56.

Inspectors wroteBased on record review and interview, the facility failed to initiate and update care plans for residents. This affected three (Residents #5, #354 and #48) of 21 residents whose care plans were reviewed The facility census was 56.

Inspectors wroteBased on record review and interview, the facility failed to complete a comprehensive assessment after a significant change in condition for one (Resident #354) of three residents sampled. The facility census was 56.

Inspectors wroteBased on record review, interview, and policy review, the facility failed to refer a resident with a serious mental disorder and dementia to the appropriate State-designated authority for a Preadmission and Resident Review (PASRR) Level II assessment/determination. This affected one (Resident #34) of one resident reviewed for PASRR. The facility census was 56.

Inspectors wroteBased on record review, observation and interview, the facility failed to prepare food in a form designed to meet the resident's individual needs. This affected three (Residents #4, #5 and #354) of three residents sampled. The facility census was 56.

Inspectors wroteBased on record review and interview, the facility failed to ensure the Ombudsman was notified when residents were discharged to the hospital. This affected one (Resident #33) of two residents reviewed for discharges. The facility census was 56.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure all Minimum Data Set (MDS) assessments were transmitted within 14 days after being completed. This affected two (Residents #19 and #46) of two residents reviewed for MDS assessments. The facility census was 56.

Inspectors wroteBased on record review, review of the facility's Self-Reported Incidents, review of the facility's policy and staff interview, the facility failed to report an injury of unknown origin to the State Survey Agency. This affected one (#58) of three residents reviewed for abuse.

Inspectors wroteBased on record review, review of the facility's policy and staff interview the facility failed to investigate a resident's injuries of unknown origin which involved a fractured tibia and fibula. This affected one (#58) of three residents reviewed for abuse.

Inspectors wroteBased on medical record review, staff interview and policy review the facility failed to ensure care plans were initiated. This affected two Residents (#12 and #35) of 19 reviewed for care plans. The census was 62.

Inspectors wroteBased on medical record review and staff interview the facility failed to ensure ensure an explanation was documented as to why a resident did not attend their care conference. This affected one (#35) of 24 residents reviewed for care conferences. The census was 62.

Inspectors wroteBased on medical record review, observation, staff interview and policy review the facility failed to ensure a resident who was dependent on staff for personal hygiene received oral hygiene. This affected one Resident (#34) of 24 reviewed for activities of daily. The census was 62.