Phoenix of Maple Heights

Inspectors wroteBased on observation, interviews, and review of the facility policy and procedure, the facility failed to ensure the residents' environment was clean, sanitary, and was in good repair. This had the potential to affect all residents residing in the facility. The census was 88.

Inspectors wroteBased on record review and staff interview the facility failed to maintain the services of a registered nurse for at least eight consecutive hours a day, seven days a week as required. This had the potential to affect all 88 residents currently residing in the facility.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure the medical director was an active participant of the Quality Assessment and Assurance (QAA) committee. This had the potential to affect all residents. The facility census was 88.

Inspectors wroteBased on observation, interview, record review, review of the Centers for Disease Control and Prevention (CDC) guidelines, and facility policy review the facility failed to maintain an effective infection control program, failed to ensure appropriate personal protective equipment (PPE) was utilized during resident care, and failed to ensure annual Tuberculosis (TB) assessments were completed annually since the last annual survey dated 04/28/22. This had the potential to affect all 88 residents residing in the facility. Findings Include: 1. The entrance conference was held on 06/03/24 at 9:19 A.M. with the Administrator and Chief Clinical Officer (CCO) #490. The facility identified Licensed Practical Nurse (LPN) #517 as the facility's Infection Preventionist (IP). Interview with the Director of Nursing (DON) on 06/10/24 at 3:33 P.M. [...]

Inspectors wroteBased on interview, record review, and policy review, the facility failed to implement an effective antibiotic stewardship program. This had the ability affect all 88 residents residing in the facility. Findings Include: Interview with the Chief Clinical Officer (CCO) #490 on 06/11/24 from 11:44 A.M. through 1:15 P.M. she has been overseeing the antibiotic stewardship program for approximately the last eight months. The facility's identified Infection Preventionist (IP) at the start of the survey process was Licensed Practical Nurse (LPN) #517. CCO #490 confirmed LPN #517 just received her IP certification on 06/10/24. LPN #517 has been tracking infections and the antibiotics used to treat the infections. LPN #517 is a full-time 7:00 P.M. to 7:00 A.M. supervisor. Every night, a report was run identifying who was on an antibiotic and why. [...]

Inspectors wroteBased on interview, record review, and policy review, the facility failed to have an Infection Preventionist providing qualified oversight of the facility's infection control. This had the ability to affect all 88 residents residing in the facility. The facility census was 88. Findings Include: The entrance conference was held on 06/03/24 at 9:19 A.M. with the Administrator and Chief Clinical Officer (CCO) #490. The facility identified Licensed Practical Nurse (LPN) #517 as the facility's Infection Preventionist (IP). Interview with the Director of Nursing (DON) on 06/10/24 at 3:33 P.M. revealed the IP, LPN #517, had completed her testing and was certified as the IP today. CCO #490 was the person acting as the IP for the facility for the last few months. Interview with CCO #490 on 06/10/24 at 3:40 P.M. revealed she has been the IP for the facility for the past eight months. [...]

Inspectors wroteBased on record reviews, interviews, and facility policy review the facility failed to ensure all medications had an appropriate diagnosis for Residents #1, #15, #16, and #62. This affected four residents (#1, #15, #16, and #62) of five residents reviewed for unnecessary medications. The facility census was 88.

Inspectors wroteBased on record review, staff interview, and facility policy review the facility failed to ensure physician orders for psychotropic medications included the diagnosis for each medication for Residents #11, #15, #16, and #62. The facility also failed to ensure monitoring of behaviors and adverse side effects from the use of psychotropic medications affecting for Residents #16 and #62. This affected four residents (#11, #15, #16, and #62) of five residents reviewed for unnecessary medications. The facility census was 88.

Inspectors wroteBased on observation and interview the facility failed to ensure a medication cart remained locked when the nurse was not in attendance. This affected one of two medication carts located on the second floor and had the potential to affect all residents except for 14 residents (#7, #11, #22, #25, #29, #33, #36, #40, #45, #54, #72, #78, #83, and #140) located on the secure unit. The facility census was 88.

Inspectors wroteBased on observation, interview, record review, and facility policy review facility failed to prevent public indecency to ensure residents were treated with dignity at all times. This affected one resident (#72) of three residents reviewed for dignity and had the potential to affect all residents that may have witnessed Resident #72's public indecency. The facility census was 88.

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 Resident #26's mental health condition as required. This affected one resident (#26) of one resident reviewed for preadmission screening and resident review (PASARR). The facility census was 88.

Inspectors wroteBased on medical record review, observation, interview, and facility policy review the facility failed to ensure comprehensive care plans were created for Resident #26, #63, and #72. This affected three residents (#26, #63, and #72) of three residents reviewed for care plans. The facility census was 88.

Inspectors wroteBased on record review, interview, and facility policy review the facility failed to ensure Resident #67 had orders to care for a urostomy and failed to ensure supplies were available. This affected one resident (#67) of one resident who received ileostomy and colostomy care. The facility census was 88.

Inspectors wroteBased on observation, interview, record review, and facility policy review the facility failed to ensure Resident #12 had current oxygen orders and an oxygen care plan and failed to ensure portable oxygen tanks were secured. This affected one resident (#12) of ten residents receiving oxygen. The facility census was 88.

Inspectors wroteBased on record review, interview, and facility policy review the facility failed to ensure monitoring prior to and following dialysis treatments for Resident #63. This affected one resident (#63) of one resident residing at the facility receiving dialysis. The facility census was 88.

Inspectors wroteBased on observation, interview, and record review, the facility failed to monitor resident behaviors, develop resident centered care plans with interventions specific for the resident's behaviors, or implement interventions when behaviors occurred for Resident #72. This affected one resident (#72) of two residents reviewed for behavioral health. The facility census was 88. Findings Include: Review of the medical record revealed Resident #72 was admitted to the facility on [DATE] with diagnoses including psychosis, schizoaffective disorder, bipolar disorder, factitious disorder (a condition in which a patient intentionally falsifies medical or psychiatric symptoms and can be self-induced or fabricated), and mood disorder. Review of the physician's orders for Resident #72 dated 06/23/23 was an order to document resident's behaviors every shift. [...]

Inspectors wroteBased on medical record review, ancillary services appointment lists, interviews, and facility policy review the facility failed to ensure dental services were provided to Resident #26 as needed. This affected one resident (#26) of one resident reviewed for dental services. The facility census was 88.

Inspectors wroteBased on record review, observation, interview, and facility policy review the facility failed to ensure call lights were functional and in reach for Residents #5, #12, and #13. This affected three residents (#5, #12 and Resident #13) of 88 residents reviewed for call lights. The facility census was 88.

Inspectors wroteBased on facility assessment review and staff interview, the facility failed to ensure its facility assessment contained the necessary required information related to contracted nurses and state tested nurse aides. This had the potential to affect all 88 residents residing at the facility.

Inspectors wroteBased on facility employee file review and interview, the facility failed to ensure two State Tested Nurse Aides (STNAs) #494 and #498 of four STNAs reviewed received the required 12 hours annually of continuing education credits. This had the potential to affect all 88 residents residing at the facility.

Inspectors wroteBased on observation, record review, interview and facility policy review, the facility failed to ensure Resident #35's bilateral lower extremity non-pressure wound care was completed as ordered by the physician. This finding affected one resident (#35) of three residents reviewed for wounds.

Inspectors wroteBased on observation, interview and review of facility policy, the facility did not ensure facility air temperatures were maintained between 71 to 81 degrees Fahrenheit (F). This affected all 87 residents residing in the facility. The facility census was 87.

Inspectors wroteBased on observation and interview the facility failed to ensure adequate food temperatures. This had the potential to affect to all residents that resided in the facility. The facility census was 91.

Inspectors wroteBased on interview and record review the facility failed to accurately document the times medication was administered. This affected three of three residents (#62, #63 and #64) reviewed for medication administration documentation. The facility census was 91.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure that one resident (Resident #4) was served their lunch meal at the same time as the other residents seated at the dining table. This affected one (Resident #4) of three (Resident #55 and Resident #57) seated at a table in first floor dining room. The facility census was 92.

Inspectors wroteBased on record review and interview, the facility failed to ensure accurate advance directive orders matched throughout the medical record for Resident #42. This affected one of 24 residents reviewed for advanced directives. The facility census was 92.

Inspectors wroteBased on interview and observation, the facility failed to ensure nail care was provided. This affected three (Resident #37, Resident #53, and Resident #58) out of five residents (Resident #8 ad Resident #42). The facility census was 92. Findings Include: 1. Review of the open record of Resident #37 revealed he was admitted to the facility on [DATE] and then readmitted on [DATE]. His admitting diagnoses included major depressive disorder, type II diabetes, dementia, severe protein calorie malnutrition, bipolar disorder and fracture of the neck of the left femur. Review of this resident's Minimum Data Set assessment dated [DATE] revealed this resident was alert and oriented times three. Review of his of activities of daily living revealed he needed supervision with set up for bed mobility, transfers, dressing, eating, toilet use and personal hygiene. Observation on 04/26/22 at 8:00 A.M. [...]

Inspectors wroteBased on observation and interview the facility failed to ensure the medical supplies inside the treatment cart were not expired, and failed to ensure medications opened were dated with the date they were opened. This has the potential to affect 14 residents (Resident #6, Resident #7, Resident #17, Resident #23, Resident #27, Resident #33, Resident #35, Resident #56, Resident #61, Resident #84, Resident #86, Resident #87, Resident #90 and Resident #292); three residents (Resident #15, Resident #43, Resident #87) out of three residents reviewed for insulin not dated and for eye drops not dated when opened; and it had the potential to affect five residents (Resident #18, Resident #33, Resident #52, Resident #80 and Resident #90) out of five residents reviewed for expired medications/supplies. The facility census was 92. Findings Include 1. Observation of the cart on 04/26/22 at 8:30 A.M. [...]

Inspectors wroteBased on observation and interview the facility failed to ensure the dining room chairs were safe and in good working order. This had the potential to affect nine residents (Resident #13, #14, #16, #18, #20, #24, #40, #64 and #74) who used chairs in the dining room. The facility census was 92.

Inspectors wroteBased on observation and interview, the facility failed to ensure staff used a beard restraint when preparing and plating food for residents to prevent hair from contaminating food during meal service. This finding had the potential to affect all seventy residents residing in the facility who received meals from the kitchen and the dining rooms.

Inspectors wroteBased on interview and record review, the facility failed to establish an effective infection prevention, control and monitoring program. This had the potential to affect all 70 residents who resided in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure an effective antibiotic use and monitoring program. This had the potential to affect all 70 residents who resided in the facility.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure a clean and sanitary smoking area. This finding affected Resident #268 and had the potential to affect all twenty-four smokers (Residents #1, #4, #5, #20, #24, #26, #27, #33, #34, #35, #39, #40, #41, #42, #47, #48, #50, #52, #53, #59, #63, #65, #267 and #268) who reside in the facility and smoke in the courtyard. The facility census was 70.

Inspectors wroteBased on record review and interview, the facility failed to ensure comprehensive assessments were complete and accurate. This finding affected five (Residents #22, #33, #46, #47 and #57) of twenty-one residents reviewed for comprehensive assessments.

Inspectors wroteBased on record review and interview, the facility failed to accurately inform residents of their discharge date s from Medicare Part A affecting Residents #270, #272 and #273. This affected three of four residents reviewed for beneficiary notifications. Findings Include: 1. Resident #270 was admitted to facility on 07/03/18. Her clinical census report revealed her last covered day (LCD) of Medicare A as 07/24/18 and Medicaid would start on 07/25/18 as a payment source. Resident #270 was issued a Notice of Medicare Non-Coverage form (NOMNC) for a LCD of 07/30/18 and it was signed by Resident #270 on 07/27/18. Further review of Resident #270's record revealed a Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF ABN). It was issued with a start date of 07/30/18 and was signed by Resident #270 on 07/27/18. Interview on 03/27/19 at 6:01 P.M. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to develop a comprehensive, resident centered care plan for Resident #53 regarding urinary/bladder infections and his need to self-catheterize. This affected one of two residents reviewed for catheters. The facility census was 70.

Inspectors wroteBased on record review and interview, the facility failed to ensure Resident #2's neurological examinations were completed as required after an unwitnessed fall. This finding affected one of five residents reviewed for accidents.

Inspectors wroteBased on record review and interview, the facility failed to ensure Resident #36's catheter was changed according to the physician orders. This affected one of two resident reviewed for urinary catheters.

Inspectors wroteBased on record review and interview, the facility failed to ensure Resident #46's arteriovenous (AV) fistula (a vascular access device surgically created for kidney dialysis) was monitored according to the physician orders. This finding affected one of one resident reviewed for dialysis.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure vital signs were checked as ordered prior to the administration of a blood pressure medication for Resident #47. This affected one of five residents reviewed for unnecessary medications.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure Resident #366's medications were administered according to the physician orders and with an error rate of less than 5% (percent). This finding affected one (Resident #366) of five residents observation for medication administration. A total of 26 medications were administered with two errors resulting in a medication error rate of 7.69%.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure expired medications were discarded appropriately. This finding affected three (Residents #17, #53 and #55) of three residents whose insulin was stored in the two front hall medication storage cart.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the results of laboratory testing for Resident #53 were reported promptly to the ordering physician. This affected one of two residents reviewed for catheters.

Inspectors wroteBased on record review and interview, the facility failed to ensure Resident #36's and Resident #44's medical records contained complete and accurate documentation. This affected one (Resident #36) of five residents reviewed for accidents and one (Resident #44) of two residents reviewed for hospitalizations.