University Manor Health & Reha

Inspectors wroteBased on observation, record review and interview, the facility did not maintain an ambient temperature in resident rooms and common areas. This finding had the potential to affect all 42 residents residing on the second floor and all 25 residents residing on the third floor. The facility census was 143.

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review and interview, the facility failed to ensure Resident #74 was free from physical abuse. This finding affected one (Resident #74) of four residents reviewed for abuse. Findings Include: Review of Resident #701's medical record revealed the resident was admitted on [DATE] and discharged on 01/06/25 with diagnoses including schizoaffective disorder, diabetes and vascular dementia. Review of Resident #701's Quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed the resident exhibited moderate cognitive impairment. Review of Resident #701's progress note dated 01/04/25 at 9:30 A.M. [...]

Inspectors wroteBased on observation, interview, and review of facility policy, the facility failed to ensure medications were prepared and administered for one resident at a time. This had the potential to affect the 35 residents living on the fifth floor (Resident #8, #10, #13, #15, #20, #23, #25, #28, #31, #38, #40, #43, #50, #57, #59, #60, #64, #66, #71, #72, #74, #80, #82, #83, #84, #87, #90, #91, #97, #98, #107, #108, #114, #124, and #126). The total census was 144.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure residents who resided on the fifth floor were provided activities as scheduled. This affected 34 residents (Residents #2, #4, #9, #14, #18, #19, #21, #22, #23, #24, #26, #27, #29, #31, #34, #38, #41, #43, #44, #46, #58, #61, #65, #68, #78, #79, #90, #91, #93, #97, #102, #107, #119 and #123) who resided on the fifth floor secured unit. The facility census was 148.

Inspectors wroteBased on record review, interview and review of monthly pharmacy recommendations, the facility failed to ensure pharmacy recommendations were addressed by the physician timely. This affected four residents (Residents #10, #19, #75, and #92) of five residents reviewed for medication regimen reviews. The facility census was 148.

Inspectors wroteBased on observation and interview the facility failed to ensure the resident environment on the fourth floor was maintained in good repair. This had the potential to affect all 42 residents (#1, #3, #6, #7, #11, #12, #16, #36, #37, #39, #45, #49, #51, #52, #56, #57, #60, #64, #72, #73, #77, #80, #83, #85, #87, #89, #92, #98, #106, #108, #109, #111, #112, #114, #120, #128, #133, #137, #140, #144, #145, and #148) who resided on the fourth floor. The facility census was 148.

Inspectors wroteBased on record review, interview, and policy review the facility failed to ensure Resident #198's monies from the authorized resident fund account (RFA) were dispersed timely upon the resident's death. This affected one (Resident #198) of five residents reviewed for resident funds.

Inspectors wroteBased on record review, interview, and review of the facility policy and procedure the facility failed to ensure advanced directives were accurate and readily available. This affected three residents (#87, #99 and #143) of four residents reviewed for advanced directives. The facility census was 148.

Inspectors wroteBased on record review and interview, the facility failed to provide Residents #29, #43 and #47 and/or their resident representatives, at the time of transfer or in cases of emergency transfer within 24 hours, written information which explained the duration of the bed-hold and the reserve bed payment policy including the resident's return to the next available bed. This affected three (Residents #29, #43 and #47) of four residents reviewed for hospitalization.

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 (#106) of one resident reviewed for preadmission screening and resident review (PASARR). The facility census was 148.

Inspectors wroteBased on record review, interview, and review of the facility policy and procedure, the facility failed to ensure individualized care plans were developed and accurate for three residents (#40, #92, and #133) of 29 sampled residents whose care plans were reviewed. The facility census was 148.

Inspectors wroteBased on record review, interview, and policy review, the facility failed to ensure Resident #44's care plans were updated to reflect the resident's behaviors and interventions which required the resident to sleep on a flat yoga mat on the floor with no furniture in the room. The facility also failed to ensure Residents #13 and #29's care conferences were conducted at least quarterly. This affected three (Residents #13, #29 and #44) of four residents reviewed for care plans.

Inspectors wroteBased on medical record review, bathing/showering documentation review, facility policy review and interview, the facility failed to ensure bathing/showering was completed as required for one Resident #110 who required total assistance with activities of daily living. This affected one (#110) of one resident reviewed for bathing. The facility census was 148.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure assessment and monitoring of a wound to Resident #79's left great toe. This affected one (Resident #79) of four residents reviewed for wounds.

Inspectors wroteBased on interview and record review the facility failed to ensure pre and post dialysis communication was completed. This affected two residents (#100 and #133) of two residents reviewed for dialysis. The facility census was 148.

Inspectors wroteBased on record review and interview, the facility failed to ensure Resident #19's as-needed antipsychotic medications were limited to fourteen days until the physician evaluated the resident, and non-pharmacological interventions were attempted prior to administering as-needed antipsychotic medications. This affected one (Resident #19) of five residents reviewed for medication administration.

Inspectors wroteBased on observation, record review, and interview the facility failed to ensure the coordination of services to make certain residents received the correct diets. This affected two residents (#19 and #29) of seven residents (#19, #29, #31, #100, #119, #134, and #143) reviewed for nutrition. The facility census was 148.

Inspectors wroteBased on record review, interview, and policy review the facility failed to ensure Resident #95 was provided education and offered the influenza and pneumococcal vaccines. This affected one (Resident #95) of five residents reviewed for immunizations.

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, interview, facility self-reported incident (SRI) review, and facility policy review the facility failed to prevent an incident of staff to resident emotional abuse, based on the reasonable person concept, when State Tested Nurse Aide (STNA) 314 posted a video showing Resident #5 on social media. This affected one resident (#5) of six residents reviewed for abuse. The facility census was 144.

Inspectors wroteBased on observation, interview and review of facility policy, the facility did not ensure garbage was properly disposed of to prevent the harborage pests. This had the potential to affect all 144 residents. The facility census was 144.

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review and interview, the facility did not ensure the physician and/or nurse practitioner was notified of abnormal laboratory results for Resident #113. This affected one resident (#113) of three residents reviewed for physician notification of laboratory results. The facility census was 144.

Inspectors wroteTHIS DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THE ON-SITE INVESTIGATION Based on medical record review, staff interview, resident representative interview, law enforcement interview, review of facility self-reported incidents (SRIs), review of police reports, review of police body camera footage, review of emergency medical services (EMS) run reports, review of hospital records, review of the Facility Assessment, and review of facility policies, the facility failed to ensure Resident #1 was free from physical abuse from Resident #2. This resulted in Immediate Jeopardy and serious life-threatening harm on 03/12/24 at approximately 5:00 A.M. when Resident #1 was found on the floor in a prone position (face down on the stomach) in his room with blood coming out of the left side of his head and face. [...]

Inspectors wroteBased on medical record review, staff interview, review of facility self-reported incidents (SRIs), review of the Facility Assessment, and policy review, the facility failed to ensure adequate behavioral health services and person-centered care planning were in place to address the individualized needs of residents with history of mental disorders and history of violent behaviors against other residents. This affected one (#2) of three residents reviewed for behaviors. The facility census was 143. Findings Include: Review of Resident #2's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included paranoid schizophrenia, paranoid personality disorder, anxiety disorder, and violent behavior. [...]

Inspectors wroteBased on review of personnel files and staff interview, the facility failed to ensure state tested nurse aides (STNAs) were given yearly performance evaluations as required. This affected two (#291 and #296) of two STNA's personnel files reviewed who were employed for more than one year at the facility. This had the potential to affect all 143 residents residing in the facility. The facility census was 143. Findings Include: 1. Review of the personnel record for STNA #291 revealed a hire date of 12/23/22. There was no evidence of a yearly performance evaluation completed for STNA #291 for the last year. 2. Review of the personnel record for STNA #296 revealed a hire date of 01/13/22. There was no evidence of a yearly performance evaluation completed for STNA #296 for the last year. Interview with Human Resources Director (HRD) #350 on 04/16/24 at 11:30 A.M. [...]

Inspectors wroteBased on interview, record review and observation, the facility failed to provide pressure ulcer wound care as ordered. This affected two (#48 and #56) of three residents reviewed for wound care. The facility identified 13 residents (#26, #46, #48, #50, #56,#57, #60, #65, #69, #80, #95, #99, and #135) with wounds. The facility census was 142.

Inspectors wroteBased on record review, observation and interview the facility failed to use appropriate infection control techniques when providing wound care. This affected two (#48 and #56) of two residents observed for wound care. The facility identified 13 residents (#26, #46, #48, #50, #56,#57, #60, #65, #69, #80, #95, #99, and #135) with wounds. The facility census was 142.

Inspectors wroteBased on observation, record review, review of the facility Elopement/Unauthorized Absence policy and procedure and interviews, the facility failed to provide adequate supervision and individualized and comprehensive interventions to prevent Resident #101 from eloping from the facility. This resulted in Immediate Jeopardy and the likelihood of actual harm on 08/29/23 at approximately 9:48 A.M. when Resident #101, who was cognitively impaired and assessed to be at high risk for elopement, exited the facility grounds without staff knowledge, during a supervised smoke break. Staff failed to identify Resident #101 was missing until approximately 12:15 P.M. when the resident was not available for lunch. On 08/29/23 at 5:14 P.M. Resident #101 was found by police, approximately 2.8 miles away from the facility on a street corner. The resident was transported to the hospital for evaluation. [...]

Inspectors wroteBased on review of the Facility Assessment, personnel record review, and interview, the facility failed to provide behavioral health training on hire. This had the potential to affect all 138 residents in the facility.

Inspectors wroteBased on record review, staff interview, review of facility Self-Reported Incidents (SRIs) and review of the facility policy, the facility failed to ensure Resident #140 was free from abuse. This affected one resident (#140) of two residents two residents reviewed for physical abuse. The facility census was 138.

Inspectors wroteBased on record review and staff interview the facility failed to ensure their abuse policy was implemented to prevent abuse toward Resident #140, to ensure Resident #140 was assessed properly after being abused, and to ensure the allegation of abuse was reported to the state agency. This affected one resident (#140) of two residents two residents reviewed for abuse.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure an allegation of physical abuse was reported to the State Agency timely. This affected one resident (Resident #140) of two residents reviewed for abuse.

Inspectors wroteBased on record review and staff interview the facility failed to ensure tuberculosis screening was completed for newly hired employees as required. This affected six facility employees of nine employees whose personnel files were reviewed and had the potential to affect all 119 residents residing in the facility.

Inspectors wroteBased on record review and interview, the facility failed to initiate timely spend-down notifications and assistance for two of five residents reviewed for facility-managed funds (Resident #68 and #11). The total census was 119.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents received quarterly care-plan conferences. This affected one of one residents reviewed for care plan conferences (Resident #15). The total census was 119.

Inspectors wroteBased on interview and record review, the facility failed to draw recommended and ordered blood labs to monitor the nutrition status of Resident #105. This affected one of four residents reviewed for nutrition. The total census was 119.

Inspectors wroteBased on record review and interview, the facility failed to monitor lab values for Resident #105, including those needed to track the effectiveness of medications. This affected one of five residents reviewed for unnecessary medications. The total census was 119.

Inspectors wroteBased on record review and staff interview, the facility failed to complete and transmit resident discharge Minimum Data Set (MDS) assessments. This affected four residents (#1, #2, #4 and #5) out of five reviewed for assessments. The facility census was 119.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure resident snacks were stored in a safe and sanitary manner to prevent contamination and/or potential food borne illness. This had the potential to affect all 143 of 143 residents receiving meals from the kitchen.

Inspectors wroteBased on observation and interview the facility failed to maintain a safe, functional, sanitary and comfortable environment for all residents. This had the potential to affect all 143 residents residing in the facility.

Inspectors wrote4. Review of the medical record revealed Resident #23 was admitted to the facility on [DATE] with diagnoses including chronic kidney disease requiring dialysis and diabetes. The quarterly MDS 3.0 assessment, dated 01/09/19 revealed the resident required the extensive assistance from one person for dressing and personal hygiene. The resident was assessed to have mild cognitive impairment. Record review revealed no evidence of resistance to any personal hygiene care in the care plan. Observation on 04/16/19 at 9:17 A.M. revealed Resident #23 was in a wheelchair waiting to be picked up for an appointment. The resident had a large amount of long facial hair on her chin. Interview on 04/16/19 at 9:17 A.M. with Resident #23 revealed she did not want to have chin hair and had not realized it was that long. The resident stated her daughter would often take care of it when she had time. [...]

Inspectors wroteBased on observation, record review and interview the facility failed to ensure kitchen staff followed menu spreadsheets as written. This affected five residents receiving pureed meals (Resident #9, #41, #86, #106 and #295) and 10 residents receiving mechanical soft meals (Resident #6, #7, #16, #33, #60, #65, #90, #120, #126 and #292) who resided on the second floor during the dinner meal service on 04/16/19. The facility census was 143 residents.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure Resident #138, who was dependent on staff for personal care received appropriate and complete incontinence care. This affected one resident (Resident #138) of one resident reviewed for incontinence care.

Inspectors wroteBased on record review and interview the facility failed to develop a person-centered plan to address Resident #114's dementia. This affected one resident (Resident #114) of two residents reviewed for dementia care.

Inspectors wroteBased on observation, record review and interview the facility failed to maintain a medication error rate of less than five percent. The medication error rate was calculated to be 32 percent and included eight medication errors of 25 medication administration observations. This affected two residents (Resident #63 and #291) of three residents observed for medication administration.

Inspectors wroteBased on record review and interview the facility failed to ensure medical records were maintained in a complete and accurate manner for all residents. This affected one resident (Resident #138) of one resident reviewed for incontinence care, one resident (Resident #39) of one resident reviewed for edema and one resident (Resident #240) of two residents reviewed for catheters.

Inspectors wroteBased on resident council interview, staff interview and review of the local post office website, the facility failed to ensure mail was delivered on Saturday. This has the potential to affect all 143 residents residing in the facility.