Triple Creek Retirement Community

Based on medical record review, staff interviews and policy review, the facility failed to ensure documentation was completed regarding a resident's meal/dietary intake. This affected one (#45) out of three residents reviewed for meal service. The facility census was 43.

Findings include:

Medical record review for Resident #45 revealed an admission on 04/16/24 and a discharge on 04/18/24. Diagnoses include acute kidney failure, asthma, and cerebral infarction without deficits.

Review of the admission Minimum Data Set (MDS) assessment dated 04/21/24 for Resident #45 was not completed due to discharge from the facility.

Review of the baseline plan of care dated 04/16/24 for Resident #45 revealed the resident was on a regular diet, mechanical soft with thin liquids.

Review of the active physicians' orders for Resident #45 revealed an order dated 04/16/24 stating regular diet, mechanical soft with thin liquids.

Review of the electronic health record for Resident #45 for dietary intake revealed there was no documentation the resident consumed any meals during her stay at the facility.

Interview on 05/28/24 at 2:10 P.M. with the Director of Nursing (DON) verified the facility did not have any documentation for Resident #45's meal intake during the resident's stay. DON stated the staff should be documenting the percentage of food consumed at each meal in the electronic health record.

Review of the facility policy titled Meal Service, dated 01/2024 revealed if an individual is not accepting of their food an appropriate an alternate is offered and the staff will assist the individual as needed.

This deficiency represents non-compliance investigated under Complaint Number OH00153301.

Based on observation, staff interview, medical record review, and policy review, the facility failed to ensure staff utilized proper hand hygiene during wound dressing change procedures. This affected one (#06) resident of three residents reviewed for wound care. The facility census was 47.

Findings include:

Review of the medical record for Resident #06 revealed an admission on 02/01/24 with diagnoses including, but not limited to, fracture of lower end of left radius, encephalopathy, rhabdomyolysis, atherosclerotic heart disease, peripheral vascular disease, chronic obstructive pulmonary disease, and stroke.

Review of the admission Minimum Data Set (MDS) assessment for Resident #06 dated 02/06/24 revealed the assessment was still in progress.

Review of the plan of care dated 02/13/24 for Resident #06 revealed the resident had a pressure ulcer. Interventions include medications as ordered, assess, and record the condition of skin, observe and report signs of infection, observe for and report signs of pain related to pressure, pressure cushion to chair and mattress, diet as ordered, and weekly skin assessments.

Review of the physician orders dated 02/13/24 for Resident #06 revealed the resident was ordered to have the pressure ulcer on the left hip cleansed with normal saline and apply nickel thick layer of Santyl ointment 250 units/gram, cover with alginate pad and secure with a foam dressing every other day and as needed (PRN) for soiling or dislodgement.

Observations of wound care for Resident #06 on 02/15/24 at 10:00 A.M. with Licensed Practical Nurse (LPN) #86 revealed the residents bed side table was wiped down with sani-wipes and draped with a towel. The wound supplies were placed on the towel and pulled close to the resident's bedside. LPN #86 completed hand hygiene with soap and water, then donned gloves. The dressing to resident's left hip was removed and placed into the plastic trash bag. LPN #86 proceeded to cleanse the wound with normal saline and four by four gauze pads. LPN #86 then removed her gloves, completed hand hygiene, donned gloves, and applied Santyl ointment to the wound bed. LPN #86 applied collagen alginate to wound bed and covered with foam bordered dressing.

Interview with LPN #86 n 02/15/24 at 10:15 A.M. revealed she was unsure of what the policy stated regarding hand hygiene and confirmed she removed old dressing from left hip and cleanse the wound without changing her gloves.

Interview with the Director of Nursing (DON)on 02/15/24 at 11:00 A.M. revealed LPN #86 should have removed her gloves after removing the old wound dressing and completed hand hygiene prior to the application of the new dressing.

Review of the facility policy titled Dressing Changes, dated 12/31/23 revealed to ensure measures that will promote and maintain good skin integrity while maintaining standard measures that will minimize and control contamination. The staff would remove soiled dressing and discard it in plastic bag or trash can, remove and dispose of gloves and wash hands with soap and water. Then apply a second pair of disposable gloves and follow physician orders for application of treatments.

Based on medical record review and staff interview, the facility failed to provide written notification to the resident and/or their representative prior to the resident's transfer to the hospital. This affected four (#10, #36, #50 and #204) out of four residents reviewed for discharge from the facility. The facility census was 52.

Findings include:

1. Record review for Resident #10 revealed she was admitted to the facility on 02/10/22. Diagnoses include acute and chronic respiratory failure with hypoxia, heart failure, chronic respiratory failure with hypoxia, cerebrovascular disease, atherosclerotic heart, old myocardial infarction, chronic obstructive pulmonary disease, asthma, poly neuropathy, diabetes mellitus two, diverticulosis of intestine, major depressive disorder, obesity, sleep apnea, and anxiety disorder.

Review of the quarterly Minimum Data Set (MDS), dated 05/20/22, revealed Resident #10 had intact cognition. Further review of the MDS assessment revealed she required extensive assistance from staff with bed mobility, transfers, dressing, toilet use and personal hygiene. Resident #10 required limited assistance from staff with eating.

Review of Resident #10's nursing progress notes revealed she was discharged to the hospital on 05/08/22 and returned to the facility on 05/15/22. Resident #10 discharged to the hospital on 08/08/22 and returned to the facility on 08/12/22. Further review of Resident #10's medical record revealed there was no evidence of the facility providing the resident and/or their representative with a written notification regarding the resident's transfer to the hospital.

2. Record review for Resident #36 revealed an admission date of 10/29/21. Diagnosis include arthroplasty, hypertensive urgency, asthma, hypothyroidism, diabetes mellitus two, depression, osteoarthritis, insomnia, dysphagia, hypertension, gastro-esophageal reflux disease without esophagitis, and myocardial infarction.

Review of the quarterly MDS assessment, dated 07/13/22, revealed Resident #36 had impaired cognition. Further review of the MDS assessment revealed she required supervision from staff with bed mobility, transfers, dressing, eating, toilet use, and personal hygiene.

Review of Resident #36's progress notes revealed she was discharged from the facility on 06/24/22 and admitted to the hospital. Resident admitted to the facility from the hospital on 06/29/22. Further review of Resident #36's medical record revealed there was no evidence of the facility providing the resident and/or their representative with a written notification regarding the resident's transfer to the hospital.

3. Record review for Resident #50 revealed an admission date of 07/13/22. Diagnoses include pneumonia due to pseudomonas, hypertensive heart, chronic kidney disease with heart failure, chronic systolic (congestive) heart failure, end stage renal disease, athererotic heart disease of native coronary artery without angina pectoris, non rheumatic aortic (valve) stenosis, malignant neoplasm of prostate, secondary malignant neoplasm of bone, obstructive and reflux uropathy, diverticulosis of intestine, part unspecified, anemia, pleural effusion, hyperkalemia, myositis, obstructive sleep apnea, insomnia, obesity, hyperlipidemia, and pneumonia.

Review of the MDS assessment, dated 07/15/22, revealed Resident #50 had impaired cognition. Further review of the MDS assessment revealed he required extensive assistance from staff with bed mobility, transfers, dressing, toilet use, and personal hygiene. He required supervision from staff with eating.

Review of the nursing progress notes for Resident #50 revealed he was discharged to the hospital on 06/22/22. Resident #50 readmitted to the facility on 07/14/22 as a new admission. Further review of Resident #50's medical record revealed there was no evidence of the facility providing the resident and/or their representative with a written notification regarding the resident's transfer to the hospital.

4. Record review for Resident #204 revealed the resident was admitted to the facility on 06/23/22. Diagnoses include metabolic encephalopathy, sepsis, urinary tract infection, hypertensive chronic kidney disease, chronic kidney disease, stage 3, diverticulosis of intestine, acute kidney failure, obstructive and reflux uropathy, anemia, hypothyroidism, diabetes mellitus two, vitamin B deficiency, vitamin D deficiency, depression, and Barrett's esophagus.

Review of the five day MDS assessment, dated 08/08/22, revealed he had impaired cognition. Further review of the MDS assessment revealed he required extensive assistance from staff with bed mobility, transfers, dressing, toilet use, and personal hygiene. He required supervision from staff with eating.

Review of the nursing progress notes for Resident #204 revealed he was discharged from the facility to the hospital on 07/19/22. Resident #204 returned from the hospital on 08/05/22. Further review of Resident #204's medical record revealed there was no evidence of the facility providing the resident and/or their representative with a written notification regarding the resident's transfer to the hospital.

Interview on 08/17/22 at 3:06 P.M. with the Administrator confirmed the facility has failed to notify Resident #10, #36, #50, and #204 and/or their representative in writing of discharge from the facility.

Based on medical record review staff interview and review of the facility policy, the facility failed to provide notification of bed hold days available to residents who have discharged from the facility. This affected four (#10, #36, #50 and #204) out of four residents reviewed for discharge from the facility. The facility census was 52.

Findings include:

1. Record review for Resident #10 revealed she was admitted to the facility on 02/10/22. Diagnoses include acute and chronic respiratory failure with hypoxia, heart failure, chronic respiratory failure with hypoxia, cerebrovascular disease, atherosclerotic heart, old myocardial infarction, chronic obstructive pulmonary disease, asthma, poly neuropathy, diabetes mellitus two, diverticulosis of intestine, major depressive disorder, obesity, sleep apnea, and anxiety disorder.

Review of the quarterly Minimum Data Set (MDS), dated 05/20/22, revealed Resident #10 had intact cognition. Further review of the MDS assessment revealed she required extensive assistance from staff with bed mobility, transfers, dressing, toilet use and personal hygiene. Resident #10 required limited assistance from staff with eating.

Review of Resident #10's nursing progress notes revealed she was discharged to the hospital on 05/08/22 and returned to the facility on 05/15/22. Resident #10 discharged to the hospital on 08/08/22 and returned to the facility on 08/12/22. Further review of Resident #10's medical record revealed there was no evidence of the facility provided the resident and/or their representative with bed hold information when the resident was transfer to the hospital.

2. Record review for Resident #36 revealed an admission date of 10/29/21. Diagnosis include arthroplasty, hypertensive urgency, asthma, hypothyroidism, diabetes mellitus two, depression, osteoarthritis, insomnia, dysphagia, hypertension, gastro-esophageal reflux disease without esophagitis, and myocardial infarction.

Review of the quarterly MDS assessment, dated 07/13/22, revealed Resident #36 had impaired cognition. Further review of the MDS assessment revealed she required supervision from staff with bed mobility, transfers, dressing, eating, toilet use, and personal hygiene.

Review of Resident #36's progress notes revealed she was discharged from the facility on 06/24/22 and admitted to the hospital. Resident admitted to the facility from the hospital on 06/29/22. Further review of Resident #36's medical record revealed there was no evidence of the facility provided the resident and/or their representative with bed hold information when the resident was transfer to the hospital.

3. Record review for Resident #50 revealed an admission date of 07/13/22. Diagnoses include pneumonia due to pseudomonas, hypertensive heart, chronic kidney disease with heart failure, chronic systolic (congestive) heart failure, end stage renal disease, athererotic heart disease of native coronary artery without angina pectoris, non rheumatic aortic (valve) stenosis, malignant neoplasm of prostate, secondary malignant neoplasm of bone, obstructive and reflux uropathy, diverticulosis of intestine, part unspecified, anemia, pleural effusion, hyperkalemia, myositis, obstructive sleep apnea, insomnia, obesity, hyperlipidemia, and pneumonia.

Review of the MDS assessment, dated 07/15/22, revealed Resident #50 had impaired cognition. Further review of the MDS assessment revealed he required extensive assistance from staff with bed mobility, transfers, dressing, toilet use, and personal hygiene. He required supervision from staff with eating.

Review of the nursing progress notes for Resident #50 revealed he was discharged to the hospital on 06/22/22. Resident #50 readmitted to the facility on 07/14/22 as a new admission. Further review of Resident #50's medical record revealed there was no evidence of the facility provided the resident and/or their representative with bed hold information when the resident was transfer to the hospital.

4. Record review for Resident #204 revealed the resident was admitted to the facility on 06/23/22. Diagnoses include metabolic encephalopathy, sepsis, urinary tract infection, hypertensive chronic kidney disease, chronic kidney disease, stage 3, diverticulosis of intestine, acute kidney failure, obstructive and reflux uropathy, anemia, hypothyroidism, diabetes mellitus two, vitamin B deficiency, vitamin D deficiency, depression, and Barrett's esophagus.

Review of the five day MDS assessment, dated 08/08/22, revealed he had impaired cognition. Further review of the MDS assessment revealed he required extensive assistance from staff with bed mobility, transfers, dressing, toilet use, and personal hygiene. He required supervision from staff with eating.

Review of the nursing progress notes for Resident #204 revealed he was discharged from the facility to the hospital on 07/19/22. Resident #204 returned from the hospital on 08/05/22. Further review of Resident #204's medical record revealed there was no evidence of the facility provided the resident and/or their representative with bed hold information when the resident was transfer to the hospital.

Interview on 08/17/22 at 3:06 P.M. with the Administrator confirmed the facility has failed to notify Resident #10, #36, #50, and #204 of their bed hold days.

Review of the facility policy titled, Bed Hold Notification

Based on medical record review, observations, staff and resident interviews and policy review, the facility failed to maintain an effective pest control program. This had affected two (#10 and #36) out of two residents reviewed for pest control. The facility census was 52.

Findings include:

1. Record review for Resident #10 revealed she was admitted to the facility on 02/10/22. Diagnoses include acute and chronic respiratory failure with hypoxia, heart failure, chronic respiratory failure with hypoxia, cerebrovascular disease, atherosclerotic heart, old myocardial infarction, chronic obstructive pulmonary disease, asthma, polyneuropathy, diabetes mellitus two, diverticulosis of intestine, major depressive disorder, obesity, sleep apnea, and anxiety disorder.

Review of the quarterly Minimum Data Set (MDS), dated 05/20/22, revealed Resident #10 had intact cognition. Further review of the MDS assessment revealed she required extensive assistance from staff with bed mobility, transfers, dressing, toilet use and personal hygiene. Resident #10 required limited assistance from staff with eating.

2. Record review for Resident #36 revealed an admission date of 10/29/21. Diagnoses included arthropathy, hypertensive urgency, asthma, hypothyroidism, diabetes mellitus two, depression, osteoarthritis, insomnia, dysphagia, hypertension, gastro-esophageal reflux disease without esophagitis, and myocardial infarction.

Review of the quarterly MDS assessment, dated 07/13/22, revealed Resident #36 had impaired cognition. Further review of the MDS assessment revealed she required supervision from staff with bed mobility, transfers, dressing, eating, toilet use, and personal hygiene.

Observation on 08/16/22 at 9:51 A.M. during an interview with Resident #36 revealed the resident was sitting on the side of the bed. Observation of the wall next to her bed revealed a large colony of ants crawling all over the wall, over the bedside chair, and along the carpet.

Interview on 08/16/22 at 10:07 A.M. with Licensed Practical Nurse (LPN) #53 confirmed ants were crawling all over the chair, up the wall and all over the floor in Resident #36's room.

Interview on 08/16/22 at 12:38 P.M. with Resident #10 stated she has had an ongoing issue with ants in her room.

Interview on 08/17/22 at 8:48 A.M. with Maintenance Supervisor (MS) #68 revealed the facility utilizes a professional pest control company to spray for pest monthly. MS #68 stated the facility is treated monthly, however, if pest are identified in a resident's room the facility maintenance staff will treat until the next monthly visit from the professional pest control program. MS #68 confirmed Resident #36 had an infestation of ants in her room and the issue should have been referred to the professional pest control company for treatment.

Follow up interview on 08/17/22 at 3:42 P.M. with the MS #68 confirmed the facility has never had Resident #10 or Resident #36's room treated by the professional pest control company utilized by the facility. MS #68 confirmed each room had ant infestation.

Review of the facility policy tiled Pest Control dated 08/07/2018, revealed the facility will maintain an ongoing pest control program to ensure the building is kept free of insects and rodents.