O'Neill Healthcare Fairview Park

Based on medical record review and interview, the facility failed to provide restorative therapy as ordered and/or care planned. This affected four residents (Resident #77, Resident #78, Resident #79, and Resident #120) of four residents reviewed for therapy services. Facility census was 91.

Findings include:

1. Review of the medical record for Resident #120 revealed an admission date of 09/18/24. Resident #120 was discharged on 05/28/25. Diagnoses included malignant neoplasm of the prostate, secondary malignant neoplasm of the bone, chronic kidney disease, stage four, dementia, dysphagia and history of falls.

Review of the quarterly Minimum Data Set (MDS) assessment, dated 05/06/25, revealed Resident #120 had impaired cognition. Resident #120 required supervision for ambulation.

Review of the plan of care dated 10/14/24 revealed Resident #120 was receiving Restorative Nursing Services (RNS) for ambulation baseline of 75-150 feet with contact guard assist (CGA), staff walking close to resident and front wheeled walker (FWW). Interventions included Resident #120 was to receive RNS up to six times a week for 15 minutes a day, and for staff to encourage Resident #120 to participate in the program to achieve goal. The goal was for Resident #120 to maintain ability through the next review as evidenced by continued ambulation of 75-150 feet with CGA and FWW.

Review of physician orders for dated 01/14/25 indicated Resident #120 was to receive Restorative Nursing Services (RNS) for ambulation per restorative plan of care.

Review of Resident #120's medical record revealed no evidence of restorative nursing services being completed per the plan of care.

Interview on 06/23/25 at 2:28 P.M., Certified Nurse Assistant (CNA) #585 revealed Resident #120 was on the restorative program using two-pound weights for lower extremities and ambulation Monday through Friday. CNA #585 revealed she can't complete the therapy when she is pulled to work the floor. CNA #585 stated her being pulled has slowed down in the past two weeks, so she was able to complete her assignments.

Interview on 06/23/25 at 4:07 P.M., the Director of Clinical Services (DCS) #701 revealed Resident #120 was not on a restorative therapy program, and therapy was not to assess until the next review period.

Interview on 06/25/25 at 9:15 A.M., Regional Administrator #700 and Administrator #601 confirmed the lack of evidence to show Resident #120 received restorative therapy.

2. Review of the medical record for Resident #77 revealed an admission date of 03/15/25. Diagnoses included malignant neoplasm of the stomach and type two diabetes mellitus.

Review of the quarterly Minimum Data Set (MDS) assessment, dated 06/22/25, revealed Resident #77 had intact cognition. Resident #77 required maximum assistance for ambulation.

Review of the plan of care dated 11/19/24 revealed Resident #77 received RNS ambulation program up to six days a week for 15 minutes a day. Resident #77 also received range of motion and strengthening exercises to maintain /improve strength in both lower extremities using a two-pound ankle weight when seated, two sets for 15 repetitions.

Review of the facility restorative care flow record dated April, May and June 2025 revealed Resident #77 did not received therapy for ambulation or strengthening in April 2025, Resident #77 received restorative therapy for ambulation and strengthening three times in May 2025. Resident #77 received no restorative therapy for strengthening in June 2025, but did ambulate 10 times in June 2025.

Interview on 06/24/25 at 2:47 P.M. with Resident #77 revealed staff have never used weights during restorative therapy sessions and therapy hasn't been provided in weeks. A family member present who visits throughout the week revealed therapy was not provided in weeks.

Interview on 06/25/25 at 9:15 A.M., Regional Administrator #700 and Administrator #601 confirmed the lack of evidence to show Resident #77 received restorative therapy as care planned.

3. Review of the medical record for Resident #78 revealed an admission date of 08/17/25. Diagnoses included hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side, difficulty in walking and foot drop, and unspecified foot.

Review of the quarterly Minimum Data Set (MDS) assessment, dated 04/01/25, revealed Resident #78 had intact cognition. Resident #78 required substantial assistance for mobility.

Review of the plan of care dated 04/11/25 revealed Resident #78 received RNS for range of motion, strengthening and transfer exercises six to seven times a week to maintain /improve strength in both lower extremities using a two-pound ankle weight when seated, two sets for 15 repetitions.

Review of the facility restorative care flow record dated April, May and June 2025 revealed Resident #78 did not receive restorative therapy for strengthening in April 2025. Resident #78 received therapy for strengthening four times in May 2025 and no restorative therapy for strengthening in June 2025. The flow sheet for June 2025 indicated Resident #78 received assistance with ambulation two times in June.

Interview on 06/24/25 at 2:51 P.M., Resident #78 she had not received therapy in months.

Interview on 06/25/25 at 9:15 A.M., Regional Administrator #700 and Administrator #601 confirmed the lack of evidence to show Resident #78 received restorative therapy as care planned.

4. Review of the medical record for Resident #79 revealed an admission date of 02/15/25. Diagnoses included hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side and chronic kidney disease.

Review of the quarterly Minimum Data Set (MDS) assessment, dated 04/01/25, revealed Resident #79 had impaired cognition. Resident #79 required substantial assistance for mobility.

Review of the plan of care dated 04/26/24 revealed Resident #79 received RNS for range of motion, strengthening and transfer exercises to six to seven times a week to maintain /improve strength in both lower extremities using a one-pound ankle weight when seated, two sets for 15 repetitions.

Review of the facility restorative care flow record dated April, May and June 2025 revealed Resident #79 received one session of restorative therapy for strengthening/transfers in April 2025 and five times in May 2025. Resident #79 did not receive therapy for strengthening/transfers in June 2025.

Interview on 06/24/25 at 2:39 P.M., Resident #79 stated she was not receiving restorative therapy like she should.

Interview on 06/25/25 at 9:15 A.M., Regional Administrator #700 and Administrator #601 confirmed the lack of evidence to show Resident #79 received restorative therapy as care planned.

This deficiency represents non-compliance investigated under Complaint Number OH00166104.

THE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY.

Based on interview, review of employee personnel files, review of employee handbook and review of abuse policy revealed the facility did not ensure residents were free from potential neglect when staff were sleeping while on duty. This had the potential on 08/05/24 to affect 16 Residents: #1, #4, #9, #10, #13, #18, #20, #22, #28, #29, #36, #44, #58, #76, #85, and #99 when Licensed Practical Nurse (LPN) #608 was assigned to on the south hall was found sleeping. This also had the potential on 09/04/24 to affect 22 Residents: #1, #4, #9, #10, #13, #18, #20, #22, #28, #29, #36, #42, #44, #58, #66, #71, #76, #85, #90, #99, #106, and #107 when LPNs #604 and #613 were assigned to on the south hall were found sleeping. The facility census was 105.

Findings included:

1. Review of personnel file for LPN #608 revealed a hire date of 07/02/24 and she received new hire orientation on 07/02/24 which included the handbook regarding the following actions by an employee would be considered gross misconduct and would result in immediate termination that included sleeping while on duty.

Review of Daily Schedule for 08/05/24 revealed LPN #608 was assigned to the south hall from 7:00 P.M. to 7:30 A.M. She was assigned the following 16 Residents: #1, #4, #9, #10, #13, #18, #20, #22, #28, #29, #36, #44, #58, #76, #85, and #99.

Review of witness statement dated 08/06/24 and completed by LPN #610 revealed she went to lunch and when she came back LPN #608 was sleeping. She revealed she was intentionally noisy, and LPN #608 awoke.

Review of witness statement dated 08/07/24 and completed Director of Nursing (DON) revealed she called LPN #608, and LPN #608 verified on 08/05/24 she had nodded off.

Review of Termination Report dated 08/12/24 revealed LPN #608 was terminated due to sleeping while on duty. The report was signed by the Administrator, and Human Resource (HR) #614 on 08/12/24. LPN #608 did not sign the termination.

Interview on 10/30/24 at 4:13 P.M. with Former Certified Nursing Assistant (CNA) #609 revealed on 08/05/24 she saw LPN #608 sleeping multiple times throughout the shift on 08/05/24. She revealed she would sleep approximately ten to twenty minutes each time as she would wake up and then dose back off.

Interview on 10/30/24 at 4:20 P.M. with LPN #610 revealed LPN #608 was sleeping at the nurse's station in front of the computer with her head on the table. She revealed she had her eyes closed and that she startled her when she woke LPN #608 up by making noise.

2. Review of personnel file for LPN #613 revealed a hire date of 04/03/23 and she received new hire orientation on 04/03/23 which included the handbook regarding the following actions by an employee would be considered gross misconduct and would result in immediate termination that included sleeping while on duty.

Review of personnel file for LPN #604 revealed a hire date of 11/15/23 as she worked first shift as a CNA until she became licensed as an LPN on 07/26/24. Her first day of training as a nurse was on 09/04/24 from 7:00 P.M. to 7:30 A.M. She received new hire orientation on 11/15/23 which included the handbook regarding the following actions by an employee would be considered gross misconduct and would result in immediate termination that included sleeping while on duty.

Review of Daily Schedule for 09/04/24 revealed LPN #613 was training LPN #604 to the south hall from 7:00 P.M. to 7:30 A.M. They were assigned the following 22 Residents: #1, #4, #9, #10, #13, #18, #20, #22, #28, #29, #36, #42, #44, #58, #66, #71, #76, #85, #90, #99, #106, and #107.

Review of Termination Report dated 09/05/24 revealed LPN #604 was terminated due to sleeping while on duty. The report was signed by the Administrator, DON and HR #614 on 09/05/24. LPN #604 did not sign the termination.

Review of Termination Report dated 09/05/24 revealed LPN #613 was terminated due to failing or refusing to cooperate fully with a facility investigation or inspection. The report was signed by the Administrator, and HR #614 on 09/05/24. LPN #613 did not sign the termination.

Review of witness statement dated 09/05/24 and completed by LPN #604 revealed she did not recall falling asleep on 09/04/24. She stated she did watch a movie during down time.

Review of witness statement dated 09/05/24 and completed by LPN #613 revealed on 09/04/24 she was sitting in the social area facing the window on the unit and was not sleeping on the job.

Review of witness statement dated 09/05/24 and completed by LPN #605 revealed on 09/04/24 she noticed LPN #604 and LPN #613 sleeping from 3:00 A.M. till 4:45 A.M. in the dining room.

Review of witness statement date 09/05/24 and completed by CNA #607 revealed she seen two nurses, LPN #604 and LPN #613, both sleeping.

Review of witness statement dated 09/05/24 completed by CNA #606 revealed two nurses, LPN #604 and LPN #613, were sleeping.

Review of witness statement dated 09/05/24 and completed by CNA #615 revealed on 09/04/24 she seen two nurses, LPN #604 and LPN #613, sleeping in the dining room.

Interview on 10/30/24 at 4:16 P.M. with CNA #606 revealed she witnessed both, LPN #604 and 613, sleeping while on duty. She revealed one was sleeping by the window in a chair leaning to one side and her head down but not on the table. She revealed the other was by the piano sitting next to the wall with her eyes closed. She revealed she did not know which nurse was where but that both were sleeping at the same time.

Interview on 10/30/24 at 4:47 P.M. with Administrator and DON verified on 08/05/24 LPN #608 was observed to be sleeping while on duty by more than one staff member. LPN #608 was terminated for sleeping on duty. They verified on 09/05/24 LPN #613 was training LPN #604 and both were observed sleeping while on duty by more than one staff member. They verified LPN #604 and LPN #613 were both terminated.

Interview on 10/31/24 at 10:02 A.M. with HR #615 revealed any new hire she goes over line by line regarding the employee handbook including sleeping on duty which would result in immediate termination.

Review of undated employee handbook revealed the following actions by an employee would be considered gross misconduct and would result in immediate termination that included sleeping while on duty.

Review of facility policy labeled, Abuse, Neglect, Involuntary Seclusion, Misappropriation Prevention dated October 2017 revealed all residents would be free from abuse and neglect. Neglect was defined as failure of the facility, its employees or service providers to provide goods and services to a resident that were necessary to avoid physical harm, pain, mental anguish or emotional distress.

The deficient practice was corrected on 09/05/24 when the facility implemented the following corrective actions:

On 08/12/24 LPN #608 was terminated due to sleeping while on duty.

On 09/05/24 LPN #613 was terminated due to failing or refusing to cooperate fully with a facility investigation or inspection regarding her sleeping while on duty.

On 09/05/24 LPN #604 was terminated due to sleeping while on duty.

On 09/05/24 during employee orientation HR #614 continued to educate all new employees regarding the employee handbook regarding the following actions by an employee would be considered gross misconduct and would result in immediate termination that included sleeping while on duty.

On 09/05/24 with the awareness and termination of staff sleeping the DON had been coming in a few times a week at times as early as 2:00 A.M. and rounded on the units to ensure staff were not sleeping. No staff were observed to be sleeping.

On 09/05/24 all staff were in serviced by the Administrator that sleeping on duty was not tolerated and would result in immediate termination and staff were in serviced on the abuse policy.

On 10/08/24 all staff were in serviced again by the Administrator, DON, and HR #614 that sleeping on duty was not tolerated and would result in immediate termination

This deficiency represents non-compliance investigated under Complaint Number OH00158747.

Based on record review, resident interview, observation, staff interview, and resident family interview, the facility failed to ensure dependent residents received proper nail care. This affected one (Resident #58) of three residents reviewed for activities of daily living (ADL) care. The facility census was 105 residents.

Findings include:

Review of the medical record for Resident #58 revealed an admission date of 12/24/22 with diagnoses including chronic congestive heart failure, high blood pressure, osteoarthritis, major depression, gastroesophageal reflux disease, bilateral artificial knee joints, and cataracts.

Review of the consent form for Resident #58 dated 09/17/24 revealed the resident had consented to podiatry care.

Interview on 09/23/24 at 10:30 A.M with Resident #58 confirmed her representative had asked the facility to have the podiatrist cut her toenails and assess her feet a long time ago, but the resident was unable to remember the specific date of the request. Resident #58 confirmed her nails needed to be trimmed and neither the staff nor the podiatrist had assisted her.

Observation on 09/23/24 at 10:45 A.M of Resident #58's feet revealed both feet had very long thick toenails. Resident #58's toes were overlapped, and the toenails were growing and pressing in the overlapped toes. The skin on Resident #58's feet was dry, red and scaly.

Interview on 09/23/24 at 11:00 A.M. with State Tested Nursing Assistant (STNA) #110 confirmed Resident #58's toenails were long and thick and needed to be trimmed by a podiatrist.

Interview on 09/23/24 at 12:38 P.M. with Resident #58's representative confirmed she had asked the head nurse approximately two months ago to have the podiatrist look at the resident's feet and cut her toenails. Resident #58's daughter stated the facility did not follow-up with her and the podiatrist had not cut the residents toenails or addressed her deformed toes with bunions.

Interview on 09/23/24 at 2:34 P.M. with Nursing Unit Manager Licensed Practical Nurse (NUM-LPN) #111 stated the Social Service Director (SSD) had spoken with Resident #58's representative regarding the need for podiatry to evaluate and treat the resident's feet and cut her toenails. NUM-LPN #111 stated the SSD was responsible to ensure the podiatry visit was scheduled. NUM-LPN #111 confirmed she did not speak to Resident #58 or her daughter to follow-up with them regarding the podiatrist or their concern with the care of the resident's feet.

Interview on 09/23/24 at 2:23 P.M. with Director of Nursing (DON) confirmed she was not aware of Resident #58's or Resident #58's representative's concern. The DON stated the podiatrist had made a visit to the facility on 09/18/24 but did not see Resident #58. The DON stated she had contacted Resident #58's daughter who informed her she had asked the SSD to have Resident #58's feet evaluated during the month of August 2024.

Interview on 09/23/24 at 2:30 P.M. with the Administrator confirmed she was performing the SSD's job duties while the SSD was on a leave of absence. The Administrator confirmed she had no knowledge of Resident #58's representative's request to schedule a podiatry visit to evaluate the resident's feet and cut her toenails.

This deficiency represents non-compliance investigated under Complaint Number OH00156781.