Heritage of Euclid LLC

Based on observation, interview, record review, Self-Reported incident (SRI) review, and review of the facility Abuse police the facility failed to ensure Resident #10 was free of physical abuse.

Actual Harm occurred on 01/16/24 at approximately 11:55 A.M. when Resident #39 threw a hot beverage on Resident #10 and proceeded to punch her with a closed fist multiple times in the head and upper body resulting in extensive burns to the resident's bilateral breast and neck region as well as bruising under her left eye. Resident #10 revealed the day of the incident she was in significant pain and the burns continued to hurt a lot. Upon return from the hospital on 01/16/24, Resident #10 expressed to Licensed Practical Nurse (LPN) #607 that she was afraid. She also revealed she had isolated herself as she did not want to go to the dining room as it reminded her of what happened and made her depressed. She revealed I just want to stay in my room. This affected one resident (#10) out of eight residents reviewed for abuse. The facility census was 38.

Findings Include:

Review of medical record for Resident #10 revealed an admission date of 11/03/23 with diagnoses including Wernicke's encephalopathy, hypertension, major depression, and tachycardia.

Review of the ALF: SLUMS- V3 (screening test for dementia) dated 11/03/23 and completed by LPN #609 revealed Resident #10 had normal cognition.

Review of the Health Service Evaluation dated 11/27/23 and completed by LPN #602 revealed Resident #10 had no behaviors and was independent with her activities of daily living (ADL) including ambulation, transfers, bathing, grooming, and dressing.

Review of closed medical record for Resident #39 revealed an admission date of 07/20/23 and discharge date of 01/16/24. Her diagnoses included schizoaffective disorder and hypertension. There were no previous incidents of physical aggression documented in her medical record other than the incident, dated 01/16/24.

Review of the service plan dated 09/16/23 revealed Resident #39 had behaviors including resisting care, verbal aggression, and exhibiting inappropriate behaviors including disrobing, taking belongings from others, wandering, and showing anger. Interventions included one on one supervision, mental health services, and report changes from baseline to the nurse.

Review of the Health Service Evaluation dated 11/29/23 and completed by LPN #610 revealed Resident #39 had intact cognition and no behaviors. She was independent with her ADL including ambulation, transfers, bathing, grooming, and dressing.

Review of Self-Reported Incident (SRI) tracking number 243136 dated 01/16/24 revealed the facility substantiated an allegation of resident-to-resident physical abuse. The SRI revealed Resident #39 was in the dining room eating when Resident #10 came out and sat down in the dining room. The SRI revealed Resident #39 walked up and started punching Resident #10 and Resident #10 stood up and tried to get away but fell. Resident #39 then attempted to kick Resident #10, but the nurse intervened and separated the residents. The SRI revealed Resident #39 was asked what caused her to attack Resident #10 and she stated, she called me a name and started snickering. The SRI revealed Resident #10 was taken to her room and assessed. Resident #10 was crying, in shock that she was attacked and complained of pain to areas where she was hit. Emergency medical services (EMS) were contacted and transported both Resident #10 for medical evaluation and Resident #39 for psychological evaluation in separate ambulances. The SRI revealed the police were notified and a report #24-00259 was obtained. The investigation revealed, per staff, Resident #10 had walked to the dining room and never said a word to anyone. There was nothing in the SRI regarding Resident #10's burns.

Review of incident report dated 01/16/24 at 11:55 A.M. and completed by LPN #602 revealed the nurse heard a commotion behind her and when she turned to see what was happening Resident #39 was on Resident #10's side of the table hitting her in the head area. The report revealed Resident #10 stood up and while trying to flee fell at which point LPN #602 was able to get in between Resident #10 and Resident #39 to stop the incident. The report revealed LPN #602 attempted to assess for injury but Resident #10 was too upset and complained of chest pain. LPN #602 called EMS to transport her to the hospital.

Review of the nursing note dated 01/16/24 at 1:18 P.M. and completed by LPN #602 revealed she heard a commotion behind her and when she turned to see what was happening the other resident was on Resident #10's side of the table hitting her in the head area. The note revealed Resident #10 stood up and while fleeing fell at which point LPN #602 was able to get in between both residents stopping the incident. The note revealed Resident #10 complained of chest pain, and EMS was called and transported Resident #10 to the hospital for assessment.

Review of the After Visit Summary dated 01/16/24 revealed Resident #10 was seen per Emergency Room Physician Assistant (PA) #608 due to assault. The summary revealed she diagnosed Resident #10 with contusion of face and burns. There was no description regarding the burns including measurements, degree and/or appearance. PA #608 ordered Bacitracin 500 units per gram ointment topically to affected area two times a day and Oxycodone Acetaminophen (pain medication) 5-325 milligrams (mg) tablet by mouth every eight hours as needed for pain for three days.

Review of the nursing note dated 01/16/24 at 8:40 P.M. and completed by LPN #607 revealed Resident #10 returned from the hospital at 7:40 P.M. The note revealed the hospital diagnosed the resident with assault, burns to her chest, right side of face, and neck, and a contusion. She was ordered pain medication for three days and Bacitracin topical treatment to her affected areas for seven days. The note revealed Resident #10 had stated she was afraid

Based on record review and interview the facility failed to ensure medications were administered per physician orders. This affected three residents (#2, #3, and #4) of four residents reviewed for medication administration.

Findings Include:

1. Review of Resident #2's medical record revealed an admission date of 07/13/15 with diagnoses including schizoaffective disorder, depression, anxiety, shortness of breath, dementia, asthma, and high blood pressure.

Review of the March 2023 Medication Administration Record (MAR) revealed no evidence Resident #2 received her evening medications on 03/08/23. The medications included: atorvastatin (cholesterol medication) 20 milligrams (mg) orally (po), diltiazem (anti-hypertensive medication) 180 mg po, levothyroxine (thyroid hormone replacement) 25 micrograms (mcg) po, Melatonin (sleep aide) 6 mg po, montelukast (allergy medication) 10 mg po, benztropine (used to treat movement disorders) 0.5 mg po, docusate sodium (stool softener) 100 mg po, ipratropium bromide solution 0.02% inhalation (breathing treatment) , Vitamin D 3 2000 units po and ziprasidone (antipsychotic medication) 40 mg po.

Interview with the Executive Director/Director of Nursing (ED/DON) on 03/09/23 at 1:30 P.M. revealed Licensed Practical Nurse (LPN) #113 was the only nurse working on the night of 03/08/23. The ED/DON revealed a resident had fallen and thought maybe the nurse had just forgot to document the administration of the medications for the resident. The facility was unable to verify the medications had been administered as ordered.

2. Review of Resident #3's medical record revealed an admission date of 02/23/23 with diagnoses including myasthenia gravis (a chronic autoimmune, neuromuscular disease that causes weakness in the skeletal muscles), bipolar disorder, rheumatoid arthritis, seizures, depression, anxiety, high blood pressure, diabetes, and chronic obstructive pulmonary disorder.

Review of the March 2023 MAR revealed no evidence Resident #3 received her evening medications on 03/08/23. The medications included: levothyroxine (thyroid hormone replacement) 75 mcg po, Ativan (anti-anxiety medication) 0.5 mg po, zolpidem (sedative) 5 mg po, buspirone (antianxiety medication) 10 mg po, carvedilol (anti-hypertensive medication) 25 mg po, Eliquis (anticoagulant medication) 5 mg po, ferrous sulfate 325 mg po, gabapentin (anticonvulsant medication) 300 mg po, lamotrigine (anticonvulsant/mood stabilizer) 200 mg po, levetiracetam (anticonvulsant) 750 mg po, Linzess (used to treat irritable bowel syndrome with constipation) 145 mcg po, Macrobid (antibiotic) 100 mg po, Metformin (used to treat diabetes) 500 mg po, Symbicort Inhalation Aerosol 160-4.5 mcg 2 puffs inhaled, valsartan (antihypertensive medication) 160 mg po and Fentanyl Patch 72 hour 50 mcg/hour transdermal and change every 72 hours for pain.

Interview with the ED/DON on 03/09/23 at 1:30 P.M. revealed LPN #113 was the only nurse working on the night of 03/08/23. The ED/DON revealed a resident had fallen and thought maybe the nurse had just forgot to document the administration of the medications for the resident. The facility was unable to verify the medications had been administered as ordered.

Follow-up interview with the ED/DON on 03/09/23 at 2:00 P.M. revealed Resident #3 did not have her old Fentanyl patch removed and the new one applied as ordered on 03/08/23. LPN #111 was currently removing the old patch and applying a new patch.

3. Review of Resident #4's medical record revealed an admission date of 06/14/18 with diagnoses including stroke, high blood pressure, and depression.

Review of the March 2023 MAR revealed there was no evidence indicating Resident #4 received her evening medications on 03/08/23. The medications included: atorvastatin 10 mg po, Vitamin D 3 2000 units po, calcium carbonate 600 mg po and memantine (used to slow the progression of Alzheimer's disease) 10 mg po.

Interview with the ED/DON on 03/09/23 at 1:30 P.M. revealed LPN #113 was the only nurse working on the night of 03/08/23. The ED/DON revealed a resident had fallen and thought maybe the nurse had just forgot to document the administration of the medications for the resident. The facility was unable to verify the medications had been administered as ordered.

This violation represents non-compliance investigated under Complaint Number OH00140869.

Based on observation, record review and Resident Council Minute review the facility failed to maintain a clean and orderly environment following water damage. This had the potential to affect all 40 residents residing in the facility.

Findings include:

Review of the email correspondence from the facility to the Regional Director of Maintenance (RDM) #200 dated 02/16/23 revealed the total ceiling tile needed at the facility would be 60 tile.

Review of the order slip dated 02/20/23 at 9:27 A.M. revealed six cases of ceiling tile, measuring 96 square feet per case, were ordered.

Review of the email correspondence from RDM #200 to Corporate Staff #225 dated 02/20/23 at 9:43 A.M. revealed RDM #200 was not ordering anything until he received approval.

No further emails or documentation was provided regarding the ceiling tile.

Review of the February 2023 Resident Council Minutes dated 02/21/23 revealed residents inquired when are they going to fix this place up?

An environmental tour with the Executive Director/Director of Nursing (ED/DON) and Director of Maintenance (DOM) #105 on 03/07/23 from 1:20 P.M. to 1:40 P.M. revealed the South Hall on the first floor had missing tile from water damage that began on 12/24/22 into 12/25/22 when water pipes began to burst. The tile in the entire hall had been removed and the hall had a musty smell. Interview with DOM #105 and ED/DON at the time of the observation confirmed the tile were missing from the water damage and they did not have any additional information to when the tiles would be replaced. Further interview verified it had been almost three months since the water lines burst and no work had been completed for the missing ceiling tile in the South Hallway.

This violation represents non-compliance investigated under Complaint Number OH00140720.

Based on record review and interview the facility failed to ensure necessary fire drills were conducted each shift. This had the potential to affect all 41 residents currently residing in the facility.

Findings include:

Review of fire drill worksheets from 01/01/22 through 01/31/2023 revealed evidence of fire drills were conducted on 01/19/22 on first shift, 01/26/22 on second shift, 03/24/22 on first shift and 06/29/22 on first shift. There was no evidence drills were performed on all shifts in April, May, July, August, September, October, November or December 2022.

Interview on 01/31/23 at 12:33 P.M. revealed the director of maintenance (DOM) #211 verified he was not performing monthly fire drills on each shift.

Based on record review and interview the facility failed to ensure to conduct two disaster drills as required. This had the potential to affect all 41 residents currently residing in the facility.

Findings include:

Review of fire drill and disaster worksheets from January 2022 through January 2023 revealed no evidence of any disaster drills being completed and recorded.

Interview on 01/31/23 at 12:33 P.M. revealed the director of maintenance (DOM) #211 verified he did not conduct disaster drills.

Based on record review and interview the facility failed to ensure the monthly self-inspection form was completed as required. This had the potential to affect all 41 residents currently residing in the facility.

Findings include:

Review of fire drill binder revealed no evidence of the facility recording on the monthly self-inspection form.

Interview on 01/31/23 at 12:33 P.M. revealed the director of maintenance (DOM) #211 verified he was not recording on the monthly self-inspection form.