Wesley Woods at New Albany

Based on medical record review, staff interview and facility policy and procedure review, the facility failed to ensure one Residents (#36) received their medications as prescribed by the physician. This affected one of three sampled residents for medications. The facility census was 37.

Findings Include:

Review of the medical record for Resident #36 revealed an initial admission date of 08/31/18 with the admitting diagnoses of hypertension, torticollis, glaucoma, cerebrovascular accident, retention of urine, dysphagia, generalized muscle weakness and symbolic dysfunctions.

Review of the brief interview for mental status (BIMS) dated 10/07/21 revealed a score of three out of fifteen indicating the resident had a severe cognitive deficit.

Review of the monthly physician orders for April 2023 identified orders dated 02/25/23 Seroquel (medication used to treat mood and/or mental disorders) 50 milligrams (mg) by mouth daily at bedtime, 03/23/23 Buspar (medication used to treat anxiety) 7.5 mg by mouth twice daily, Depakote Sprinkles (medication used to treat seizures and/or mood disorder) 125 mg with the special instructions to give two capsules twice daily, Lorazepam intensol liquid (medication used to treat anxiety) 2 mg/ml with the special instructions to give 0,25 ml twice daily, Senna (medication used to treat constipation) 8.6 mg by mouth twice daily, Tylenol (medication used to treat pain) 325 mg with the special instructions to give two tablets twice daily, 03/24/23 Norvasc (medication used to lower blood pressure) 5 mg by mouth daily, Losartan (medication used to lower blood pressure) 50 mg daily by mouth, Melatonin (medication used to induce sleep) 3 mg by mouth daily at bedtime, Zoloft (medication used to treat depression) 75 mg by mouth daily, and 03/28/23 Colace (medication used to treat constipation) liquid 15 milliliters (ml) by mouth daily,

Review of the resident's April 2023 Medication Administration Record (MAR) revealed the resident had not received her physician ordered medication on the following dates 04/09/23, 04/13/23, 04/14/23, 04/15/23, 04/16/23, and 04/25/23.

On 04/27/23 at 4:00 P.M., interview with the Director of Nursing (DON) verified Resident #36 failed to receive physician ordered medications as ordered.

Review of the policy titled, Medication Administration

Based on observation, interview and policy review the facility failed to ensure staff hair was restrained during meal preparation and serving. This had the potential to affect all seventeen residents residing in the facility.

Findings included:

Observation on 02/10/23 at 8:25 A.M. of Dietary Aide #207 working in the kitchenette without her hair covered. Dietary Aide #207 had part of her hair pulled back in a ponytail, but she had a section of long bangs on the right side of her head hanging down to her chin line. At this time, observation revealed a container of hair nets above the employee hand washing sink.

Observation on 02/10/23 at 8:54 A.M. of Dietary Aide #207 continuing to work in the kitchenette without her hair covered. An interview at the time revealed Dietary Aide #207 had never been informed to wear a hair covering while working in the kitchenette in the facility.

Observation on 02/10/23 at 9:03 A.M. of Dietary Aide #207 putting on a hairnet after Executive Chef #205 spoke with her.

Interview on 02/10/23 at 9:03 A.M. with Executive Chef #205 verified staff are to wear hairnets when in the kitchenette.

Review of facility policy titled, Contamination and spoilage, undated, revealed food associates will effectively restrain hair to effectively keep their hair from contacting exposed food. Examples of restrained hair include but are not limited to hats, hair covering or nets, beard restraints, clothing that covers body hair, and having hair pulled back using a hair restraint such as hair tie.

This violation represents an incidental finding discovered during investigation of Complaint Number OH00139960.

Based on observation, interview and call light audit, the facility failed to ensure sufficient staff to timely meet resident needs. This affected Resident #11 and had the potential to affect all 20 residents in the Memory Care unit. The facility census was 92.

Findings include:

1. Review of Resident #11's clinical record revealed a 10/14/21 admission with diagnoses including Parkinson's disease, diabetes, hypertension and dementia without behavioral disturbance. Resident #11 had left sided weakness and mobilized using a motorized wheelchair. Review of a Managers Evaluation dated 10/07/22 revealed Resident #11 needed checked and changed for incontinence with a two person assist.

Interview 12/05/22 at 1:51 P.M. with Resident #11 revealed earlier in the day he had a bowel movement in his pants because he waited 45 minutes for his call light to be answered to be taken to the toilet. Resident #11 indicated Licensed Practical Nurse (LPN) #205 answered the call light and he told her what happened.

Interview 12/05/22 at 2:46 P.M. with LPN #205 revealed she answered Resident #11's call light along with Scheduler #265. She said she was called over the walkie talkie by State Tested Nurse Aide (STNA) #230 asking if she could come and help. STNA #230 indicated Resident #11 was upset he had been waiting a long time for someone to answer his call light and he had soiled his pants. STNA #230 indicated to LPN #205 that Resident #11 had been waiting 30 minutes. LPN #205 revealed Resident #11 was a two person assist and utilized a sit to stand lift to be stood and lowered to the toilet. LPN #205 verified Resident #11 had been incontinent of bowel movement.

Review of the alarm system activation data that morning revealed Resident #11 activated his call alarm at 9:31:33 seconds A.M. A duplicate alarm was sent at 9:33:18, 9:35:05, 9:37:42 and 9:43:43. The call was answered 9:43:50, 12 minutes and 17 seconds later.

The system was activated again at 9:49:27 A.M. A duplicate alarm was sent at 9:50:32, 9:54:24, 9:56:12, 10:00:54, 10:01:25, 10:04:50 and 10:07:20. The call was answered 10:07:26, 17 minutes and 59 seconds later.

The system was activated again at 10:10:36 A.M. A duplicate alarm was sent at 10:13:49, 10:16:47, 10:20:59, 10:25:34, and 10:33:09.

At 10:34:40, 10:37:39 A.M., 10:40:38, 10:43:36, 10:46:35 the system sent email notifications to a former Director of Nursing and another person unknown.

At 10:49:34 A.M. the incident canceled by falling off end of email chain.

Interview 12/05/22 at 4:59 P.M. with LPN #205 revealed she was unable to say when Resident #11's call light was answered but it was on at least from 10:10:36 A.M. through 10:49:34 A.M., 38 minutes and 58 seconds.

2. Observation 12/05/22 at 1:42 P.M. of the Memory Care Unit revealed nine residents in the lounge area in front of the nurse station. The television was on. There were no staff in the area. No staff could be located in the halls or nurse station. After making a circle through the unit back to the lounge area no staff were located. There continued to be no staff monitoring the nine residents in the lounge area. At 2:07 P.M. Activities #270 was located alone in the activity room. She was informed the residents were without supervision. She left the room and said she was going to do nails on Resident #11. At 2:09 P.M., STNA #230 was in the hall and indicated she had been in the restroom. Personal Care Assistant (PCA) #206 entered the hallway and indicated she had been in a room with Resident #18.

Interview on 12/05/22 at 2:09 P.M. with STNA #230 and PCA #206 revealed they had 20 residents on their assignment in the Memory Care unit. Approximately six residents required two staff assist that resulted in both STNA #230 and PCA #206 being in the same room when those six residents required assistance. A nurse was assigned to residents in the Memory Care unit and the general population of the assisted living. At time of interview two call lights were going off. One from Resident #6 which was activated at 1:47 P.M. by the surveyor when the resident asked the surveyor where her room was and one from Resident #11 who STNA #230 and PCA #206 stated activated the call light prior to Resident #6, a minimum of 22 minutes prior for both residents. When the care givers left the area to answer the call lights the residents in the lounge area were unsupervised again. The nurse was not on the unit.

Observation at 2:20 P.M. revealed Activities #270 entered the lounge and was provided nail care.

Based on record review, interview and policy review, the facility failed to meet training requirements for staff members who provided personal care services. This affected three (State Tested Nurse Aide (STNA) #200, Personal Care Assistant (PCA) #202, and STNA #211) out of six staff whose personnel records were reviewed. The facility census was 92.

Findings include:

Personnel record review on 12/06/22 at 1:30 P.M. revealed STNA #200, PCA #202 and STNA #211 had no documented completion of first aid training within sixty days of hire.

Review of the facility's undated policy Orientation and Training on 12/06/22 at 3:15 P.M. revealed personal care staff were required to complete or have documented completion of first aid training within sixty days of hire.

Interview with the Director of Nursing on 12/06/22 at 3:30 P.M. confirmed no first aid training was completed or documentation of completion was in their personal care staff personnel records.

Based on record review, interview and policy review, the facility failed to ensure staff received initial and annual training for special populations. This affected State Tested Nurse Aide (STNA) #200 and Personal Care Assistant (PCA) #202, two out six personnel whose records were reviewed. There were 20 residents residing in the Memory Care unit.

Findings include:

Personnel record review on 12/06/22 at 1:30 P.M. revealed STNA #200 and PCA #202 had no evidence of the required four hour annual special population training.

Review of the facility's undated Orientation and Training policy on 12/06/22 at 3:15 P.M., revealed staff were to have two hours of initial training with in fourteen days of hire and four hours of annual continuing education for special populations.

Interview 12/6/22 at 3:30 P.M. with the Director of Nursing confirmed the personnel records of STNA #200 and PCA #202 did not have evidence of the required training being completed.

Based on record review and staff interview, the facility failed to assess a pressure ulcer weekly. This affected one Resident #35 of two residents identified with pressure ulcers. The facility census was 92.

Findings include:

Review of Resident #35's clinical record revealed a 05/17/19 admission with diagnoses including chronic atrial fibrillation, heart failure, muscle weakness, anemia, hypertension, hypothyroidism, cataracts and vitamin D deficiency.

The resident was hospitalized from 08/19/22 until 8/22/22 for bradycardia (slow heart rate) and had her pacemaker generator replaced and then was admitted to the skilled nursing facility from the hospital. She was readmitted to assisted living on 09/24/22. Review of the admission assessments revealed a pressure ulcer assessment was initiated but not completed. Further review of the clinical record revealed no assessment of the sacrum from the time of readmission.

Review of the physician orders revealed an order dated 09/23/22 to cleanse open area to sacrum with normal saline, pat dry, apply Santyl (enzymatic debrider) nickel thick)to wound bed only, apply moistened gauze over Santyl, then cover with foam dressing everyday and as needed every night shift.

Review of a nurse note 12/04/22 indicated the nurse was called to Resident #35's room due to bright red spots on toilet paper. The note indicated there was no active bleeding from the sacral wound. The resident was noted to have a hemorrhoid.

Interview 12/05/22 at 1:15 P.M. with Resident #35 revealed she was a retired nurse. Resident #35 said she was receiving several dressing changes including a couple to her legs. Resident #35 revealed the nurses changed the dressings daily and if the did not know how, the found someone who did know. Resident #35 refused to allow observations of wound care.

Interview 12/06/22 at 5:59 P.M. with the Director of Nursing (DON) revealed she was hired after Resident #35's readmission. The DON did not know Resident #35 had a pressure ulcer and if she had known she would of ensured the wound practitioner saw the resident. The DON revealed she worked on the floor 12/04/22 and was the author of the nurse note dated 12/04/22. The DON described the area on the sacrum as a small slit.

The facility provided an assessment of Resident #35's sacrum dated 12/07/22. The assessment described the area as located on the left buttock, measuring 1.0 centimeter (cm) length by 1.0 cm width with 0.5 cm depth. There was no odor, yellow minimal drainage and the surrounding area was red. The resident had no pain in the area.

On 12/08/22 the facility provided documentation from prior to Resident #35's readmission from when the resident was on the skilled unit. The documentation indicated the area to the sacrum developed 08/24/22 as an unstageable (stage not clear) pressure ulcer. The treatment orders were changed 08/27/22 to the current order. The last wound note, provided prior to readmission to the assisted living, revealed a sacral pressure ulcer measuring 0.5 cm length by 0.5 cm width. The ulcer was noted as unstageable with no exudate or odor. The wound bed was slough (dead tissue). Surrounding skin color was normal. Surrounding tissue/wound edges were normal.

Based on observation, log review, policy review and interview, the facility failed to store food and maintain kitchen in a sanitary manner. This affected all the residents in the facility. The census was 92.

Findings include:

1. Tour of the assisted living kitchenette on 12/05/22 at 12:45 P.M. revealed a container of Dannon vanilla flavor lowfat yogurt opened 12/04/22 with a best by date of 12/04/22. Interview at the time of the observation with Dietary Aide (DA) #268 verified the yogurt was expired.

2. Tour on 12/05/22 at 2:17 P.M. of the memory care kitchenette revealed a container of Dannon vanilla flavor lowfat yogurt opened with a best by date of 12/04/22 and an undated bowl of fruit cocktail in the refrigerator. There was not a thermometer in the reach in refrigerator to ensure the correct temperature was maintained. A container of prune juice opened 11/02/22 with a use by date of 11/07/22 was on the counter. Interview at the time of the observation with DA #263 verified the expired yogurt, prune juice, and undated fruit cup. DA #263 further verified there was not a thermometer in the refrigerator to monitor the temperatures.

3. Further observation revealed a Dry Storage/Refrigerated Storage guideline and a typed expirations date after opened for food items commonly used in satellite kitchens that contradicted each other posted in kitchen areas. Interview on 12/05/22 at 3:43 P.M. with Cook #265 revealed she did not know which one she was supposed to follow so she split the difference. Interview on 12/05/22 at 3:46 P.M. with Executive Chef #266 verified the posted information for kitchen staff gave different time lengths of storage for the same food items. Executive Chef #266 stated they needed to provide one standard guideline.

4. Tour on 12/06/22 at 11:32 A.M. of the main kitchen which was located in the independent living area of the building revealed the following.

a. The ice cream cooler had five gallon containers of Buckeye, chocolate, and butter pecan ice cream with the lids off or ajar. There was not a thermometer in the ice cream cooler.

b. The walk in refrigerator contained pumpkin apple bisque with a use by date of 11/30/22, cheeseburger soup with a use by date of 12/04/22, Bluecheese with a use by date of 11/12/22, 61 boneless porkchops thawed and seasoned uncovered on a tray, a large container of juice the had white mold thick around the rim and on top of the surface with a use by date of 08/22/22.

c. The reach in refrigerator in the back prep area contained an uncovered piece of cake topped with berries and an uncovered piece of peach pie

. The reach in refrigerator across from the tray line contained coleslaw with a discard date of 12/04/22, three undated fruit cups, an undated bowl of macaroni salad, sliced cheese wrapped in Saran which was undated, and ham salad with a use by date of 11/14/22.

Interview on 12/06/22 at 11:46 A.M. with Dining Service Manager #262 verified there was expired, undated and uncovered food in the ice cream cooler, walk in, and reach in refrigerators.

e. Observation of the cooking area revealed the shelf above the cooktop was greasy with dust and hair stuck to it, and the ansel system above the cooktop was dusty. Interview 12/06/22 at 11:48 A.M. with Cook #261 verified the grease, dust and hair on surfaces over the cooking range.

Review of the facility's Food and Supply Storage policy revised 01/22 included all food, non-food items and supplies used in food preparation were to be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption. Most, but not all, products contained an expiration date. The word Sell by, Best By, Enjoy by, or Use by should precede the date. The sell by date was the last date food could be sold or consumed: do not sell products in retail areas or place on patient trays/resident plates past the date on the product. Foods past the use by sell by, Best By or enjoyed by date should be discarded. Cover, label and date unused portions and open packages. The policy indicated to complete all sections on a label, or other approved labeling system. Products were good through the close of business on the date noted on the label.

Review of the Assistant Cook To Do List included extra salads, sides etc, make sure to label and date!

Based on observation, staff interview and policy, the facility failed to ensure trash cans with food scraps and garbage in the kitchenettes in the Memory Care and Assisted living areas had lids. This had the potential to affect all the residents in the facility. The census was 92.

Findings include:

Observations on 12/05/22 at 12:45 P.M. of the Assisted Living kitchenette revealed the trash can with food scraps did not have a lid. Interview at the time of the observation with Dietary Aide (DA) #268 verified food garbage was in the trash can and was exposed and not covered with a lid.

Observation on 12/05/22 at 2:17 P.M. of the Memory Care Kitchenette revealed a trash can with food garbage uncovered. Used coffee grounds were noted on the top. Interview at the time of the observation with DA #263 verified the garbage was not covered.

Review of the facility's 10/19/13 policy Solid Waste Disposal included to keep lids to all trash receptacles closed unless actively in use.

2. Review of Resident #4's clinical record revealed a 01/13/22 admission with diagnoses including Parkinson's disease, major depressive disorder, hypertension and protein calorie malnutrition. Further review revealed no evidence of fire, tornado, or disaster training.

Interview of RN #256 12/06/22 at 3:25 P.M. confirmed there was no documentation upon admission of fire safety, tornado or other disaster education or training in Resident #4's record.

3. Review of Resident #11's clinical record revealed a 10/14/21 admission with diagnoses including Parkinson's disease, diabetes, hypertension and dementia without behavioral disturbance. Further review revealed no evidence of fire, tornado, or disaster training on admission as required.

Interview of RN #256 on 12/06/22 at 3:25 P.M. confirmed there was no documentation upon admission of fire safety, tornado or other disaster education or training in Resident #11's record.

Based on observation and interview, the facility failed to post the most recent statement of deficiencies (SOD) issued to the home. This had the potential to affect all the residents in the facility. The census was 92.

Findings include:

Tour of the facility on 12/05/22 from 12:45 P.M. to 3:40 P.M. revealed the facility was a large three story building with an exterior entrance to the Assisted Living and Memory care units and a separate entrance to the Independent Living. There was no evidence of the results of the Ohio Department of Health annual or complaint investigations in the common areas or on each individual unit. Interview on 12/06/22 at 10:50 A.M. with Registered Nurse #258 revealed she thought the SOD would be at the nurse stations.

Interview on 12/06/22 at 10:52 A.M. with State Tested Nurse Aides (STNA) #230 and STNA #259 on the Memory Care Unit revealed they checked the nurse station and could not find any previous survey results.

Interview on 12/06/22 at 11:09 A.M. with Licensed Practical Nurse (LPN) #205 verified the staff could not locate any previous inspection findings on the Memory Care Unit.

Interview on 12/06/22 at 12:20 P.M. with LPN #220 revealed they were unable to locate any previous inspection results on the second floor Assisted Living section of the facility.

Interview 12/06/22 at 2:30 P.M. with Executive Director #250 verified the facility was unable to locate the posted survey inspection results in the facility. The ED verified there were no inspection results readily accessible to visitors or residents.