Shepherd of the Valley - Liberty

Based on record review and interview, the facility failed to notify the physician of Resident #14's elopement from the facility. This affected one resident (#14) of three residents reviewed notification of change in condition. The facility census was 47.

Findings include:

Review of the medical record for Resident #14 revealed an admission date of 09/14/23 with diagnoses including diabetes, Alzheimer's disease, and osteoarthritis.

Review of the resident assessment dated 09/14/23 revealed Resident #14 was oriented to person place and time.

Review of the elopement assessment dated 09/14/23 revealed Resident #14 was not at risk for elopement.

Review of the medical record revealed Resident #14 did not have a physician's order that he was permitted to go on leave of absences independently.

Interview on 11/15/23 at 7:41 A.M. with State Tested Nurse Aide (STNA) #200 revealed on the morning of 11/09/23 she went to get Resident #14 to take him downstairs to the barbershop, and he was not in his room. She went downstairs and the receptionist told her she saw Resident #14 walk out the front door, which was not uncommon for Assisted Living (AL) residents. Approximately 20 to 30 minutes later, Resident #14 returned to the facility via a delivery driver without injury. The resident told staff he was going to the barbershop. The church he was at was only about 0.25 miles away. Resident #14 had an appointment card in his hand for the barber at Shepherd of the Valley Liberty. The delivery driver saw the card, assumed he came from there, and drove him back to the facility.

Review of the medical record revealed no documented evidence of Resident #14's elopement on 11/09/23.

Interview on 11/15/23 at 9:41 A.M. with Resident #14 revealed the resident recalled leaving the building and was told upon return that he needed to let someone know, and to sign out when he wanted to leave. He revealed he did not know that prior to leaving.

Interview on 11/15/23 at 1:16 P.M. with the Director of Nursing (DON) confirmed Resident #14 left the building without notifying anyone on 11/09/23.

Interview on 11/15/23 at 2:21 PM with Medical Doctor (MD) #203 confirmed he had no knowledge of Resident #14's elopement.

Interview on 11/15/23 at 3:22 P.M. with the Director of Nursing (DON) confirmed no one notified the MD #203 of Resident #14's elopement.

This violation is an incidental finding investigated under Complaint Number OH00148284.

Based on record review, interview, and policy review the facility failed to document an elopement in the medical record, failed to have documented evidence of a thorough investigation of an elopement, and failed to document the incident on the incident log. This affected one resident (#14) of three residents reviewed for elopement. The facility census was 47. Findings include: Review of the medical record for Resident #14 revealed an admission date of 09/14/23 with diagnoses including diabetes, Alzheimer's disease, and osteoarthritis. Review of the resident assessment dated 09/14/23 revealed Resident #14 was oriented to person place and time. Review of the elopement assessment dated 09/14/23 revealed Resident #14 was not at risk for elopement. Review of the medical record revealed Resident #14 did not have a physician's order that he was permitted to go on leave of absences independently. Interview on 11/15/23 at 7:41 A.M. with State Tested Nurse Aide (STNA) #200 revealed on the morning of 11/09/23 she went to get Resident #14 to take him downstairs to the barbershop, and he was not in his room. She went downstairs and the receptionist told her she saw Resident #14 walk out the front door, which was not uncommon for Assisted Living (AL) residents. Approximately 20 to 30 minutes later, Resident #14 returned to the facility via a delivery driver without injury. The resident told staff he was going to the barbershop. The church he was at was only about 0.25 miles away. Resident #14 had an appointment card in his hand for the barber at Shepherd of the Valley Liberty. The delivery driver saw the card, assumed he came from there, and drove him back to the facility. Review of the medical record revealed no documented evidence of Resident #14's elopement on 11/09/23. Review of the incident log dated 08/01/23 through 11/14/23 revealed no evidence of Resident #14's elopement. Interview on 11/15/23 at 1:16 P.M. with the Director of Nursing (DON) confirmed Resident #14 left the building without notifying anyone on 11/09/23. She verified she did not document the incident in the medical record or on the incident log. There was no documented evidence of a thorough investigation of the elopement. Review of the facility policy titled DocumentationBased on record review, interview, and policy review the facility failed to document an elopement in the medical record, failed to have documented evidence of a thorough investigation of an elopement, and failed to document the incident on the incident log. This affected one resident (#14) of three residents reviewed for elopement. The facility census was 47.

Findings include:

Review of the medical record for Resident #14 revealed an admission date of 09/14/23 with diagnoses including diabetes, Alzheimer's disease, and osteoarthritis.

Review of the resident assessment dated 09/14/23 revealed Resident #14 was oriented to person place and time.

Review of the elopement assessment dated 09/14/23 revealed Resident #14 was not at risk for elopement.

Review of the medical record revealed Resident #14 did not have a physician's order that he was permitted to go on leave of absences independently.

Interview on 11/15/23 at 7:41 A.M. with State Tested Nurse Aide (STNA) #200 revealed on the morning of 11/09/23 she went to get Resident #14 to take him downstairs to the barbershop, and he was not in his room. She went downstairs and the receptionist told her she saw Resident #14 walk out the front door, which was not uncommon for Assisted Living (AL) residents. Approximately 20 to 30 minutes later, Resident #14 returned to the facility via a delivery driver without injury. The resident told staff he was going to the barbershop. The church he was at was only about 0.25 miles away. Resident #14 had an appointment card in his hand for the barber at Shepherd of the Valley Liberty. The delivery driver saw the card, assumed he came from there, and drove him back to the facility.

Review of the medical record revealed no documented evidence of Resident #14's elopement on 11/09/23.

Review of the incident log dated 08/01/23 through 11/14/23 revealed no evidence of Resident #14's elopement.

Interview on 11/15/23 at 1:16 P.M. with the Director of Nursing (DON) confirmed Resident #14 left the building without notifying anyone on 11/09/23. She verified she did not document the incident in the medical record or on the incident log. There was no documented evidence of a thorough investigation of the elopement.

Review of the facility policy titled Documentation

Based on record review and interview, the facility failed to document a resident elopement on the incident log. This affected one resident (#14) of three residents reviewed for elopement. The facility census was 47.

Findings include:

Review of the medical record for Resident #14 revealed an admission date of 09/14/23 with diagnoses including diabetes, Alzheimer's disease, and osteoarthritis.

Review of the resident assessment dated 09/14/23 revealed Resident #14 was oriented to person place and time.

Review of the elopement assessment dated 09/14/23 revealed Resident #14 was not at risk for elopement.

Review of the medical record revealed Resident #14 did not have a physician's order that he was permitted to go on leave of absences independently.

Interview on 11/15/23 at 7:41 A.M. with State Tested Nurse Aide (STNA) #200 revealed on the morning of 11/09/23 she went to get Resident #14 to take him downstairs to the barbershop, and he was not in his room. She went downstairs and the receptionist told her she saw Resident #14 walk out the front door, which was not uncommon for Assisted Living (AL) residents. Approximately 20 to 30 minutes later, Resident #14 returned to the facility via a delivery driver without injury. The resident told staff he was going to the barbershop. The church he was at was only about 0.25 miles away. Resident #14 had an appointment card in his hand for the barber at Shepherd of the Valley Liberty. The delivery driver saw the card, assumed he came from there, and drove him back to the facility.

Review of the medical record revealed no documented evidence of Resident #14's elopement on 11/09/23.

Interview on 11/15/23 at 9:41 A.M. with Resident #14 revealed the resident recalled leaving the building and was told upon return that he needed to let someone know, and to sign out when he wanted to leave. He revealed he did not know that prior to leaving.

Interview on 11/15/23 at 1:16 P.M. with the Director of Nursing (DON) confirmed Resident #14 left the building without notifying anyone on 11/09/23. She verified she did not document the incident in the resident's medical record or on the incident log and should have.

Interview on 11/15/23 at 1:35 P.M. with Resident #14's nephew, who has been the resident's power of attorney (POA) for several years, stated the resident was used to being independent and thought he was confused since it was a new place and was not sure about the rules.

Interview on 11/15/23 at 2:21 P.M. with Medical Doctor (MD) #203 revealed Resident #14 is confused. He has been treating the resident for 30 years and noticed he had some confusion starting about end of August 2023 when he last saw the resident. He stated last week he ordered routine labs. He stated the facility did not notify him of the elopement on 11/09/23. He stated Resident #14 was very independent and thinks needs acclimated to the facility. He stated if he knows the boundaries, he will listen; he didn't know the rules.

Interview on 11/15/23 at 3:22 P.M. the DON verified MD #203 was not notified of Resident #14's elopement on 11/09/23.

This violation represents noncompliance investigated under Complaint Number OH00148284.

Based on record review, observations and interviews the facility failed to maintain sufficient staffing levels to provide appropriate supervision and to assist residents with their activities of daily living in a timely manner and/or as scheduled. This affected six (Resident #10, #26, #17, #34, #35, #37) residents and had the potential to affect all 47 residents.

Findings include:

Review of the medical record for Resident #17 revealed an admission date of 08/31/20. Diagnoses included malignant neoplasm of unspecified site and hereditary and idiopathic neuropathy. Review of the resident assessment dated 08/16/23 revealed Resident #17 had fluctuations in orientation and required one person assistance with bathing.

Review of the medical record for Resident #34 revealed an admission date of 10/25/22. Diagnoses included unspecified dementia, encephalopathy, and chronic obstructive pulmonary disease. Resident #34 resided on the memory care unit. Review of the resident assessment dated 08/30/23 revealed Resident #34 had fluctuations in orientation, required one person assistance with transfers and toileting, and used a wheelchair to move about the unit.

Review of the fall risk assessments dated 05/08/23 and 08/30/23 revealed Resident #34 was at high risk for falls.

Review of nurse progress notes from September through October 2023 revealed Resident #34 had three falls and transferred without staff assistance.

Review of the incident log dated August through October 2023 revealed Resident #34 fell on 09/17/23, 09/23/23, and 10/04/23.

Review of the medical record for Resident #35 revealed an admission date of 09/15/23. Diagnoses included unspecified dementia, altered mental status, muscle wasting and atrophy, cognitive communication deficit, and weakness. Resident #35 resided on the memory care unit.

Review of the admission screening assessment dated 09/15/23 revealed Resident #35 was oriented to person, required limited assistance for walking and toileting, had impaired vision, and used a wheelchair to move about the unit.

Review of the fall risk assessment dated 09/15/23 revealed Resident #35 was at high risk for falls.

Review of nurse progress notes from September through October 2023 revealed Resident #35 had several falls, got out of his wheelchair and walked without staff assistance, wandered into other resident rooms, and was verbally and physically aggressive toward staff.

Review of the incident log dated August through October 2023 revealed Resident #35 fell on 09/17/23, 09/26/23, 10/06/23, 10/07/23, 10/13/23, 10/18/23, 10/23/23, and 10/27/23.

Review of schedules and timecards for September and October 2023 revealed there were two staff scheduled from 10:00 P.M. to 6:00 A.M. on 09/16/23, 09/17/23, 09/23/23, 09/24/23, 10/08/23, 10/14/23, and 10/20/23. The census averaged 45 to 47 residents; 17 residents resided on the memory care unit.

Interviews on 10/26/23 from 8:46 A.M. to 9:03 A.M. with Licensed Practical Nurse (LPN) #100, State Tested Nurse Assistant (STNA) #101, LPN #102, and STNA #103 revealed there was not enough staff to check/change, toilet and shower residents as needed. They stated there were five residents on the memory care unit who were moderate to high risk for falls, two residents with exit seeking behaviors, one resident who transferred other residents when staff were not around, and one resident who required a mechanical lift for transfers. The staff stated they used the mechanical lift by themselves due to a lack of staff. It was not unusual to have only one staff working on the memory care unit for hours at a time. The LPNs indicated there were times when they left their assigned areas to answer call lights on the independent living unit. The staff took their staffing concerns to management who told staff to think outside the box. Each staff member appeared genuinely concerned and were tearing up when expressing their concerns.

Observations on 10/26/23 at 10:07 A.M. revealed Resident #35 was in his wheelchair in the dining room. As soon as STNA #101, who was the only staff on the unit, walked down the hall to assist another resident, Resident #35 stood up and walked across the dining room approximately 15 feet to a table. Resident #35 leaned on tables and chairs as he ambulated to the table. Interview with STNA #101, immediately after the observation, revealed Resident #35 ambulated by himself all day and when there was only one staff on the unit and that staff was helping other residents, Resident #35 was not supervised.

Interview with the Director of Nursing on 10/31/23 at 10:36 A.M. verified there were two staff scheduled from 10:00 P.M. to 6:00 A.M. on 09/16/23, 09/17/23, 09/23/23, 09/24/23, 10/08/23, 10/14/23, and 10/20/23.

Observation on 10/31/23 at 12:50 P.M. revealed STNA #111 was the only staff on the memory care unit assisting residents. Resident #35 was in his wheelchair seated at a table in the dining room. STNA #111 was assisting another resident to her room. STNA #111 directed Resident #35 to stay in his chair until she returned. When STNA #111 was approximately 20 feet down the hall with the other resident, Resident #35 stood up and walked approximately 15 feet across the dining room to another table. When STNA #111 returned and observed Resident #35 sitting at another table she stated, this is what he does all the time. STNA #111 stated she was the only staff in the memory care unit from 12:50 P.M. to 1:25 P.M. because the other staff assigned to the memory care unit was on lunch break.

Observation on 10/31/23 at 2:27 P.M. revealed STNA #101 was walking toward the memory care unit; STNA #101 was approximately five feet from the memory care unit door. When STNA #101 entered the unit, no other staff were observed in the unit. Interview with STNA #101, at the time of the observation, revealed the unit was left unattended when she was transferring memory care residents to activities and getting laundry which was located approximately 50 feet down the hall from the memory care unit. Three residents were left unsupervised while STNA #101 was not in the unit, Resident #34, #35 and #37.

Interview on 10/31/23 at 2:37 P.M. with a family member of Resident #37 revealed she had visited Resident #37, who resided in the memory care unit, one afternoon and observed STNA #101 working by herself. The residents were in the living room asking for assistance and trying to get out of wheelchairs. STNA #101 looked stressed and overwhelmed. On another occasion, about a month ago, the family member could not locate Resident #37. Staff assisted the family member in searching for Resident #37 and found her in another resident's room trying to get into bed.

Interview on 10/31/23 at 3:04 P.M. with Resident Assistant (RA) #109 revealed there was not enough staff to provide resident care, assistance, and showers. The residents were not getting two showers a week as scheduled.

Interview on 10/31/23 at 5:08 P.M. with STNA #110 revealed she had worked at the facility for years and staffing was the worst she had ever seen. STNA #110 stated one time, when she was working by herself from 5:00 P.M. to 7:30 P.M., she was showering a resident when a call light went off. STNA #110 finished the shower and went to answer the call light. Resident #26 had fallen because she attempted to walk to the bathroom independently because she did not want to soil herself. STNA #110 called the nurse who was assisting Resident #10 who had also fallen. STNA #110 stated another resident, Resident #11, was crying to go to the bathroom because there was no one to assist her. STNA #110 expressed great concern related to resident care and safety.

Interview on 11/01/23 at 9:41 A.M. with the daughter of Resident #17 revealed she was concerned about staffing; her mother only received one shower a week. An interview with Resident #17 at 9:48 A.M. confirmed she only received showers on Sundays and wanted showers more frequently.

Review of shower sheets revealed Resident #17 received three showers in September and four in October 2023.

Review of shower sheets revealed Resident #34 received six showers in September and five in October 2023.

Review of shower sheets revealed Resident #35 received two showers in September and five in October 2023.

Review of the facility's shower list revealed all residents were scheduled a minimum of two showers per week. This was verified by STNA #101 on 10/31/23 at 4:58 P.M.

Interview on 11/01/23 at 10:55 A.M. with the Administrator and Director of Clinical Services #112 and #113 revealed they did not have concerns regarding staffing. The Administrator stated the staffing model worked at two of their sister facilities. Of note, the two sister facilities did not have memory care units.

This violation represents non-compliance investigated under Complaint Number OH00147283.

Based on record review and interview the facility failed to ensure personal care services were provided as planned. This affected three (Resident #34, #35, and #17) of 17 residents residing on the memory care unit.

Findings include:

Review of the medical record for Resident #17 revealed an admission date of 08/31/20. Diagnoses included malignant neoplasm of unspecified site and hereditary and idiopathic neuropathy.

Review of the resident assessment dated 08/16/23 revealed Resident #17 had fluctuations in orientation and required one person assistance with bathing.

Review of the medical record for Resident #34 revealed an admission date of 10/25/22. Diagnoses included unspecified dementia, encephalopathy, and chronic obstructive pulmonary disease. Resident #34 resided on the memory care unit.

Review of the resident assessment dated 08/30/23 revealed Resident #34 had fluctuations in orientation, required one person assistance with transfers and toileting, and used a wheelchair to move about the unit.

Review of the medical record for Resident #35 revealed an admission date of 09/15/23. Diagnoses included unspecified dementia, altered mental status, muscle wasting and atrophy, cognitive communication deficit, and weakness. Resident #35 resided on the memory care unit.

Review of the admission screening assessment dated 09/15/23 revealed Resident #35 was oriented to person, required limited assistance for walking and toileting, had impaired vision, and used a wheelchair to move about the unit.

Interviews on 10/26/23 from 8:46 A.M. to 9:03 A.M. with Licensed Practical Nurse (LPN) #100, State Tested Nurse Assistant (STNA) #101, LPN #102, and STNA #103 revealed there were not enough staff to check/change, toilet and shower residents as needed. The staff stated they used the mechanical lift by themselves due to a lack of staff.

Interview on 10/31/23 at 3:04 P.M. with Resident Assistant (RA) #109 revealed there was not enough staff to provide resident care, assistance, and showers. The residents were not getting two showers a week as scheduled.

Interview on 11/01/23 at 9:41 A.M. with the daughter of Resident #17 revealed her mother only received one shower a week. An interview with Resident #17 at 9:48 A.M. confirmed she only received showers on Sundays and wanted showers more frequently.

Review of shower sheets revealed Resident #17 received three showers in September and four in October 2023.

Review of shower sheets revealed Resident #34 received six showers in September and five in October 2023.

Review of shower sheets revealed Resident #35 received two showers in September and five in October 2023.

Review of the facility's shower list revealed all residents were scheduled a minimum of two showers per week. This was verified by STNA #101 on 10/31/23 at 4:58 P.M.

This violation represents non-compliance investigated under Complaint Number OH00147283.

Based on interview, observation, and facility policy review the facility failed to ensure leftover foods were used by and/or discarded within three days of preparation and failed to discard expired milk. This had the potential to affect all 45 residents residing in the facility.

Findings include:

Observation of the walk-in cooler on 03/13/23 at 9:16 A.M. revealed one hundred and eleven, eight-ounce (oz) milk containers with a best buy date of 03/12/23 and one plastic Ziploc bag of chopped chicken with a date of 02/22/23.

Observation of the hinged two-door Turbo Air refrigerator on 03/13/23 at 9:20 A.M. revealed three, four oz hamburgers dated 03/03/23 and a container of green beans dated 03/02/23.

Interview on 03/13/23 at 9:21 A.M. with Dietary Director #600 verified the milk containers were expired as the date on the containers was 03/12/23, and the dates for the chicken, hamburgers, and green beans were not used within three days of preparation per facility policy.

Review of the facility policy labeled, Food Safety Requirements Policy (Use and Storage of Food and Beverage Brought in For Resident, Food Procurement

Based on interview and record review the facility failed to ensure its central heating system was checked at least every two years by a heating contractor. This had the potential to affect all 45 residents residing at the facility.

Findings include:

Review of Certification of Final Inspections and Approval