Pearlview Rehab & Wellness Ctr

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview the facility failed to ensure the long term care ombudsman was notified of transfers to the hospital for three residents (#8, #30, and #42) of four residents (#2, #8, #30, and #42) reviewed for hospitalizations. The facility census was 39. Findings include: 1. Review of the medical record for Resident #8 revealed an initial admission date of 03/14/23. Diagnoses included pulmonary embolism, major depressive disorder, dementia, and Alzheimer's disease. Review of the discharge return anticipated Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #8 had an unplanned discharge to an acute hospital. Review of the nurses' notes dated 07/21/23 at 4:15 A.M. revealed Resident #8 was found by an aide attempting to get out of bed stating they needed to go to work, when discussing with the resident that she lived at the nursing home she became increasingly confused and difficult to re-direct. Normal baseline was slight confusion. Resident #8 was sent to the emergency room…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, staff and resident interviews and review of facility policy, the facility failed to ensure residents requiring assistance with activities of daily living received showers/bathing as scheduled. The affected two of three residents (Resident #23 and Resident #30) reviewed for showers/bathing. The facility census was 39. Findings Included: 1. Review of the medical record for Resident #23 revealed an admission date of 02/22/23. Diagnoses included but were not limited to dementia, stage III chronic kidney disease and nontraumatic intracranial hemorrhage and seizures. Review of the plan of care dated 02/23/23 revealed Resident #23 had a self-care deficit related to confusion, limited mobility and limited range of motion and required total dependence of two staff for showers twice weekly. Resident #23 was noted to be resistant to care at times. Review of the comprehensive Minimum Data Set (MDS) 3.0 quarterly assessment dated [DATE] revealed Resident #23 was cognitively intact and required…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, and record review, the facility failed to maintain a clean and sanitary environment. This affected three residents (#30, #38, and #45) of three residents reviewed for physical environment. The census was 39. Findings include: Interview on 11/06/23 at 9:45 A.M. with Resident #45 revealed no one cleaned his room. Observation at the time of interview revealed the bathroom floor had dirt buildup in the four corners of floor and there was feces in the toilet bowl. There was a buildup of dirt behind the entrance door to Resident #45's room. Observation of Resident #30's room on 11/07/23 at 9:39 A.M. revealed crumbs on the floor under and behind the bed, and near the sink area. Behind the entrance door into Resident #30's room there was a buildup of dirt. In Resident #30's bathroom there was a dirty, dry towel at the base of the pipe of the toilet and on the floor at the base of the toilet there was a tan colored stain. There was also dirt buildup in the four corners of the bathroom floor. Observation on 11/07/23 at 11:54 A.M. revealed Housekeeper (HSK)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, review of Ohio Departments Enhanced Information Dissemination Collection (EIDC) system, policy review and staff interview, the facility failed to timely report the allegation of physical abuse to the appropriate state agency. This affected one (#16) of three residents reviewed for potential abuse and neglect. The facility census was 44. Findings include: Review of the medical record for the Resident #16 revealed an admission date of 09/02/16. Diagnoses included dementia without behavioral disturbance, major depressive disorder, generalized anxiety disorder, and bipolar disorder. Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/01/23, revealed Resident #16 was rarely understood and required extensive assistance with two staff for activities of daily living (ADLs) except eating required extensive assistance with one staff. Interview on 08/23/23 at 1:30 P.M., with State Tested Nursing Assistant (STNA) #350 revealed she reported on 08/15/23 to the Administrator she was told by STNA #341, that on 08/13/23, Nursing Assistant (NA) #329 slapped…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on medical record review, emplyee time sheet review, employee disciplinary review and staff interviews, the facility failed to ensure all resident records had accurate documentation. This affected one (#45) of six residents reviewed for accurate medical records. The census was 44. Finding include: Review of the closed medical record for Resident #45 revealed an admission date of 08/17/23. Diagnosis included bacterial endocarditis. Review of the physician orders revealed an order for Ampicillin-Sulbactam Sodium (antibiotic) intravenous (IV) every six hours. Keep central line dressing intact. Review of the Medication Administration Report for August 2023 revealed on 08/12/23 Ampicillin-Sulbactam Sodium doses given at 8:00 A.M., 12:00 P.M. and 4:00 P.M., were signed off by the Former Director of Nursing (DON). Review of the Ampicillin-Sulbactam Sodium administration details revealed on 08/12/23 at 8:00 A.M., Licensed Practical Nurse (LPN) #313 had signed off the medications and then it was strike out on 08/12/23 at 11:20 A.M. by LPN #313, reason declined order and then was signed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, staff interview, medical record review and review of policy, the facility failed to maintain appropriate hand hygiene during the tracheostomy (trach) care. This affected one (#43) of two residents identified as having a trach. The facility census was 44. Findings include: Review of the medical record for the Resident #43 revealed an admission date of 01/24/23 and a readmission date of 07/17/23. Diagnoses included diffuse traumatic brain injury, diabetes mellitus, acute respiratory failure with hypoxia, and hydrocephalus. Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/21/23, revealed the resident was in a persistent vegetative state. The resident required total dependence with two staff for activities of daily living except eating was total dependence of one staff. Review of the physician's order for August 2023 revealed Resident #43 revealed an order for trach care every shift and as needed. Observation of trach care on 08/28/23 at 5:56 A.M., with Registered Nurse (RN) #340 and Licensed Practical Nurse (LPN) #306 revealed RN #340 placed the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interview the facility failed to ensure call lights were within reach and accessible for Residents #4, #17, #34, #36, and #40. This affected five (#4, #17, #34, #36, and #40) of 51 residents reviewed for call light placement. Findings include: 1. Resident #4 was admitted to the facility on [DATE] with diagnoses including diabetes mellitus, anxiety disorder, and major depressive disorder. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #4 had severe cognitive impairment and required extensive assistance with activities of daily living (ADLs). Observation and interview on 11/07/21 at 12:30 P.M. revealed Resident #4 did not have a call light cord attached to the wall. Interview with Certified Nursing Assistant (CNA) #108 at the time of observation verified the call light was out of reach and that Resident #4 would be able to use the call light if it was within reach. 2. Resident #17 was admitted to the facility on [DATE] with…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure wound treatments for Resident #27 and weekly weights for Resident #21 were consistently completed as ordered. This affected one (Resident #27) of one resident reviewed for non pressure related wounds and one (Resident #21) of four residents reviewed for nutrition. The facility census was 51. Findings include: 1. Review of the medical record revealed Resident #27 was admitted to the facility on [DATE] with diagnoses including chronic respiratory failure with hypoxia, congestive heart failure, diabetes and morbid obesity. Review of the plan of care related to actual skin impairment initiated on 02/16/21 indicated she had a wound related to a recurrent abscess on her right thigh. One of the interventions was to provide treatments per the physician's orders. Review of the comprehensive assessment (MDS 3.0) dated 10/01/21 indicated she was alert, oriented and independent in daily decision making ability. She received application of non surgical wound…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, interview, and review of facility policy and procedure the facility failed to ensure oxygen concentrator filters were maintained in a clean manner. This affected six (Residents #4, #17, #27, #32, #36 and #44) of six residents reviewed who used oxygen concentrators. The facility census was 51. Findings include: Review of the medical record revealed Resident #36 was admitted to the facility on [DATE] with diagnoses including obstructive sleep apnea and respiratory failure. Review of the physician order dated 01/22/21 indicated to provide oxygen at two liters per minute to keep oxygen saturation levels above 92%. On 11/07/21 at 10:42 A.M. observation of Resident #36's oxygen concentrator revealed there were filters on each side. Both filters were observed with an accumulation of thick white dust and debris. On 11/08/21 at 10:43 A.M. an environmental tour of the facility was conducted with the Administrator. Oxygen concentrators were observed for Residents #4, #17, #27, #32, #36…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview the facility failed to ensure staffing information was posted on a daily basis. This had the potential to affect all 51 residents currently residing in the facility. Findings include: On 11/07/21 at 8:00 A.M. observation revealed the posted staffing information was dated 11/05/21. Interview with the Receptionist on 11/07/21 at 8:03 A.M. verified the posting was dated 11/05/21. Interview with the Administrator on 11/08/21 at 10:45 A.M. revealed it was the responsibility of the nursing supervisor to post the staffing information on the weekends.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, staff interview, review of facility policy, and review of the Centers for Disease Control and Prevention medical (CDC) guidelines the facility failed to ensure all staff wore proper Personal Protective Equipment (PPE) when delivering a lunch tray to Resident #204. This affected Resident #204 and had the potential to affect all 51 residents currently residing in the facility. Findings include: Review of Resident #204's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses that included chronic kidney disease, diabetes mellitus and atrial fibrillation. Review of the admission Minimum Data Set (MDS) 3.0 assessment revealed it was in progress. There was no evidence found the resident had been vaccinated for COVID 19. Observation on 11/06/21 at 12:55 P.M. of tray service on the quarantine unit revealed Certified Nursing Assistant (CNA) #134, who was not wearing any PPE, delivered Resident #204's lunch tray to his room. At the time of the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, resident interviews and staff interviews, the facility failed to ensure 22 residents (Residents #2, #3, #5, #6, #7, #8, #11, #12, #13, #15, #17, #19, #23, #29, #30, #31, #34, #37, #38, #39, #43 and #45) were informed, in advance, of proposed treatment and provided the option to choose or decline. The facility census was 48. Findings include: Interview with Resident #17 occurred on 12/27/19 at 2:14 P.M. Resident #17 identified on 12/12/19 a unknown male came into her room told her he was getting her free diabetic shoes and custom molded inserts. Resident #17 revealed, the man then measured her feet and took pictures of them. Resident #17 confirmed she was never asked, prior to this person's arrival if she wished to obtain this service. The interview identified her roommate, Resident #8, whom can not provide any consent, was also measured for these shoes. Interview with the facility Administrator on 12/27/19 at 2:46 P.M. was completed. The interview confirmed the facility could…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, medical record reviews, resident and staff interviews, the facility failed to ensure adequate staffing was available to ensure eight residents (Residents #3, #14, #17, #21, #22, #28, #36 and #46) of 48 residents received medications timely on 12/26/19. The facility census was 48. Findings include: Review of Resident #17's medical record identified admission to the facility occurred on 06/05/17, with medical diagnoses including paraplegia, chronic kidney disease, borderline personality, post-traumatic stress disorder (PTSD), Lupus, neurogenic bladder, anemia, anxiety, diabetes mellitus and morbid obesity. The record revealed Resident #17 was cognitively intact and able to make her needs know. Interview with Resident #17 occurred on 12/26/19 at 9:42 A.M. and revealed she believed there was not enough staff working in the facility. The resident stated at times she had a difficult time being put to bed when she wanted to be. The resident additionally identified her medications, scheduled for 8:00 A.M. this morning, had not been administered, including her insulin.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 3. Resident #21 was admitted on [DATE] with diagnoses including type one diabetes mellitus, history of diabetic foot ulcer, morbid obesity, hyperlipidemia, lymphedema, hypothyroidism, abnormal glucose, venous insufficiency, hypertension, cellulitis of right lower limb, and chronic embolism and thrombosis of deep veins of unspecified lower extremity. Resident #21 was followed by endocrinology for blood glucose control. Resident #21's physician's order dated 09/25/19 revealed she was ordered insulin regular human (conc) solution, 500 unit per milliliter, inject 145 units subcutaneously one time a day at 8:00 A.M. and inject 65 units subcutaneously one time a day at 11:30 A.M. for type one diabetes mellitus with hyperglycemia. Review of Resident #21's physician's order dated 12/26/19 revealed per certified nurse practitioner, may administer morning medications late, one time order on this date. Interview on 12/28/19 at 12:00 P.M. with Director of Nursing (DON) revealed although Resident #21's insulin was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on medical record review, family and staff interviews, the facility failed to ensure one (Resident #25) of 16 sampled residents/families were invited to participate, on at least a quarterly basis, to plan their care meeting. The facility census was 48. Findings include: Review of Resident #25's medical record identified admission occurred 01/19/19 with medical diagnosis including dementia, repeated falls and colon cancer. The record identified an initial care planning conference occurred on 01/25/19, which included Resident #25's family. The record lacked any evidence of additional care planning meetings in which the family/resident was invited to participate. The record identified a significant change in condition assessment was completed on 11/13/19 (due to initiation of hospice), a quarterly assessment was completed on 10/28/19 and 07/20/19. The facility was noted to conducted the meetings without family participation. Interview with Resident #25's daughter occurred on 12/27/19 at 1:45 P.M. The interview identified the family had not been invited to participate in any care…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, medical record review, family and staff interviews, the facility failed to provide one (Resident #25) of two residents, whom was dependent, with daily shaving. The facility census was 48. Findings include: Review of Resident #25's medical record identified admission occurred 01/19/19 with medical diagnoses including dementia, repeated falls, colon cancer and anemia. Review of the most recent Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #25 required extensive assistance of one staff with all activities of daily living (ADL). Review of Resident #25's written plan of care identified he was unable to perform his ADL. The written plan did not evidence the residents preferences to be shaved daily. The plan did not address what the staff should do if the resident refused showers and or shaving. Interview with Resident #25's daughter occurred on 12/27/19 at 1:45 P.M. The interview identified the family had come in several times to visit, and the resident had not been…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure Resident #46 received activities to meet his current and past interests. This affected one resident (Resident #46) of one resident reviewed for activities. Findings include: Resident #46 was admitted on [DATE] and readmitted on [DATE] with diagnoses including major depressive disorder, dementia and Alzheimer's Disease. Resident #46's quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed his cognition was severely impaired, was totally dependent on staff for transfers and required extensive assistance with locomotion. Resident #46's Activity assessment dated [DATE] revealed the resident was a former railroad engineer and was active in his Catholic religion. Resident #46's active comprehensive care plan revealed a focus for alteration in supervised/organized recreation characterized by little or no involvement, and lack of attendance related to preference for independent self-directed activities. Intervention to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on medication administration observation, medical record review, review of manufacture's recommendations and staff interviews, the facility failed to ensure insulin pens were properly utilized to ensure adequate dosing. This affected Resident #38 and had the potential to affect 11 additional residents (Resident #4, #13, #16, #17, #21, #22, #23, #24, #26, #28 and #45) identified as utilizing insulin pens. The facility census was 48. Findings include: Medication administration observation occurred with Registered Nurse (RN) #110 on 12/27/19 at 7:30 A.M. RN #110 prepared medications for Resident #38, which included a Lispro insulin pen and Flovent inhaler (corticosteriod). RN #110 was unable to locate the Lispro insulin pen for Resident #38 and obtained a new one. She set the dial to four units of Lispro insulin and administered the medication to Resident #38. RN #110 did not prime the insulin pen prior to setting and/or giving the dose of insulin to the resident. Review of Resident #38's medical record revealed admission to the facility occurred on 11/26/14 with medical…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, medical record review, review of manufacturer's recommendations and staff interviews, the facility failed to ensure one (Resident #38) of three sampled residents received medications as ordered by the physician. Medication administration observation identified two of 27 medications were not administered in accordance with physician's orders, resulting in a medication error rate of 7.4%. This had the potential to affect all 48 residents residing in the facility. Findings include: Medication administration was observed with Registered Nurse (RN) #110 on 12/27/19 at 7:30 A.M. RN #110 prepared medications for Resident #38 which included a Lispro insulin pen and Flovent inhaler (corticosteriod). RN #110 administered two puffs of the Flovent inhaler for Resident #38. RN #110 also administered four units of Lispro insulin subcutaneously (sq). Review of Resident #38's medical record revealed admission to the facility occurred on 11/26/14 with medical diagnoses including diabetes and chronic respiratory failure. The record revealed on 12/26/19 the physician's orders…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to ensure Resident #24 was served the correct portion size of pureed chili. This affected one resident (Resident #24) of one resident observed to be served a pureed diet, with the potential to affect two residents (Resident #24 and Resident #37) who were ordered a pureed diet in the facility. Findings include: Review of the Menu Extension spreadsheet for lunch on 12/27/19, revealed residents on a pureed diet should be served pureed chili with a number six scoop. Review of the Disher Scoop Sizes and Conversions- Chefs Resources form, undated, revealed a number six scoop was 5.33 ounces and a number eight scoop was 4 ounces. Observation on 12/27/19 at 12:10 P.M. revealed [NAME] #104 used a number eight scoop to serve pureed chili to Resident #24. Interview with Dietary Technician #77 at this time confirmed a number eight scoop was used, and the spreadsheet identified a number six scoop. Review of the list of resident diets, provided by the facility, revealed Resident #24 and Resident #37 were ordered a pureed diet.