Eagle Creek Nursing Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to timely revise fall care plan interventions. This affected one resident (#35) out of the three residents reviewed for falls. The facility census was 54. Findings include: Record review for Resident #35 revealed this resident was admitted to the facility on [DATE] and had diagnoses including muscle weakness, unsteadiness on feet, chronic gout, depression, anxiety, and history of falls. Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/12/22, revealed this resident had moderately impaired cognition and was assessed to require supervision for bed mobility and extensive assistance from one staff member for transfers and toileting. Review of the care plan, dated 11/02/18, revealed this resident was at risk for falls. Interventions included non-skid strips in front of chair, non-skid strips to floor beside bed, and reminder sign to ask for assistance with transfers and ambulation. Observation on 08/24/22 at 4:05 P.M. revealed…

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 ordered medications was available and administered as ordered by the physician. This affected one resident (#36) out of the four residents observed for medication administration. The facility census was 54. Findings include: Record review for Resident #36 revealed this resident was admitted to the facility on [DATE] and had diagnoses including heart failure, hypertension, atrial fibrillation, and Gastro-Esophageal Reflux Disease (GERD). Review of the quarterly Minimum Data Set (MDS) assessment, dated 07/12/22, revealed this resident had mildly impaired cognition and was assessed to require extensive assistance from two staff members for bed mobility, limited assistance from one staff member for transfers, and extensive assistance from one staff member for toileting. Review of the physicians order, dated 10/20/21, revealed an order to administer one capsule of Aspirin 162.5 milligram 24 hour Extended Release medication every day.…

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, observation, staff interview and policy review, the facility failed to ensure proper infection control techniques were maintained while providing care in an isolation room and in the facility laundry room. This affected one (#14) randomly observed resident receiving care by staff who was in isolation precautions and also had the potential to affect all 88 residents whose laundry was completed at the facility. The facility census was 88. Findings include: 1. Review of Resident #14's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including anxiety disorder, depression, hypertension, diabetes mellitus Type II, cerebral infarction, mild cognitive impairment and pseudobulbar affect. Review of the physician orders for Resident #14 included an order on 08/24/19 for contact isolation due to infection (Pseudomonas and Methicillin Resistant Staphylococcus Aureus (MRSA)) in a heel wound which continued to be current on the 10/2019 physician monthly…

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, review of a dryer cleaning schedule and policy review, the facility failed to ensure the dryer was properly cleaned. This had the potential to affect all 88 residents residing at the facility. Additionally, the facility failed to maintain a sanitary and odor free environment. This had the potential to affect all 14 residents (#8, #13, #18, #20, #31, #33, #41, #43, #45, #77, #80, #81, #85, and #342) residing on the 400 unit. The facility census was 88. Findings Include: 1. During tour of the laundry area on 10/24/19 at 2:32 P.M. with Maintenance Supervisor #75 and Medical Records Staff #58 a build up of lint was noted in two of the three dryers in the laundry room. The dryers were empty. Review of the dryer cleaning schedule indicated the dryers had been free of lint at 1:00 P.M. The scheduled also indicated no laundry personal worked in the facility from 1:00 P.M. to 3:00 P.M. Maintenance Supervisor #75 and Medical Records Staff #58 confirmed the dryers were empty of any articles, the cleaning sheet indicated there was no lint at 1:00 P.M.,…

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 record review and interview, the facility failed to ensure physician visit notes were accessible in the resident's medical record. This affected seven (#21, #78, #54, #12, #13, #77 and #25) of 18 residents reviewed for complete and accessible medical records. The facility census was 88. Findings include: 1. Record review revealed Resident #21 was admitted to the facility on [DATE] with the following diagnoses; difficulty in walking, hypertension, transient cerebral ischemic attack, chronic obstructive pulmonary disease, unspecified psychosis, anxiety disorder and major depressive disorder. Review of Resident #21's quarterly Minimum Data Sets (MDS) assessment dated [DATE] revealed the resident to be severely cognitively impaired and required extensive assistance with bed mobility, transfers, dressing, toileting and personal hygiene. Resident #21 also required supervision with eating on the 07/20/19 MDS. Review of Resident #21's chart on 10/23/19 revealed no physician visits noted in the resident's…

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, medical record review, staff interview, and policy review, the facility failed to maintain residents dignity with toileting. This affected one (#20) out of 21 residents reviewed for privacy and dignity. The facility census was 88. Findings include: Review of the medical record for Resident #20 revealed an admission date of 05/20/16 with diagnoses including but not limited to dementia, history of falling, hypertension, and anxiety. Review of the quarterly minimum data set assessment dated [DATE] revealed cognitive status was not assessed, she received extensive assistance for toileting and hygiene needs and was frequently incontinent of bladder. Review of social service note dated 10/18/19 revealed Resident #20 had severe cognitive impairment. Review of physician orders dated October 2019 revealed Resident #20 is to use the bedside commode. Review of care plan revealed Resident #20 had an activity of daily living performance deficit related to limited mobility and required assistance 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 medical record review, staff interviews, review of the Ohio Revised Code and policy review, the facility failed to maintain proper documentation of residents advanced directive wishes for their code statuses on valid forms. This affected two (#63 and #89) of two residents reviewed for advanced directives. The resident census was 88. Findings include: 1. Record review of Resident #89's chart revealed resident was admitted to the facility on [DATE] with the following diagnoses; schizophrenia, insomnia, hypocalcemia, dementia with behavioral disturbance, muscle weakness, dissociative conversion disorder, epilepsy anemia, other nail disorder and dysphagia. Review of Resident #89's quarterly Minimum Data Sets (MDS) assessment dated [DATE] revealed resident to be severely cognitively impaired and required extensive assistance with bed mobility, transfers, dressing, toileting and personal hygiene. Resident #89 also required supervision with eating on the 09/30/19 MDS. Review of Resident #89's electronic…

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 interview and policy review, the facility failed to notify the physician and family when a resident had a fall. This affected one resident (Resident #79) of three residents reviewed for falls. Facility census was 88. Findings Include: Review of Resident #79's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including osteoporosis with history of pathological fracture, anxiety, depression, emphysema, history of cerebral infarction, and endometrium cancer. Review of the medical record for Resident #79 revealed two sons were identified to be contacted in case of emergency. Review of the quarterly Minimum Data Set completed on 10/01/19 indicated no cognitive delay. Resident #79 was identified as requiring supervision with all activities of daily living. Review of the fall risk evaluation completed on 07/22/19 indicated Resident #79 was a low fall risk, had no falls during the past 90 days, no cognitive status change, adequate vision,…

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 interview and policy review, the facility failed to ensure residents received written bed hold notifications within 24 hours of their discharges from the facility. This affected two (#21 and #56) of two residents reviewed for discharge notification. The facility census was 88. Findings include: 1. Record review revealed Resident #21 was admitted to the facility on [DATE] with the following diagnoses; difficulty in walking, hypertension, transient cerebral ischemic attack, chronic obstructive pulmonary disease, unspecified psychosis, anxiety disorder and major depressive disorder. Review of Resident #21's quarterly Minimum Data Sets (MDS) assessment dated [DATE] revealed the resident to be severely cognitively impaired and required extensive assistance with bed mobility, transfers, dressing, toileting and personal hygiene. Resident #21 also required supervision with eating on the 07/20/19 MDS. Review of Resident #21's chart revealed resident was discharged to the psychiatric…

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, and staff interviews, the facility failed to ensure a resident that remained in the facility had a pre-admission screening and resident review (PASARR) prior to admission to the facility. This affected one (#54) of one resident reviewed for PASARR. The facility census was 88. Findings include: Record review revealed Resident #54 was admitted to the facility on [DATE] with the following diagnoses; schizophrenia, bipolar disorder, other dysphagia, chronic obstructive pulmonary disease, hypothyroidism, unspecified abnormalities of gait and mobility, muscle weakness and unsteadiness on feet. Review of Resident #54's quarterly Minimum Data Sets (MDS) assessment dated [DATE] revealed the resident to be severely cognitively impaired and required extensive assistance with personal hygiene, toileting and dressing. Resident #54 also required supervision with bed mobility, transfers and eating on the 09/05/19 MDS. Review of Resident #54's chart revealed the resident did not have a…

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 2. Review of Resident #35's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including dementia, hypertension, anxiety, Alzheimer's disease, unspecified psychosis (07/31/19), and artificial right hip joint. Review of the quarterly MDS completed on 08/08/19 indicated Resident #35 had severe cognitive impairment, required extensive assistance of two staff for activities of daily living. The staff assessment of Resident #35 mood revealed depressed, trouble falling asleep, feeling tired, appetite concerns. Resident #35 had indicators for psychosis including delusions and no behaviors were identified. A review of the physician orders indicated Resident #35 was currently receiving Meloxicam 7.5 milligrams (mg) daily for inflammation, Levothyroxine Sodium 25 micrograms (mcg) daily for hypothyroidism, Tramadol 50 mg two times daily for pain and Tylenol 325 mg two tablets ever four hours as needed for pain. The physician orders indicated Lovenox (an anticoagulant) 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, medical record review, staff interview, and policy review, the facility failed to provide timely incontinence care to a resident. This affected one (#20) out of two residents reviewed for activities of daily living. The facility census was 88. Findings include: Review of the medical record for Resident #20 revealed an admission date of 05/20/16 with diagnoses including but not limited to dementia, history of falling, hypertension, and anxiety. Review of the quarterly minimum data set assessment dated [DATE] revealed cognitive status was not assessed, she received extensive assistance for toileting and hygiene needs and was frequently incontinent of bladder. Review of social service note dated 10/18/19 revealed Resident #20 had severe cognitive impairment. Review of physician orders dated October 2019 revealed Resident #20 is to use the bedside commode. Review of care plan revealed Resident #20 had an activity of daily living performance deficit related to limited mobility 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation and staff and resident interview , the facility failed to conduct an accurate skin assessment of a resident's skin tear. This affected on (#79) of 18 residents reviewed. Facility census was 88. Findings include: Review of Resident #79's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including osteoporosis with history of pathological fracture, anxiety, depression, emphysema, history of cerebral infarction, and endometrium cancer. Review of the quarterly Minimum Data Set completed on 10/01/19 indicated no cognitive delay. Resident #79 was identified as requiring supervision with all activities of daily living. A nursing progress noted dated 10/16/19 at 5:15 A.M. indicated Resident #79 slid off the side of the bed onto the floor which resulted in a skin tear to right arm. A post fall nursing progress note on 10/16/19 at 5:15 PM. indicated the resident's skin tone was normal, skin warm and dry. Dressing was dry and intact. A…

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, medical record review and staff interview, the facility failed to ensure a resident received appropriate care and services to prevent a further decline in the resident's contractures. This affected one (#78) of two residents reviewed for range of motion. The facility census was 88. Findings include: Record review revealed Resident #78 was admitted to the facility on [DATE] with the following diagnoses; Huntington disease, restlessness and agitation, flaccid hemiplegia affecting right dominant side, dysphagia, muscle weakness, contracture of right knee, contracture of left knee, unspecified dementia with behavioral disturbance and hyperlipidemia. Review of Resident #78's quarterly Minimum Data Sets (MDS) assessment dated [DATE] revealed the resident to be severely cognitively impaired and required total dependence with bed mobility, eating, transfers, dressing, toileting and personal hygiene. Review of Resident #78's occupational therapy Discharge summary dated [DATE] revealed resident 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to ensure the physician had review the monthly pharmacist drug regimen review and any concerns were addressed in a timely manner. This affected two (#15 and #25) of five residents reviewed for unnecessary medications. Facility census was 88. Findings include: 1. Review of Resident #15's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses of dementia, heart failure, malaise, major depression and malignant neoplasm of esophagus. Review of the quarterly Minimum Data Set (MDS) completed on 10/04/19 indicated Resident #15 had severe cognitive impairment. Resident #15 required one person limited assistance with mobility, one person extensive assistance with dressing, eating, toilet use and personal hygiene. No indications for psychosis were identified. Antipsychotics were used on a daily basis and no gradual dose reduction (GDR) was done since the past review. Review of the physician orders revealed…

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, staff interview and review of medication information from Medscape, the facility failed to ensure residents drug regimen were free from unnecessary medications when Resident #25 was prescribed Ranexa (a drug used to treat angina, chest pain) without an accurate diagnosis. This affected one (#25) of five residents reviewed for unnecessary medications. The facility census was 88. Findings include: Record review of Resident #25 revealed an admission date of 04/18/16 with pertinent diagnosis of: anxiety disorder, heart failure, essential hypertension, hyperlipidemia, hypothyroidism, abdominal hernia, arthropathy, diverticulitis of intestine, muscle weakness, psychosis, dementia with behavioral disturbance, visual hallucinations, malaise, dysphagia, asthma, age related osteoporosis, major depressive do, dry eye syndrome, blindness in one eye, hearing loss, difficulty in walking, and chronic obstructive pulmonary disease. Review of the 07/23/19 quarterly Minimum Data Set (MDS) assessment revealed Resident #25 is never or rarely understood and requires…

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 interview and policy review, the facility failed to ensure a resident was free from unnecessary medication when the staff failed to implement a gradual dose reduction (GDR) for an antipsychotic medication as ordered by the physician. This affected one (#15) of five residents reviewed for unnecessary medications. Facility census was 88. Findings include: Review of Resident #15's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses of dementia, heart failure, malaise, major depression and malignant neoplasm of esophagus. Review of the quarterly Minimum Data Set completed on 10/04/19 indicated Resident #15 had severe cognitive impairment. Resident #15 required one person limited assistance with mobility, one person extensive assistance with dressing, eating, toilet use and personal hygiene. No indications for psychosis were identified. Antipsychotics were used on a daily basis and no GDR had occurred since the past review. Review 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, staff and resident interviews, and policy review the facility failed to obtain labwork and urinalysis per physician orders. This affected two (#13 and #25) out of seven residents reviewed for labs. The facility census was 88. Findings include: 1. Review of the medical record for Resident #13 revealed an admission date of 04/13/18 with diagnoses including but not limited to end stage renal dialysis, urinary tract infection, retention of urine, and panic disorder. Review of quarterly minimum data set (MDS) assessment dated [DATE] revealed Resident #13 had no cognitive deficits, had presence of indwelling Foley catheter, and received dialysis treatment. Review of physician telephone order dated 07/03/19 revealed order to obtain urinalysis due to blood in urine. Review of the medical record was silent that any urinalysis was obtained as ordered on 07/03/19. Review of care plan revealed Resident #13 had urinary retention, presence of catheter, history of urinary tract infections…

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, observation and staff and resident interview, the facility failed to ensure dental services were offered to residents. This affected one (#3) of one residents reviewed for dental concerns. Facility census was 88. Findings include: Review of Resident #3's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including depression, asthma, seizures, hypertension, colostomy status, anxiety, history of wound to buttock and developmental disorder. Review of the quarterly Minimum Data Set (MDS) dated [DATE] indicated no cognitive delay and required one person extensive physical assistance for person hygiene including brushing teeth. The annual MDS dated [DATE] indicated no dental concerns. Review of State Tested Nursing Assistant (STNA) documentation for 09/2019 and 10/2019 indicated Resident #3 was extensive assistance of one person for oral hygiene which was provided two times daily. Review of the physician orders for Resident #3 indicated services…

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.