Heritage Healthcare of Painesville

In the surveyor’s words

From the most serious findings on record at Heritage Healthcare of Painesville, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Nov 24, 2021

  Based on observation, interviews, record review, review of the facility investigation, and review of the policy on elopement, the facility failed to provide adequate supervision resulting in one resident (Resident #2) with diagnoses including moderate cognitive impairment, hallucinations, and [CONDITION(S)], eloping from the facility. This resulted in Immediate Jeopardy on 11/07/21 at approximately 7:45 P.M. when Resident #2 exited the facility without staff knowledge and staff failed to respond appropriately to a sounding door alarm. […]

• Actual harm, isolatedF686Nov 24, 2021

  Based on observation, interview, record review, and facility policy review the facility failed to ensure adequate pressure relieving interventions and treatments were ordered and implemented to prevent and treat pressure ulcers for Resident #23. Actual harm occurred on 09/27/21 when Resident #23, who required extensive assistance with one staff for bed mobility and was always incontinent of urine and bowel, was admitted with a Stage IV (a full thickness tissue loss with exposed bone, tendon or muscle) sacral pressure ulcer, developed an unstageable (a full thickness tissue loss covered by extensive necrotic tissue) right buttock pressure ulcer which was not promptly and consistently treated resulting in deterioration and the need for sharp debridement on 10/20/21 to reduce the risk of… […]

• No harm, potential for more than minimal, widespreadF880Sep 18, 2024

  Based on review of personnel files and interview, the facility did not ensure tuberculosis testing was completed on or prior to the date of hire for the Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON) #202, Human Resources/Payroll #205, State tested Nurse Aide (STNA) #212, Licensed Practical Nurse (LPN) #243, and LPN #238. This affected seven of the 12 personnel files reviewed and had the potential to affect all 52 residents residing in the facility. Findings include: Review of the personnel file for the Administrator revealed the date of hire was 07/03/24, and the tuberculosis test was not administered until 07/16/24. […]

• No harm, potential for more than minimal, widespreadF812Jun 29, 2023

  Based on record review, observation and interview, the facility did not ensure cold food temperatures were being appropriately monitored to prevent risk of food born illness. This had the potential to affect all 47 residents receiving meals from the kitchen. Findings include: Review of the food committee minutes, dated 05/18/23, revealed a concern that cold foods were not always served cold. Observation on 06/27/23 at 8:06 A.M. revealed a tray full of cups of milk and orange juice was sitting at the 100 hall nursing station. The tray nor milk and orange juice cups were not on ice nor had any other obvious method of being kept cold. Aides took drinks from the tray and put them on meal trays as they entered resident rooms to serve breakfast. […]

• No harm, potential for more than minimal, widespreadF804Jan 9, 2023

  Based on observation and interview, the facility failed to serve palatably hot food. This had the potential to affect all residents residing in the facility who receive meals. The facility identified two residents (#32 and #52) with physician's orders for nothing by mouth (NPO). The facility census was 58. Findings include: Observation on 01/04/23 from 1:41 P.M. to 1:53 P.M. revealed the trays for the 200-hall left the kitchen at 1:41 P.M. Staff began passing the trays at 1:43 P.M. All the trays on the unit were passed by 1:53 P.M. Observation on 01/04/23 at 1:53 P.M. revealed the chicken in mustard sauce was 123 degrees Fahrenheit (F), the mashed potatoes were 126 degrees F, and the succotash was 110 degrees F. […]