Mentor Hills Post Acute

In the surveyor’s words

From the most serious findings on record at Mentor Hills Post Acute, in the surveyor’s own words.

• Actual harm, isolatedF686Jul 25, 2024

  Based on observation, record review, interview, and facility policy review the facility failed to develop and implement a comprehensive and individualized pressure ulcer prevention program to prevent the development of pressure ulcers, to timely identify new pressure ulcers and to ensure wound care was completed as ordered. This affected two residents (#51 and #79) of four residents reviewed for pressure ulcers. The facility census was 102. Actual Harm occurred on 07/12/24 when Resident #51, who had a history of pressure ulcers, was dependent on staff assistance for most all activities of daily living (ADL) including toileting, hygiene, shower, dressing, transfers, and required partial to moderate assistance with rolling left and right in bed, was found to have an in-house acquired Stage… […]

• Actual harm, isolatedF689Jul 29, 2021

  Based on record review, interviews with staff and review of the facility fall investigation, the facility failed to provide adequate staff assistance with bed mobility to prevent the fall of Resident #100, who required assistance of two staff with bed mobility. The facility failed to have an accurate Kardex and care plan indicating the resident required two staff assist to prevent falls. Actual Harm occurred on [DATE] when Resident #100 rolled out of bed onto the floor while being assisted by one staff member with bed mobility during incontinence care and sustained fractures of the right humerus and pelvis and expired in the facility on [DATE]. This affected one (Resident #100) of three residents reviewed for falls. […]

• No harm, potential for more than minimal, widespreadF880Feb 13, 2025

  Based on observation, interview, record review, review of the Centers for Disease Control and Prevention (CDC) guidelines and facility policy review, the facility failed to use appropriate transmission-based precautions (TBP) for Resident #84, utilize enhance barrier precautions (EBP) when indicated for Residents #12, #57 and #58 and failed to perform wound care using appropriate infection control practices for Residents #1, #12, #41, and #57. This affected one resident (#84) out of two residents reviewed for TBP, affected three residents (#12, #57 and #58) of six residents reviewed for EBP and affected four residents (#1, #12, #41, and #57) of six residents reviewed for wound care. […]

• No harm, potential for more than minimal, widespreadF812Sep 19, 2022

  Based on observation and interview the facility failed to maintain a clean and sanitary environment in the kitchen. This had the potential to affect all 95 residents provided food and beverages from the facility. The facility census was 95. Findings include: Observations on 09/12/22 from 10:10 A.M. to 10:24 A.M. during the initial tour of the kitchen with Dietary Manager #458 revealed the overhead vents above the grill top were greasy and dusty as was the back ledge behind the grill top, the light bulbs above the grill top, and the fire extinguisher nozzles. Inside the microwave was dirty. The sanitizer in one of the sanitizer buckets wasn't at a high enough concentration to be effective. The sanitizer was used for wiping down the counters. The ceiling had areas that were dirty/dusty. […]

• No harm, potential for more than minimal, patternF690Jun 1, 2023

  Based on medical record review, staff interview, observation, and policy review, the facility failed to ensure residents who were incontinent were provided incontinence care in a timely manner. This affected five (Resident #25, #33, #78, #90 and #91) out of six residents reviewed for timely incontinence care. The facility census was 86. Findings include: 1. Review of Resident #33's medical record revealed an admitted [DATE] and diagnoses which included dementia, anxiety disorder, spinal stenosis cervical region and difficulty in walking. […]