365520
11/30/2023
Phoenix of Maple Heights
19900 Clare Ave Maple Heights, OH 44137
F 0804
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Level of Harm - Minimal harm or potential for actual harm
Based on observation and interview the facility failed to ensure adequate food temperatures. This had the potential to affect to all residents that resided in the facility. The facility census was 91.
Residents Affected - Many
Findings include: Interview on 11/28/23 at 9:30 A.M. with Resident #64 revealed her meals were always cold. Interview on 11/28/23 at 10:31 A.M. with Residents #53 and #54 revealed their meals were always cold. Interview on 11/28/23 at 11:40 A.M. with Chef #215 revealed he was aware of residents concerns regarding food temperatures. Chef #215 stated the temperatures were taken prior to the trays leaving the kitchen. The facility did not have heated food boxes for transporting meals. Observation of food temperatures being obtained at time of interview revealed the rigatoni was 149 degrees Fahrenheit (F), sausage and peppers were 171 degrees F and the broccoli was 181 degrees F. A test tray left the kitchen at 12:08 P.M. and was on the floor at 12:10 P.M. At 12:35 P.M., after all residents were served the test tray was completed. The rigatoni was 109 degrees F, the sausage and peppers were 110 degrees F, and the broccoli was 107 degrees F. The temperatures were confirmed by Chef #215. Upon tasting the food items, each was cold. This deficiency represents non-compliance investigated under Complaint Number OH00147909.
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365520
365520
11/30/2023
Phoenix of Maple Heights
19900 Clare Ave Maple Heights, OH 44137
F 0842
Level of Harm - Minimal harm or potential for actual harm
Residents Affected - Few
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Based on interview and record review the facility failed to accurately document the times medication was administered. This affected three of three residents (#62, #63 and #64) reviewed for medication administration documentation. The facility census was 91.
Findings include: 1. Review of Resident #62's physician orders for November 2023 revealed an order for Aricept (used to treat dementia) 10 milligrams (mg) at 7:00 A.M. Review of the Medication Administration Record (MAR) for November 2023 revealed Aricept 10 mg was documented as administered on 11/01/23 at 2:45 P.M., 11/02/23 at 12:43 P.M., 11/05/23 at 1:15 P.M., 11/09/23 at 6:00 P.M., 11/16/23 at 3:35 P.M. and 11/28/23 at 12:32 P.M. 2. Review of Resident #63's physician orders for November 2023 revealed orders for benzotropine (used to treat Parkinson's disease) 2 mg at 7:00 A.M., and Depakote (seizure medication) 125 mg at 7:00 A.M. Review of the MAR for November 2023 revealed benzotropine and Depakote were documented as administered on 11/01/23 at 2:46 P.M., 11/03/23 at 11:37 A.M., 11/07/23 at 11:19 A.M., 11/09/23 at 5:51 P.M., 11/16/23 at 3:32 P.M., 11/19/23 at 12:04 P.M. and 11/23/23 at 11:45 A.M. 3. Review of Resident #64's physician orders for November 2023 revealed orders for Incruse (inhaler) at 7:00 A.M., metoprolol (blood pressure medication) 25 mg at 7:00 A.M. and buspirone (anti-anxiety medication) 5 mg at 7:00 A.M. Review of MAR for November 2023 revealed the Incruse, metoprolol and buspirone were documented as administered on 11/07/23 at 1:35 P.M., 11/16/23 at 3:26 P.M., 11/19/23 at 11:15 A.M., 11/21/23 at 1:32 P.M. and 11/27/23 at 11:37 A.M. Interview and review of Resident #62's, #63's and #64's MARs on 11/29/23 at 12:19 P.M. with the Director of Nursing (DON) revealed the administration times documented on the MARs were not accurate. The DON said the medications were given within the ordered time frames but the nurses did not document the medications were administered at the time of the administration; they went back to the MARs at a later time to document the medications had been administered. The DON stated the nursing staff had been educated on documenting medications at the time of administration. Interview on 11/29/23 at 1:48 P.M. with Resident #62 revealed she received her medications in a timely manner. Interview on 11/29/23 at 1:53 P.M. with Resident #63 revealed she received her medications in a timely manner. Review of facility policy titled Administration Procedures for All Medications revised 08/20 revealed after administration the medication was to be documented in the MAR. This deficiency represents non-compliance investigated under Complaint Number OH00147909.
365520
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