State inspectors showed up at Fairlawn Rehab and Nursing the first week of March 2018 to investigate a handful of complaints at the Copley nursing home.

While there, inspectors catalogued 26 deficiencies, problems big enough to threaten residents’ health — like untreated bedsores and unchecked or untreated diabetes — to slights and poor management that hurt resident dignity. The problems affected dozens of residents.

Some of the nursing home’s staff — including its administrator — have since left or been fired.

But old problems linger and inspectors continue to find new issues, putting the nursing home on the federal government’s worst of the worst list.

Inspectors’ reports shield the names of patients and staff from view, assigning them numbers instead.

Here are the stories of some of the residents at Fairlawn Rehab and Nursing in March 2018 and the problems that inspectors laid out in their reports:

 

Resident 10

Admission June 2017 after a heart attack, respiratory failure, brain damage and severe septic shock.

When an inspector entered her room, “there was a very strong sour odor coming from her feet and her toe nails were long, jagged, broken with tiny bits of pink nail polish.”

Her husband said he removed dressings covering sores on her heels the day before because the staff hadn’t changed them in about a week. He applied protective boots for her heels — which staff was supposed to be using — but inspectors said they didn’t fit right.

Records showed the woman — immobile and largely unresponsive — had only three baths in three months even though she was scheduled to be bathed twice weekly.

Her family, on a recent day while braiding her hair, discovered a new bedsore on her head. It was covered with a bandage, but inspectors found no notes of the painful wound in physician records or any staff plans to treat it. The woman winced, inspectors noted, every time her husband moved her head.

 

Resident 18:

Admission January 2018 with end-stage renal failure, paranoid schizophrenia, anemia, muscle weakness.

Inspectors found him in his room wearing sweatpants, a stained jacket zipped to the top of his neck, a hat covering his ears and deck shoes with no socks. The man, with several days of beard growth, didn’t know the date or time, but told inspectors he had fallen three times since moving into Fairlawn Rehab and now had to use a wheelchair.

Inspectors noted he had severe cognitive impairment and required supervision to walk. Records showed he broke his hip a month after moving into the facility, falling alone in the shower room. Inspectors found no staff plan to prevent future falls. The man told inspectors he was supposed to ask for help, but it took a long time and added “you know how that goes.”

 

Resident 25:

Admitted May 2017 with end-stage renal disease, diabetes and morbid obesity.

Inspectors found her wrapped in blankets because the temperature in her room was 51 degrees. In February, a physician ordered the staff to clean and dress a wound on her right heel every night until it healed. The resident told inspectors she was “lucky” if staff changed the dressing once or twice per week and inspectors noted the wound had worsened since the physician ordered the staff to care for it.

An inspector watched a nurse, aided by an LPN, change the dressing. Neither bothered pulling a curtain or closing a door for the woman’s privacy in a shared room. Inspectors noted that the nurse did wash his hands and slip on gloves. But he did not clean off the resident’s bedside table — crowded with crackers, Kleenex, remote controls and a cellphone — before resting his supplies there.

When a nurse touched the wound, the resident “yelled out ‘ouch.’ ” Inspectors noted the LPN did not wash hands between dirty and clean portions of cleaning and dressing a wound, not properly cleaning scissors after dropping them on the floor.

 

Resident 33:

Admitted May 2014 following a leg amputation and ongoing respiratory failure, morbid obesity, diabetes and peripheral vascular disease.

In January 2018, a physician ordered staff to cleanse the resident’s right foot with saline, pat dry, apply skin protectant, cover with gauze and dressing daily or more often as needed. Inspectors said a review of records for February and March 2018 “revealed many days without a signature to indicate the care was provided.”

On the day of the inspection, the wound was dressed, but it wasn’t dated — something the staff does to show the last time the wound was taken care of. The resident’s roommate — “said he had to do the dressing because there were not enough staff to do the dressing change.” The roommate said he also did her colostomy care and emptied her catheter bag “because the nurses don’t.” The roommate said he had a visiting wound consultant teach him how to change the dressing and she provided the supplies.

Resident 33 confirmed that story and added her roommate had trouble helping her because he had a cast on his arm.

 

Resident 43:

Admitted November 2017 after a leg amputation, irregular heartbeat, chronic pain, hypertension, diabetes, depression and end-stage renal disease.

When an inspector entered his room, “a strong, foul odor was noted” and the inspector saw a dark brown stain on the sheet between the resident’s left foot and sheet. He had a bulky gauze wrap on the foot dated from five days before. A dressing on his thigh was dated three days before.

“Interview with an anonymous staff member at the time of observation revealed the resident’s dressings were never changed and it was terrible he had to be treated that way.” When asked, a nurse said she did not know why the dressing had not been changed.

The inspector watched as just after midnight a nurse changed the dressings, which had adhered to the man’s foot and had to be soaked off with saline. Underneath, a wound covered his entire left heel, the side of his foot and reached his ankle. The nurse could not find wound assessments to show if the wound had grown, but the inspector noted the resident had no pressure sores when he was admitted.

The next day, another nurse observed green drainage from the foot and said she was going to notify the physician and have resident sent to the emergency room. Inspectors said he was at risk of serious harm when he developed an “avoidable, in-house unstageable pressure ulcer.” Inspectors said four other patients “had pressure ulcers developed in-house that facility was unaware of and not treating.”

 

Resident 76

Admitted May 2016 with diagnoses that included personality disorder, depression, hyperglycemia, anxiety, hypertension and diabetes.

The resident told inspectors the staff was neither testing his glucose nor providing insulin regularly because of “short staffing.” A physician’s order said Resident 76 should get insulin with meals and other insulin based on results of glucose testing. If his glucose was ever higher than 400, the staff was supposed to call the physician.

When inspectors returned a day later, they discovered the staff failed to check his blood sugar before breakfast — as they should have — and had not given him insulin. The resident, inspectors said, was upset and warned them that “this place is going to kill someone” An LPN revealed the patient’s blood sugar that day was 413, but did not contact the resident’s doctor as the physician had ordered. Inspectors discovered that the resident’s blood sugar had climbed over 400 several times in recent months and no physician was ever notified.

Most diabetics aim to keep their blood sugar between 80 and 180.

 

Resident 44

Admitted July 2016 with end-stage renal disease, tracheostomy — a surgery that inserts a tube in the neck to help a patient breathe — and morbid obesity.

In January 2018, a physician ordered staff to take care of the resident’s tracheostomy every shift, or more as needed, for excess secretions. Inspectors found no evidence of care during one shift on six days. Another older physician order from 2017 told staff to change the inner tube of the tracheostomy every night shift.

Inspectors found no evidence that had happened during three recent shifts. The resident told inspectors other tubing was supposed to be changed every Sunday and that it hadn’t happened in three weeks.

 

Resident 65

Admitted November 2017 with chronic viral hepatitis C, which can cause liver cancer and death.

Inspectors found the man and others residents eating meals in first-floor dining room out of styrofoam containers. Residents told inspectors the nursing home “must have run out of plates.” An aide told inspectors the facility did not have enough clean, reusable plates and that staff failed to pick up and return dirty plates from previous meals for cleanups.

When inspectors checked medical records for Resident 65, they noted that a physician in February recommended the man have a liver ultrasound. Inspectors, however, found no record that staff ever scheduled the test. An LPN told inspectors it was a nurse’s responsibility and a nurse verified no appointment had ever been scheduled.

A maintenance man, meanwhile, said more plates had been purchased and that he would provide inspectors with an invoice. But by the next day, more plates had arrived from another nursing home owned by the same company that owns Fairlawn Rehab.