Failure to Schedule Timely Outside Services for Resident
Summary
The facility failed to schedule an appointment for outside services in a timely manner for a resident who was experiencing severe shoulder pain. The resident, who had been receiving cortisone shots for shoulder pain prior to admission, reported excruciating pain rated at 10/10 and expressed a need to see an outside provider for treatment. Despite the resident's request and the physician's recommendation for follow-up with an orthopedic provider, no appointment was made. The resident's clinical record showed a history of muscle weakness, osteoarthritis, and pain in both upper arms, and a previous hospital record indicated a need for orthopedic follow-up. Interviews with facility staff revealed a lack of action in scheduling the necessary appointment. The unit clerk stated that she was waiting for the facility administration to respond to make the appointment, while the Director of Nursing could not provide a reason for the delay, citing the high demand for services among residents. The deficiency was identified as a failure to employ or obtain outside professional resources to provide necessary services when the facility did not have a qualified professional available.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Two residents did not have required outside medical appointments properly coordinated or scheduled, including an orthopedic consult and nephrology visits, due to failures in arranging appointments and transportation as ordered by physicians. Staff interviews and record reviews confirmed that appointments were missed or not scheduled, and facility policies for arranging and documenting such services were not followed.
A resident with multiple medical and behavioral diagnoses, who was dependent for ADLs and required bariatric care, was not transported to scheduled medical appointments because local transportation companies could not accommodate bariatric transfers. Despite reminders from the resident's family and documentation in the facility assessment that bariatric care was provided, the facility did not ensure the resident attended necessary outside appointments.
The facility failed to provide safe and appropriate transportation for three residents to their dialysis treatments, resulting in them being pushed in wheelchairs up an unlit, steep road in adverse weather conditions. Staff and residents expressed concerns about the safety and discomfort of this practice.
Failure to Coordinate and Arrange Required Outside Medical Appointments
Penalty
Summary
The facility failed to ensure that required outside professional services were obtained and appointments were coordinated for two residents. For one resident with diagnoses including adjustment disorder, chronic respiratory failure, morbid obesity, dysphagia, and depression, there was an order for an orthopedic consult following the identification of a benign cyst in the right knee. Despite the physician's order, the appointment was not scheduled, and there was no documentation in the nursing progress notes regarding the order or the scheduling of the consult. The resident reported not having the suggested follow-up, and staff interviews confirmed that the appointment was not arranged as required. For another resident with chronic respiratory failure, COPD, diabetes with neuropathy, morbid obesity, and stage 4 chronic kidney disease, there were multiple missed or rescheduled nephrology appointments. The resident required bariatric transportation, and staff interviews and documentation revealed that transportation issues led to the rescheduling of appointments. Although transportation was confirmed for some appointments, others were cancelled or rescheduled, and staff could not consistently recall the reasons for these changes. The facility's own policies required collaboration and documentation for arranging such services, but these were not followed. The deficiency was identified through record reviews and staff interviews, which showed that the facility did not ensure timely scheduling and coordination of outside appointments as ordered by physicians. This affected both residents reviewed for appointment coordination, with failures in both arranging necessary consults and providing appropriate transportation for medical appointments.
Failure to Provide Transportation for Bariatric Resident to Medical Appointments
Penalty
Summary
The facility failed to provide required transportation services for a resident with multiple complex medical conditions, including lymphedema, Milroy's disease, autistic disorder, attention deficit hyperactive disorder, and expressive language disorder. The resident was cognitively intact but dependent for activities of daily living. Medical records indicated that the resident had scheduled appointments with a cardiologist and a plastic surgeon, but was not transported to these appointments as ordered. The resident's mother repeatedly reminded staff about the need for a signed referral and the upcoming appointments. Interviews with the DON and the resident's physician confirmed that the resident had not attended any outside medical appointments due to the inability of local transportation companies to transfer bariatric residents. The facility assessment documented that the facility provided care for residents requiring bariatric care, yet no arrangements were made to ensure transportation for this resident. The resident's mother expressed concern about the lack of transportation and the need for transfer to a facility that could meet this requirement.
Inadequate Transportation Services for Dialysis Patients
Penalty
Summary
The facility did not ensure that three residents had safe and appropriate transportation services to their dialysis treatments. Observations revealed that residents were pushed in wheelchairs up a road approximately 1000 feet from the facility to the dialysis center. The road had no edge lines, was not lit by streetlights, and included a steep hill, making the journey difficult and unsafe, especially in adverse weather conditions. The facility census was 71, and four residents required transportation to dialysis, but only three were affected by the deficiency. Resident #48, who had a history of a broken neck and other significant medical conditions, reported being pushed in a wheelchair to dialysis three times in two weeks, including once in a thunderstorm. She described the journey as uncomfortable due to the jarring and bumps on the road. Resident #40, with chronic obstructive pulmonary disease and end-stage renal disease, also reported being pushed to dialysis three times, including once in heavy snow. Resident #17, with multiple medical issues including spina bifida and end-stage renal disease, reported being pushed to dialysis at least six times and expressed concern about the safety of traveling on a road used by cars. Interviews with staff confirmed the practice of pushing residents in wheelchairs to dialysis when transportation was unavailable. Staff members expressed concerns about the safety of this practice, particularly when navigating the steep hill and in adverse weather conditions. The Director of Nursing acknowledged the issue and stated that transportation was scheduled but did not always show up. She also mentioned that the facility did not have a transport vehicle and that rescheduling dialysis appointments was not always possible. The deficiency was investigated under Complaint Number OH00152858.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
