Canfield Healthcare Center

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when a housekeeper physically abused a resident by pushing the resident in his wheelchair, causing him to fall and hit his head on a medication cart. The housekeeper then placed his hands around the resident's neck and punched him with a closed fist. Multiple staff members witnessed the incident, and the resident was subsequently found sitting on the floor, refusing immediate assessment and assistance. The incident was also captured on video, which showed the housekeeper approaching the resident, placing both hands on the resident's neck/shoulder area, and pushing him out of the frame. Staff members responded to the altercation, and the resident was later transferred to the emergency room for evaluation at his brother's request. The resident involved had a history of multiple medical and psychiatric conditions, including a recent femur fracture, diabetes, repeated falls, substance dependencies, bipolar disorder, depression, insomnia, and anxiety. At the time of the incident, the resident was cognitively intact, required supervision for all activities of daily living, and used a wheelchair for mobility. The care plan identified risks for mood disruptions and falls, with interventions in place for behavioral support and safety education. Despite these interventions, the resident became involved in a verbal altercation with housekeeping staff, which escalated to physical abuse by the housekeeper. Witness statements from staff, including CNAs and LPNs, corroborated the resident's account of being choked, punched, and pushed, resulting in a fall from the wheelchair. The police were called, and a report was filed. The resident reported pain and had a small abrasion on his lower back but declined immediate pain medication and assessment, preferring to wait for his brother before going to the hospital. The incident was reported to the state agency, and the facility's abuse policy defined the actions as physical abuse. The deficiency was cited as Immediate Jeopardy and Actual Harm due to the failure to protect the resident from abuse.

Removal Plan

• Social Service Designee (SSD) #524 separated Housekeeper #582 and Resident #66 and provided for resident safety.
• Housekeeper #582 was suspended pending investigation by the Administrator.
• The Director of Nursing (DON) notified Medical Director #585 and Resident #66's emergency contact/brother of the incident.
• The Administrator notified the local police department.
• The Administrator collected witness statements from facility staff that observed the incident.
• The Administrator changed all of the door codes in the facility (to prevent unauthorized access to the building).
• The Administrator reviewed the facility abuse policy with no changes to the policy deemed necessary.
• The Administrator initiated training on the facility Abuse Policy, Aggressive and Combative Behavior Management Policy, and Resident Rights with all staff, including initiation of a posttest with a theme of Just Walk Away! The training was completed.
• Resident #66 was transferred to the local ER for evaluation per his brother's request.
• SSD #524 interviewed all interviewable residents in facility related to abuse.
• Registered Nurse (RN) #538 completed skin checks on residents unable to be interviewed related to abuse.
• RDCO #578 completed training on Abuse Policy with all staff via OnShift.
• RDCO #578 completed training on policy on Management of Combative and Aggressive Behavior with all staff via OnShift.
• RDCO #578 completed training related to Identifying, Preventing and Managing Aggressive Behaviors with all staff via OnShift.
• RDCO #578 completed training on resident rights policy with all staff via OnShift.
• SSD #524 assessed Resident #66's psychosocial status at baseline psychosocial status.
• The Administrator in collaboration with Healthcare Services Group terminated Housekeeper #582's employment.
• The Administrator reiterated to Human Resources #587 to continue to ensure newly hired employees were educated on the abuse policy upon hire during orientation.
• The facility implemented a plan for SSD #524 to conduct interviews with five employees weekly related to abuse and five residents weekly related to abuse for four weeks, then monthly for two months. Compliance with the interviews would be overseen by the Administrator. Results of the interviews would be reviewed with the Quality Assurance and Performance improvement (QAPI) committee for additional recommendations as warranted.

Penalty

Inspection fine: $177,180

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide adequate supervision and intervention to prevent resident elopement, resulting in two separate incidents where residents left the facility unsupervised and without proper authorization. In the first incident, a resident with a history of psychiatric hospitalization, cognitive disorder, and a court-appointed guardian was admitted to the facility and immediately expressed a desire to leave. Despite being assessed as an elopement risk and having a guardian who instructed staff not to allow unsupervised departures, the resident was permitted to sign out for a leave of absence (LOA) without a physician order or guardian consent. The resident's whereabouts were unknown until police returned him to the facility later that day. Documentation revealed that staff relied primarily on cognitive assessment scores and did not consistently consult with guardians or follow clear protocols for LOA, especially for new admissions or residents with guardianship in place. In the second incident, another resident with severe dementia, mood disorder, and a history of confusion was allowed to exit the facility unsupervised after a CNA entered the door code for him to go outside and smoke. The resident was last seen at the facility in the evening and was later found by police the next morning, disoriented and sleeping behind a gas station half a mile away. The facility's records showed that the resident was not previously identified as an elopement risk, and staff did not recognize the need for increased supervision or the use of a wanderguard. The delay in identifying the resident as missing and the lack of immediate notification to police further contributed to the deficiency. Additionally, the facility lacked adequate systems to identify and manage risks associated with residents leaving the facility unsupervised. There was inconsistency in how staff determined which residents could safely leave, with reliance on cognitive scores and incomplete communication with guardians and families. The facility also failed to individualize fall interventions for another resident and did not adequately supervise several residents regarding smoking and possession of smoking materials, further indicating lapses in accident prevention and supervision.

Removal Plan

• Administrator provided all staff education related to the facility elopement policy and procedures.
• Assistant Director of Nursing (ADON) #805 completed wandering assessments for all residents.
• Administrator conducted a facility elopement drill.
• ADON #805 spoke with Resident #13's guardian, related to the resident's ability to leave the facility with supervision.
• DON, Unit Manager #844 and ADON #805 re-assessed all residents for elopement risk.
• The door codes were changed by the door company.
• All residents were reviewed to determine if they were able to go on LOA supervised or unsupervised and orders were written to reflect the findings.
• DON, ADON #805 and Unit Manager #844 consulted with resident families/guardians and physicians to determine resident LOA status.
• DON/designee placed a list of residents (#4, #8, #9, #10, #11, #13, #22, #25, #31, #33, #34, #36, #43, #51, #53, #55, #61, and #66) who were not permitted to go on leave of absence (LOA) unsupervised at both nurses' stations and at the front receptionist area.
• Regional RN #869 reviewed and updated the elopement binders on all units.
• All staff were educated by Regional RN #869, LPN #865, Mobile Business Office Manager #890, Administrator, DON, ADON #805, Regional Director of Environmental Services #891, Dietary Manager #876, and Regional Dietary Manager #892 regarding all residents being required to have a physician order for LOA and if the LOA was required to be supervised or could be unsupervised.
• All staff were educated that nobody was to assist any resident out of the facility for any reason without consulting with the charge nurse who was assigned to that resident.
• Once a staff member confirmed with the nurse that a resident was permitted to go LOA, the staff member must enter the code without the resident seeing the code.
• At no time was it appropriate to give the code to a resident or family.
• Education included the facility door codes would be changed weekly.
• Education included not permitting residents to smoke in front of the facility and only permitting smoking in the designated courtyard.
• DON/designee were assigned to review the LOA list daily in clinical meetings Monday through Friday and updates were to be completed if needed. A new list would be placed at both nursing stations and front desk on an ongoing basis.
• A process was initiated for the DON/designee to review new admissions in clinical meeting for LOA status on an ongoing basis.
• Human Resources (HR) #851/designee was assigned the duty to ensure all new hires were educated on the LOA process on an ongoing basis.
• The facility implemented a plan to conduct elopement drills by the DON/designee on a weekly basis each shift for four weeks then on an as needed basis.
• The DON/designee was scheduled to interview five staff members on the LOA process weekly for four weeks then on an as needed basis.
• The results of all audits were to be reported, reviewed and trended for compliance through the facility Quality Assurance Committee for a minimum of six months then randomly thereafter for further recommendation.
• The Administrator/designee was to observe five smokers weekly for four weeks then on an as needed basis to ensure they were smoking in the appropriate areas.
• The results of all audits were to be reported, reviewed and trended for compliance through the facility Quality Assurance Committee for a minimum of six months then randomly thereafter for further recommendation.

Penalty

Inspection fine: $177,180

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide adequate supervision and intervention to prevent resident elopement. Resident #13 was admitted after a psychiatric hospitalization with diagnoses including delusional disorder, antisocial personality disorder, anxiety disorder, apraxia, difficulty walking, and insomnia. He had a guardian, was assessed as an elopement risk, and was documented as having exit-seeking behavior shortly after admission. Despite this, he was permitted to leave the facility unattended on leave of absence without guardian consent or a documented planned return time, and his whereabouts were unknown until he was returned by police escort later that same day. Resident #13’s record showed conflicting information about his ability to leave independently. A nursing admission assessment described him as alert and oriented, with no prior wandering history noted, while other documentation showed he was not accepting the admission situation, expressed anxiety about leaving, and was determined to be at risk for elopement or unsafe wandering. A later nursing note documented that he began to exit seek and a wanderguard was applied. The facility’s leave of absence process relied on cognitive status and staff judgment, and staff interviews showed uncertainty about who determined he could leave. The guardian stated she had told the facility the resident was homeless and had nowhere to go and believed he should not have been allowed to leave alone. The facility also failed to adequately supervise Resident #61, who was admitted with unspecified dementia with behavioral disturbance, mood disorder, alcohol dependence in remission, and cognitive communication deficit, and whose BIMS score reflected moderate cognitive impairment. On the evening of the incident, staff observed him outside to smoke, and a CNA entered the door code and let him out the front door. Later, staff realized he was missing, searched the facility and grounds, and contacted family, police, and the hospital. Police later found him sleeping behind a gas station about one-half mile from the facility, confused and unable to explain how he got there. The resident was transported to the hospital for evaluation and later returned to the facility.

Penalty

Inspection fine: $177,180

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that progress notes and medical records for multiple residents were comprehensive, accurate, and maintained in chronological order, as required by accepted professional standards. For one resident with complex medical needs, including pressure ulcers and opioid dependence, there were no status updates or discharge documentation after a hospital transfer, and attempts to contact the resident's spouse were not recorded. The admissions director confirmed that tracking and documentation protocols were not followed, especially when the resident was transferred to an out-of-network hospital. Another resident with psychiatric and mobility diagnoses had progress notes that were incomplete and inaccurate. Nursing staff documented a leave of absence but failed to clearly identify which parties were notified, and subsequent notes referenced the wrong date of the event. In a separate case, a resident with impaired cognition and multiple mental health diagnoses experienced a witnessed staff-to-resident verbal abuse incident, but there was no documentation in the progress notes regarding the incident, the investigation, or notifications to the physician, family, or police. Additional deficiencies included multiple late entry notes for a resident with severe malnutrition and cognitive deficits, with staff acknowledging that documentation was not completed timely due to workload. Another resident's record showed a lack of documentation regarding the rationale for a urinalysis order, family notification, and late entries for antibiotic use, with staff confirming that behaviors and notifications were not recorded. The facility's own policy requires timely, accurate, and complete documentation, but these standards were not met in the reviewed cases.

Penalty

Inspection fine: $177,180

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure eight consecutive hours of RN coverage was provided every day. Review of schedules and time punches for 01/01/25 through 01/07/25 showed that on 01/01/25 one RN was scheduled and worked from 7:30 P.M. to 12:30 A.M.; on 01/02/25, an RN worked 7.75 consecutive hours and left at 3:26 P.M., and another RN did not clock in until 6:54 P.M., leaving a gap in RN coverage of eight consecutive hours. The schedules and time sheets also showed only 4.5 hours of RN coverage on 01/04/25, and RN coverage did not start until 6:40 P.M. on 01/05/25. Unit Manager #844 stated that during the reviewed week the facility had three RNs, including the DON, and all three were trying to provide RN coverage along with their assigned duties. The Administrator acknowledged that the DON covered the floor on some of those days and that the census was over 60, but no time sheet was provided showing the hours the DON worked as a charge nurse.

Penalty

Inspection fine: $177,180

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Facility administrative staff failed to identify deficient practices and failed to notify the Administrator of known non-compliance in an attempt to increase compliance. During an interview, the Activity Director stated that getting activity assistants to consistently document activities had been an ongoing issue, and the Administrator stated she had not been made aware of the documentation non-compliance. The Administrator also verified that some employees were allowed to continue working even though their criminal background check results had not been received within the time frame required by state regulations, and stated the prior Human Resource Director had not informed her of the issue. The Administrator stated she was unsure what training the DON received before or when accepting the position. Review of the DON’s file showed she had been licensed as an RN, had prior LTC and plasma center work history, was hired as a charge nurse, then promoted to Unit Manager and later to DON. The DON’s nursing license expired with no Board action documented. Interviews during the survey determined the DON did not guide staff and/or did not understand or ensure implementation of policies related to resident discharges, leave of absence policies, or the role of guardians in providing input into the care of residents deemed incompetent to make their own decisions. The facility also failed to have an updated, accurate facility assessment; the Administrator verified it had been drafted from a generic company assessment and had not been individualized to the facility and its services.

Penalty

Inspection fine: $177,180

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to conduct and document a facility-wide assessment that was accurate and specific to its available services. Review of the updated assessment showed multiple incomplete or non-specific sections, including blank areas for diverse spiritual and religious programs, the frequency of those programs, activities for a dementia care unit, ancillary service contracts, and the number of hours per week required for a risk nurse. The assessment also stated the facility had a specialized dementia care unit with additional staff training for Alzheimer’s and dementia care and that it offered in-house dialysis services with an onsite dialysis provider, but the Administrator later verified these services were not provided at the facility. During interview, the Administrator stated that non-applicable areas should have been deleted or marked not applicable, and provided no rationale for the other blank sections.

Penalty

Inspection fine: $177,180

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure appropriate infection control practices during incontinence care for Resident #6. Resident #6 was admitted on 06/05/25 with diagnoses including immobility syndrome (paraplegic), severe protein-calorie malnutrition, ESBL resistance, dysphagia, gastrojejunal ulcer without hemorrhage or perforation, and current gastrostomy status for enteral feeds. The resident was dependent on staff for toileting hygiene, incontinence care, dressing, and transfers, and required supervision for personal hygiene, eating, and oral hygiene. During observation of incontinence care on 08/27/25 at 10:42 A.M., CNA #837 gathered supplies, washed hands, donned gloves and PPE, removed the resident’s soiled brief and chux pad, and cleaned the resident from front to back. The CNA then failed to remove the soiled gloves and perform proper hand hygiene before applying a new brief. During interview, the CNA confirmed gloves were not changed and hand hygiene was not performed before the clean brief was applied. The facility also failed to ensure appropriate TB screening for two employees. CNA #831, hired on 04/06/23, had two-step Mantoux results from 01/10/20 and 01/17/20, but there was no evidence of annual screening between 2020 and the hire date, and no evidence of TB testing or screening until 06/11/25. CNA #812, hired on 08/14/24, had two-step TB skin tests from 08/31/23 and 09/09/23, but there was no evidence of testing or screening upon hire, and the screening form was not completed until 06/10/25. The Administrator verified on 09/04/25 that there was no evidence of TB skin testing or screening being completed upon hire for either employee. The facility’s TB Risk Assessment and Control Plan and TB Symptom Screen Policy-Employee required screening upon hire and annually.

Penalty

Inspection fine: $177,180

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that care conferences were completed quarterly for four residents, as required by policy and regulatory standards. Record reviews, interviews, and policy review revealed that care conferences for these residents were either not held or not documented within the required quarterly timeframe. For example, one resident with hemiplegia, aphasia, and dependency for all ADLs had their last documented care conference several months prior to the review, with no evidence provided for more recent conferences. Another resident with ataxic cerebral palsy and schizophrenia had a significant gap between care conferences, despite routine care plan updates. Similar deficiencies were found for two other residents with complex medical and cognitive needs, where care conferences were either not conducted or not documented as required. The facility's policy stated that care plans should be reviewed quarterly and/or with significant changes in care, with attendees signing and dating meeting documents. However, documentation for care conferences was missing or incomplete for the affected residents, despite ongoing care plan revisions. Interviews with the Social Service Designee confirmed the lack of evidence for timely care conferences. This deficiency was identified during a complaint investigation and affected half of the residents reviewed for care conferences.

Penalty

Inspection fine: $177,180

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a resident's co-guardians were permitted to exercise their authority to consent or decline influenza and COVID-19 immunizations. The resident, who had diagnoses including ataxic cerebral palsy, epilepsy, nutritional anemia, schizophrenia, and obsessive-compulsive disorder, was admitted with co-guardians appointed for personal decisions. The medical record listed the co-guardians as primary contacts, and official court documents confirmed their status as co-guardians of the person. Despite this, the care plan did not specifically reference the guardians, instead using the term 'resident representative.' Consent forms for both COVID-19 and influenza vaccinations were signed by the resident, who was assessed as cognitively intact, rather than by the co-guardians. The Director of Nursing (DON) acknowledged uncertainty regarding the consent process and had the resident sign the forms, although she stated she contacted the guardian by phone, which was not documented in the record. This resulted in the co-guardians not being given the opportunity to exercise their legal authority to consent or decline immunizations for the resident.

Penalty

Inspection fine: $177,180

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to notify the legal guardians of two residents regarding significant changes in their conditions and events affecting their care. In the first case, a resident with a history of psychiatric disorders, cognitive impairment, and a legal guardian was admitted and immediately expressed a desire to leave the facility. Although the guardian was initially contacted and advised staff to calm the resident and use an involuntary psychiatric hold if necessary, the resident was later allowed to sign out on a leave of absence (LOA) without further consultation with the guardian. The resident left the facility, returned later with police escort, and the guardian was not notified of either the departure or the return in a timely manner. Documentation showed that the guardian would have imposed restrictions on LOA if consulted, and staff did not notify the guardian as required by policy. In the second case, another resident with ataxic cerebral palsy, epilepsy, schizophrenia, and a legal guardian was sent to the hospital after being found unresponsive. The facility's records had not been updated to reflect the current legal guardian, as the previous guardian had passed away. Nursing staff attempted to contact the deceased guardian and only later tried to reach the correct guardian, but no voice message was left. The nurse practitioner also attempted to contact the guardian but could not recall if a message was left and stated a preference not to leave messages that might cause panic. There was no documentation of successful notification to the legal guardian regarding the resident's hospitalization. Facility policy required prompt notification of guardians or responsible parties in the event of significant changes, such as hospitalization or LOA. In both cases, the facility did not follow its own policies for notification, resulting in guardians not being informed of critical events affecting the residents. The deficiencies were identified through medical record review, staff and guardian interviews, and policy review, affecting two of the 22 residents reviewed for notification.

Penalty

Inspection fine: $177,180

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when a certified nursing assistant (CNA) was verbally abusive to a resident with impaired cognition and multiple mental health diagnoses, including schizoaffective disorder, major depressive disorder, and anxiety. The resident required significant assistance with daily activities and was dependent on staff for personal care. During an observation, the CNA yelled loudly and aggressively at the resident, telling her to stop crying or the door would be shut. The resident was observed crying quietly at the time, and there were no progress notes documenting the incident. The CNA later justified her behavior by stating the resident was upsetting others and needed to stop. The resident was later interviewed and reported feeling scared when the CNA yelled at her. Additional observations showed the resident crying with staff attempting to console her, and at another time, she was quietly in her room without distress. The facility's policy on abuse, neglect, and misappropriation was reviewed and indicated an intent to prevent such incidents and ensure proper staff screening. However, the actions of the CNA constituted verbal abuse, and the facility failed to protect the resident from this mistreatment.

Penalty

Inspection fine: $177,180

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Resident #6, who was admitted with immobility syndrome, severe protein-calorie malnutrition, and ESBL resistance, was found to be dependent on staff for all activities of daily living, including bathing. The resident was cognitively intact and had a care plan indicating a self-care performance deficit, requiring full staff assistance. Despite being scheduled for showers on Wednesdays and Fridays during the night shift, documentation and interviews revealed that the resident did not consistently receive showers or bed baths as scheduled. Progress notes and shower records showed significant gaps between bathing events, with some refusals documented but also instances where the resident requested a bed bath and there was no evidence it was provided. Interviews with staff, including CNAs and the DON, confirmed that showers were not always given as scheduled, with some staff citing staffing shortages or unwillingness to provide showers, while others denied staffing issues but could not explain the missed care. The facility's policies required routine daily care, including bathing, to be provided by CNAs under nurse supervision, and perineal care to be planned according to individual needs and preferences. However, the records and staff interviews indicated that these policies were not consistently followed for Resident #6, resulting in missed scheduled showers and bed baths.

Penalty

Inspection fine: $177,180

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide one-on-one activities tailored to meet the interests and needs of residents who were unable or unwilling to participate in group activities. This deficiency was identified through record review, observation, interviews, and facility policy review, and affected three residents. Documentation for scheduled one-on-one activities was either missing or incomplete, and staff interviews confirmed that these activities were not consistently offered or recorded as required by the residents' care plans. One resident with schizoaffective disorder, major depressive disorder, and impaired cognition was care planned to receive one-on-one activities twice weekly, but documentation showed only a single entry for the month, with the resident denying the activity. The resident reported not being offered opportunities to attend activities outside her room and described staff as unkind and unengaged during visits. Staff interviews confirmed that one-on-one activities were not consistently documented or provided, and the activity director acknowledged the lack of documentation for these visits. Another resident with chronic respiratory failure, obstructive sleep apnea, and major depressive disorder was also scheduled for twice-weekly one-on-one activities. Documentation showed only a few instances of staff visiting to chat or provide reading material, with no evidence that the scheduled frequency was met. The resident expressed a preference for in-room activities related to his interests, such as video games and movies, but reported that the activity department did not accommodate these preferences. A third resident with ataxic cerebral palsy, epilepsy, and schizophrenia was care planned for personalized activities and one-on-one visits due to declining health, but there was no documentation to support that these activities were provided. Staff interviews confirmed that most one-on-one activities consisted of sitting and chatting, with no documented evidence of these interactions.

Penalty

Inspection fine: $177,180

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a resident's emergency contact was notified of a change in condition. Medical record review showed that the resident's father, who was listed as the primary emergency contact, had passed away in 2022, but the chart was not updated to reflect this. As a result, no family member was notified when the resident experienced a significant change in condition. The resident, who had multiple diagnoses including ataxic cerebral palsy, epilepsy, anemia, thoracic aortic aneurysm, schizophrenia, obsessive compulsive disorder, and major depressive disorder, required assistance with activities of daily living and personal care. Progress notes indicated that a urinalysis with culture and sensitivity was ordered without documentation of the reason, the ordering provider, or family notification. Additionally, late entry notes were made regarding antibiotic use, but these were completed a month after the events occurred, and there was no evidence of timely documentation or family notification. On one occasion, a registered nurse found the resident unresponsive and, after consulting with a physician and nurse practitioner, the resident was sent to the hospital. The nurse practitioner attempted to contact the family but received no response. Interviews with facility staff confirmed that the emergency contact information was outdated and that there was no documentation of family notification regarding the resident's change in condition or new medical orders. The facility's policy required notification of resident representatives or authorized family members for changes in condition, but this was not followed in this case.

Penalty

Inspection fine: $177,180

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure residents were informed of the risks and benefits of medications before those medications were started. This deficiency affected two of five residents reviewed for medication use in a facility with a census of 72. For Resident #2, the medical record showed multiple diagnoses including COPD, stroke-related weakness and paralysis, type 2 diabetes mellitus, atherosclerosis, hyperlipidemia, peripheral vascular disease, hypertension, insomnia, bipolar disorder, generalized anxiety disorder, overactive bladder, and GERD. The resident had orders for multiple medications, including apixaban, atorvastatin, Plavix, divalproex sodium, duloxetine, ezetimibe, gabapentin, furosemide, Lantus, meloxicam, metformin, naloxone, and trazodone. A consent to treat form from Psychotherapies services stated the resident understood medication management might involve physical side effects, but Regional RN #896 verified there was no documentation showing the resident had been informed of the potential risks and benefits of the individual medications prescribed. For Resident #10, the medical record showed diagnoses including type 2 diabetes mellitus, generalized anxiety disorder, mild intellectual disabilities, anemia in chronic kidney disease, schizoaffective disorder, major depressive disorder, hypothyroidism, hyperlipidemia, chronic kidney disease stage two, diabetic polyneuropathy, slow transit constipation, ataxia, vitamin B12 deficiency anemia, vitamin D deficiency, and hypertension. A quarterly MDS assessment indicated the resident was cognitively intact. Medication orders included clozapine, divalproex sodium, and trazodone. On interview, Regional RN #896 verified the facility was unable to locate evidence that Resident #10 had been informed of the risks and benefits of the medications she was receiving.

Penalty

Inspection fine: $177,180

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to honor a resident’s bathing preferences by not providing showers in accordance with the resident’s stated choice. Resident #79, who was admitted on 08/20/25 and had diagnoses including type 2 diabetes mellitus with diabetic polyneuropathy, generalized muscle weakness, anxiety disorder, depression, anemia, hyperlipidemia, bipolar disorder, hypertension, arthropathic psoriasis, osteoarthritis, and lumbago with sciatica, was assessed as alert and oriented to person, place, and time. The admission nursing assessment documented a preference for a shower on day shift twice a week. During a resident council meeting on 08/27/25, Resident #79 stated she had been at the facility for one week and had not received showers, despite speaking with several nursing assistants about it. The resident reported being told she was not on the shower schedule. Review of bathing records showed one shower on 08/20/25 and bed baths on 08/22/25, 08/23/25, and 08/25/25. The shower schedule did not include Resident #79, and an LPN verified that her name was not on the schedule.

Penalty

Inspection fine: $177,180

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure required face-to-face physician visits occurred for two residents reviewed for physician visits. Resident #72 was admitted on 06/25/25 with diagnoses including rhabdomyolysis, COPD, depression, hypertension, gout, adult failure to thrive, chest pain, and insomnia. The record showed physician and nurse practitioner documentation for visits on 06/26/25, but there was no further evidence of physician visits as of 09/09/25; Regional RN #896 verified that only the 06/25/25 physician visit could be located and that all other visits were made by the nurse practitioner. Resident #74 was admitted on 06/10/25 with diagnoses including type 2 diabetes mellitus, hypertension, peripheral vascular disease, major depressive disorder, hyperlipidemia, anemia, spinal stenosis, and a displaced fracture of the upper end of the right humerus. The nurse practitioner completed the initial medical evaluation instead of the physician, with the nurse practitioner visit documented on 06/17/25 and the physician's initial visit note dated 06/19/25; Regional RN #896 verified that the initial medical evaluation in the facility was made by the nurse practitioner rather than the physician.

Penalty

Inspection fine: $177,180

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure adequate monitoring of laboratory values to determine whether medications were within the recommended therapeutic range for one resident. Resident #2 had diagnoses including bipolar disorder, generalized anxiety disorder, chronic respiratory failure, and chronic obstructive pulmonary disease. Divalproex sodium delayed release (Depakote) 250 mg every morning and at bedtime was ordered on 01/23/24 for bipolar disorder, but there was no evidence that a Depakote level had been obtained since the medication was started. During interview, the CNP stated she had started in July 2025, was unaware the resident had not received a Depakote level, and said she would order one. Medscape information reviewed by surveyors stated that valproic acid levels should be monitored, with a therapeutic range of 50-100 mcg/ml and toxic levels greater than 100 mcg/ml.

Penalty

Inspection fine: $177,180

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to arrange timely outside orthopedic services for a resident who had a fall and sustained a skin tear to the left hand knuckles, followed by new left hand swelling. The resident had diagnoses including left-sided weakness and paralysis following a stroke, COPD, generalized muscle weakness, cognitive communication deficit, major depressive disorder, atrial fibrillation, heart disease, stage 3 CKD, and hepatitis C. After x-ray results were reviewed, the resident was referred to orthopedics for further management for a closed fracture of the distal end of the left radius and a closed dislocation of the distal radioulnar joint of the left wrist. A nursing note documented that the orthopedic provider received the referral and would contact the facility to schedule an appointment, but there was no further documentation of an appointment being made or of follow-up contact with the orthopedic office for an extended period. A later note indicated multiple attempts were made to contact orthopedics with no return calls, and an alternate referral would be made. During interview, the unit manager stated she had printed and sent the paperwork to the orthopedic office and made several calls to confirm receipt and obtain an appointment, but she did not call every day and could not provide a clear time frame for when the office had called back.

Penalty

Inspection fine: $177,180

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain furniture in proper working order in resident rooms, affecting four residents whose environment was screened for safety, functionality, and comfort. In one room occupied by two residents, two drawers of the built-in dresser were missing and/or broken, and the bottom left drawer was off track and difficult to access; one resident stated he had been admitted after the other and suggested the other resident might know how long the drawers had been broken, while the other resident said one drawer front had recently broken and the other had been broken since before admission. In another room, one drawer front was missing and the resident stated the drawer had been like that since admission. In a third room, one drawer front was also missing. The medical records reviewed showed the residents had diagnoses including COPD, anxiety, depression, and generalized muscle weakness, and the residents whose records were reviewed were cognitively intact.

Penalty

Inspection fine: $177,180

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure criminal background check results were received within the State-required 30-day timeframe and allowed staff to continue working with direct resident contact while those results were still pending. Review of the criminal background check log, time punches, policy, and interviews showed that CNA #816 was hired on 01/15/25 and fingerprints were obtained the same day, but she was permitted to work on 02/14/25 and again on 02/18/25 before her background check results were available; the results were received on 02/17/25 and reviewed on 02/18/25. On 09/08/25, the Mobile HR Manager stated he could not explain why CNA #816 continued to work before the results were received and reviewed, and the Administrator stated HR was responsible for monitoring the 30-day timeframe. Further review showed the same issue with CNA #900, who was hired and fingerprinted on 01/09/25 and continued to work on 02/15/25 and 02/16/25 before the background check results were reviewed on 02/18/25. LPN #898 was hired on 01/15/25 with fingerprints obtained that day, worked on 02/18/25 after the 30-day period had passed, and her results were not received and reviewed until 02/20/25; the log showed no disqualifying offenses and that she was appropriate for hire. CNA #899 was also hired and fingerprinted on 01/15/25, worked on 02/14/25 after the 30-day period, and her results were received on 02/17/25 and reviewed on 02/18/25. The Administrator verified these staff were allowed to continue working when their results were not received within 30 days, and also stated the HR director had not informed her of any staff whose background check results were delayed.

Penalty

Inspection fine: $177,180

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to complete required performance evaluations for certified nursing assistants (CNAs). Review of CNA #812's personnel file showed a hire date of 08/14/24, but there was no evidence of an annual performance review being completed. On 09/04/25 at 2:00 P.M., the Administrator verified that she was unable to locate an annual performance review, and although the electronic system indicated it was completed, the form was blank. Review of CNA #816's personnel file showed a hire date of 01/15/25, but there was no evidence of a 90-day performance review, which is a more stringent state regulation, being completed. On 09/04/25 at 2:00 P.M., the Administrator verified that she was unable to locate a 90-day performance review for CNA #816.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that the written discharge summary for Resident #65 accurately reflected the amount of Oxycodone provided at the time of discharge. Resident #65, who had diagnoses including paraplegia, chronic pain syndrome, and major depression, was discharged with a care plan that included medication management for chronic pain. A physician order indicated that the resident was to receive Oxycodone 20 mg four times a day. However, the discharge summary inaccurately stated that the resident would receive a 30-day supply of medication, while only 30 tablets of Oxycodone, equating to a seven-and-a-half-day supply, were actually provided. Interviews with the Regional Nurse and the Director of Nursing confirmed the discrepancy between the discharge summary and the actual amount of medication given. The Regional Nurse acknowledged the error as clerical, and the Director of Nursing confirmed that the discharge instructions inaccurately documented a 30-day supply of medications. The facility's policy on transfer and discharge required reconciliation of all pre-discharge medications, which was not accurately followed in this case. This deficiency was investigated under Master Complaint Number OH000163758.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility did not ensure an allegation of physical abuse was thoroughly investigated, affecting one resident of three reviewed for abuse. Resident #70, who had intact cognition and no memory impairment, reported that another resident, Resident #32, entered his room and physically assaulted him by grabbing his right knee, which had recently undergone replacement surgery. Despite Resident #70's complaints of severe pain and a disheveled bandage, the facility's Director of Nursing (DON) and staff did not find evidence of physical abuse and suspected Resident #70 of seeking additional pain medication. The facility's investigation did not include skin checks of non-interviewable residents or interviews with other residents, and it did not address the physical abuse allegation in detail. Resident #32, who had severe cognitive impairment and a history of behavioral disturbances, was involved in the incident. On the day of the reported incident, Resident #32 was aggressive with staff, striking a nurse, and was subsequently placed on one-to-one supervision and sent for psychiatric evaluation. The facility's investigation concluded that there was no intent by Resident #32 to harm Resident #70, and the incident was classified as verbal abuse rather than physical abuse. However, the investigation lacked thoroughness, as it did not include detailed witness statements or address the physical abuse allegations made by Resident #70. The Ombudsman and Resident #70 both reported the physical abuse allegations to the facility, but the DON did not file a self-reported incident (SRI) for physical abuse with the Ohio Department of Health. The facility's policy on abuse, neglect, and misappropriation requires accurate and timely reporting of incidents and a thorough investigation, which was not adhered to in this case. The deficiency represents noncompliance identified during the investigation of the complaint.