Elmwood Assisted Living & Skilled Nursing Of Fremo

Penalty

Inspection fine: $196,999

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 protect residents from mental abuse by staff, resulting in Immediate Jeopardy and the potential for serious harm. Staff members were observed willfully harassing, mocking, and ridiculing three residents. This included laughing at residents during care, making fun of their physical disabilities, teasing them to elicit angry responses, and encouraging inappropriate gestures and language. These actions led to one resident exhibiting agitated behaviors and another feeling emotionally distressed. The incidents were discovered when a registered nurse observed video footage on a staff member's personal cell phone. The footage showed staff members engaging in inappropriate behavior with the residents, including causing agitation and coercing inappropriate actions. The nurse initially did not report the incidents due to fear of staff reprisal. The facility's investigation confirmed the abuse, with multiple staff members involved in the incidents. The residents involved had various medical conditions, including Alzheimer's disease, dementia, major depressive disorder, and physical disabilities. The facility's policy on abuse, neglect, and exploitation was not adhered to, as the staff's actions constituted willful infliction of mental anguish and humiliation. The facility's failure to protect the residents from such abuse was a significant deficiency.

Removal Plan

• The ED placed RN #300, STNA #400, STNA #401, STNA #403, and STNA #404 on suspension pending investigation.
• The ED began an investigation into the abuse allegations. The allegations were reported to the State Survey Agency and Law Enforcement. The local police were contacted.
• The local police came to the facility and interviewed staff regarding the allegations. No further actions were taken by law enforcement.
• The ED began education for all staff regarding potential abuse and exploitation. All staff were in-serviced.
• The ED notified the family of Resident #3 regarding the allegations. The families of Resident #1 and Resident #2 were notified by the ED.
• The DON completed skin assessments for Resident #1, #2, and #3 with no skin concerns identified.
• Certified Nurse Practitioner (CNP) assessed Residents #1, #2, and #3 with no concerns identified.
• The facility terminated the employment of RN #300, STNA #400, STNA #401, STNA #403, and STNA #404.
• Interview with Licensed Practical Nurse (LPN) #500, STNA #600, and STNA #601 confirmed in-service attendance regarding potential abuse and exploitation.
• The ED interviewed 11 additional interviewable residents to assess for any abuse having occurred. The ED also interviewed 24 additional staff regarding any additional knowledge of abuse. All residents and staff denied any knowledge of abuse.
• The ED began monitoring for abuse by completing random interviews with residents able to be interviewed. The ED began making random observations for those residents who cannot be interviewed to ensure there are no negative signs of abuse or reports of inappropriate staff to resident interactions.

Penalty

Inspection fine: $196,999

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 the privacy and confidentiality of residents by allowing staff to video record them during private and personal interactions. This deficiency affected three residents, all of whom were recorded without consent. The residents involved had various medical conditions, including Alzheimer's disease, dementia, major depressive disorder, and anxiety disorder. The facility's policy explicitly prohibited the use of personal cell phones to take photos or videos of residents, yet this policy was violated by several staff members. The incident came to light when it was reported that two staff members had videos of residents on their cell phones. These videos included footage of staff taunting a resident with a baby doll, encouraging another resident to say curse words and make rude gestures, and mocking a resident during a transfer. The investigation revealed that multiple staff members were involved in these recordings, and the videos were shown to other staff members, including a registered nurse who initially did not report the incident due to fear of reprisal. The facility's investigation confirmed the unauthorized video recordings and led to the termination of the involved staff members. The Executive Director verified that staff used personal cell phones to obtain video footage of residents, which violated the facility's privacy and cell phone use policy. The local police department was also involved, responding to a report of harassment and confirming the existence of the videos. Despite the denials from some staff members, the evidence gathered during the investigation supported the allegations of privacy violations.

Penalty

Inspection fine: $196,999

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 timely reporting of alleged abuse incidents to the administrator, affecting three residents. Resident #1, with severe cognitive impairment and dependent on staff for daily activities, was subjected to inappropriate behavior by staff, including pinching and taunting. Resident #2, also with severe cognitive impairment and multiple health issues, was mocked by staff for his amputation. Resident #3, with intact cognition but dependent on staff, was coerced by staff to engage in inappropriate gestures and language. The incidents were captured on video by staff members and shared among them. Agency STNA #402 reported the incidents to the administrator after being informed by RN #300, who had witnessed the videos but initially refrained from reporting due to fear of reprisal. The videos depicted staff members engaging in abusive behavior, such as pinching Resident #1's breast, mocking Resident #2's amputation, and taunting Resident #3 while on the toilet. The facility's policy mandates immediate reporting of any suspected abuse or mistreatment to the appropriate authorities. However, RN #300 failed to report the incidents promptly, leading to her suspension and eventual termination. The facility's investigation substantiated the abuse allegations, resulting in the termination of the involved staff members.

Penalty

Inspection fine: $196,999

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 protect residents from mistreatment by staff who continued working after allegations of abuse were made. The investigation revealed that staff members had videos on their cell phones showing them taunting and abusing residents. These actions included pinching a resident's breast, mocking a resident with an amputation, and encouraging a resident to make rude gestures. Despite these allegations, the staff involved continued to work at the facility before being suspended. The investigation into the allegations was inadequate, as it only involved interviews with the accused staff members and the affected residents. No other staff or potential witnesses were interviewed, and no additional residents were questioned to determine if others were involved or had witnessed the incidents. This lack of thorough investigation contributed to the deficiency, as it failed to fully uncover the extent of the mistreatment and ensure the safety of all residents. The facility's policy on abuse, neglect, exploitation, and misappropriation of property was not followed properly. The policy required the removal of the accused staff from direct resident care and a comprehensive investigation, including interviews with all potential witnesses. However, the delay in reporting and the limited scope of the investigation led to a failure in protecting residents and addressing the allegations promptly.

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 a resident was not improperly discharged, affecting one of three residents reviewed for discharge. The resident, who had multiple chronic conditions including chronic kidney disease, major depressive disorder, and chronic obstructive pulmonary disease, was initially given a 30-day discharge notice due to non-payment. However, the resident was not discharged on the specified date, and no new 30-day discharge notice was issued before the resident was eventually discharged after being admitted to the hospital for pneumonia. The facility did not allow the resident to return from the hospital unless she was approved by insurance to receive skilled care, despite being aware that the resident had applied for Medicaid prior to the discharge notice expiration. Interviews with the Director of Nursing, Admissions Coordinator, and Executive Director confirmed that the facility did not issue a new discharge notice and was aware of the Medicaid application but did not act accordingly. The facility's policy, last revised in June 2023, stated that a 30-day discharge notice must be provided prior to discharge and that discharge would not occur unless the resident failed to pay for their stay. The policy also mentioned that non-payment applies if the resident does not submit the necessary paperwork for third-party payment. Despite this policy, the facility did not follow the proper procedures, leading to the improper discharge of the resident. This deficiency was investigated under Complaint Number OH00152725.

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 complete safe and orderly discharge planning for Resident #23, who had a complex medical history including chronic kidney disease, major depressive disorder, anxiety, chronic pain, hypertension, emphysema, bipolar disorder, chronic obstructive pulmonary disease, chronic respiratory failure with hypoxia, cirrhosis of the liver, type two diabetes mellitus, and fibromyalgia. The resident required partial to moderate assistance with transfers, substantial assistance with toileting, and was not ambulatory. Despite these needs, there was no care plan in place for discharge planning, and the resident's medical record lacked documentation of discharge planning from 12/18/23 through 03/11/24. The resident was admitted to the hospital for pneumonia on 03/11/24 and was not allowed to return to the facility unless approved by insurance for skilled care, despite having applied for Medicaid on 01/18/24. The Director of Nursing confirmed that no discharge planning had taken place for the resident. The facility's policy on Resident Discharges, last revised in 06/2023, stated that the discharge needs of each resident would be identified, resulting in the development of a discharge plan and summary to assist the resident in adjusting to their new living environment. However, this policy was not followed in the case of Resident #23. The deficiency was investigated under Complaint Number OH00152725, and it was confirmed that the facility did not prepare the resident for discharge, leading to non-compliance with the established discharge planning procedures.

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 residents were provided bed hold notices when transferred to the hospital. This deficiency affected three residents, identified as Resident #22, Resident #23, and Resident #24. Resident #22, who had multiple diagnoses including heart failure and chronic obstructive pulmonary disease, was admitted to the hospital on 05/04/24, but no bed hold notice was provided. Similarly, Resident #23, with diagnoses such as chronic kidney disease and major depressive disorder, was admitted to the hospital for pneumonia on 03/11/24 without receiving a bed hold notice. Resident #24, who had conditions including heart failure and chronic kidney disease, was sent to the hospital on 02/21/24 for lethargy and other symptoms, but also did not receive a bed hold notice. An interview with the Admissions Coordinator (AC) #20 confirmed that the residents were not provided bed hold notices when transferred to the hospital. AC #20 admitted to being unaware of the requirement to provide a bed hold notice when residents were transferred to the hospital. A review of the facility's policy on Resident Transfers/Discharge, Re-hospitalizations, and Bed Hold, last revised in 03/2024, indicated that the facility was supposed to inform the responsible party of the Bed-Hold Policy and provide the Notice of Bed Hold when residents left the facility. This deficiency was investigated under Complaint Number OH00152725.