Forest Hills 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

Surveyors identified a failure to store food in accordance with professional standards and facility policy, creating the potential for foodborne illness for nearly all residents who received food from the kitchen. In the walk-in cooler, they observed multiple items that were opened and partially used without any open dates, including two cartons of heavy whipping cream, bins of individually poured and covered beverages, and a tray of covered fruit cocktail bowls. A large pan of pasta with ground meat was stored with the serving scoop resting directly on the food, covered with plastic wrap and not dated. A cart in the cooler held a 22-quart container of dark liquid with no label or date, and a pink plastic pitcher resting directly on the cart surface, which was coated with a dark unidentified material. A box of bacon was stored directly on the floor. The Director of Dietary Services confirmed the presence of undated, unlabeled, and improperly stored food items in the walk-in cooler. In the walk-in freezer, surveyors found an unsealed and undated bag of frozen chicken breasts and an unsealed and undated bag of pork pizza topping, which the Director of Dietary Services also confirmed. The reach-in cooler used for tray line contained a variety of pre-poured juices, milk, thickened beverages, and tea that were covered but not dated. At a nurses' station refrigerator, surveyors observed a plastic bag of food labeled with a resident’s name and dated more than a week earlier, along with three half-sandwiches wrapped in plastic without dates; the LPN present verified these findings. In a resident’s personal refrigerator, three undated bags of grapes with visible mold were found, and a CNA confirmed the grapes were moldy and undated. Facility policies required cold foods to be stored at least six inches above the floor, wrapped or in covered containers, labeled, and dated, and required resident refrigerators to be monitored daily, with food appropriately labeled and unsafe or moldy food discarded. These practices were not followed, resulting in the cited deficiency under the complaint investigation.

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

Surveyors identified a deficiency related to the facility’s failure to respond to and follow up on concerns raised during Resident Council meetings, affecting multiple residents who attended these meetings and potentially all residents in the facility. Review of Resident Council minutes for three consecutive months showed residents repeatedly voiced concerns about noise at night, aides on night shift not staying on task, delays in being assisted out of bed in time for activities, bathrooms not being cleaned properly, running out of ordered food, and rooms not being cleaned on weekends. The minutes did not document any follow-up actions or responses to these concerns. Residents reported that Resident Council meetings had become poorly attended because residents felt that nothing changed when they brought up issues. Interviews with the Resident Council President and other residents confirmed that specific concerns, such as poor food flavor and temperature and staff cell phone use during work time leading to slow call light response and delayed tasks, had been raised in Resident Council but had not resulted in noticeable changes. One resident recounted that a former cook had attended a meeting, listened to food-related complaints, and stated he would make menu and preparation changes, but residents perceived no improvement in food quality afterward. Another resident confirmed that concerns about staff cell phone use had been discussed, but she was unaware of any action taken. The Administrator acknowledged there was no standard method for addressing Resident Council concerns and confirmed that, although concerns were addressed after minutes were completed, communication about any actions taken did not get back to the residents.

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

Medication labeling and storage were not maintained for two residents receiving insulin. Resident #95, who had diagnoses including fibromyalgia, type 2 diabetes, and polyneuropathy, had an insulin aspart pen that was observed opened but undated in the Rehab South medication cart. The LPN confirmed the insulin did not have an open date. Resident #82, who had diagnoses including cerebral atherosclerosis, hyperlipidemia, and type 2 diabetes, had insulin glargine observed with an open date of 03/28/26. The LPN confirmed the open date and stated the insulin was expired and should be discarded. The facility policy stated insulin was to be discarded after 28 days and all multi-use vials required an open date, with expired medications removed from active supply and destroyed. Medication carts were also observed unsecured. On the 1100 hallway, an unattended unlocked medication cart was observed sitting in the hallway while several unlicensed staff and residents walked past it. The LPN confirmed the cart had been left unattended and unlocked. The DON confirmed nurses are never to leave a med cart unlocked and unattended. The facility policy stated medication carts are to be locked when not attended by people with authorized access.

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 prepare pureed foods in a manner that preserved the nutritional content of the food. During observation, a cook prepared pureed peas by pouring peas from a large metal pan into a food processor and adding approximately one quart of chicken broth and two tablespoons of thickening powder. He then blended the mixture, checked the consistency, added approximately one tablespoon more thickener, and continued blending. He later continued to run the food processor while adding an additional six tablespoons of thickener until the peas reached the desired consistency. The cook verified that he blended approximately two liters of peas, one quart of chicken broth, and nine tablespoons of thickener when preparing the pureed peas. The District Manager stated that food should be blended before liquid is added to minimize the use of excess liquid and the need for excess thickener. The Registered Dietitian stated that adding too much liquid could require more thickener to achieve the desired consistency, which could negatively affect the nutritional content of the food, and could also impact consistency as the food cooled, creating a potential choking hazard. The facility recipe for pureed peas stated that the peas should be blended until smooth, and then thin liquid or commercial thickener should be added to achieve the desired consistency.

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

Surveyors found that the facility failed to implement an adequate baseline care plan addressing activities of daily living (ADL) needs for a newly admitted resident. The resident was admitted with diagnoses including postprocedural intestinal obstruction and dementia, and the MDS assessment documented severely impaired cognition and a need for staff assistance with ADLs. The baseline care plan, dated on the admission day, only noted that the resident had an ADL self-care performance deficit due to comorbidities and did not include further details about the resident’s basic ADL care needs. An interview with the MDS LPN confirmed that the baseline care plan lacked the basic information needed to care for the resident. Review of the facility’s Baseline Care Plan/48 Hour Care Plan policy showed that baseline care plans were required to include information regarding resident needs for assistance with ADLs, which was not done in this case. This deficiency was cited for one resident out of 13 reviewed for baseline care plans, with a facility census of 112 residents, and was investigated under Complaint Number 2963128.

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 deficiency involves the facility’s failure to address a resident’s impaired range of motion in the comprehensive care plan. The resident was admitted with diagnoses including anoxic brain damage, persistent vegetative state, and type 2 diabetes mellitus. An MDS assessment documented that the resident was in a persistent vegetative state with no discernible consciousness, was dependent on staff for all ADLs, and had impaired range of motion in all extremities. Despite this, review of the resident’s care plan showed no interventions related to the limited range of motion. During an interview, the MDS LPN confirmed that the resident’s limited range of motion was not included on the care plan and acknowledged that this information should be present so staff are aware of the limitations. Facility policy stated that the care plan is the written treatment provided to enable optimal personalized care and services, but the resident’s range of motion needs were not incorporated, resulting in the cited deficiency. This deficiency was identified for one resident reviewed for limited range of motion, in the context of eight residents in the facility who had limited range of motion and an overall census of 112 residents. It was investigated under Complaint Number 2963128.

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 deficiency involves the facility’s failure to provide adequate assistance with activities of daily living (ADLs), specifically nail care, for residents who were unable to perform these tasks independently. One resident with type 2 diabetes mellitus, legal blindness, and adult failure to thrive had an MDS assessment indicating intact cognition but a need for partial/moderate assistance with bathing and personal hygiene. On observation, this resident’s fingernails were long, extending approximately one half inch beyond the fingertips. The resident reported disliking the length of his fingernails because it interfered with his ability to press buttons on his TV remote. The Activity Director confirmed that the fingernails were long and needed trimming. A subsequent observation the next day showed the fingernails remained long, and the resident confirmed that no one had offered to cut his fingernails since the prior day. Another resident, admitted with anoxic brain damage, persistent vegetative state, and type 2 diabetes mellitus, had an MDS assessment indicating a persistent vegetative state with no discernible consciousness, dependence on staff for all ADLs, and impaired range of motion in all extremities. During an observation with an LPN, this resident’s fingernails were noted to be long, extending approximately one quarter inch beyond the fingertips, and the LPN verified that the fingernails were long and needed trimming. Review of the facility’s undated “Routine Resident Care” policy showed that the facility was responsible for providing routine daily care, including assistance with ADLs. The failure to ensure nail care for these residents constituted noncompliance and was investigated under multiple complaint numbers.

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 ordered opioid analgesic medications were available for administration as prescribed, resulting in missed scheduled doses for two residents. One resident, admitted with wedge compression fractures of multiple thoracic vertebrae, muscle weakness, and COPD, had an order for oxycodone 10 mg every six hours. Review of the MAR showed the 6:00 p.m. dose on 04/27/26 was not signed as administered. The resident reported that the facility had recently run out of his routine oxycodone and that he missed a scheduled pain medication dose. The DON confirmed that the 6:00 p.m. oxycodone dose on 04/27/26 was not given because the medication was not available. Another resident, admitted with diagnoses including polyneuropathy, type 2 diabetes mellitus, prostate cancer, and anxiety disorder, had an order for oxycodone-acetaminophen 5-325 mg every six hours. Review of the MAR showed the 6:00 p.m. dose was not signed as administered. The resident reported that in the previous month there was a day when he did not receive his scheduled pain medication because it was not available. The DON confirmed that the 6:00 p.m. dose of oxycodone-acetaminophen on 03/16/26 was not administered due to the medication not being available. This deficiency was identified during complaint investigations under Complaint Numbers 2704502, 2656097, and 2673312.

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 provide care and services to maintain or improve range of motion for a resident who was at risk for contractures. Resident #1 was admitted with diagnoses including anoxic brain damage, persistent vegetative state, and type two diabetes mellitus. The MDS assessment documented that the resident was in a persistent vegetative state, had no discernible consciousness, was dependent on staff for all activities of daily living, and had impaired range of motion to all extremities. The resident’s responsible party reported that the resident’s hands seemed stiff and were not moving easily when she tried to stretch them during a visit. The medical record showed no evidence that occupational therapy was consulted for the resident’s limited range of motion. The Director of Therapy confirmed the resident had not been evaluated or screened by OT since admission and stated the resident’s persistent vegetative state placed him at risk for contractures. During observation, OT assessed the resident and confirmed the shoulders were tight with increased muscle tone, and stated the resident could benefit from range of motion exercises and staff education. The OT also verified the resident was at risk for worsening contractures and had not been evaluated by OT since admission. The facility policy stated that the care planning team would coordinate care to meet resident care needs.

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 medications were administered only with an appropriate indication for use for one resident. Resident #13 was admitted with diagnoses including heart disease, myocardial infarction, and tobacco use, and the MDS described the resident as cognitively intact and needing minimal assistance with ADLs. The physician ordered a transdermal nicotine patch for smoking cessation in April 2026, and the MAR documented refusals of the patch from 04/14/26 through 04/29/26. During interview, the resident stated he had not smoked or vaped since admission and confirmed he had refused the nicotine patch on some days. On observation, the resident was wearing an undated nicotine patch on his left upper arm, and he stated it had been there for several days. An LPN confirmed the resident was wearing the patch and stated she did not think he was a smoker. The DON later confirmed the resident was not a smoker and that staff had not asked about tobacco use upon admission, and also confirmed the resident should not have had an order for a nicotine patch because he was not a smoker.

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 enhanced barrier precautions (EBP) were implemented as appropriate for a resident who was colonized with candida auris. Resident #13 was admitted with diagnoses including heart disease, myocardial infarction, and tobacco use, and the hospital discharge summary noted the resident was colonized with candida auris and was in contact isolation while in the hospital. The MDS assessment showed the resident was cognitively intact and required minimal assistance with ADLs. During interview, the DON confirmed he was unaware of the resident’s candida auris diagnosis, that the diagnosis had not been added to the facility diagnosis list, that the resident had not been placed in any type of isolation, and that the facility had not tested the resident for candida auris since admission. The DON later verified that after speaking with the Medical Director, an order was given for the resident to be placed in EBP.

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

Staff failed to maintain the confidentiality of residents' medical records by leaving a laptop unattended on top of the medication cart in the 400 hall. The laptop was open and displayed a resident's name and medication list, making private health information visible to anyone passing by, including residents, staff, and visitors. This was directly observed during a survey, and the responsible RN confirmed leaving the laptop unattended with sensitive information accessible. Further observation revealed that the same unattended laptop displayed multiple resident records, again making confidential information accessible to unauthorized individuals. The facility's policy requires staff to turn off computer screens and not leave open medical records unattended, but this protocol was not followed. The administrator confirmed that nursing staff are expected to lock their laptop screens when stepping away from the medication cart to protect resident privacy.

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 a resident received necessary vision services as required. The resident, who had diagnoses including Alzheimer's disease, major depressive disorder, hypertension, and glaucoma, had a physician's order for an eye doctor visit as needed and was prescribed Latanoprost eye drops for glaucoma. The care plan identified impaired visual function and included interventions such as arranging consultations with an eye care practitioner. Despite a referral being sent in June for the resident to be seen by the facility eye doctor, the resident had not been seen by an eye doctor since admission in 2020. Interviews with staff confirmed that the resident had not received an eye doctor visit and that her glasses could not be located. The resident herself was unaware of the whereabouts of her glasses, and a CNA reported never having seen her wear glasses during nine months of employment. The facility's policy required referrals for eye care appointments as needed, but this was not followed, resulting in the resident not receiving appropriate vision services.

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

Dietary staff failed to perform proper hand hygiene during meal preparation and service, as observed on multiple occasions. One dietary aide was seen scratching her head and face, touching her clothes and pants, and then handling plates and food items without washing or sanitizing her hands. These actions were observed during both lunch and breakfast tray lines, and the aide continued to prepare and serve food after touching her face, hair, and clothing. The facility's policy required hand hygiene after such contact, and both the Dietary Manager and Administrator confirmed that staff were expected to follow these procedures. Additionally, the facility did not ensure that milk served on the tray line was maintained at the required temperature of 41 degrees Fahrenheit or less. During breakfast service, lactose-free milk was poured into cups and left on the tray line without being held in ice. When the temperature was checked, the milk measured 43 degrees Fahrenheit, above the acceptable limit. The Dietary Manager acknowledged that the milk could not be served at that temperature, and both the DON and Administrator stated their expectation that food and drink temperatures be kept within required ranges.

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 the facility failed to properly transcribe and update a change in advance directive order for one resident. The resident, who had moderate cognitive impairment as indicated by a BIMS score of 12, was initially documented as a full code upon admission, meaning they wished to receive CPR. However, the resident later expressed a desire to change their code status to Do Not Resuscitate (DNR) Comfort Care, and signed the appropriate DNR order form. Despite this, the resident's electronic health record (EHR) and current orders continued to reflect full code status, and the change was not updated in the EHR as required. Interviews with staff revealed that the process for updating code status involved multiple roles, including the Director of Social Services (DSS), nursing staff, and the medical records nurse. The DSS and DON both stated that the change in code status should have been communicated and documented in the EHR, but this was missed during a period when the facility did not have a DSS. The former medical records nurse did not upload the DNR form or update the EHR, resulting in the resident's code status remaining incorrect in the medical record.

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 provide copies of medical records as requested, affecting a resident who had been discharged. The resident, who was cognitively intact, had signed an authorization form requesting her complete medical records to be sent to an attorney's office. Despite the request being received and signed by the resident, there was no documentation to support that the request had been addressed or completed. The facility's administrator confirmed that the request had not been completed, acknowledging that the facility's process involves verifying the authenticity of the request and signature before processing the records within 30 days. However, this process was not followed in this instance. The facility's procedures for releasing clinical records require a properly executed authorization and compliance with HIPAA regulations, but these procedures were not adhered to, resulting in the deficiency.

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 neurological checks were completed for residents who experienced unwitnessed falls or falls involving the head. This deficiency was identified in two residents. Resident #63, who had diagnoses including metabolic encephalopathy and dementia, experienced a fall where he was found sitting on the floor near his geri chair. Although the resident was assessed with no injuries, the required neurological checks were not signed off as completed until several days later by the Director of Nursing (DON), indicating a lapse in timely documentation and potentially in the execution of the checks. Resident #85, with a history of falling and moderately impaired cognition, fell while attempting to pick something up off the floor, resulting in facial abrasions and a broken lens of her glasses. Despite the involvement of the head in the fall, no neurological checks were completed following the incident. The DON confirmed that the facility's protocol required neuro-checks for such falls, but they were not ordered or documented. The Nurse Practitioner (NP) who assessed the resident after the fall also acknowledged that neuro-checks should have been conducted according to the facility's policy.

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 a resident's drug regimen was free from unnecessary medications, specifically affecting a resident with a history of cellulitis, insomnia, cognitive communication deficit, and dysphagia. The resident was admitted with these diagnoses and later experienced an episode of diarrhea attributed to the administration of Miralax. Despite this, the resident was ordered to have their stool checked for Clostridium difficile (C.diff), and subsequently, Vancomycin was prescribed and administered for 10 days without documented evidence of a positive C.diff culture. The deficiency was identified during a complaint investigation, where it was revealed that the Director of Nursing confirmed the administration of Vancomycin without positive C.diff results. The medication was prescribed based on a verbal report from a nurse to a Nurse Practitioner, who then gave a verbal order for the antibiotic without reviewing written results. This oversight led to the unnecessary administration of antibiotics to the resident.

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 laboratory tests were conducted as ordered by physicians for two residents, which had the potential to affect all 108 residents in the facility. Resident #59, who had diagnoses including cellulitis, insomnia, cognitive communication deficit, and dysphagia, was ordered to have a stool test for Clostridium difficile (C.diff) after experiencing diarrhea. However, there was no documented evidence that the stool test was completed as ordered. The Director of Nursing (DON) confirmed the absence of documentation for the stool culture. Resident #109, who had diagnoses including dysarthria, aphasia, hemiplegia, hemiparesis following cerebral infarction, anxiety, depression, vascular dementia, and breast cancer, was ordered to have a complete blood count (CBC) with differential after complaining of weakness and fatigue. Despite the physician's order, there was no documented evidence that the CBC was completed. The DON verified that the CBC was not conducted due to a change in lab companies during that week, resulting in the resident's labs being missed. This deficiency was investigated under Complaint Number OH00160169.

Penalty

Inspection fine: $16,801

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 dependent on staff was safely secured in a wheelchair with an appropriate seat belt during transportation in a facility van to a physician's visit. This resulted in Immediate Jeopardy when a transport driver abruptly stopped the facility van, causing the resident to come out of her wheelchair and land on the floor, sustaining a hematoma, increased pain, and lacerations that required sutures. The incident affected one of three residents reviewed for the use of assistive devices during transportation, with a total of 23 residents utilizing wheelchairs and the transport van who would require seat belts engaged. The resident involved was an elderly female with multiple diagnoses, including morbid obesity, fibromyalgia, disc degeneration, cerebral infarction, muscle weakness, gait abnormalities, chronic respiratory issues, polyarthritis, and hypertension. She was cognitively intact and required transportation via wheelchair. During the trip, the transport driver failed to properly secure the resident, and when the van stopped abruptly, the resident slid out of her wheelchair and landed on the floor. The driver then drove back to the facility with the resident lying unsecured on the floor, further endangering her. Upon returning to the facility, the resident was assessed and found to have a laceration on her right knee, which required sutures, and other injuries. The transport driver did not follow the facility's policy of calling 911 immediately after the incident and instead returned to the facility. The facility's investigation revealed that the driver had been previously educated on the proper transportation protocols but failed to adhere to them during this incident.

Removal Plan

• Resident#15 arrived back at the facility and was immediately assessed by Licensed Practical Nurse (LPN)/Unit Manager #37 and former DON #38.
• Nurse Practitioner (NP) #62 was notified and ordered Resident #15 to be sent to the ER.
• 911 was called by LPN #39.
• Former DON #38 notified Resident #15's family.
• EMS arrived at the facility and transported Resident #15 to the ER for further evaluation and treatment.
• Former DON #38 and LPN #39 updated Resident #15's care plan to include: Send Resident #15 to the ER, wheelchair safety education for the resident, provide an escort for all transport/appointments and skin/laceration care.
• The Administrator ceased all transportation for in-house facility transports.
• The Administrator and former DON #38 interviewed FTD #34 and an investigation started regarding the entire incident and actions that transpired during the incident.
• A van inspection was completed by Maintenance Director #41 and no mechanical issues or malfunctions were discovered.
• FTD #34 was interviewed, and a written statement was obtained. FTD #34 received a final level Corrective Action Form conducted for failure to follow transportation protocol. FTD #34 was suspended pending an investigation of the incident to allow for investigation, education, and ensure no other incidents had occurred. FTD #34 did not return to work and made no other transportation after this incident for the facility.
• The transportation policy was reviewed with the three staff members authorized to complete resident transports. Maintenance Director #41, Transportation Driver (TD) #30, and FTD #34.
• The designated facility TD will perform inspections for the transportation vehicle/equipment to ensure safe and functional operation every day prior to any transportation needs.
• These inspections are to be verified by Maintenance Director #41 after each inspection is completed for the next 30 days then the facility will transition to three times weekly for three months and then monthly ongoing.
• Should Maintenance Director #41 not be available to complete this verification, it will be performed by Regional Director of Maintenance #40/Designee.
• Central Supply Coordinator/Transportation Scheduler #31 conducted an audit of a 30-day lookback of all resident's transportation provided by facility to ensure no other incidents had occurred.
• No concerns were identified from this audit.
• Resident #15 was immediately switched to another transportation service. The Administrator secured an outside transportation company for all facility transports until further notice. All appointments were transferred to the outside provider.
• To monitor for ongoing compliance, Maintenance #41/Designee will audit the facility van three times weekly for three months and then will perform inspections monthly ongoing to ensure the transportation vehicle/equipment is safe and functioning.
• To monitor for ongoing compliance, Maintenance Director #41/Designee will audit via observations and return demonstrations of the facility transportation drivers weekly for one month and then monthly for three months to ensure residents are secured appropriately and safely.
• To monitor for ongoing compliance, Maintenance Director #41/Designee will supervise one transportation run monthly for one year to ensure appropriate transportation methods are in place per the facility's policy. This was implemented and started when in-house transports were resumed. All results of the audits will be included in each QAPI with any findings.
• Resident #15 was transported back to the facility. Resident #15 sustained a laceration on her right knee and seven sutures were placed. All other imaging and diagnostics tests were negative.
• Former DON #38 interviewed Resident #15 and received her verbal statement.
• Resident #15 stated she was riding in the transport van and when the driver (FTD #34) stopped, she slid out of her wheelchair. Resident #15 indicated she stayed on the floor of the van until the driver got back to the building and then she went to the hospital. Resident #15 was educated on safety during transports.
• Regional Director of Maintenance #40 conducted one-on-one (1:1) training, conducted competencies and check offs with a return demonstration with all three authorized transportation drivers (Maintenance Director #41, FTD #34 and TD #30) to ensure previous education was understood and to remain compliant with safety precautions. FTD #34 was not reinstated afterwards due to FTD #34 providing the facility with his resignation.
• Education included: Vehicle safety, Safety and Health Programs, Mandatory Transport Driver Training, Drivers Training Classroom Curriculum, Company Vehicle Driver Program (Fleet Safety Program), Safer Transportation of Wheelchair Passengers, Passenger Safety During Transport, New Driver Request Forms, Transport Staff Performance Agreement, Emergency Supplies Check list, Monthly Preventative Maintenance, and Quarterly Vehicle Inspection Reports and initiated immediately. The policy was reviewed again by Regional Director of Maintenance #40 with the Administrator, Maintenance Director #41, FTD #34 and TD #30. Regional Director of Maintenance #40 conducted competencies and check offs with a return demonstration to ensure previous education was understood and to remain compliant with safety precautions.
• The transportation policy was reviewed by the Administrator. All facility transportation remained stopped and no new changes were implemented to the policy. All facility transports were being conducted by an outside provider.
• A Post Traumatic Stress Disorder (PTSD) screen was completed on Resident #15 and added to the care plan by Director of Social Services #66. The following new interventions were added: To assist and identify what triggers PTSD episodes, encourage slow/deep breathing exercises, reassuring conversation with pleasant topics, observe for increased agitation, anxiety, and offer quiet areas and comfort items, observe resident in group situations and prevent resident from becoming over stimulated, sudden unexpected noises, and new/tv programming may also trigger resident incident, offer quiet area, speak in calm quiet voices and offer reassurance.
• An Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting was held with attendees including: The Administrator, Former DON #38, Medical Director (MD) #64, LPN/Clinical Manager #70, Maintenance Director #41, LPN/Unit Manager #37, Central Supply Coordinator #31, LPN #39, [NAME] President of Risk Management #72, Regional Director of Clinical Operations (RDCO) #78, and Regional Director of Operations (RDO) #80 regarding this incident and discussion was held regarding transportation protocols and safety, falls, and steps the facility is taking moving forward to prevent further reoccurrence of the incident.
• The vehicle insurance company obtained a report of the incident and once the insurance started their investigation their findings were handled through the insurance. No results/findings have been returned to the facility.
• Resident #15 had an outside appointment at a physician's office and did not have any identified concerns during the transport via the outside provider.
• Interviews with TDs #30 and #58 and Maintenance Director #41, each stated they were in-serviced and educated on properly transporting residents and are utilizing the complete Q'Straint system.
• Review of four (#27, #50, #38 and #21) additional resident's medical records who required assistive devices for transportation revealed no concerns.
• Review of the facility's Transportation Safety Audits including Inspections and Ride Along's revealed the audits were performed as scheduled with no issues identified.

Penalty

Inspection fine: $16,801

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 medications were administered by qualified staff, affecting four residents. Medical record reviews revealed that two Medication Technicians (MTs) administered medications to residents without the proper certifications from the Ohio Board of Nursing (OBN). The Administrator, Unit Manager, and Director of Nursing confirmed that MTs #90 and #91 did not have the required certifications to administer medications in a Skilled Nursing Facility (SNF). The MTs were certified to administer medications in an Intermediate Care Facility (ICF), and the Administrator mistakenly believed these certifications were valid for SNFs as well. The MTs had been administering medications to residents without the proper qualifications, and their employee files lacked the necessary documentation from the OBN. The affected residents had various medical conditions, including acute respiratory failure, diabetes, congestive heart failure, dementia, hemiparesis, alcoholic liver disease, morbid obesity, dysphagia, anxiety, depression, pulmonary edema, chronic kidney disease, lupus, dysarthria, aphasia, bone density disorder, gout, acute kidney failure, low back pain, breast cancer, and chronic pain. Despite the lack of proper certification, there were no reported medication errors or incidents involving the MTs. The facility's policy stated that only licensed or authorized personnel could administer prescribed medication, and the job description for Certified Medication Technicians required state-approved training and certification, which the MTs did not possess.