Rolling Hills Rehab And Care Ctr

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 sufficient licensed nursing staff on all shifts and adequate CNA staffing to meet resident needs, including a period when no nurse was present in the building. On one afternoon, two nurses left the facility, resulting in a gap of approximately 40 minutes to 1.5 hours with no licensed nurse on site while about 65–70 residents remained in the building. During this time, residents requested medications and nursing interventions, including removal of IV tubing from a PICC line, but no nurse was available to respond. A resident with diagnoses including peritoneal abscess, anemia, and a history of substance abuse reported that medications were often late and that on the day she left against medical advice, she walked the halls with IV antibiotic tubing hanging from her arm and could not find any nurse in the facility. Multiple CNAs and nurses reported that staffing was routinely insufficient across shifts, especially on nights, with only one CNA on each side of the building and two nurses and two CNAs for nearly 70 residents. Staff described being unable to complete timely incontinence care, showers, toileting, feeding assistance, and medication and treatment administration. They reported residents being found soaked in incontinence products at shift change, residents remaining in bed most or all day due to lack of staff to get them up, and residents waiting extended periods for call lights to be answered, sometimes 30 minutes or longer. Staff also reported that medications were consistently late, often documented as being “in the red,” and that nurses and CNAs frequently had to stay hours past their shifts due to call-offs and high workload. Residents and a resident representative corroborated that there were not enough staff to supervise and assist residents. Residents reported long waits for call lights to be answered, delays in receiving water and other basic assistance, and instances of being left on the toilet for prolonged periods while waiting for staff to return. Some residents described other residents wandering into their rooms without staff intervention, and one resident reported that she had to redirect confused residents herself. Another resident reported not receiving migraine medication after notifying a nurse leader and activating the call light twice more, with no staff response. Residents also noted that staff appeared frustrated and that staff turnover was high. Review of the facility’s admission agreement showed that the facility agreed to provide 24-hour nursing care and assistance or supervision with activities of daily living, including toileting, bathing, feeding, and ambulation. The facility assessment stated that its purpose was to determine necessary resources to care for residents during routine operations and emergencies and to inform staffing decisions, including day, evening, and night shifts, recruitment and retention, and contingency planning for staffing shortages. However, the assessment only identified the need for a full-time DON, ADON, MDS nurse, and part-time wound care nurse and did not specify how many licensed nurses were needed for the resident population or provide details on recruitment or contingency plans. This lack of detailed staffing planning, combined with ongoing staff departures and reliance on minimal staffing, contributed to repeated instances where resident care and supervision needs were not met. Human resources staff acknowledged difficulty filling night shift schedules for both nurses and CNAs and described recent initiation of agency use to fill open shifts. A newly hired LPN reported being scheduled to work independently on a unit during what was supposed to be an orientation day, without prior training on that unit. Staff interviews consistently described high-acuity residents, including geriatric psychiatric residents with behavioral issues, residents with frequent falls, and residents requiring 1:1 supervision or two-person mechanical lift transfers, being cared for with staffing levels that staff considered inadequate. The facility’s failure to ensure continuous licensed nurse coverage and adequate direct care staffing on all shifts, as well as its incomplete facility assessment regarding licensed nurse staffing and contingency planning, led to delays and omissions in resident care and supervision for the entire resident population.

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 the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week, and failed to employ and have an actively working full-time Director of Nursing (DON). Review of staff clock-in times and resident records showed no documentation of an RN being in the building for eight consecutive hours on 02/21/26 or 03/08/26. The facility assessment dated 01/30/26 stated the facility must have a full-time DON, full-time Assistant DON (ADON), full-time wound care nurse, and full-time MDS nurse, but these positions were not filled or actively working in the facility during the survey period. Multiple staff interviews confirmed the absence of key nursing leadership and RN coverage. CNAs reported there was no DON, ADON, MDS nurse, or wound care nurse in the facility and that there was no nursing management available to report issues or concerns to. Human resources staff stated the previous DON gave a 30‑day notice but stopped working before the end of the notice period, and the ADON resigned effective immediately, leaving those positions vacant; positions for MDS nurse, wound care nurse, and ADON remained open. An LPN reported the facility was short on RN hours, that RNs were scheduled but often did not show up or quit, and that the situation worsened without a DON or ADON in the building. Other staff confirmed the facility was not meeting required RN hours, that RN names were placed on schedules and PPD sheets without the individuals being physically present, and that no corporate nurses came in to fill in for the DON or ADON.

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 administer an IV antibiotic according to the physician’s order and to incorporate the resident’s IV therapy into the care plan. A resident admitted with diagnoses including abscess of the spleen, chronic viral hepatitis C, and peritoneal abscess had a physician’s order for Cubicin (daptomycin) 350 mg IV once daily at 9:30 a.m. for an abdominal abscess, with an active order through 03/24/26. The resident also had a left arm PICC/midline with orders to monitor for leaking and signs and symptoms of infection every shift. Record review showed that the resident’s care plan contained no documentation, goals, or interventions related to the IV medication therapy for the active infection, nor for the maintenance, use, or observation of the PICC line. Review of the medication administration record revealed that the Cubicin dose scheduled for 9:30 a.m. on 02/27/26 was not administered until 3:20 p.m., six hours late, by an LPN. In interview, the LPN stated that on that date she was the only nurse administering medications to nearly 70 residents and that medications, including this resident’s Cubicin, were given late. The Regional Director of Clinical Operations confirmed that the IV antibiotic was documented as administered six hours after the scheduled time. Facility policy on medication therapy stated that each resident’s medication regimen shall include only those medications necessary to treat existing conditions and that medication-related issues shall be reviewed as part of quality assurance activities. This situation was cited as a deficiency under the referenced master complaint number.

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 supervision and interventions to prevent an identified elopement-risk resident from leaving the building unsupervised. The resident had diagnoses including dementia, type 2 diabetes, hypertension, anxiety, major depressive disorder, and neurocognitive disorder with Lewy bodies. A Significant Change MDS showed a BIMS score of 03, indicating severe cognitive impairment. The resident used a wheelchair and required moderate assistance for transfers and mobility. An elopement assessment completed earlier in the year scored the resident as high risk for elopement, and the care plan identified the resident as an elopement risk/wanderer with a history of attempts to leave the facility unattended and impaired safety awareness. The care plan for this resident included goals to maintain safety and interventions such as distracting the resident from wandering with diversions and structured activities, identifying patterns of wandering and diverting as needed, initiating 1:1 supervision if the resident exhibited exit-seeking or verbalized wanting to leave, monitoring for fatigue and weight loss, providing activities of interest to deter wandering, and providing supervision for off-unit activities. Despite these identified risks and planned interventions, on the day of the incident the resident was able to leave the building without staff awareness. The resident’s wheelchair remained inside the facility, and staff later reported they were unsure how the resident had the strength to open the doors and ambulate outside, as they had rarely seen the resident walk and knew the resident required assistance for mobility. The event came to light when another resident, while watching TV, noticed a man sitting on a parking stop in the parking lot in the rain and realized it was a resident. This resident activated the call light and informed a CNA that there was a resident outside. Staff then observed the elopement-risk resident sitting outside in the rain in the parking lot and assisted him back into the building. Multiple CNAs and the administrator confirmed that staff only became aware the resident had left the building after being alerted by another resident. The facility’s written policy on unsafe wandering and elopement stated that staff will identify residents at risk, assess for risk factors, care plan for elopement risk with safety interventions such as monitoring plans and devices, and treat a missing resident as a facility-wide emergency with initiation of an elopement/missing resident procedure; however, the resident was able to exit and remain outside unsupervised until discovered by another 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 deficiency involves the facility’s failure to provide food in a mechanically altered form as ordered for a resident who required a mechanical soft diet. The resident was admitted with diagnoses including Alzheimer’s disease and hypertension, and a quarterly MDS assessment documented that she was dependent on staff for eating and required a mechanically altered diet. An undated facility list of residents needing mechanically altered diets also identified her as requiring a mechanical soft diet. Despite these documented needs, staff interviews revealed that the kitchen was cutting food into large pieces rather than preparing it in an appropriate mechanical soft form. A CNA reported that mechanical soft food should be small, but the kitchen was only cutting food into large pieces, and another CNA stated that kitchen staff were providing regular food to residents who required a mechanical soft diet, including this resident. During an observation of the resident’s supper tray, the meal ticket correctly indicated a mechanical soft diet, but the tray contained a hamburger cut into large pieces and placed on a full-size bun. The CNA present at the time of observation confirmed that this was not appropriate for a mechanical soft diet and stated that the hamburger in large pieces on the tray would not be safe for the resident to consume. This noncompliance was investigated under a specific complaint number and affected one of three residents reviewed for appropriate diets, with 13 residents in the facility identified as requiring mechanically altered diets.

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 a comprehensive facility-wide assessment to determine the resources necessary to care for residents competently during routine operations and emergencies. Review of the facility assessment dated 01/30/26, completed by the administrator, showed it did not address the resident population, including the number of residents, the facility’s capacity, or the care required based on behavioral health needs, cognitive disabilities, and overall acuity. Further review showed the assessment did not address direct care staff such as RNs, LPNs, and CNAs, and did not document the overall number of facility staff needed to ensure a sufficient number of qualified staff to meet each resident’s needs as identified through assessments and care plans. During an interview, the regional director of clinical operations and the administrator confirmed that the facility assessment was not completed with all required elements. This deficiency was identified as an incidental finding during the course of a complaint investigation, and the facility census at the time was 65 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

Surveyors identified multiple environmental deficiencies throughout the facility, including persistent sewer odors originating from the South Unit shower room, which extended into the 100 and 200 hallways and nurse's station. The carpet behind the nurse's station was observed to be stained and dirty, and the wallpaper near the vending machine was pulled away, revealing mold spots behind it. In the vending room, carpet tiles were improperly installed, loose, and missing under the snack vending machine. The North Unit shower room had missing and broken tiles on the floors and walls, missing corner strips, a brown/black substance on the walls, partially missing skid strips, and dirty floors. These conditions were confirmed by multiple staff members, including the Maintenance Director, who noted that some issues had not yet been addressed due to recent hiring and ongoing repairs. Interviews with staff and residents confirmed the ongoing presence of sewer odors, particularly in the South Unit shower room and adjacent hallways. One resident reported the odor lingering down the hallway near their room. Additional observations included a resident room with a strong urine odor, a black substance inside the toilet bowl, and flooring in the bathroom that was coming up and stained. These findings were corroborated by several staff members present during the observations. The facility census at the time was 51 residents, all of whom had the potential to be affected by these environmental deficiencies.

Penalty

Fine: $139,3209 days payment denial

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 was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.

Penalty

Fine: $139,3209 days payment denial

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 administer its operations in a manner that enabled it to use its resources effectively and efficiently. This deficiency was identified based on observations and findings by surveyors, indicating that the facility did not meet the required standards for resource management. Specific actions or inactions leading to this deficiency are not detailed in the report provided.

Penalty

Fine: $139,3209 days payment denial

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 implement an effective pest management program, resulting in a widespread issue with flies and gnats throughout the building. Multiple staff members, including CNAs and LPNs, reported that flies and gnats were prevalent in resident rooms and common areas, with some attributing the problem to musty odors, damp carpeting, and lack of daily housekeeping. Observations confirmed the presence of flies and gnats in various locations, including the nurses' station, vending machine room, and crash cart room. Staff and residents reported being bitten, and families brought in bug spray and fly swatters due to the severity of the infestation. Some staff noted the absence of window screens as a possible entry point for pests. Residents were directly affected, with reports of flies swarming around individuals, particularly those requiring topical creams, and flies landing on personal belongings. The issue was noted to be persistent and worsening, with both staff and family members expressing concern over the lack of resolution. The deficiency was observed to have the potential to impact all 52 residents in the facility, as pests were present in both private and communal spaces.

Penalty

Fine: $139,3209 days payment denial

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 was provided transportation to a scheduled medical appointment, despite being aware that transportation was unavailable. The resident, who had diagnoses including type 2 diabetes, vascular dementia, anemia, hypertension, and nicotine dependence, was cognitively intact with a BIMS score of 13. Documentation showed that as of 07/18/25, the facility knew transportation was not available, but there was no evidence that alternative arrangements were attempted so the resident could attend the appointment. On the day of the appointment, the resident prepared and waited at the front of the building for transport, but the van did not arrive. After inquiring with staff, the resident was informed that the appointment was cancelled due to the van being broken, but he had not been notified beforehand. The resident expressed confusion and frustration about not being kept informed, despite having requested updates. The dermatology office confirmed the appointment was scheduled and cancelled on the same day. The facility's admission agreement indicated that transportation services were among the physician-ordered services available to residents.

Penalty

Fine: $139,3209 days payment denial

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 an accurate and up-to-date care plan for a resident with multiple complex medical conditions, including respiratory failure, type 2 diabetes, COPD, GERD, osteoarthritis, anemia, atherosclerotic heart disease, insomnia, schizophrenia, hypercholesterolemia, overactive bladder, borderline personality disorder, hypothyroidism, pyoderma, hypertension, anxiety, major depressive disorder, chronic kidney disease, kidney failure, and who was dependent on renal dialysis. The resident was cognitively intact and had a physician's order for hemodialysis every Monday, Wednesday, and Friday. The care plan, completed on 04/11/25, indicated that the resident received dialysis at a specific center in St. Clairsville and included interventions such as encouraging attendance at scheduled dialysis appointments, monitoring vital signs, and assessing the AV fistula site. However, interviews with staff at the St. Clairsville dialysis center revealed that the resident no longer received dialysis at their facility and had not done so for some time. Further interviews confirmed that the resident was actually receiving dialysis at a different center in Bridgeport. The resident also confirmed this information. Despite this change, the care plan had not been updated to reflect the new dialysis location, resulting in inaccurate documentation. The facility's policy requires the care plan to be individualized and based on the resident's comprehensive assessment, developed by an interdisciplinary team, but this was not followed in this instance.

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 section of peeling wallpaper approximately 12 inches long was observed near the baseboard of the back wall in the Social Services Director's (SSD) office. When the wallpaper was pulled back, black areas resembling mold were visible on the drywall. The Director of Maintenance (DM) was aware of the peeling wallpaper but was not aware of the mold-like areas beneath it. During the survey, residents were seen stopping at the SSD office and speaking with the SSD, who kept her office door open. The SSD reported that she had notified the Administrator about the peeling wallpaper and her concerns regarding air quality in her office. She was offered the option to move to another office but did not relocate, as she did not receive confirmation that the air quality in the alternative office would be tested. The SSD also informed the Regional Director of Maintenance about her concerns. The Regional DM later acknowledged that he should have insisted on the SSD relocating so repairs could be made, but the SSD declined to move due to the amount of items in her office and her impending departure from the position.

Plan Of Correction

This plan of correction ("POC") has been prepared at the request of the Ohio Department of Health, and not because this facility agrees with and/or admits to any of the allegations contained within the notice of deficiency issued by the Department. This POC does not constitute an admission that any of the citations are legally and/or factually correct, to include the scope and severity associated thereto. For the avoidance of doubt, this facility asserts that it was in substantial compliance with all data tags cited by the Department before, during, and after the dates referenced in the notice of deficiency and the dates on which the Department conducted the survey. This POC does not establish any standard of care, contract, obligation, and/or position beyond those of a reasonably prudent nursing home, and this facility reserves the right to raise all possible contentions and defenses in any administrative, civil or criminal action or proceeding. Rolling Hills Rehabilitation and Care Center will continue to ensure employees have a clean and comfortable environment. This plan of correction serves as Rolling Hills Rehabilitation and Care Center's allegation of substantial compliance. Staff member #84 stated she had no adverse effects as a result of this deficiency, she currently does not have any signs/symptoms related to potential mold exposure. The areas of suspected mold were contained and undisturbed. Staff member #84 was immediately moved to a clean and comfortable environment on 06/05/2025 with assistance from facility maintenance and other members of the management team using proper PPE and disinfected all items that were possibly exposed using fungicide. An air quality test was performed on 06/05/2025 with no negative findings. On 06/05/2025 the office was sealed off, locked, and placed under construction. On 06/06/2025 the areas of concern were treated twice with mold armor. On 06/12/2025 another air quality test was performed with no negative findings, and the office was reopened and used for operation as of 06/16/2025. The facility followed all CDC recommendations for all potential mold remediation. A whole facility baseline audit was completed to ensure a clean and comfortable environment by the facility Administrator on 06/12/2025. There were no negative findings identified through this audit. All residents located on the unit in proximity to the social services office were assessed along with a review of their EHR by the Director of Nursing on 06/12/2025 to ensure there was no negative impact, with no negative findings. The Director of Nursing reviewed the infection control log on 06/13/2025 for signs/symptoms of respiratory concerns in the last 30 days related to potential mold exposure, with no negative findings. Interviews were initiated on 06/06/2025 and completed on 06/13/2025 with all interview-able residents by the facility Administrator and designee, to ensure no current concerns with potential mold. There were no negative findings identified. An audit of the grievance/concern log was completed over the past 90 days with no concerns from family, visitors, or staff of suspected mold in the facility. We have not received any reports by staff and/or visitors of adverse effects as a result of this deficient practice. Verbal education on the facility's best practice for reporting environmental concerns was completed on 06/10/2025 for all facility staff by the facility Administrator. A facility walkthrough will be completed weekly for four weeks by the facility administrator/designee, starting on or by the week of 06/13/2025. Results will be brought to the Quality Assurance Committee for further review and recommendations. Facility administrator will be responsible for overall compliance with this plan.

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 resident representatives were notified when there were changes in residents' treatments or medications, as required by policy. In the case of one resident with anoxic brain damage, epilepsy, and other conditions, there were four documented occasions over five months where new orders or changes in condition occurred, but there was no evidence that the resident's designated representative, her sister, was notified. Although the resident was cognitively intact and able to communicate, she had expressed her desire for her sister to be informed of any changes, a preference that was not consistently honored or documented by the facility. Another resident with unspecified dementia and moderately impaired cognition had changes in condition and new orders issued on multiple occasions. The resident's son was listed as the primary emergency contact, but there was no documented evidence that he was notified of significant changes, including the discovery of a blood clot and new medication orders. While the resident's daughter was informed in one instance, the primary contact was not, and the facility's staff could not provide documentation to show that proper notification occurred as required. A third resident, diagnosed with Parkinson's disease, congestive heart failure, and moderate cognitive impairment, also experienced several changes in condition and new orders without evidence that his durable power of attorney for healthcare, his son, was notified. Despite the resident being made aware of the changes, the facility's policy and the resident's records indicated that the son should have been informed due to the resident's cognitive status and the son's legal authority. The DON confirmed that the notifications were not documented as required, and no additional evidence was provided to show that the representative had been informed.

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 implement fall prevention interventions as outlined in the care plans for two residents identified as being at risk for falls. For one resident with diagnoses including anoxic brain damage, epilepsy, and major depressive disorder, the care plan required that her garbage can be kept within reach to prevent her from attempting to get up unassisted. Observation revealed that the garbage can was placed out of her reach, and both the resident and the Director of Nursing confirmed that this intervention was not being followed, despite its inclusion in the care plan. Another resident, with diagnoses such as adult failure to thrive, dizziness, hypertension, unspecified dementia, and difficulty walking, had a care plan intervention requiring a visual reminder in her room to call for assistance. Observation found that after the resident was moved to a new room, the visual reminder was not transferred with her. An LPN confirmed that the intervention was not in place in the new room and was unaware of the requirement, even though the sign had been present in the resident's previous room. The facility's policy on managing falls requires staff to implement resident-centered fall prevention plans based on individual risk factors. In both cases, the specific interventions designed to mitigate fall risk were not carried out as documented in the residents' care plans, resulting in non-compliance with the facility's own policies and procedures for fall prevention.

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 implement and document preoperative orders for a resident scheduled for a craniotomy. The resident, who had severe cognitive impairment and multiple diagnoses including aftercare following nervous system surgery, diabetes, major depression, hypertension, and hyperlipidemia, was on a daily aspirin regimen as a blood thinner. Despite being scheduled for neurosurgery, there were no preoperative orders in the medical record to hold aspirin or provide other specific instructions prior to the procedure. The resident continued to receive aspirin up to the day before surgery. The lack of preoperative instructions was discovered when the resident arrived at the hospital for surgery, and the neurosurgery department identified that aspirin had not been held, placing the resident at high risk for bleeding. As a result, the surgery was cancelled and had to be rescheduled. Interviews with facility staff revealed that the nurse responsible for entering preoperative orders did not document or implement any instructions regarding medication management, nor did they seek clarification from the surgeon when such orders were missing. Facility policy required that changes in care plans and significant events be accurately documented in the resident's medical record. However, the process for receiving, documenting, and acting on preoperative orders was not followed. The Director of Nursing confirmed that the failure to hold aspirin and the absence of preoperative documentation directly led to the cancellation of the resident's surgery.

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 maintain a clean and comfortable environment in a shared shower room used by residents on the 100 and 200 units. One resident reported avoiding the shower room on her unit due to a persistent bad odor and visible stains on the floor, opting instead to use a different shower room. Direct observation confirmed a musty, sewage-like odor and a gray-brown stain on the floor near the shower stall. Both a housekeeper and the facility administrator acknowledged the presence of the odor and stain, with the administrator noting a perceived improvement due to a lack of recent complaints. A CNA reported that the odor issue began about a month prior, temporarily improved, but recurred after multiple showers were given in the room.

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 the governing body was actively engaged and involved in the oversight of the Quality Assurance Performance Improvement (QAPI) program, affecting all 50 residents. The facility had not conducted any QAPI meetings since before their last annual survey, which was completed on 11/17/22. This lack of engagement was confirmed through interviews with the facility's Administrator and the Medical Director, who both acknowledged the absence of QAPI meetings and the lack of a functioning QAPI program. The Medical Director was not informed about the absence of the QAPI program since his hiring, and the Administrator admitted to the lack of evidence for any QAPI meetings since the last annual survey. The governing body was responsible for reviewing QAPI information quarterly and ensuring compliance with the QA committee, but there was no evidence of their involvement or attendance at any QA meetings since the last annual survey. The facility's policies outlined the governing board's responsibility for the management and operation of the facility, including the establishment and implementation of a QAPI program. However, the governing body failed to fulfill these responsibilities, as confirmed by the President of Clinical Operations, who verified the absence of a QAPI program and the governing body's lack of attendance at QA meetings.

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 residents or their representatives were informed about their right to communicate with local, state, or federal officials before signing an arbitration agreement or within thirty days of signing it. This deficiency affected all residents in the facility, which had a census of 50. The facility's arbitration agreement did not include information about the right to communicate with officials, and interviews with the Administrator and Admission Staff #502 confirmed that this guidance was not provided to residents or their representatives. Additionally, the facility lacked a policy and procedure regarding arbitration agreements.

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 their arbitration agreement allowed for a mutually agreeable arbitrator and venue, potentially affecting all residents. The arbitration agreement specified that disputes would be resolved by binding arbitration administered by the American Arbitrators Association, or another reasonable arbitration association chosen solely by the facility if the former did not enforce pre-dispute arbitration agreements. The agreement also stated that the venue for arbitration would be near the facility's principal place of business. Interviews with the Administrator and Admission Staff revealed that the agreement did not provide residents or their representatives with a choice of arbitrator or venue, and there was no policy or procedure regarding arbitration agreements in place at the facility.

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 establish a comprehensive Quality Assurance and Performance Improvement (QAPI) program that effectively evaluated areas in need of improvement and monitored the effectiveness of corrective actions. This deficiency affected all 50 residents in the facility. The facility's survey history revealed multiple citations in areas such as nursing services, quality of care, admission discharge and transfer, freedom from abuse neglect and exploitation, and food and nutrition services. Despite submitting plans of corrections, there was no evidence that these were reviewed or further interventions were implemented by the QAPI committee. An interview with the facility's Administrator revealed that there was no documentation of a comprehensive QAPI program being implemented since the last annual survey. The Administrator could not provide evidence of quarterly meetings or that the committee had thoroughly evaluated and identified areas needing improvement. Additionally, there was no documentation showing that prior deficient practices were being monitored to ensure the plan of correction was implemented and sustained. The facility's undated QAPI policy outlined the goals and responsibilities of the QAPI Committee, but there was no evidence these were being met.

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 hold quarterly Quality Assurance and Performance Improvement (QAPI) meetings with the required members, affecting all 50 residents. The QAPI committee did not meet since before the last annual survey, which was completed on 11/17/22. The facility's survey history showed multiple complaint surveys resulting in citations across various care areas, with plans of correction indicating findings would be reported to QAPI for review. However, the facility's QAPI attendance logs confirmed the absence of meetings, and the Medical Director, who was aware of the need for quarterly meetings, confirmed that no QAPI meetings had been held since his hire. The facility's policy required a QAPI committee to meet monthly, with a specific composition including the Administrator, DON, Medical Director, and other representatives. Despite this, the facility did not adhere to its policy, as evidenced by the Administrator's admission of the lack of meetings and the Medical Director's acknowledgment of the absence of a QAPI program. The failure to conduct these meetings meant the facility was not actively monitoring or addressing the care and services provided, as intended by the QAPI program.

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 maintain privacy during the administration of medication to a resident, which was observed by surveyors. Resident #160, who has a medical history including diabetes mellitus, acute respiratory failure, and asthma, was affected by this deficiency. The resident had physician orders for Lovenox injections and a Lidocaine patch for pain management. During the medication administration, the registered nurse (RN) did not ensure the resident's privacy, leaving the door open and the curtain unclosed, which allowed the resident to be visible from the hallway. The RN administered the Lovenox injection and applied the Lidocaine patch without providing adequate privacy, exposing the resident's abdomen and rib cage. This was confirmed during an interview with the RN, who acknowledged the failure to maintain privacy. The facility's policy on Quality of Life and Dignity, which mandates the protection of resident privacy during personal care and treatment procedures, was not adhered to in this instance.

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 timely transfer notices to residents and/or their representatives when residents were transferred to the hospital. This deficiency affected two residents out of three reviewed for hospitalization and discharge. Resident #55, who had multiple diagnoses including diabetes mellitus, chronic kidney disease, and heart failure, was transferred to the hospital but did not receive a transfer/discharge form. The Director of Nursing confirmed that no written notice was given to the resident or their representative at the time of transfer. Similarly, Resident #45, who had a complex medical history including acute kidney failure and heart disease, was transferred to the hospital following an episode of unresponsiveness. The facility's records showed no evidence of a transfer notice being provided for this hospitalization. The facility's policy requires a written notice to be given as soon as practicable in urgent medical situations, but this was not adhered to in these cases. The Administrator acknowledged the absence of the transfer notice, attributing it to the unexpected departure of the staff responsible for completing the forms.

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 bed hold notices to residents or their representatives following hospital transfers, affecting two residents. Resident #55, who had multiple diagnoses including diabetes mellitus and heart failure, was transferred to the hospital but did not receive a bed hold notice. The Director of Nursing confirmed the absence of such documentation, which was required by the facility's policy. Similarly, Resident #45, who was privately paying for their stay and had conditions such as acute kidney failure and heart disease, was transferred to the hospital due to an episode of unresponsiveness and sepsis. The facility did not provide a bed hold notice for this resident either. The Administrator acknowledged the oversight, attributing it to the unexpected departure of the staff member responsible for completing the form. The facility's policy required written information to be given to residents or their representatives prior to transfers.

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 psychiatric progress notes were obtained from an outside provider for a resident, leading to a lack of awareness of a new diagnosis of schizoaffective disorder. The resident, who was admitted with diagnoses including encephalopathy, PTSD, unspecified psychosis, major depressive disorder, and anxiety disorder, did not have the new diagnosis added to their medical record or care plan. The facility did not follow up with the psychiatrist's office to receive chart notes from the resident's visits, resulting in the omission of the schizoaffective disorder diagnosis from the resident's records. Additionally, the facility failed to accurately transcribe changes to the resident's psychiatric medications. An order was written to continue Abilify and start Olanzapine, but the facility's records showed discrepancies in the medication administration. The resident received 12 extra doses of Abilify due to inaccurate transcription of the physician's order. The Director of Nursing confirmed these issues, acknowledging that the facility did not obtain the necessary chart notes and failed to accurately transcribe medication orders.

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 obtain a physician-ordered urinalysis (UA) and culture and sensitivity (C&S) for a resident, which delayed antibiotic treatment for a urinary tract infection (UTI). The resident, who had severe cognitive impairment, unspecified dementia, end-stage renal disease, and muscle wasting and atrophy, complained of pain upon urination and abdominal pain. Despite an order being placed on 10/25/24 for a UA C&S due to these symptoms, the test was not conducted until 10/30/24. The delay was due to an error in transcribing the order to the Medication Administration Record (MAR), which was not caught until 10/29/24. The Director of Nursing (DON) confirmed that the transcription error led to a delay in obtaining the necessary laboratory tests, which subsequently delayed the initiation of antibiotic therapy. The culture results, completed on 11/03/24, indicated the presence of Escherichia coli (E-coli), confirming the UTI. The facility's policy on Medication and Treatment Orders, dated July 2016, did not include a process for transcribing physician orders to the MAR, contributing to the oversight.

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 proper weight monitoring and nutritional supplement administration for three residents, leading to deficiencies in their care. Resident #25 experienced an 18-pound weight increase over a short period, which was not reweighed as per the facility's protocol. Despite the resident's concern about her weight gain, the staff, including the LPNs and the DON, acknowledged the oversight in not reweighing the resident, attributing it to a missed observation by both the DON and the dietitian. Resident #158, who was admitted with a requirement for weekly weight checks, only had his weight recorded once upon admission. This oversight was confirmed by the Administrator and the RD, who stated that the facility's policy required weekly weight checks for new admissions. The resident's family expressed concern about potential weight loss, highlighting the importance of regular monitoring, which was not adhered to in this case. Resident #16, diagnosed with Alzheimer's Disease and other conditions, did not receive the ordered Pro-Stat supplement for nearly three months due to a transcription error. Additionally, the facility failed to obtain weekly weights as ordered, which was confirmed by the DON. The RD was unaware of both the lack of weekly weight checks and the missed supplement administration, indicating a lapse in communication and adherence to care plans for this 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 proper storage of nebulizer masks for two residents, affecting their respiratory care. Resident #47, diagnosed with COPD and emphysema, had a nebulizer mask that was consistently observed to be uncovered and improperly stored on multiple occasions. Despite the facility's policy requiring nebulizer equipment to be rinsed, disinfected, and stored in a labeled plastic bag, the mask was left exposed, as confirmed by both the resident and staff interviews. This oversight was noted over several days, indicating a lapse in adherence to the facility's respiratory care protocols. Additionally, the facility did not adhere to physician orders regarding oxygen administration for Resident #25, who also had COPD among other health issues. The resident's oxygen flow rate was set higher than prescribed, and the oxygen humidification bottle was found empty, contrary to the facility's policy that mandates regular checks to ensure proper oxygen flow and humidification. This was confirmed by an LPN and the Director of Nursing, highlighting a failure to follow established procedures for safe oxygen administration.

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 a resident with the prescribed Anbesol Maximum Strength Mouth/Throat Gel for tooth pain, as ordered by the physician. The resident, who had a history of type two diabetes mellitus, chronic obstructive pulmonary disease, dysphagia, and muscle weakness, was admitted with a care plan that included managing oral health problems and administering medications as ordered. Despite the physician's order for the Anbesol gel dated several months prior, the medication was not administered to the resident, as confirmed by the Medication Administration Record and interviews with the resident and staff. The deficiency was attributed to a lack of communication among the facility staff regarding the need to obtain the medication from an external source, as it was not available in the facility pharmacy. The resident reported asking for the medication multiple times and was instead given Tylenol occasionally for pain relief. Interviews with the LPN and the Laundry and Housekeeping Manager, who was responsible for obtaining over-the-counter medications, revealed that the medication was not ordered or picked up until several months later, resulting in a delay in the resident's pain management.

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 pharmacy recommendation for laboratory monitoring was addressed by the physician for a resident with multiple diagnoses, including epilepsy and seizure disorder. The resident was prescribed valproic acid, a medication used for seizures, and the pharmacist recommended monitoring the valproic acid and ammonia levels in August, September, and October 2024. However, the physician did not address or sign these recommendations, and the last valproic acid level was obtained in June 2024. Interviews with the Director of Nursing and the pharmacist confirmed that the physician did not respond to the pharmacy recommendations. The pharmacist stated that his usual procedure would be to contact the physician after a second recommendation was issued. The deficiency affected one of the five residents reviewed for unnecessary medications, highlighting a lapse in the facility's process for ensuring appropriate medication monitoring and physician response to pharmacy recommendations.

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 timely dental services for a resident experiencing dental pain, affecting one out of two residents reviewed for dental services. The resident, who had been admitted with diagnoses including type two diabetes mellitus, chronic obstructive pulmonary disease, dysphagia, and muscle weakness, reported experiencing dental pain several months prior but only recently saw a dentist. The resident's care plan indicated a potential for oral/dental health problems, with goals to be free of infection, pain, or bleeding, and interventions to coordinate dental care. Despite these plans, the resident's first dental examination since admission occurred months later, revealing broken teeth and a cavity requiring extraction. The delay in dental care was attributed to miscommunication among facility staff. The Social Work Director was unaware of the resident's dental pain and stated that if informed, she would have ensured a timely dental visit. A scheduled dental appointment in July was postponed to November due to insufficient residents needing dental services at that time. The facility's policy stated that residents would receive dental services as needed, but this was not adhered to, resulting in the resident not receiving prompt dental care.

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 nutritional staff member responsible for completing quarterly reviews was qualified to assess the nutritional status of residents. This deficiency was identified through a review of records, staff interviews, and the Ohio Dietetics website, which revealed that a Certified Dietary Manager (CDM), who is a non-licensed professional without a bachelor's degree in nutrition, was conducting these assessments. The CDM was responsible for all quarterly nutritional reviews, while a Registered Dietitian, Licensed Dietitian (RDLD) handled annual, new or readmission, and significant change assessments. The CDM confirmed that she used a calculator to determine if there had been a significant change in residents' nutritional needs and whether their dietary intakes were meeting those needs. The deficiency specifically affected one resident, who had multiple complex medical conditions, including acute kidney failure, COPD, morbid obesity, type two diabetes mellitus, heart failure, a history of malignant neoplasm of the large intestine, and major depressive disorder. The resident was cognitively intact, required assistance with eating, and was on a therapeutic diet. The facility's contract with the consulting dietetics company stipulated that a nutritionist/dietitian with a minimum of a bachelor's degree in nutrition or dietetics and relevant experience should be provided, yet the CDM did not meet these qualifications. The Ohio Medical Board's guidelines state that unlicensed personnel can collect and record nutritional data but cannot evaluate or interpret it, which is considered the practice of dietetics.

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 report an allegation of misappropriation of resident property to the state agency in a timely manner, affecting one resident. The incident involved a resident who reported approximately one hundred and thirty-two dollars missing, which he had reported to the previous administration three months prior. Despite the resident's report, no follow-up was conducted, and the money was not returned. The resident, who had intact cognition and no hallucinations or delusions, had informed the previous administration about the missing money, but the issue was not resolved. Interviews with staff revealed that the resident had reported the missing money to the previous Business Office Manager, who then informed the administration during a morning meeting. The Social Work Director and the previous Administrator conducted an initial interview with the resident, who stated that the money was kept between his phone and phone case. The resident's girlfriend was mentioned as the source of the money. However, after the initial interview, no further investigation or reporting to the state agency was conducted by the previous Administrator, as required by the facility's policy. The current Administrator confirmed that the previous Administrator did not report the allegation, which was a violation of the facility's policy to report such incidents within twenty-four hours.

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 investigate an allegation of misappropriation of resident property, specifically affecting one resident. The incident involved a resident who reported that approximately one hundred and thirty-two dollars was taken from him. The resident had informed the previous administration about the missing money three months prior, but no follow-up was conducted, and the money was not returned. The resident had intact cognition and had not experienced hallucinations or delusions during the review period. The facility's self-reported incidents revealed no filing with the state agency regarding this allegation. Interviews with the Social Work Director and the current Administrator confirmed that the previous Administrator and Business Office Manager were aware of the allegation. However, there was no documentation or evidence of an investigation being conducted. The facility's policy on Abuse, Neglect, Exploitation, and Misappropriation of Resident Property mandates that all allegations be investigated within five working days, which was not adhered to in this case. The deficiency was investigated under Complaint Number OH00159928.

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 only competent staff provided tracheostomy care to residents, specifically affecting one resident with a tracheostomy. The resident had a history of malignant neoplasm of the larynx and an acquired absence of the larynx, requiring a tracheostomy tube. Upon the resident's arrival, his son demonstrated tracheostomy care to the staff. However, a State tested Nursing Assistant (STNA) later provided tracheostomy care without proper training or sterile technique, using a solution found in the resident's bathroom and a scrubber to clean the tracheostomy tube. The STNA was unaware that she was not permitted to perform tracheostomy care and was only educated on this restriction after the incident. The facility's policy required aseptic technique and the availability of a replacement tracheostomy tube at the bedside, which was not adhered to in this case. The STNA used clean gloves instead of sterile gloves and did not follow the aseptic procedure. Additionally, there was no spare tracheostomy tube available at the resident's bedside, contrary to the facility's policy. The STNA resigned after the incident but was later re-hired. The deficiency was identified during a complaint investigation, and there were no residents with a tracheostomy during the onsite survey.

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 maintain proper infection control practices to prevent the spread of COVID-19, affecting all 54 residents. Resident #14, diagnosed with COVID-19, was not properly isolated as there was no signage, PPE cart, or waste receptacle in place. Staff confirmed the absence of necessary isolation measures, which were required for droplet precautions. Similarly, Resident #31, also under strict droplet precautions, lacked isolation signage, a PPE cart, and waste receptacles, as verified by a registered nurse. Resident #47, who tested positive for COVID-19, was not adequately isolated. The room lacked proper signage, and the PPE cart was missing essential items like masks and gowns. Additionally, Resident #29, requiring enhanced barrier precautions due to a colostomy, was not provided with appropriate PPE during care. An STNA was observed providing care with only gloves, contrary to the requirement for a gown during high-contact activities. Interviews with staff revealed a shortage of N95 masks and gowns, with staff reusing N95 masks throughout the day, even after entering COVID-19 isolation rooms. The facility's policies required full PPE for COVID-positive residents and changing N95 masks after exiting such rooms. However, these protocols were not followed, indicating a significant lapse in infection control measures.

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 an admission skin assessment and administer post-trauma skin treatments as ordered for a resident admitted with multiple fractures and wounds following a motorcycle accident. The resident was admitted with hospital discharge orders for specific wound care treatments, including triad, mesalt rope, and hydrofera blue dressings, which were not implemented until several days after admission. The medical records showed no evidence of a completed admission skin assessment or timely administration of the prescribed treatments until days later. Interviews with the resident and facility staff confirmed that the wound treatments were delayed due to a weekend and a holiday. The Director of Nursing and a Licensed Practical Nurse acknowledged that the hospital discharge orders were not entered, and treatments were not administered until several days after admission. Additionally, the Wound Nurse Practitioner did not document the necessary measurements or enter new orders promptly. This deficiency was investigated under a specific complaint number.

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 all requirements were met in issuing a discharge notice to Resident #51. The resident, who had diagnoses including morbid obesity, bipolar disorder, borderline personality disorder, muscle wasting and atrophy, and hypertension, was transferred to an in-patient behavioral health unit for evaluation and treatment of suicidal ideations. The facility refused to allow the resident to return after being cleared for discharge from the psychiatric facility. The Minimum Data Set (MDS) 3.0 discharge assessment indicated an unplanned discharge to a short-term general hospital with no return anticipated. However, there was no documented evidence that the discharge notice was provided to the resident or included information about appeal rights. Email communications between the Ombudsman Program Director and the facility's Corporate RN and Administrator revealed that the discharge notice was allegedly sent on the day of the transfer, but there was no documentation to support this. A second discharge letter was issued almost 30 days later, lacking essential details such as the proposed discharge location and appeal rights. The Director of Nursing (DON) confirmed that the resident's medical record did not include updates following her discharge. The Ombudsman was working with the resident to request an appeal of the discharge, but as of the post-survey revisit, a hearing had not been held.

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 permitted to return to the facility following a hospitalization. Resident #51, who had diagnoses including morbid obesity, bipolar disorder, and borderline personality disorder, was admitted to the facility and later hospitalized due to suicidal ideations. Despite the resident's desire to return to the facility and the Ombudsman's intervention, the facility refused to readmit her, citing discharge plans to her grandmother's home and the need for a bariatric bed. The facility's policy indicated that residents may return after hospitalization, but this was not followed in this case. The resident had been living at the facility for approximately six months and had participated in care conferences where discharge planning was discussed. Initially, the plan was for the resident to return to her grandmother's home with the assistance of the Home Choice program. However, there were no additional progress notes or finalized plans for this discharge. When the resident was hospitalized for psychiatric reasons, the facility decided not to readmit her, despite her belongings still being at the facility and her expressed desire to return. Interviews with the Ombudsman, the Director of Nursing, the Administrator, and the hospital discharge coordinator confirmed that the facility refused to allow the resident to return. The hospital discharge coordinator and the resident both indicated that the facility had boxed up the resident's belongings and insisted on her discharge to her grandmother's home, despite the resident's need for continued care and her grandmother's inability to provide the necessary support. This refusal to readmit the resident was against the facility's policy and the resident's rights.

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 free from staff physical abuse, affecting two residents. Resident #56, who has diagnoses including Asperger syndrome, bipolar disorder, anxiety disorder, and Wernicke's encephalopathy, reported that a State tested Nursing Assistant (STNA) physically abused her during incontinence care. The resident described being hit on the back multiple times and verbally abused. A subsequent assessment revealed light blue markings on her left shoulder. The STNA involved was suspended pending investigation but was later reinstated due to lack of substantiating evidence. The resident's mother suggested that her daughter's sensory processing disorder might have influenced her perception of the incident. However, the facility's investigation could not substantiate the allegations due to the absence of witnesses and additional evidence. Resident #38, who has vascular dementia, hemiplegia, hemiparesis, and type two diabetes mellitus, also reported physical abuse by the same STNA. The resident claimed that the STNA was rough during care and hit him in the testicles. Despite the resident's cognitive intactness, the facility's investigation found no visible injuries and no witnesses to the incident. The STNA denied the allegations and subsequently resigned. The facility interviewed all involved parties and conducted abuse training for all staff members. The Director of Nursing (DON) reported that both residents required full assistance with care and transfers and did not usually attend activities, minimizing their contact with each other. The facility's investigation into both incidents revealed no history of false allegations from either resident. Despite the serious nature of the allegations, the facility was unable to substantiate the claims due to the lack of witnesses and physical evidence. The facility's policy on abuse, neglect, exploitation, and misappropriation of resident property defines abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish. The STNA involved had received abuse training upon hire and resigned her position following the allegations.