White Oak Manor

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 comfortable, homelike environment in good repair for all 32 residents, as evidenced by multiple areas of disrepair and inadequate lighting. During an observation of the 300 hallway, surveyors identified three burnt-out ceiling lights from outside one resident room to the end of the hallway, resulting in that end of the corridor being darker than the rest. An LPN and the Maintenance Director confirmed the presence of the three non-functioning lights and the darker lighting conditions in that section of the hallway. Review of the facility’s Safe and Homelike Environment policy showed that the facility was required to provide and maintain adequate and comfortable lighting levels in all areas, with even light levels in common areas and hallways to avoid patches of low light. Additional observations during a tour with the Administrator revealed widespread physical disrepair throughout the building. This included a three-inch hole in the wall near the reception window, dark scuff marks on the Administrator’s door, and scuff marks on multiple occupied resident room doors (rooms 104, 105, 110, 111, 113, 114, and 116). There was missing and chipping paint on other occupied resident room doors, a hole in the wall near the conference room door, scuff marks on the central bathing room door on the 100 hall, peeling paint and scuff marks on pillars in the main dining room, missing baseboards and damaged paint at the nurse’s station on the west 200 unit, and a closet door with multiple scuff marks on the west 200 unit. The heating unit in one resident’s room lacked a cover, and the kitchenette door entering the 300 unit had multiple scuff marks on its lower half, along with dark scuff marks on additional occupied resident room doors. The Administrator acknowledged that the building was in general disrepair and attributed the scuffed doors and walls to resident wheelchairs, noting recent ownership change and a new Maintenance Director. The Maintenance Director confirmed that the entire building was in need of paint. The facility’s policy required housekeeping and maintenance services to maintain a sanitary, orderly, and comfortable environment, defining “orderly” as an uncluttered, neat, and well-kept physical environment, and directing unresolved concerns to be reported to the Administrator.

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 store medications in a safe and secure manner and to administer medications in accordance with professional standards and facility policy. Surveyors observed an unlocked medication cart labeled "100/300 Halls" left unattended in an open hallway in front of the nurses’ station. The Assistant Director of Nursing confirmed the cart was required to be locked when unattended. The facility’s Storage of Medication policy stated that all drugs and biologicals must be stored in a safe, secure, and orderly manner, and that all compartments containing drugs and biologicals, including carts, must be locked when not in use and not left unattended if open or otherwise accessible. The report also describes improper medication administration practices involving four residents. One resident had a diagnosis of epilepsy and an order for phenobarbital 32.4 mg once daily for seizure control, with a care plan intervention to administer seizure medications as ordered. Another resident had localization-related idiopathic epilepsy and epileptic seizures, with an order for phenobarbital 64.8 mg twice daily and a care plan addressing altered neurological status related to seizure disorder, including administering medications as ordered. A third resident had chronic cholecystitis, psychoactive substance abuse, muscle weakness, and difficulty walking, with an order for tramadol 50 mg every six hours as needed for pain and a care plan addressing altered comfort related to pain and functional limitations, with interventions to administer medications as ordered. A fourth resident had a diagnosis of opioid dependence in remission and an order for buprenorphine HCl-naloxone (Suboxone) 8-2 mg sublingually daily for a history of substance abuse, with a care plan identifying Suboxone therapy and interventions to administer medications as ordered. During a medication pass observation, surveyors saw four clear plastic medication cups, each labeled with a resident’s name and containing a single pill, sitting on top of the medication cart. The LPN identified the pills as phenobarbital for the first two residents, tramadol for the third, and Suboxone for the fourth. The LPN acknowledged she had pre-poured all of these narcotic or controlled medications at one time so she would not have to repeatedly access the locked narcotic drawer and stated she routinely prepared all narcotics before beginning her medication pass, believing this was acceptable because the cups were labeled. The facility’s Medication Administration policy required medications to be removed from their source immediately prior to administration and administered as ordered, with observation for resident consumption, and the DON confirmed medications were not to be pre-poured prior to 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

A cognitively impaired, aphasic resident with a history of dementia, multiple sclerosis, and other significant medical conditions was identified as being at risk for elopement and was equipped with a WanderGuard device. Despite these precautions, the resident was able to exit the facility without staff knowledge and was found by police 0.6 miles away, confused and in a ditch, after a passerby called 911. The resident was unable to provide identification or details due to cognitive and communication impairments and was subsequently transported to the hospital for evaluation and treatment of hypotension. The facility's WanderGuard system, intended to prevent such incidents, was found to be non-functional during the investigation. It was discovered that an unknown individual had been entering a master override code into the system, which disarmed the WanderGuard alarms and allowed residents at risk for elopement to exit undetected. Multiple staff interviews confirmed that no alarms sounded at the time of the incident, and staff were unaware the resident was missing until notified by police. Observations and testing of the system during the survey confirmed that the alarms did not activate when the WanderGuard device was present and the override code was used. Documentation review revealed that the resident's care plan identified elopement risk and included interventions such as the use of a WanderGuard and monitoring for wandering behaviors. However, the care plan had not been updated or revised in response to changes in the resident's condition or after the incident. Staff statements indicated inconsistent awareness of the resident's whereabouts, and the facility's own self-reported incident investigation did not initially identify the root cause of the elopement. The deficiency was cited as the facility failed to provide adequate supervision and maintain a safe environment free from accident hazards, resulting in Immediate Jeopardy.

Removal Plan

• Regional Director of Clinical Services (RDCS) completed an elopement assessment on Resident #16 and reviewed the resident's elopement risk care plan.
• Pain assessment, skin assessment, neurological checks were initiated and charted in the resident record for Resident #16.
• ADON and SSD reviewed elopement assessments on all 32 residents to ensure all current residents had elopement assessments.
• One new resident identified at risk for elopement and WanderGuard placed; resident added to elopement binder.
• Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting held to discuss the elopement incident, interventions initiated, and plan of care.
• Administrator and Maintenance Director completed an elopement drill.
• Ohio Department of Health surveyor and Maintenance Director identified the WanderGuard system was not functioning as designed; staff placed for door supervision.
• Secure Care company notified to inspect the WanderGuard system.
• Secure Care company determined a universal code was being entered by unidentified staff that was overriding the system and causing the WanderGuard system to not alarm.
• All facility door codes were changed, including a change of the master override code by Administrator; master override code privy only to Administrator and Maintenance Director.
• Facility staff completed a headcount to ensure all 32 residents were accounted for.
• 42 of 43 staff were educated on the new facility door code, the elopement policy, and the abuse/neglect policy; remaining staff to be educated upon return to work.
• Agency staff provided with education; all agency staff to receive education prior to working in the facility.
• All new hires to be educated by the Maintenance Director during orientation process.
• Repeat door audit completed by the Administrator to ensure all doors and alarms were functioning.
• ADON completed a WanderGuard audit on all residents with WanderGuards.
• ADON and DON reviewed all residents' elopement risk scores for accuracy.
• Facility interdisciplinary team completed an elopement drill.
• SSD completed review of the elopement book to ensure all residents at risk were in binder.
• Ad Hoc QAPI meeting held via phone with leadership to review steps taken for the facility removal plan.
• DON/Designee to complete audits on all residents with WanderGuards to ensure proper placement and functioning.
• Maintenance Director/Designee to complete door alarm audit with emphasis on secure care alarms.
• One-to-one staff monitoring of the doors to be implemented if alarms are identified as not working.
• Audits to be conducted to ensure no behaviors related to wandering or elopement have occurred; findings to be addressed if indicated.
• Elopement drills to be conducted on each shift by the Administrator, Maintenance Director, or designee.
• Results of facility audits to be forwarded to the QAPI committee for review and 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 that the infection preventionist (IP) role was conducted by a nurse who worked at least part-time in the facility. The Facility Assessment form did not specify the required number of hours for the IP to be present to implement infection control programs and activities. Documentation showed that a regional registered nurse was designated as the current IP, but she was only present in the building once a month. Interviews with the administrator and the regional RN confirmed that the IP duties were performed monthly on-site, following the departure of the previous staff member who had served as the IP. The facility's Infection Prevention and Control Program policy indicated the existence of an infection control program, but did not address the lack of a qualified, regularly present IP.

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 care planning conferences were completed quarterly and that the interdisciplinary team (IDT) was properly involved in the care planning process for two residents. For one resident with severe dementia, schizophrenia, and other behavioral and cognitive impairments, care planning conferences were not held at the required intervals, and only the Social Service Designee and Assistant Director of Nursing attended the meetings. Other required IDT members, such as the MDS nurse, floor nurse, dietary, and activities staff, were not notified or invited to participate in the conferences. Another resident with Alzheimer's disease, aortic graft leakage, COPD, and anemia had only one care planning conference documented, with no evidence of additional required conferences. The facility's policy required regular care plan discussions with the resident or their representative at scheduled intervals and after significant changes, but this was not followed. These findings were confirmed through record review, policy review, and staff interviews.

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 bloodwork for a resident was completed according to physician orders. The resident, who had diagnoses including schizoaffective disorder bipolar type, chronic obstructive pulmonary disease, and cardiomyopathy, was readmitted and had an order for weekly potassium level testing. Review of the medical record showed that potassium levels were only obtained on three occasions, with two weekly tests missed during the ordered period. The Director of Nursing confirmed that the potassium bloodwork was not completed as ordered. Facility policy requires laboratory services to be provided or obtained when ordered by a physician or other qualified practitioner.

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 food preferences were honored during meal service. The resident, who had diagnoses including schizoaffective disorder bipolar type, chronic obstructive pulmonary disease, and difficulty in walking, was cognitively intact according to the Minimum Data Set assessment. The resident's care plan and physician orders specified a regular diet with regular texture and thin consistency, but did not include orders for Boost or chocolate milk. However, the resident's meal tickets indicated a standing order for Boost Very Vanilla at breakfast and a note for chocolate milk at lunch. The resident reported not receiving Boost at breakfast and noted its absence on the meal ticket. At lunch, the resident also did not receive the requested chocolate milk. The Dietary Manager confirmed that the resident's preferences were not honored, stating that the facility had run out of chocolate milk and the resident should have received another Boost as a substitute. Facility policies reviewed indicated that meals should accommodate resident preferences and therapeutic diets should be provided as needed, in collaboration with the resident, family, dietitian, and physician. Despite these policies, the resident's stated preferences for Boost and chocolate milk were not met during the observed meals.

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 the privacy and confidentiality of residents' personal and medical records by not properly securing medication administration packaging. During an observation, clear plastic medication packages containing residents' names, room numbers, and lists of administered medications were found discarded in an open trash receptacle attached to the medication cart. These packages were visible to anyone passing by, making identifiable resident information easily accessible. This issue affected three residents, including individuals with schizoaffective disorder, muscle weakness, difficulty walking, chronic obstructive pulmonary disease, heart failure, and cellulitis with limb loss. One resident had moderate cognitive impairment, while another had intact cognition. An interview with the DON revealed that staff were expected to remove or obscure resident names from medication packaging before disposal, either by removing the label or crossing out the name with a black marker. However, the discarded packages for the affected residents were found intact with all identifying information visible. The DON confirmed this was a violation of resident privacy and acknowledged that the facility did not have a policy addressing the proper disposal of medication packaging containing identifiable information. The facility's existing HIPAA policy only addressed electronic records and did not cover physical medication packaging.

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 an electrocardiogram (EKG) for a resident as per physician orders, which was a deficiency identified during a review of the medical records and staff interviews. The resident, who had a complex medical history including acute respiratory failure, congestive heart failure, and an abnormal EKG, was admitted with a change in condition that required immediate diagnostic tests. The physician ordered a STAT EKG, among other tests, due to the resident's congestive heart failure. However, the EKG was not completed, and there was no documentation of follow-up with the physician or the mobile x-ray company regarding the unfulfilled order. The resident's medical record showed that other ordered tests, such as a STAT chest x-ray, were completed, but the EKG was not. The Director of Nursing confirmed that the EKG was not performed and that there was no evidence of staff following up on the order or notifying the physician about the oversight. This deficiency was part of a complaint investigation, highlighting a lapse in the facility's compliance with physician orders and resident care protocols.

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 their abuse policy regarding the thorough investigation and reporting of an allegation of staff-to-resident verbal abuse involving Resident #2. Resident #2, who was admitted with diagnoses including depression, anxiety, and morbid obesity, reported to Long Term Care Ombudsmen that a State tested Nurse Aide (STNA) had verbally abused her. Despite being informed of the allegation, the facility's Administrator and Director of Nursing did not conduct a thorough investigation, did not collect staff witness statements or resident interviews, and did not submit a self-reported incident (SRI) to the state agency as required by their policy. The facility's policy mandates immediate investigation and timely reporting of abuse allegations, but these procedures were not followed. Instead, the facility held a care conference with Resident #2 and her son, during which Resident #2 stated she did not feel abused. The alleged perpetrator, STNA #63, was removed from being assigned to Resident #2 but remained on the schedule. This lack of proper investigation and reporting represents non-compliance with the facility's abuse policy and state regulations.

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 staff-to-resident verbal abuse to the state agency for a resident. The resident, who was admitted with diagnoses including depression, anxiety, morbid obesity, and a need for assistance with personal care, reported to Long Term Care Ombudsmen that a State tested Nurse Aide had called her a derogatory name. The Ombudsmen informed the facility Administrator immediately, but the Administrator and Director of Nursing did not report the allegation to the state agency as required by facility policy. The resident's care plan indicated she had an activity of daily living deficit and required assistance with bathing, toileting, and grooming. It also noted that she could display accusatory and paranoid behaviors and refused certain staff in her room. Despite this, the facility did not thoroughly investigate the allegation of verbal abuse, and the Administrator and DON confirmed they had not reported the incident to the state agency, which is a violation of the facility's policy on abuse, neglect, and exploitation.

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 thoroughly investigate an allegation of staff-to-resident verbal abuse involving Resident #2. Resident #2, who was admitted with diagnoses including depression, anxiety, and morbid obesity, reported to Long Term Care Ombudsmen that a State Tested Nurse Aide (STNA) had called her a derogatory name. The Ombudsmen informed the facility Administrator immediately, but the facility did not conduct a thorough investigation. Instead, a care conference was held with Resident #2 and her son, and the STNA was removed from being assigned to Resident #2 but remained on the schedule. No staff witness statements or resident interviews were conducted regarding the incident. The facility's policy on abuse, neglect, and exploitation mandates an immediate investigation when there is suspicion or reports of abuse. However, the Administrator and Director of Nursing confirmed that no thorough investigation was carried out. This deficiency was identified during a complaint investigation and represents non-compliance with the facility's own policies and procedures for handling allegations of abuse.