Wyant Woods Healthcare Center

Penalty

No penalty information released

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

Summary

The deficiency involves the facility’s failure to protect multiple residents from misappropriation of their medications, which are considered the residents’ belongings. Ten residents had medications that were later found in the home of a former LPN who had worked part‑time at the facility. These residents had various diagnoses including paranoid schizophrenia, Alzheimer’s disease, bipolar and schizoaffective disorders, COPD, diabetes, osteoarthritis, paraplegia, end‑stage renal disease, and anxiety disorders. Their treatment regimens included antipsychotics, antidepressants, antianxiety agents, anticonvulsants, opioids, antibiotics, antiplatelet agents, hypoglycemics, and other medications such as ibuprofen, quetiapine, ondansetron, hydroxyzine, olanzapine, cyproheptadine, ampicillin, gabapentin, metronidazole, and baclofen. The Ohio Board of Pharmacy and law enforcement identified probable drug diversion by an LPN who had worked at the facility. After the LPN’s death from an overdose of prescription drugs, medications labeled for ten different residents from the facility were found at the LPN’s residence. These included ibuprofen 600 mg and 800 mg, quetiapine 100 mg, ondansetron 4 mg, hydroxyzine 25 mg, olanzapine 10 mg, cyproheptadine 4 mg, ampicillin 500 mg, metronidazole 500 mg, baclofen 10 mg, and an empty blister pack of gabapentin 300 mg. The medications had been discontinued at the facility, and the Board of Pharmacy determined they had been removed from the facility after discontinuation and after residents were discharged or transferred. During the Board of Pharmacy’s inspection of the facility, multiple documentation and control issues were identified that related to the handling and security of medications. Signatures on controlled drug documentation were inconsistent, with variations in initials and full names, and some shift‑to‑shift narcotic counts were pre‑signed by the off‑going nurse. Documentation on medication cards or sheets did not always match the actual count, and some shift‑to‑shift counts were missing dates, signatures, and counts. Facility staff, including the Regional Director of Clinical Operations and an LPN, explained that when non‑narcotic medications were discontinued, nurses were expected to remove them from the medication cart and place them in a pharmacy return bag, but there was no method to verify that this actually occurred. The facility’s own abuse, neglect, and misappropriation policy defined misappropriation as the deliberate misplacement, exploitation, or wrongful use of a resident’s belongings without consent, and the findings showed that discontinued resident medications were not adequately secured or tracked, allowing them to be wrongfully removed and found in the former employee’s home.

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 failures in the facility’s infection prevention and control practices related to blood glucose monitoring and medication administration. One resident with diabetes and peripheral vascular disease required blood glucose monitoring; after this resident’s blood glucose level was checked, the LPN carried the blood glucose meter in her hand and then placed it in the top drawer of the medication cart without sanitizing it. The LPN stated she did not clean the meters between residents, was unsure how to clean them, and reported that she had worked at the facility for three weeks without ever cleaning the meters. Manufacturer guidelines for the meter indicated it should be cleaned and disinfected with an EPA-registered disinfectant detergent or germicide wipe, and the facility’s policy required glucose meters to be disinfected with a high-level antimicrobial wipe. The facility also failed to follow infection control standards during medication administration for three residents with various diagnoses including Alzheimer’s disease, heart failure, diabetes mellitus, schizoaffective disorder, depressive type, and chronic obstructive pulmonary disease. During observations, one LPN placed multiple medications directly into her bare hand without sanitizing or wearing gloves before administering them to a resident with impaired cognition, and another LPN placed medications into her bare hand without sanitizing or wearing gloves when administering to two residents with intact cognition. Both LPNs confirmed these practices during interviews, with one acknowledging she should have worn gloves before touching medications. The Regional Director of Clinical Operations confirmed that staff should not be popping medications into their hands and that blood glucose meters should be sanitized between each resident. Facility policy on medication administration stated that staff are not to touch medications when opening liquid or dose packs. The census at the time was 170 residents, and the deficiency was identified incidentally during a complaint investigation.

Penalty

No penalty information released

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

Summary

The deficiency involves the facility’s failure to ensure adequate supervision and implement appropriate safety interventions for a resident who operated a power wheelchair at excessive speeds inside the facility despite multiple OT assessments identifying him as unsafe and recommending restriction of power wheelchair use to outdoor areas only. The resident, admitted and re-admitted with diagnoses including COPD, hypertension, and muscle weakness, had intact cognition per a quarterly MDS. OT progress notes documented that the resident hit a door and ran over someone’s foot while driving his scooter, was very impulsive, and showed aggressive behavior quickly. Social Services, the Therapy Director, and the Nurse Unit Manager met with the resident to discuss safety concerns and offered a more appropriate wheelchair, which he declined, and informed him that further incidents would result in removal of the scooter. Subsequent OT notes showed repeated safety education and training, with the resident continuing to demonstrate poor maneuverability skills, refusing to adhere to appropriate facility speed settings, and being recommended to use the power scooter only outside the facility while using a manual wheelchair safely indoors. Further documentation and interviews showed ongoing unsafe operation of the scooter within the facility. OT notes indicated poor safety awareness, including attempts to fit through doorways that were too narrow. A CNA reported that the resident had previously run full speed into her leg with the scooter, fracturing her leg, and that she had seen him run into other people, and also reported a lack of staffing on a specified shift. Multiple observations on survey dates showed the resident speeding down hallways with the scooter set on the highest (rabbit) mode. Staff interviews confirmed that the resident “always” sped down the hall, that staff educated him but he refused to cooperate, and that he was stubborn and would not give up the scooter. The scooter was observed to be heavily damaged in the front, with the resident stating he had run into something he could not remember and that his hand had gotten stuck in the trigger area, while the scooter was again noted to be set at the fastest speed. These findings demonstrate that the resident continued to operate the power scooter unsafely inside the facility without effective supervisory or safety interventions being implemented.

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 ensure a resident rinsed his mouth after using a steroid inhaler, as required by manufacturer guidelines and facility policy. Resident #218, admitted on 07/28/25 with diagnoses including schizoaffective disorder, depressive type, and chronic obstructive pulmonary disease, had an MDS assessment indicating intact cognition. During a medication pass observed on 02/26/26 at 8:44 A.M., LPN #584 handed Resident #218 a BREO steroid inhaler. The resident took one breath from the inhaler and returned it to the nurse, and the nurse did not encourage or prompt the resident to rinse his mouth afterward. Immediately after the observation, LPN #584 stated that the resident had refused to rinse his mouth in the past, so she did not say anything on this occasion, and she agreed she should have prompted him to rinse. Later, the Regional Director of Clinical Operations confirmed that staff should be encouraging residents to rinse their mouths after using a steroid inhaler. Review of the BREO inhaler guidelines from accessdata.fda.gov indicated that after inhalation, the resident should rinse the mouth with water without swallowing to help reduce the risk of overgrowth of yeast in the mouth (oropharyngeal candidiasis). Review of the facility’s undated Medication Administration policy also noted that residents were to rinse their mouths after using a steroid inhaler. This incident was identified as an incidental finding during a complaint investigation.

Penalty

No penalty information released

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

Summary

The deficiency involves the facility’s failure to administer a resident’s scheduled medications within the facility’s required timeframes. A resident with diagnoses including hemiplegia and hemiparesis, major depressive disorder, and anxiety disorder, and with intact cognition per a quarterly MDS assessment, was ordered acetaminophen 1000 mg twice daily for pain, hydroxyzine 50 mg twice daily for anxiety, and rabeprazole 20 mg twice daily for heartburn. The facility’s medication administration policy required medications to be given within one hour before or after the ordered time, and the facility’s liberalized medication pass times defined specific time ranges for early morning, A.M., afternoon, P.M., and HS doses. Review of the MAR and the facility’s medication administration audit report showed multiple instances where the resident’s medications were administered significantly outside the ordered times. On several dates, morning doses scheduled for 7:00 A.M. were not given until early afternoon, and evening doses scheduled for around 7:30 P.M. were not administered until after midnight. These late administrations affected acetaminophen, hydroxyzine, and rabeprazole on multiple occasions. During an interview, the Regional Director of Clinical Operations confirmed that the medications listed on the audit were administered outside the scheduled timeframes. The resident was not available for interview.

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 plan meetings were offered in a timely manner to residents and their guardians, as required by facility policy. For one resident with a history of hemiplegia, epilepsy, and other neurological and psychiatric conditions, documentation showed that the last care conference occurred in May, with no subsequent meetings documented for the following quarters. The resident's guardian confirmed that no care conferences had been offered for approximately four months. Facility staff, including the social worker and LPN, acknowledged that the care plan meeting was overdue and could not provide a reason for the delay. Similarly, another resident with multiple chronic conditions, including fibromyalgia, diabetes, and psychiatric disorders, had not received a timely care plan meeting. The last documented care conference for this resident was also in May, with no further meetings scheduled until October, missing the required quarterly interval. The resident could not recall when the last care conference occurred, and staff confirmed the delay without explanation. Facility policy required attendees to sign and date care plan meeting documents, but this process was not followed as required for these 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

The facility failed to ensure that monthly pharmacy reviews and laboratory monitoring for seizure medications were conducted in a timely manner for a resident with multiple diagnoses, including epilepsy and hemiplegia. The resident was prescribed several anticonvulsant medications, such as Phenobarbital, Levetiracetam (Keppra), Carbamazepine (Tegretol), Gabapentin, Dilantin, and Divalproex Sodium (Depakote). Despite being on these medications, there was a significant lapse in laboratory monitoring, with the last documented lab for seizure medication levels occurring in January. Pharmacy recommendations for ongoing lab monitoring were not addressed by the attending physician, and the pharmacist did not identify the need for additional lab tests during monthly reviews over several months. The resident experienced a decline in condition, including decreased food and fluid intake, functional decline, and increased dependence on staff for care. This change in condition led to the resident being sent to the hospital, where laboratory results revealed a critically high Phenobarbital level, well above the normal therapeutic range. Hospital records indicated that the elevated Phenobarbital level required immediate medical intervention, and neurology held the medication for a period due to toxicity concerns. The facility's documentation confirmed that no labs had been ordered to monitor the resident's seizure medications in the months leading up to the hospitalization. Interviews with facility staff, including the DON, corporate nurse, pharmacist, and physician, confirmed that appropriate laboratory monitoring for seizure medications had not been performed as required. The facility's policy stated that pharmacists should report medication irregularities and that these should be addressed in a timely manner, but this process was not followed. The pharmacy recommendation form requesting regular lab monitoring was not completed or signed by the physician, and the DON acknowledged the oversight. This deficiency was substantiated through record review, interviews, and policy review.

Penalty

No penalty information released

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

Summary

A deficiency occurred when a resident with multiple diagnoses, including hemiplegia, epilepsy, and pneumonia, did not receive their prescribed antibiotic medication as ordered by the physician. The resident was dependent on staff for several activities of daily living and had intact cognition. The physician ordered Levofloxacin 250 mg, three tablets (totaling 750 mg), to be administered once daily for several days. The medication was administered as ordered on the first two days, but on the following two days, the medication was not available and was not given to the resident. There was no documented evidence that the physician was notified about the missed doses on either day. Staff interviews confirmed that the medication was not available in the facility's medication dispensing system and that the pharmacy was contacted, but the medication was not delivered. Facility policy required medications to be administered only as prescribed, but this was not followed in this instance, resulting in the resident missing two doses of their antibiotic without physician notification.

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 staff failed to provide appropriate supervision to a resident during a designated smoking break, resulting in the resident eloping from the facility. The resident involved had a complex medical history, including alcohol dependence with alcohol-induced persisting dementia, major depressive disorder, paranoid schizophrenia, bipolar disorder, delusional disorder, mild cognitive impairment, impulsive disorder, intermittent explosive disorder, cocaine abuse, and severe dementia with behavioral disturbances. The resident was identified as an elopement risk and had a care plan in place that required supervision during smoking times and placement in a secured unit. On the day of the incident, staff responsible for supervising the smoking break allowed residents to go outside to smoke but did not remain with them, instead observing from a window due to rain. During this time, the resident at risk for elopement managed to leave the secured courtyard by kicking the gate and exited the premises. The absence of direct supervision enabled the resident to leave the facility undetected for several minutes until discovered in the parking lot by another staff member who was leaving for the day. The resident was safely returned to the facility without injury. Interviews and witness statements confirmed that the staff assigned to supervise the smoking break were not physically present outside with the residents, contrary to facility policy requiring supervised smoking. The Director of Nursing verified that the root cause of the elopement was the lack of appropriate supervision during the smoke break, which allowed the resident to elope from the secured area. Facility records and policies reviewed indicated that the resident's risk for elopement was well-documented, and interventions for supervision were clearly outlined but not followed at the time of the incident.

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 respond to or resolve concerns voiced by residents regarding the lack of activities, both within and outside the facility, as documented in Resident Council meeting minutes from January 2024 through April 2025. Residents repeatedly requested more activities, including outings, but there was no documentation or evidence that the facility took action or provided responses to these concerns. Multiple interviews with residents and activity staff confirmed that activities were not provided after 4:00 P.M. or on weekends due to insufficient staffing, and the facility had not had a transportation bus for years, preventing residents from attending outside activities such as shopping, movies, or community events. Activity staff and the Activity Director acknowledged being aware of the residents' ongoing complaints about the lack of activities and transportation, citing inadequate staffing as the primary barrier. During a Resident Council meeting, all participating residents confirmed they had voiced these concerns to staff, including the Activity Director, without resolution. Facility leadership, including the Administrator and DON, confirmed awareness of the lack of transportation and insufficient daily activities, with little response to the residents' requests for outside activities.

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 activities that met the interests and needs of its residents, as evidenced by a lack of scheduled activities after 4:00 P.M. and on weekends, with only handouts being distributed during these times. Multiple residents, including those with intact cognition and diagnoses such as anxiety disorders, schizophrenia, dementia, and chronic medical conditions, expressed that attending activities was very important to them. Resident Council meeting minutes and interviews with residents and staff consistently documented ongoing complaints about the lack of activities, especially those occurring outside the facility, such as shopping or going to the movies, and the absence of a transportation bus for several years. Observations on various units revealed that residents were often left sitting in common areas with minimal engagement, such as a television playing unwatched, and scheduled activities like crafts were not provided as planned. Staff interviews confirmed that insufficient staffing prevented the delivery of activities as scheduled, and that activity staff typically left by 4:00 P.M., leaving direct-care staff to distribute handouts instead of facilitating interactive activities. The activity department was also reported to rarely visit certain units, and when activities like the in-house store were offered, residents without funds could not participate, leading to further dissatisfaction and confusion. The facility's own policy required a comprehensive activities program, including social, indoor, outdoor, and community activities tailored to individual needs and interests. However, both staff and residents reported that these requirements were not being met, with the last outside trip occurring before the COVID-19 pandemic. The lack of transportation and insufficient staffing were repeatedly cited as reasons for the failure to provide adequate activities, resulting in unmet needs for a significant portion of the 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

A deficiency was identified when an LPN failed to maintain infection control standards during medication administration and blood glucose monitoring for a resident with type 2 diabetes mellitus. The LPN prepared four medications for the resident, but after accidentally dropping them onto the medication cart, picked them up with a bare, ungloved hand and placed them back into the medication cup. The LPN confirmed during an interview that gloves were not used and appeared confused about hand hygiene requirements during medication administration. Facility policy specifically prohibits touching medications directly. Additionally, the LPN was observed checking the resident's blood sugar and then placing the used, un-sanitized glucometer on the medication cart. The glucometer remained uncleaned for approximately five minutes until prompted by surveyors, at which point the LPN used an alcohol wipe to clean it. The LPN stated that alcohol wipes and bleach wipes were used for cleaning, but bleach wipes were not always available. Facility policy requires the use of an EPA-approved disinfectant effective against Hepatitis B, Hepatitis C, and HIV, and specifically states that alcohol wipes are not appropriate for disinfecting glucometers.

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 proper assistance with personal hygiene and grooming tasks for three residents who required help with activities of daily living (ADLs). One resident with hypertensive heart and chronic kidney disease, asthma, moderate intellectual disabilities, and dementia was observed with a full beard and long fingernails, and expressed a desire to be shaved and have his nails cut. A second resident with COPD, arthritis, dementia, and cataracts was observed with a mustache and chin hairs, and stated she wanted her mustache shaved but staff had not done it. Both residents' care plans indicated a need for moderate assistance with personal hygiene, which was not provided as observed and confirmed by staff interviews. A third resident with bipolar disorder, Alzheimer's disease, and osteoarthritis was found with long, jagged, and discolored toenails. Although there was a physician order for a podiatry consultation and a care plan indicating the need for staff assistance with ADLs, the resident's toenails had not been maintained by staff or the podiatrist. Staff interviews revealed confusion about podiatry scheduling and responsibility, and the resident had not been added to the list for podiatry services. Facility policy required routine nail hygiene services, but this policy was not implemented for the affected residents.

Penalty

Inspection fine: $47,074

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 prevent an incident of staff-to-resident abuse involving a resident who was physically abused by a State Tested Nursing Assistant (STNA) using oleoresin capsicum (OC) spray, commonly known as pepper spray. This incident resulted in immediate jeopardy and caused actual physical and psychosocial harm to the resident. The resident experienced burning eyes and redness, and a subsequent PTSD assessment indicated that the resident found the event traumatic, experiencing nightmares, heightened alertness, and feelings of guilt or blame. The incident occurred when the STNA sprayed the resident in the face with pepper spray following a heated conversation. Despite the severity of the incident, the facility's response was delayed. The Unit Manager was informed of the incident via text message approximately four hours before an investigation began. During this time, the STNA continued to work in the facility, and the resident's condition was not immediately addressed by management. The resident involved had a complex medical history, including hemiplegia, aphasia, vascular dementia, and several psychiatric disorders. The behavior care plan for the resident included interventions for managing impulsive and aggressive behaviors, but these were not effectively implemented to prevent the incident. The facility's failure to promptly address the situation and protect the resident from harm highlights a significant lapse in ensuring resident safety and adherence to abuse prevention protocols.

Removal Plan

• Educated STNA #919 that she was to report any incidents related to abuse to the Administrator and DON immediately.
• Obtained STNA #919's witness statement.
• The DON interviewed STNA #942 of the alleged incident. STNA #942 relayed she was cleaning the hallway and Resident #78 must have touched the railing and touched his eyes. She also stated the floor nurse already educated her and made her dispose of the cleaning supplies. The DON obtained STNA #942's witness statement and placed STNA #942 in the receptionist area to immediately separate Resident #78 and STNA #942.
• The DON interviewed Licensed Practical Nurse (LPN) #941 who communicated cleaning supplies were used on Hickory unit and that she made STNA #942 empty the chemical mixture and educated her on not using cleaning supplies in the facility again.
• The DON notified the Administrator, Regional Director of Operations #943 and Regional Director of Clinical Operations #944 of the incident.
• The DON notified the facility's nurse practitioner (NP) of the incident and requested for NP to assess resident. The resident was assessed.
• The DON suspended STNA #942 for possibly spraying [NAME] towards Resident #78.
• The DON obtained a new order to monitor Resident #78's eyes and face for abnormalities. New order confirmed. The resident was assessed by the DON.
• The DON attempted to call Resident #78's guardian to notify the guardian of the incident. A voicemail message was left. The guardian was notified.
• The DON notified the local police department of the incident.
• Unit Manager #809 completed a respiratory assessment on Resident #78.
• Unit Manager #835 suspended LPN #941.
• All residents on the Hickory unit were assessed for respiratory, skin and eye concerns related to the chemicals that were sprayed on the unit.
• All interviewable residents were interviewed regarding abuse by Unit Manager #861. Skin sweeps were completed for residents with a low cognition.
• Facility managers completed skin checks and interviews on all facility residents.
• The DON notified the Medical Director of the incident.
• Social services staff met with Resident #78 to provide support to the resident.
• Resident #78's psych physician was notified of incident and new orders were given to increase Seroquel (antipsychotic medication).
• The DON/Designee interviewed staff on any potential abuse to ensure all incidents had been investigated and reported.
• The DON/Designee interviewed all staff on the current shift and next shift to identify if any weapons were on the facility grounds.
• The DON/Designee educated all staff on the facility policy identified as, abuse, neglect, and misappropriation with emphasis on timely reporting, who to report incidents of abuse to, ensuring safety of the residents, and effective investigation.
• The DON/Designee educated all staff on no tolerance/allowance of weapons in the facility with emphasis on what was considered a weapon. Staff were educated that all harmful substances on person, key chains, purses, backpacks must be left outside of facility. All harmful substances on keychains must be removed prior to entrance in the building. Staff educated that increase observation would be ongoing for such items and that all violations identified would result in suspension until a thorough investigation was completed and had the potential to lead to termination.
• The DON/Designee educated all facility department managers on increase supervision and Ambassador rounds with emphasis on monitoring and observation of any form of weapon, this includes observation of uniforms, keys, and open bags or purses.
• Divisional [NAME] President of Risk educated the DON and Unit Managers on reporting guidelines related to abuse, investigation, reporting, maintaining safety of residents, and what constitutes an allegation, company weapons policy and expectations.
• STNA #942's employment was terminated related to the incident with Resident #78.
• Local police were updated with findings of the facility investigation. The police were pursuing assault charges against STNA #942.
• The Administrator/Designee reviewed LPN #941 and STNA #942's employee files for background checks, references, abuse and resident rights training due to the fact they were the perpetrators in this incident.
• All facility staff were educated by an outside company on Empathy, Psychiatric Behaviors, and De-Escalation. Staff on Leave or Paid Time Off will be educated upon return and prior to working. Two employees remain on leave and will be educated by the ED/Designee upon return.
• The facility implemented a plan for the DON/Designee to educate all new staff in behavioral health management, abuse, and weapons policy. This would be ongoing as part of new hire orientation which was ongoing.
• The DON/Designee would interview five residents weekly for four weeks for any abuse concerns. Then three residents weekly for four weeks. Then randomly thereafter until compliance was confirmed.
• The Administrator/Designee would interview five staff members weekly for four weeks for any abuse concerns. Then three staff members weekly for four weeks. Then randomly thereafter until compliance was confirmed.
• The DON/Designee would review five weekly skin assessments on residents who were unable to be interviewed to ensure no new skin findings for four weeks. Then three weekly skin assessments weekly four weeks. Then randomly thereafter.
• The Administrator/Designee would audit completion of daily ambassador rounds for increased surveillance of weapons in the facility daily for four weeks then three times weekly for four weeks, then randomly thereafter.
• The Administrator/Designee would audit completion of new hire education on Weapon Free Workplace policy weekly for four weeks then randomly thereafter.
• The Administrator or DON would monitor compliance in monthly Quality Assessment and Performance Improvement (QAPI) meeting for three months, then as needed for one year.
• To ensure staff comprehend understanding of education on responding to challenging behaviors the facility implemented monthly monitoring with education and pre/post test times for months.
• The facility implemented a plan for all allegations of abuse to be reported to the Regional Director of Clinical Operations #944 by the Director of Nursing or Administrator as soon as the allegation was made as additional oversight.
• The facility implemented a plan for Regional Director of Clinical Operations #944 to monitor compliance during monthly visits for three months then on an as needed basis.

Penalty

Inspection fine: $47,074

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 properly manage food storage and labeling in the kitchen, which had the potential to affect nearly all residents receiving food services. During an inspection, surveyors observed several food items in the reach-in refrigerator that were either expired or lacked proper labeling and dating. These items included a container of beans, mayonnaise, sour cream, sliced cheese, lettuce, hot dogs, and a brown substance, all of which were not labeled or dated. Additionally, a container of yogurt was found with an expiration date that had passed, and it was noted that the yogurt had been opened without checking the expiration date. The Culinary Supervisor confirmed these observations and acknowledged that kitchen staff were responsible for ensuring food items were labeled, dated, and checked for expiration before use. This deficiency was investigated under specific complaint numbers.

Penalty

Inspection fine: $47,074

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 immediately remove a perpetrator of abuse, which affected one resident and potentially impacted 22 others. The incident involved a staff member spraying oleoresin capsicum (OC) spray, commonly known as pepper spray, at a resident. The resident, who had a complex medical history including hemiplegia, vascular dementia, and several mood disorders, was involved in a heated conversation with staff about a smoke break, which escalated to the use of pepper spray. The resident experienced burning and redness in the eyes, and the event was considered traumatic, leading to symptoms consistent with post-traumatic stress disorder (PTSD). The facility's self-reported incident (SRI) and investigation revealed that the alleged abuse occurred around 10:00 A.M., but facility management was not notified until nearly four hours later. During this time, the staff member who used the spray continued to work until being suspended at 2:15 P.M. The delay in reporting and removing the staff member from the facility exposed other residents to potential harm. Witness statements corroborated the incident, with one staff member reporting the event to a nurse and unit manager immediately after it occurred. The facility's policy on abuse prevention and response mandates the immediate removal of any employee accused of abuse from resident care areas. However, in this case, the policy was not followed promptly, as evidenced by the timeline of events and staff interviews. The failure to act swiftly in removing the perpetrator and notifying management highlights a significant lapse in the facility's adherence to its own policies, resulting in a deficiency related to resident safety and protection.

Penalty

Inspection fine: $47,074

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

Summary

The facility failed to ensure timely reporting of an abuse allegation involving a resident who was sprayed with pepper spray by a staff member. The incident affected a resident with multiple diagnoses, including hemiplegia, aphasia, vascular dementia, and bipolar disorder. The resident's behavior care plan included interventions for managing impulse disorder and aggressive behavior. On the day of the incident, the resident was involved in a heated conversation with staff about a smoke break, which escalated to the staff member using pepper spray on the resident. The facility's investigation revealed that the incident occurred around 10:00 A.M., but management was not notified until 1:55 P.M. Witness statements indicated that another staff member reported the incident to a nurse and unit manager immediately after it happened. However, the initial report suggested that the resident had cleaning chemicals in their eyes, which delayed the proper investigation. The facility's policy required immediate reporting of such incidents to the Director of Nursing and Executive Director, which did not occur in this case. Interviews with staff confirmed the timeline of events and the delay in reporting. A staff member texted a unit manager about the incident shortly after it occurred, but the information was not acted upon until later in the day. The resident experienced symptoms consistent with exposure to pepper spray, such as burning eyes and distress, and described the event as traumatic in subsequent PTSD assessments. The facility's failure to report the incident promptly and accurately represents a deficiency in compliance with their abuse prevention policy.

Penalty

Inspection fine: $47,074

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 appropriately assess and monitor a resident's closed reduction of multiple fractures, including the left ankle, right first proximal phalanx, and L1 inferior endplate. The resident was admitted with these conditions, and the medical record lacked evidence of assessments and monitoring from the time of admission until the survey date. The resident's orthopedic follow-up appointment was initially scheduled but canceled due to insurance issues, and it was rescheduled for a later date. Observations revealed inadequate care, as the resident had wrapped her feet in paper products and debris, and the left foot was wrapped with a soiled ace wrap. Interviews with facility staff, including a nurse practitioner and a licensed practical nurse unit manager, indicated that the resident's fractures were not being followed by the wound care team. The facility's administrator confirmed the lack of assessments and monitoring in the resident's medical record. The facility's wound care policy stated that residents with skin integrity issues should receive treatment based on location, stage, and drainage, but this was not adhered to in the resident's case. 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 maintain proper infection control techniques during wound care for Resident #40 and insulin administration for Resident #165. Resident #40, who had a diagnosis of diabetes and required Enhanced Barrier Precautions (EBP) due to a wound, was observed receiving wound care without the use of appropriate Personal Protective Equipment (PPE) by Registered Nurses #304 and #427. The nurses did not don PPE, failed to clean the bedside table or use a barrier, and used a soiled towel and unclean scissors during the procedure. Additionally, they did not perform hand hygiene after completing the wound care, despite the facility's policy requiring PPE for high-contact care activities. In another incident, Resident #165, who had diagnoses including diabetes and required insulin administration, was observed receiving insulin from RN #427 without the nurse wearing gloves or performing hand hygiene. The nurse administered the insulin and checked the resident's blood sugar without following proper infection control protocols. The facility's policy on medication administration mandates appropriate hand hygiene before and after each resident's medication is administered, which was not adhered to in this case.

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 manage a resident's diabetes appropriately by not administering insulin according to physician orders. Resident #165, who has diagnoses including diabetes, developmental delays, and schizophrenia, was observed during a medication administration session. The resident's physician orders for September 2024 specified administering 15 units of Fiasp, a fast-acting insulin, before meals. However, during the observation on 09/10/24, RN #427 initially dialed 18 units on the insulin pen instead of the prescribed 15 units. After realizing the mistake, the RN adjusted the dosage to 12 units and administered it. The Director of Nursing later confirmed that the correct order was for 15 units. The facility's policy mandates administering medications only as prescribed, which was not followed in this instance.

Penalty

Inspection fine: $106,243

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

Summary

The facility failed to protect a resident from physical abuse by a staff member, resulting in Immediate Jeopardy. The incident occurred when an Activity Aide (AA) physically assaulted a resident after the resident hit the aide with a cane. Despite being instructed by other staff to back away, the aide continued to attack the resident until restrained by a Maintenance Technician. This incident was witnessed by multiple staff members, and the resident expressed feeling unsafe at the facility following the event. The resident involved had a medical history that included atrial fibrillation, type two diabetes mellitus, major depressive disorder, Alzheimer's disease, and vascular dementia. The resident was noted to have moderate cognitive impairment and used a walker and wheelchair. The resident's care plan included interventions for impaired cognitive function, such as using the resident's preferred name and providing necessary cues to prevent agitation. The incident was substantiated by the facility's investigation, which included witness statements and a police report. The Activity Aide was terminated, and assault charges were filed. The facility's policy defined abuse as the willful infliction of injury or punishment resulting in harm, and the incident was found to be a violation of this policy.

Penalty

Inspection fine: $106,243

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 safe environment and provide necessary supervision to prevent a resident with multiple mental health diagnoses, including schizoaffective disorder and dementia, from eloping. The resident, who was identified as an elopement risk and had a legal guardian, managed to leave the facility without staff knowledge. This occurred after a State Tested Nursing Assistant (STNA) propped open a secured door with a wet floor sign, rendering it unsecured and accessible to residents. On the night of the incident, staff, including an STNA and a Licensed Practical Nurse (LPN), did not conduct complete rounding and were unaware that the resident had exited the facility. The resident was discovered missing the following morning when a staff member went to deliver breakfast and found the resident's room empty. The facility was unaware of the resident's whereabouts until a family member called to inform them that the resident was at their home, 16 miles away, and had been there since early morning. The resident's medical record indicated a history of elopement risk and the need for a secured unit due to her mental health conditions. Despite this, the facility's failure to ensure the door was secured and to conduct proper rounds allowed the resident to leave the facility unnoticed. The resident's care plan included interventions for elopement risk, but these were not effectively implemented, leading to the resident's unauthorized departure.

Penalty

Inspection fine: $106,243

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 adhere to its policy of hiring staff free of disqualifying offenses, including abuse, which affected three out of five personnel files reviewed. This oversight had the potential to impact all 161 residents in the facility. During a review of personnel files, it was discovered that a State Tested Nursing Assistant (STNA) was hired despite having a background check revealing past charges related to child neglect and cruelty, although these charges were dropped. Another STNA was hired with a background check showing charges for endangering children and drug possession. Additionally, a Maintenance Technician was hired with a charge for drug possession. Interviews with the Administrator confirmed that the facility's internal processes for handling questionable background checks were not followed. The Administrator acknowledged that any applicant with findings on their background checks should have been referred to the Divisional President of Human Resources for further review. The facility's policy clearly states that individuals with disqualifying offenses should not be employed, and the Administrator admitted that STNA #356 should not have been hired due to the findings of child neglect.

Penalty

Inspection fine: $106,243

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 its abuse policy and procedure regarding checking potential applicants against the Ohio Nurse Aide Registry (NAR). This deficiency was identified during a review of personnel files, which revealed that three out of five personnel files lacked evidence of being checked against the NAR prior to employment. Specifically, the personnel files of a State Tested Nursing Assistant (STNA), a Maintenance Technician (MT), and an Activity Aide (AA) did not contain documentation of NAR checks before their hire dates. The Administrator confirmed these findings and acknowledged that all staff, regardless of position, should be checked against the NAR to ensure they do not have a history of abuse, neglect, mistreatment, exploitation of residents, or misappropriation of property. The facility's policy, dated October 1, 2019, mandates that a check of the Ohio STNA registry be completed on all candidates for employment before a job offer is made. Another policy, without a specified date, requires licensure/registry checks to be performed after the interview to verify the Nurse Aide Registry. These checks are to be managed by the facility's Human Resources manager or designee, with results reviewed by the appropriate department head and administration. The failure to adhere to these policies represents noncompliance and was investigated under specific complaint numbers.

Penalty

No penalty information released

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

Summary

The facility failed to timely implement effective and individualized interventions to address the behavioral health concerns of Resident #70, who had a history of mental disorders and behavioral issues. Despite being transferred from another facility with documented behaviors such as yelling, agitation, and attempts to self-transfer, the initial care plan did not include specific interventions for these behaviors. It was only six days after admission that a care plan focus area was initiated to address these behavioral challenges, but there was no documentation to evaluate the effectiveness of the interventions implemented. Resident #70 exhibited multiple episodes of yelling, delusions, agitation, and attempts to crawl out of bed, which were documented in the Medication Administration Record (MAR) and nursing notes. However, there was a lack of documented evidence of staff interventions to address these behaviors effectively. For instance, despite being administered medications like quetiapine and venlafaxine for psychosis and depression, and hydroxyzine for anxiety, the records did not show consistent monitoring or evaluation of the effectiveness of these medications and other non-pharmacological interventions. Interviews with staff members revealed that Resident #70's behaviors were challenging and required frequent attention, but staff were often unable to provide continuous one-on-one care due to other responsibilities. The facility's policy on behavior management indicated that residents would be provided with a resident-centered behavioral management plan, but in the case of Resident #70, there was no consistent documentation or evaluation of the interventions' effectiveness. This lack of timely and effective intervention and monitoring contributed to the deficiency in providing appropriate behavioral health services to Resident #70.