Citations in West Virginia
Comprehensive analysis of citations, statistics, and compliance trends for long-term care facilities in West Virginia.
Statistics for West Virginia (Last 12 Months)
Financial Impact (Last 12 Months)
Latest Citations in West Virginia
A deficiency occurred when a lunch tray on A Hall was found to be served below required hot-holding temperature standards. During a survey, a random tray containing mashed potatoes and gravy with steak was tested by the Traveling Dietary Manager in the presence of the Administrator, and both food items measured 110°F, which did not meet required serving temperatures. The Traveling Dietary Manager and the Administrator each confirmed that the food temperature was not at the required level, and the administrative team later acknowledged this deficiency.
Surveyors found that the facility failed to provide residents with consistent and accurate readily available menus reflecting their food preferences. The Traveling Dietary Manager reported that residents could choose from multiple egg preparations, but these options were not listed on the posted menu available to residents. Additionally, the “always available” menu used in the kitchen did not match the menu provided to residents, and this discrepancy was confirmed by the Traveling Dietary Manager. The issue was identified on all menus reviewed and had the potential to affect many residents in the facility.
The facility failed to follow its abuse reporting policy when a cognitively intact resident reported that two nurses were frequently sleeping on duty and later provided an audio recording of a nurse calling the resident a "jerk." The allegation was reported by the resident to an LPN and then to an RN Infection Preventionist, but the Administrator remained unaware until the survey, and the incident was not reported to authorities within the required 2-hour timeframe. In a separate case, another resident had a verbal abuse incident reported to the state, but the facility did not complete or submit the required 5-day follow-up report, and the Administrator confirmed there was no record of that follow-up.
A resident reported unknown charges on her debit card and alleged that a former roommate had used the card without permission, estimating losses of several hundred dollars. The facility documented initial steps such as notifying external agencies, involving law enforcement, cancelling the card, separating the roommates, and assisting the resident in obtaining bank statements. However, the facility did not maintain or retain key documentation, including copies of bank statements, the total amount of funds involved, or clear follow‑up on the status and outcome of the allegation. The resident reported not receiving updates, and the BOM acknowledged that the facility lacked the resident’s financial records because they had been turned over to law enforcement and were not requested or reviewed by facility staff until shortly before the survey, resulting in an incomplete internal investigation record of the alleged misappropriation.
A resident who was cognitively intact but lacked capacity for health care decisions left the facility after breakfast and morning meds. An activities assistant saw the resident walking outside and reported this to the Manager on Duty, but no effective action was taken to verify the resident’s whereabouts or initiate a search. Nursing staff later assumed the resident was in the bathroom or out smoking when he was not in his room at mid-morning and lunchtime. The facility did not recognize the resident as missing or begin search efforts until hours later, during which time the resident hitchhiked and accepted a ride from a stranger in the community. Surveyors determined that staff had witnessed the resident outside but failed to intervene or report effectively, and that the facility remained unaware of the resident’s absence for several hours, resulting in an Immediate Jeopardy finding for neglect.
A resident who is blind and requires specific instruction during ambulation was transferred from therapy to Restorative with documented recommendations to ambulate using a walker, gait belt, and a wheelchair behind her, along with ROM and strengthening exercises. Despite a physician’s order for a Restorative Nursing Program for ambulation and ROM and the therapy recommendations communicated via an Excel spreadsheet, Restorative staff ambulated the resident without a gait belt. The resident reported becoming tired while walking, with a wheelchair behind her but not close enough, and then falling hard. She and a PTA both stated that no gait belt was used. The fall resulted in fractures to the resident’s left distal femur and right distal femur/knee area, with osteopenia noted, and the DON acknowledged that therapy recommendations had not been carried over for Restorative staff to follow.
A resident experienced multiple leg fractures after a fall, resulting in a significant change in condition and non–weight-bearing status. Although the MDS reflected that it was important for the resident to participate in group activities, favorite pastimes, and church services, the activity care plan was not revised after the injury to address her new limitations. The existing plan listed numerous preferred activities such as resident council, food committee, religious services, music, gardening, and in-room pursuits, but no new individualized interventions were added, and documentation showed only two 1:1 visits after her return from the hospital. The resident reported she could no longer get into her wheelchair, attend council or church, or join groups she enjoyed, and stated that activity staff did not visit often, while the Director of Recreation confirmed she had not attended groups since the injury and that in-room social visits were not consistently documented, resulting in a decline in activity participation and social isolation.
A resident with intact cognition and a history of active participation in group activities, Resident Council, and church sustained bilateral lower-extremity fractures and returned from the hospital non–weight bearing. The MDS significant change assessment and the activity care plan documented that group involvement, church services, and various preferred activities were important to the resident, yet no new interventions were added to the care plan after the change in condition. Activity participation records showed that the resident had no out-of-room activities and only two documented 1:1 visits, while the Director of Recreation acknowledged that group attendance had stopped and that in-room social visits were not consistently documented. The resident reported feeling unable to attend her usual groups, Resident Council, or church and stated that activity staff did not visit often, leading surveyors to find that the facility failed to provide an activities program that met her needs and interests following her significant change.
A resident was discharged to a motel with home health services, a wheelchair, medications, and a follow‑up medical appointment arranged, and received education on medications, blood glucose monitoring, emergency response, and home health services. Discharge planning discussions and a referral to the Take Me Home program were documented, and the facility agreed to pay for an initial period of the motel stay. However, record review and staff interviews confirmed that the resident was not given the required 30‑day written discharge notice prior to leaving, limiting the resident’s ability to prepare for discharge and exercise discharge‑related rights.
A resident sustained multiple lower extremity fractures after a fall, resulting in hospitalization, non-weight-bearing status, and loss of prior functional abilities such as standing, pivoting, and walking with therapy. Before the fall, the resident actively participated in out-of-room activities including Resident Council, food committee, church, and socials, but after returning from the hospital she no longer attended group activities and had only two documented 1:1 visits. Despite an MDS indicating a significant change in status and clear changes in activity participation, the activity care plan—last revised months earlier—was not updated with new interventions to address her altered condition and in-room activity needs, as confirmed by record review and staff interviews.
Improper Hot Food Serving Temperatures During Lunch Service
Penalty
Summary
The facility failed to provide resident meals at proper serving temperature during a lunch meal service on A Hall. On 03/24/26 at approximately 12:10 PM, a surveyor had a random lunch tray on A Hall temperature-tested by the Traveling Dietary Manager, with the facility Administrator present. The tested items—mashed potatoes and gravy with steak—were both measured at 110°F. During an interview at approximately 12:15 PM, the Traveling Dietary Manager confirmed that the food did not meet the required serving temperature, and at approximately 12:16 PM, the Administrator also confirmed that the food did not meet the required serving temperature. This deficiency was acknowledged by the facility’s administrative team upon survey exit on 03/25/26 at approximately 4:00 PM. No additional resident-specific clinical information or conditions were provided in the report.
Inconsistent Readily Available Menus for Resident Food Preferences
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to provide residents with consistent and accurate information about readily available menu items that accommodate resident preferences. During document review and staff interviews, the Traveling Dietary Manager stated that residents could choose from several egg preparations (omelet, scrambled eggs, hard-boiled egg, or hard-fried egg) as part of the facility’s readily available items. However, the posted readily available menu accessible to residents did not list these egg options. Additionally, the “always available” menu used in the kitchen did not match the menu provided to residents, and the Traveling Dietary Manager confirmed that the readily available menus did not correlate. This inconsistency was found on 2 of 2 menus reviewed and had the potential to affect more than a limited number of residents in a facility with a census of 90. On a subsequent interview, the facility Administrator acknowledged the deficiency during the exit interview.
Failure to Timely Report Verbal Abuse Allegation and Submit Required 5-Day Follow-Up
Penalty
Summary
The facility failed to follow its abuse prohibition policy requiring that allegations of abuse be reported to the proper authorities within two hours of identification and that required follow-up reports be completed. The policy defined verbal abuse as the willful use of disparaging or derogatory language toward residents or within their hearing. A cognitively intact resident with a BIMS score of 15 reported that two nurses who worked Monday through Thursday were "always sleeping" and that, after he reported this to administration, one of the nurses called him a "jerk." The resident had an audio recording dated 03/11/26 capturing a staff member calling him a "jerk" and confirming this characterization when questioned by the resident. The resident stated he informed an LPN, who then reported it to the RN Infection Preventionist. The RN Infection Preventionist acknowledged awareness of a phone conversation in which someone called the resident a jerk but stated she did not know the full details and thought it might have been discussed in a care plan meeting. The Administrator reported being unaware of the situation until interviewed by the surveyor, at which time the incident had not been reported within the required two-hour timeframe. The facility also failed to complete and submit a required five-day follow-up report for a separate allegation of verbal abuse involving another resident. Record review showed that this resident had been admitted and later discharged to the hospital, and that a verbal abuse incident involving this resident had been reported to the state agency on 04/15/25. However, review of the facility’s list of reportable incidents for one year revealed no evidence that the corresponding five-day follow-up report was ever sent. The Administrator confirmed there was no record of that reportable incident or of a five-day follow-up. These failures were identified for two of two residents reviewed for abuse, with a facility census of 67.
Failure to Thoroughly Investigate and Document Alleged Financial Exploitation
Penalty
Summary
The deficiency involves the facility’s failure to ensure a thorough investigation and ongoing documentation of an allegation of misappropriation of resident property for one resident. Record review showed that the resident reported unknown charges on her debit card, and the facility initiated an investigation and notified OHFLAC, APS, the Ombudsman, and local law enforcement. Progress notes documented that law enforcement interviewed the resident, the resident cancelled her debit card, and she planned to obtain information from her bank. Notes also showed that the resident obtained bank statements, attempts were made to contact the investigating officer, and law enforcement later returned to obtain the resident’s banking information and ask additional questions. The facility’s 5‑day investigation report documented that the Administrator and DON reported the allegation, assisted the resident in obtaining bank statements, reviewed charges with her, identified the alleged perpetrator as the former roommate, separated the residents, and deactivated the debit card. The investigation was labeled inconclusive with law enforcement continuing the investigation, and a later Grand Jury subpoena was issued for the resident related to alleged fraudulent use of her debit card. Despite these initial steps, at the time of survey the facility was unable to provide additional documentation or evidence of follow‑up regarding the alleged misappropriation, including the total amount of funds involved, the outcome of the investigation, or any ongoing tracking of the allegation until requested by the State Agency. In interviews, the resident stated that her former roommate used her debit card without permission, estimated that approximately $800–$900 had been spent, and reported she had not received any updates about the situation. The BOM stated the facility did not have copies of the resident’s bank statements because they had been turned over to law enforcement and that law enforcement would not release information due to an ongoing investigation. In a follow‑up interview, the resident reported that no one from the facility had requested or attempted to review her bank statements, aside from law enforcement, until shortly before the interview when the BOM inquired, demonstrating that the facility did not maintain documentation necessary to determine the extent of the alleged misappropriation. A staff member later provided a written statement that they accompanied the resident to a Grand Jury proceeding related to fraudulent use of the debit card, but the facility still lacked internal documentation of the scope and outcome of the allegation.
Failure to Respond to Known Resident Elopement and Prolonged Unnoticed Absence
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from neglect by not responding to a known elopement. A cognitively intact resident, who had a BIMS score of 14 but had been deemed by the physician to lack capacity to make health care decisions, left the facility in the morning after having breakfast and receiving morning medications. The resident’s elopement risk evaluation score was 0, indicating low risk for elopement, and the MDS indicated no wander/elopement alarm was used less than daily. The resident’s care plan identified adjustment issues related to change in lifestyle and difficulty accepting placement, with interventions focused on coping and adjustment, but did not identify elopement risk prior to the incident. At approximately 9:00 AM, an activities assistant saw the resident walking outside down a public street near a store. The activities assistant contacted the social worker, who was the Manager on Duty, shortly thereafter to report the resident’s location. The activities assistant then clocked in for her shift around 9:03–9:05 AM. Despite this report, no effective action was taken by facility staff at that time to verify the resident’s whereabouts, intervene, or initiate a search. The social worker later stated she did not realize anything was going on until early afternoon, explaining that she missed the information about the resident being at the store while she was talking with other residents during the phone call. During the period from roughly 9:15 AM to 1:55 PM, there was a delay in supervision and monitoring of the resident. The LPN assigned to the resident reported administering morning medications and exchanging pleasantries with the resident earlier that morning, consistent with the facility’s elopement timeline. The CNA assigned to the resident stated that the resident was in the room during breakfast, but when she entered the room around 10:30 AM to provide a snack to the roommate, the resident was not present and she assumed he was in the bathroom. At lunchtime, when the CNA did not see the resident, she assumed he was out smoking. The facility did not recognize the resident as missing or initiate search or recovery actions until approximately 1:30 PM, when the activities assistant reported that the resident was not present for a smoke break. The State Agency determined that staff had witnessed the resident outside the facility but failed to intervene or report effectively, and that the facility remained unaware of the resident’s absence for about 4.5 hours, creating an Immediate Jeopardy situation due to the resident being unsupervised in the community for an extended period. The resident later reported that he was attempting to travel to another town to attend to personal business, hitchhiking to a nearby city and then walking further when he found the bus station closed. He described being offered a ride and food by a man who drove him to a restaurant, where he was eventually picked up by someone from the nursing home. The State Agency concluded that the facility’s failure to act on the known elopement and to promptly identify and respond to the resident’s absence constituted neglect and placed the resident at immediate risk for serious harm or death.
Failure to Use Gait Belt During Restorative Ambulation Resulting in Resident Fractures
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards of practice when a resident participating in Restorative Therapy ambulation was walked without a gait belt, contrary to therapy recommendations. Record review showed the resident experienced a fall and was sent to the emergency room with pain in both legs, where diagnostic imaging revealed an anterior apex angulated distal femur diametaphyseal fracture with impaction in the left femur and an impaction and comminuted anterior apex angulated fracture of the distal fifth metaphysis in the right knee, with osteopenia noted. The resident, who is blind and requires specific instruction when ambulating, had been transferred from therapy to Restorative with recommendations documented on an Excel spreadsheet to ambulate with a walker, gait belt, and wheelchair behind the resident, up to 70 feet, along with ROM and strengthening exercises. A physician’s order for a Restorative Nursing Program for ambulating and ROM was in place, with the expectation that Restorative staff would refer back to therapy’s recommendations for safety measures. Interviews confirmed that on the day of the fall, staff ambulated the resident without a gait belt. The PTA identified the location of the fall and stated that a gait belt had not been used while walking the resident. The DOR reported that therapy staff had always used a gait belt with this resident and that the recommendation to use a gait belt was communicated via the Excel spreadsheet used by Restorative Therapy to receive therapy orders and recommendations. The resident, who had a BIMS score of 15 and thus had capacity, stated that she became tired while walking with Restorative staff, that a wheelchair was behind her but not close enough, and that she fell hard; she reported that staff did not have a gait belt on her and believed that if a gait belt had been used, she would not have fallen so hard. The DON stated she was not aware of the Excel spreadsheet and confirmed that therapy recommendations were not carried over for Restorative Therapy to follow.
Failure to Revise Activity Care Plan After Significant Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received ongoing opportunities to participate in meaningful activities consistent with her interests and preferences following a significant change in condition. The resident experienced a fall on 02/18/26, was sent to a local emergency room for pain in both legs, and diagnostic radiology revealed an anterior apex angulated fracture of the distal left femur with impaction and an impaction and comminuted anterior apex angulated fracture of the distal right femur metaphysis, with osteopenia noted. She was hospitalized for these fractures and returned to the facility on 02/24/26. A subsequent MDS with an ARD of 02/27/26 documented a significant change in status and indicated that it was important for the resident to do things with groups of people, participate in her favorite activities, and attend church services. Record review showed that the resident’s activity care plan, originally initiated in 2020 and revised multiple times through 03/03/2025, contained numerous interventions reflecting her preferences, including in-room visits, participation in food committee and resident council, church and religious services, group singing and cooking, gardening, pet visits, listening to religious/bluegrass/country music, watching TV and keeping up with the news, and engaging in favorite activities such as church, sewing, cooking, reading, and gardening. The care plan also noted her use of a wheelchair and need for accommodations for visual impairments. However, there were no new or revised activity interventions added to address her new non–weight-bearing status and functional limitations after the fractures, and no changes to the activity care plan were documented following the significant change in condition. During interview, the resident, who had decision-making capacity and a BIMS score of 15, reported that prior to the fall she had been able to stand, pivot, and walk with therapy, and that she had been active in resident council, church, and social activities. She stated that since her return from the hospital she could not get into her wheelchair, could not attend resident council meetings or church, and could not participate in the group activities she enjoyed. She reported that activity staff did not visit her very often and became tearful while describing her situation. The Director of Recreation confirmed that the resident had not attended group activities since returning from the hospital, was non–weight-bearing for 10 weeks, and that anything done with her was now in-room. The Director of Recreation also stated that the resident did not receive one-to-one visits “per se” and that social visits were not documented. Surveyors identified that only two one-to-one visits had been documented since the resident’s return from the hospital and that there was a significant decline in her activity participation without corresponding revisions to her care plan, which led to the finding of failure to provide consistent, individualized activity interventions and ongoing opportunities for meaningful activities.
Failure to Adjust Activities Program After Resident’s Significant Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to provide an activities program that met the interests and needs of a resident who experienced a significant change in condition and activity participation. The resident, who was cognitively intact with a BIMS score of 15 and served as president of the Resident Council, sustained fractures to the left distal femur and right distal femur/knee area after a fall and was hospitalized. Diagnostic imaging showed an anterior apex angulated, impacted distal femur diametaphyseal fracture on the left and an impacted, comminuted anterior apex angulated fracture of the distal fifth metaphysis of the right knee, with osteopenia noted. After hospitalization, the resident returned to the facility and had an MDS with a significant change assessment, with Section F indicating that it was important for her to do things with groups of people, participate in favorite activities, and attend church services. Record review showed that prior to the fall and fractures, the resident participated in out-of-room activities, including Resident Council, food committee, parties, and socials. The activity care plan, originally created in 2020 and revised multiple times through early 2025, documented numerous preferences and important activities for the resident, such as in-room visits, participation in food committee, church, singing, cooking, gardening, going outside in good weather, pet visits, listening to religious and other music, watching TV, reading, and engaging in religious services and voting. The care plan also noted that it was important for her to engage in her favorite activities and to have opportunities to make choices related to meaningful activities. However, there were no new interventions added or changes made to the activity care plan after her significant change in condition and return from the hospital. Activity participation records from the beginning of the year through the time of survey showed that since her readmission from the hospital, the resident had no out-of-room activity participation and only two documented one-to-one visits, both on the same day. During interview, the resident reported that she could no longer stand, pivot, or get into her wheelchair, and that she was now unable to attend Resident Council meetings, church, or be around people as she had before. She expressed distress about missing family gatherings she had been working toward attending and stated that activity staff did not visit very often and that she could not go out to the groups she liked. The Director of Recreation confirmed that the resident had not attended group activities since returning from the hospital due to being non–weight bearing, that anything done with her was now in-room, and that social visits were not consistently documented. The Administrator and Director of Recreation acknowledged that documentation showed only two one-to-one visits and no updated interventions on the care plan since before the significant change, leading to the finding that the facility failed to provide a program of activities to meet this resident’s needs and interests after her change in condition.
Failure to Provide Required 30‑Day Written Discharge Notice
Penalty
Summary
The facility failed to provide a required 30‑day written discharge notice to a resident prior to discharge. A complaint was received by the State Agency stating that the resident was being discharged to a hotel and that the facility would pay for the first 28 days, after which the resident would be responsible for their own expenses. The complainant reported the resident had no income and uncertainty existed about how the resident would obtain food and medications. Record review showed that on one date, Social Services documented discharge planning discussions and a referral to the Take Me Home program at the resident’s request, and an assessment note indicated discharge planning documentation was completed. Further record review revealed that on the day of discharge, Social Services documented that the resident was discharged to a motel with home health services arranged, a wheelchair provided, medications supplied, and a follow‑up appointment scheduled. Nursing documentation from the same day showed the resident received education on medications, blood glucose monitoring, emergency response, and home health services prior to discharge. However, there was no evidence in the medical record that the resident was provided a written 30‑day discharge notice before leaving the facility. In an interview, the Social Worker, in the presence of the Administrator, confirmed that the resident had chosen discharge to a motel and that the facility paid for 28 days at the hotel and provided 14 days of medications, and also confirmed that a 30‑day discharge notice was not issued. The deficient practice had the potential to affect the resident by limiting the ability to adequately prepare for discharge and exercise rights regarding the discharge process.
Failure to Update Activity Care Plan After Significant Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to update an activity care plan following a resident’s significant change in condition and participation. The resident experienced a fall on 02/18/26, resulting in fractures to the left distal femur and right distal femur/knee, with osteopenia noted on diagnostic imaging. She was hospitalized and returned to the facility on 02/24/26. A subsequent MDS with an ARD of 02/27/26 identified a significant change in status. Despite this, the resident’s activity care plan, originally initiated in 2020 and revised multiple times through 03/03/2025, was not revised after the fall and significant change to reflect her new limitations and altered participation in activities. Prior to the fall, the resident had been able to stand, pivot, and transfer to her wheelchair, and was walking up to 100 feet with therapy. She was active in out-of-room activities, including Resident Council, food committee, parties, socials, church, and other group activities. After the fall, she reported that she now had a rod in her left leg, a brace on her right leg, and was non-weight bearing for 10 weeks, which prevented her from getting into her wheelchair and attending the activities she previously enjoyed. She expressed distress about no longer being able to attend Resident Council meetings, church, and family gatherings, and stated that activity staff did not visit very often and that she could not go out to the groups she liked. During the interview, she was observed to be tearful. Record review of activity participation from 01/01/2026 to the present showed that the resident had participated in out-of-room activities before the fall but had no out-of-room participation after her return from the hospital. The records also showed that since the significant change, she had only two documented one-to-one visits, both on 03/04/26. The Director of Recreation confirmed that the resident had not attended group activities since returning from the hospital and was non-weight bearing, and stated that anything done with her was now in-room. The Director also stated that social visits were not documented as one-to-one visits. Surveyors noted that there were no new or revised interventions on the activity care plan since 01/2025 despite the significant change in the resident’s condition and participation, and the Administrator and Director of Recreation confirmed that the documentation reflected this lack of update.
Some of the Latest Corrective Actions taken by Facilities in West Virginia
- The Infection Preventionist educated nursing staff on the use of Enhanced Barrier Precautions (EBP) during high-contact resident care activities. (L - F0880 - WV)
- Observation rounds were conducted to ensure staff donned appropriate Personal Protective Equipment (PPE) for residents on EBP, with immediate corrective actions taken as necessary. (L - F0880 - WV)
- All staff were reeducated on the infection prevention and control program, including appropriate PPE usage, with post-tests to validate understanding. (L - F0880 - WV)
- The Director of Nursing scheduled ongoing observation rounds across all shifts to monitor PPE compliance, adjusting the frequency over time, and reported findings to the Quality Improvement Committee. (L - F0880 - WV)
Failure to Implement Enhanced Barrier Precautions for MDROs
Penalty
Summary
The facility failed to ensure Enhanced Barrier Precautions (EBP) were followed for residents with Multidrug-resistant Organisms (MDROs), leading to an immediate jeopardy situation. Observations and interviews revealed that staff did not consistently wear gowns when providing care to residents on EBP. For instance, two Nurse Aides were observed providing direct care to a resident with MDROs while only wearing gloves, despite an EBP sign on the door. The resident confirmed that staff had not worn gowns during care. Another resident with a history of ESBL and a Foley catheter also reported that staff did not wear gowns during care. Further investigation showed that a resident with a Foley catheter and wounds with MRSA and ESBL was initially on EBP, but the precautions were later changed to contact precautions. The Infection Preventionist and Corporate RN confirmed that staff had not been adhering to the EBP policy. The Infection Preventionist had only been in the role for a few weeks, which may have contributed to the oversight. The facility had 49 residents on EBP for MDROs, including MRSA, CRE, VRE, and ESBL. The failure to follow EBP had the potential to affect all residents, staff, and visitors, leading to the immediate jeopardy call. The facility's policy required EBP for residents with MDROs, chronic wounds, or indwelling medical devices during high-contact care activities, but this was not consistently implemented.
Removal Plan
- The Infection Preventionist provided education to the nursing staff regarding the use of EBP during high contact resident care activities.
- The Infection Preventionist/designee conducted an observation round to ensure nursing staff is donning Personal Protective Equipment for residents who are in enhanced barrier precautions with any corrective action immediately upon delivery.
- All center staff will be reeducated by the Director of Nursing/designee regarding the facility's infection prevention and control program, including the use of appropriate PPE for residents in enhanced barrier precautions. A posttest will be completed to validate understanding.
- All staff not available during the initial reeducation timeframe will be provided reeducation including a posttest by the Director of Nursing/designee prior to the next scheduled shift.
- New staff will be provided education and a posttest during orientation by the Infection Preventionist/designee.
- The Director of Nursing/designee will conduct an observation round to ensure nursing staff is donning appropriate PPE for residents who are in enhanced barrier precautions daily across all shifts, including weekends and holidays, then 5 times a week, then 3 times a week, then randomly thereafter.
- Results of monitors will be reported by the Nursing Home Administrator/designee to the Quality Improvement Committee monthly for any additional follow-up and/or in-servicing until the issue is resolved, then randomly thereafter as determined by the Quality Improvement Committee.
Failure to Protect Residents from Abuse and Nonconsensual Contact
Penalty
Summary
The facility failed to protect two residents from abuse, resulting in immediate jeopardy situations. Resident #75 was subjected to verbal abuse by LPN #28, causing fear and anxiety among the residents. Witnesses reported that LPN #28 yelled and used inappropriate language towards Resident #75, discussing personal medical information in front of others. Despite multiple witness statements confirming the verbal abuse, the facility did not initially substantiate the report, and LPN #28 continued to work at the facility. Resident #91, who suffers from end-stage dementia and is rarely understood, was involved in a nonconsensual sexual contact incident with another resident, Resident #61. The facility's staff, including the social worker and DON, failed to assess Resident #91's ability to consent to sexual contact, relying instead on the resident's wandering behavior as a form of consent. The healthcare decision maker's approval was inappropriately used to justify the lack of investigation into the incident, and the facility's care plan included provisions for privacy during such encounters, which was inappropriate given the residents' inability to consent. The facility's inaction in both cases placed all residents at risk, as the staff failed to recognize and address the abuse and neglect. The lack of proper assessment and understanding of consent, combined with the failure to take immediate corrective action, resulted in a serious deficiency in the care and protection of the residents.
Removal Plan
- The administrator, Director of Nursing and Human Resources Director terminated employee #28. All staff were informed that all or any form of abuse or neglect toward a resident would result in immediate termination.
- All residents were interviewed by administrative staff to ensure that they felt safe and had never endured any type of abuse or neglect. Any residents unable to be interviewed were assessed for any visible signs of abuse or neglect with any corrective action immediately upon discovery.
- The Director of Nursing and Social Worker has begun in-servicing ALL staff about facility abuse and neglect zero tolerance policy and procedure and failure to comply resulting in immediate termination. All staff will be in-serviced prior to their next shift, and virtually if need be.
- The Administrator will ensure adherence to the Abuse and Neglect Policy and Procedure, ensure that any employee who commits any act of abuse or neglect will be terminated immediately. The Social Worker will complete the log attached for all reports of abuse and neglect and turn the log in to the Administrator each time a complaint is made so the Administrator can handle corrective action of the staff immediately. To ensure continued compliance, the monitoring log will be re-evaluated.
- The administrator assigned 1:1 staffing at all times for resident #91 to ensure she is free from non-consensual sexual acts. All staff were informed that all residents are to be kept free from non-consensual sexual harm despite their mental capacities.
- All residents were interviewed by administrative staff to ensure that they had never been subject to non-consensual acts of sexual nature with any corrective action immediately upon discovery.
- The Director of Nursing and Social Worker has begun in-servicing ALL staff about facility's policy and procedure about resident engaging in sexual acts and what is prohibited. All staff will be in-serviced prior to their next shift, and virtually if need be.
- The Administrator will ensure adherence to the Resident Sexual Acts Policy and Procedure, ensure that staff intervene prior to any non-consensual sexual acts occur between residents. All residents within the building will be evaluated for their capabilities to consent to sexual acts. A monitoring log will be completed to ensure that all residents are evaluated for their capabilities to consent to sexual acts upon admission, at any cognitive change, and/or quarterly thereafter. To ensure continued compliance, the monitoring log will be re-evaluated at the Quarterly and Quality Assurance meeting.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect residents from abuse, as evidenced by multiple incidents involving a resident who inappropriately touched, verbally, and physically assaulted other residents. The facility did not properly document, investigate, or report these incidents, which prevented the identification of victims and the provision of necessary services to them. This lack of action resulted in physical and psychosocial harm to the victims and placed all residents at risk of serious harm or death. Resident #213 was involved in numerous incidents of inappropriate behavior, including touching female residents inappropriately, making threatening statements, and engaging in physical altercations with other residents. Despite these behaviors being documented in progress notes, the facility failed to cross-reference these notes with incident logs, leading to a lack of investigation and reporting. The resident's behavior was known to escalate, particularly after returning from a behavioral health hospital, yet the facility did not implement effective interventions to manage these behaviors. Interviews with facility staff revealed a lack of awareness and action regarding the resident's abusive behavior. The Administrator and Unit Manager were unable to identify the victims or confirm any interventions in place during evenings and weekends. The Social Services Designee noted that the resident had a history of similar behaviors and expressed a desire to be removed from the facility. Despite these known issues, the facility did not maintain direct supervision of the resident, further contributing to the risk of harm to other residents.
Removal Plan
- Resident #213 was placed on 1:1 direct observation with a facility staff member until physician interventions are successful in managing behaviors.
- An immediate fax reporting of allegation was completed and sent to OHFLAC.
- The physician was notified with new orders as follows; increased Trazadone to 150mg at bedtime, changed his Paxil to bedtime, and 1 on 1 with staff member.
- The resident's care plan was updated with new orders and 1:1 observation intervention.
- All alert residents were interviewed by the Unit Managers to identify other concerns and no other issues were identified.
- All staff members were immediately re-educated on reporting allegations of abuse immediately to OHFLAC, APS, Ombudsman or other licensing board as warranted by the Unit Manager.
- All staff were educated on notifying a supervisor of any allegation immediately to assist with interventions necessary for immediate protection of residents.
- All staff not available will be re-educated on reporting allegations of abuse and notifying a supervisor immediately prior to the start of their next scheduled shift.
- The Unit Managers will monitor progress notes daily to identify potential concerns of abuse.
- The Administrator and Director of Nursing will review incident and accident reports to identify potential concerns.
- Any allegations will be reported to OHFLAC, Ombudsman, APS and other licensing boards as warranted.
- All allegations of abuse and neglect will be reviewed at the facilities Quality Assurance and Performance Improvement meeting each month.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure food was stored and prepared in a manner that prevents the spread of foodborne illnesses. During an observation of the noontime meal, a facility cook prepared chicken pot pie and recorded its temperature at 143 degrees Fahrenheit, which is below the required 165 degrees Fahrenheit. Despite being informed of the inadequate temperature, the food was served to residents. A review of service line checklists revealed multiple instances where food items were not cooked to the appropriate temperature, including pureed rancher chicken, jambalaya, turkey, hot dogs, and pureed hot dogs. The facility's kitchen was found to be in an unsanitary condition with numerous items improperly labeled or stored past their expiration dates. During an initial tour of the kitchen, several items in the reach-in refrigerator, walk-in cooler, and dry storage were either not labeled or had expired, including bowls of cake, applesauce, pudding, salad, and various juices. The kitchen's cleanliness was also compromised, with food particles in the microwave, debris on the steam table shelves, and baked-on food on cooking equipment. The state agency identified these failures as placing all 55 residents in immediate jeopardy due to the potential for serious harm or death from foodborne illnesses. The facility was notified of the immediate jeopardy situation, which began when the state agency first identified the failure to cook food to the appropriate temperature. The deficient practices had the potential to affect all residents as they all receive meals from the facility's kitchen.
Removal Plan
- An assessment was conducted with all residents currently residing within the center by director of nursing/designee to determine if any residents reported or exhibiting signs and/symptoms that could be related to food borne illness resulting in no concerns reported.
- All center residents will be monitored each shift for new onset food borne illness symptoms.
- The center administrator/designee provided all available dietary staff education on the Food Preparation Policies, which includes the requirement to take appropriate temperatures and record them on the Service Line Checklist to ensure food is prepared and held at a safe temperature to prevent the spread of food borne illness prior to serving food from the service line with post-test to validate understanding. All dietary staff not available for education and training will be re-educated upon return to work.
- An ongoing audit will be conducted by the interim food services manager/designee, for each meal and randomly thereafter to ensure appropriate temperatures as determined by food service production logs, are obtained, and recorded on the Service Line Checklists prior to the service of meal. Food outside of required temperatures will not be served. Audits will be reviewed weekly with the ED or designee and submitted for review to the Quality Assurance Committee and then when random audits are completed.
Neglect and Improper Care in LTC Facility
Penalty
Summary
The facility failed to ensure residents were free from abuse and neglect, as evidenced by multiple incidents observed by surveyors. Resident #6 experienced neglect when staff failed to provide timely incontinence care. Despite the resident's call light being activated, staff members were observed ignoring the call and delaying assistance. The resident expressed frustration over the delay, and the Director of Nursing (DON) confirmed that such delays were neglectful. The resident's care plan indicated a need for frequent repositioning and assistance with toileting, which was not adhered to during the incident. Resident #237 also suffered from neglect due to delayed incontinence care. The resident was observed in a compromised position in bed, with a strong smell of urine and later bowel movement emanating from the room. Despite the resident's repeated calls for help, staff members either ignored the calls or refused to assist, citing that the resident was not their responsibility. The DON expressed surprise at the situation, indicating a lack of awareness of the ongoing neglect and emphasizing the need for teamwork among staff to prevent such occurrences. Resident #331 experienced improper handling after a fall. The resident, who was care planned for falls and required a mechanical lift for transfers, was lifted manually by staff members after falling from a wheelchair. This improper lifting technique was contrary to the resident's care plan and resulted in the resident expressing pain during the process. The incident report for the fall was inaccurately completed, and the resident's Power of Attorney was not notified of the fall, highlighting further deficiencies in communication and adherence to care protocols.
Removal Plan
- The allegation of neglect was reported to VPCO and ADON. The allegation was reported to the state survey office, APS and Ombudsman by Social Worker. A thorough investigation was initiated.
- A skin assessment was completed by a nurse. A trauma assessment was completed by Social worker.
- A skin assessment was completed by ADON. A trauma assessment was completed by the Social Worker.
- Resident #237 was assessed by social worker, with no concerns noted. A thorough investigation was initiated and completed by social worker.
- Resident #6 was assessed by social worker, with no concerns noted. A thorough investigation was initiated and completed by social worker.
- Current residents have been assessed for any signs and symptoms of abuse/neglect. Those residents with BIMs >8 were interviewed by the management team for any abuse/neglect concerns.
- Those residents with BIMs < 8 were physically assessed by the nursing supervisors for any signs and symptoms of abuse/neglect.
- Abuse/neglect assessments, interviews and questionnaires were reviewed by the Administrator for any indications of abuse/neglect concerns. There were 5 concerns voiced during the interviews and were addressed at time of concern.
- Grievances/concerns were reviewed for the last 60 days with no trends noted by social worker and Administrator.
- All staff will be re-educated on abuse/neglect by the ADON or designee. This training was performed to facilitate discussion and question and include examples. Staff who were unable to attend will be provided with the education prior to working their next scheduled shift. Any new staff will be educated upon hire prior to providing patient care. Agency staff will be educated prior to working their next scheduled shift.
- 5 Call light audits will be conducted per shift by DON or designee. 5 residents will be interviewed per day by DON or designee for care concerns/allegations of neglect.
- Observations for resident needs will be conducted of 5 residents on day shift and 5 residents on night shift. The results of these audits will be reviewed through the QAPI committee.
- A nurse from the regional team or corporate office has been onsite or available by phone and will follow up with facility. The nurses from the regional team or home office assist with investigations, observing staff treatment of residents, performing chart audits and providing oversight and consultation.
Deficiency in Addressing Abuse and Seclusion Allegations
Penalty
Summary
The facility failed to administer its resources effectively and efficiently, leading to a deficiency in ensuring the safety and well-being of its residents. The administration did not adequately address and substantiate allegations of physical abuse and involuntary seclusion involving two residents. In one incident, a resident's head was held by a nurse aide while a registered nurse performed a nasal swab for COVID testing, despite the resident's apparent distress and resistance. Multiple staff and resident statements confirmed the occurrence of this incident, yet the facility's investigation deemed it unsubstantiated. In another incident, a resident was allegedly subjected to involuntary seclusion when a registered nurse locked the resident's wheelchair and held it to prevent the resident from leaving the room. This action was reported as possible involuntary seclusion, but the facility's investigation also found this allegation unsubstantiated. Despite multiple witness statements and the resident's own account, the facility administration did not take appropriate actions to ensure the safety of the residents involved or prevent future occurrences. The failure to address these incidents placed all residents at risk for serious harm, as the alleged perpetrators remained employed at the facility. The administration's inaction and failure to substantiate the allegations despite clear evidence from multiple sources highlight a significant deficiency in the facility's management and oversight of resident care and safety.
Removal Plan
- Employee(RN) #40 will have extensive abuse and neglect training by the Regional Team Member.
- Employee (NA) #55 will have extensive abuse and neglect training by the Regional Team Member.
- Residents with BIMS scores of 12 and above were interviewed for potential physical abuse.
- Residents with BIMS scores of 11 or below had a skin assessment completed for potential physical abuse.
- Staff will be reeducated on the Abuse, Neglect, and Misappropriation Policy through in person, text blast will be physically educated with signatures. The training will be conducted by the Regional Team Member.
- There will be training for all staff on Resident Rights including the right to be free from any physical restraints imposed for purposes of discipline or convenience and not required to treat the resident medical symptoms.
- The training will be conducted by the Regional Team Member.
- Staff will be reeducated on restraint alternatives.
- There will be a team review of all reportable events to determine if physical abuse occurred, per state definitions. The team will include Social Services, Director of Nursing or Designee, and Executive Director.
- Audits will be conducted by the regional Director of Clinical Operations with correction upon discovery.
- Audit results will be reviewed by the QAPI Committee.
Failure to Maintain Safe Hot Water Temperatures
Penalty
Summary
The facility failed to maintain hot water mechanical equipment in safe operating condition, resulting in a resident being bathed in water at 134 degrees Fahrenheit, which led to second-degree burns on multiple parts of the resident's body. The staff responsible for monitoring water temperatures and maintaining equipment were aware that the hot water had been measuring more than 110 degrees Fahrenheit since January 2023 but did not take corrective action. This created an immediate jeopardy situation that affected all facility residents. The incident was reported to the state agency, revealing that a nurse aide had placed the resident in a whirlpool tub without checking the water temperature, leading to severe burns. The registered nurse on duty failed to assess or treat the resident's burns in a timely manner, despite being asked multiple times by certified nurse assistants. The maintenance supervisor had been monitoring the water temperatures but did not report the excessive temperatures or attempt to make any changes to meet regulatory compliance. The facility's hot water temperature logs showed consistent readings above the regulatory limit of 110 degrees Fahrenheit from January 2023 through December 2023. Despite this, there was no documentation of corrective actions or adjustments to the hot water system. Interviews with staff revealed a lack of awareness and reporting of the high temperatures, and the facility's preventative maintenance and casualty prevention plan were not followed, as the safety surveillance reports were not provided to the Quality and Performance Improvement Committee as required.
Removal Plan
- Suspend the nurse aide, take all tubs out of service and check for malfunction.
- Suspend the registered nurse in addition to the nurse aide and shut down the bathtubs.
- Place the identified whirlpool (tub) out of service and investigate what may have caused the increased hot water temperature in the tub.
- Replace the malfunctioning hot water tank thermostat.
- Institute a more frequent monitoring of hot water temperatures and prevent resident use of hot water above 110 degrees.
- Stop all showers and tub baths until hot water can be restored to no higher than 110 degrees.
- Direct maintenance staff to physically shut off all hot water access by residents as an added precaution pending further maintenance evaluation/repairs to the hot water system.
- Institute temperature checks of hot water outlets on the resident units.
- Report temperatures found to be greater than 110 degrees immediately to the administrator and prevent residents from using the water.
- Initiate repairs on the hot water system to isolate the hot water distributed to the resident care areas and ensure residents have no access to hot water until the final repairs are made.
- Provide reeducation to staff reiterating appropriate hot water temperatures and completing maintenance work orders if issues are suspected with the temperature of the water system.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect residents from abuse by another resident, identified as Resident #20, who exhibited physical, verbal, and sexually abusive behaviors towards other residents and staff. The incidents began on 04/19/23 and continued through 07/05/24, with at least 20 noted occurrences. The facility did not consistently report these behaviors as required, nor did they consistently notify the physician and responsible party. Additionally, the victims were not consistently identified, and interventions were not consistently implemented to prevent further abuse. Resident #20, a male resident with dementia and Alzheimer's disease, has a history of inappropriate sexual behaviors and aggression. Despite this, the facility failed to take adequate measures to manage his behaviors and protect other residents. Multiple incidents were documented where Resident #20 engaged in inappropriate touching, verbal aggression, and physical threats towards other residents and staff. These incidents were not properly reported or investigated, and the facility did not notify the physician or the resident's power of attorney as required by their policy. The facility's policy on abuse prohibition was not effectively implemented, as evidenced by the lack of investigations, follow-up assessments, and reporting of incidents. Interviews with staff revealed that they were aware of Resident #20's behaviors, yet no comprehensive actions were taken to address the situation. The facility's failure to adhere to its own policies and procedures resulted in an Immediate Jeopardy situation, putting residents at risk of serious harm.
Removal Plan
- Resident #20 was placed on one to one.
- The Director of Nursing (DON)/designee interviewed residents with Brief Interview for Mental Status (BIMS) of 7 or below if the resident permitted for potential sexual, verbal and physical abuse with any corrective action immediately upon discovery.
- Re-education was provided by the Director of Nursing (DON)/designee to all employees to ensure allegations of sexual, verbal, physical abuse are identified, immediate intervention put in place to prevent reoccurrence, immediately reported to the appropriate states agencies and thoroughly investigated.
- A post-test to validate understanding. Any employees not available during this time frame will be provided re-education, including post-test upon the beginning of next shift to work. New employees will be provided education, including post-test during orientation by the DON/designee.
- The Director of Nursing (DON)/designee will monitor progress notes to ensure that allegations of sexual, verbal, physical abuse have been correctly identified, reported in a timely manner and appropriate intervention put in place to prevent the reoccurrence daily across all shifts including weekends and holidays, then 3 times a week then randomly thereafter.
- Results of monitors will be reported by the Director of Nursing (DON)/designee monthly to the Quality Improvement Committee (QIC) for any additional follow-up and or in-servicing until the issue is resolved, then randomly thereafter as determined by the QIC committee.
Failure to Provide Safe Dialysis Care
Penalty
Summary
The facility failed to provide appropriate dialysis care for a resident who required such services, as evidenced by multiple instances of blood pressure being taken in the resident's left arm, where an arteriovenous (AV) fistula was located. This practice is against professional standards as it can lead to serious complications such as clots, loss of use of the fistula, and potentially a stroke. The resident's medical records showed several documented instances where blood pressure was taken in the left arm, despite clear orders and care plans indicating that this should not occur. Additionally, the facility did not complete post-dialysis assessments for the resident upon their return from dialysis sessions. The dialysis communication book lacked documentation of these assessments, which are crucial for monitoring the resident's condition and ensuring any complications are promptly addressed. The care plan for the resident included instructions to monitor for signs of infection, edema, and bleeding upon return from dialysis, but these were not consistently followed. Observations revealed that there was no signage in the resident's room or on their person to alert staff about the restricted limb for blood pressure measurements. Interviews with staff, including an LPN and the Director of Nursing, confirmed that the orders and care plan were not adhered to, leading to the deficiency. This oversight placed the resident at immediate risk of serious injury, prompting the state agency to determine the situation as an immediate jeopardy.
Removal Plan
- Resident #9 will be evaluated by the licensed nurse upon return to the facility.
- All dialysis residents have the potential to be affected.
- The Unit Managers/designee conducted an audit for all residents on dialysis with specific B/P orders to be taken and POST dialysis assessment is completed upon return to the facility with any corrective action immediately upon discovery.
- The Order for B/P not to be taken in the Left arm on Resident #9 will be added to the Medication Administration Record in all Capital letters and will be added to the care plan and kardex in capital letters.
- The Director of Nursing(DON)/designee will reeducate all nursing staff with a posttest to validate understanding regarding hemodialysis graft, fistula care, communication, and documentation.
- Verify orders and instructions from hemodialysis facility or hospital, if patient is a new Admission.
- Evaluate access site daily and on completion of hemodialysis (HD) or home hemodialysis (HHD) treatment. Observe for signs of complications.
- Inspect fistula site for decrease or absence of vein dilation.
- Palpate for distal thrill.
- Auscultate for bruit.
- Palpate skin around graft/fistula for warmth.
- Evaluate skin around vascular access noting redness, swelling, local warmth, exudate, tenderness.
- Observe for presence of fever, chills, hypotension and notify physician/advanced practice provider (APP) and hemodialysis facility staff for complications.
- Protect access site from getting wet for several hours after HD or HHD treatment.
- Avoid trauma or treatment procedures in the accessed extremity, such as limiting activity of extremity, blood pressure measurement, venipuncture, injection of any type, use of creams or lotions on the access site.
- Instruct patient to avoid excessive pressure on the extremity or strain and in strengthening exercises to enhance blood flow if permitted by physician/APP and dialysis facility.
- Document location of access site on admission assessment, status of access site in Nurses' notes, status of pulses distal to access area, color and temperature of extremity, presence or absence of pain or numbness, status of bruit and thrill, notification and response of physician/APP and dialysis facility, patient education and family involvement, nursing intervention.
- Center staff will communicate with the certified dialysis facility regarding the ongoing assessment of the patient's condition by monitoring for complications before and after hemodialysis (HD) treatments received at a certified dialysis facility.
- Prior to a patient leaving the Center for HD, a licensed nurse will complete the top portion of the Hemodialysis Communication Record, or the state required form and send with the patient to his/her HD facility visit.
- Following completion of the HD, the dialysis facility nurse should complete and return the form and return it or other communication to the Center with the patient.
- Upon return of the patient to the Center, a licensed nurse will review the certified dialysis facility communication, evaluate/observe the patient, and complete the post-hemodialysis treatment section on the Hemodialysis Communication Record or state required form.
- Notify the certified dialysis facility if the form is not returned with the patient and ask that it be faxed to the Center.
- Document notification of certified dialysis facility regarding return of form or other communication.
- Maintain the Hemodialysis Communication Record or state required form in the patient's medical record.
- Any licensed nurses not available during this time frame will be provided re-education, including post-test and return demonstration by DON/designee prior to the beginning of the next shift to work.
- New Licensed nurses will be provided education, including post-test during orientation by the DON/designee.
- Annual in-servicing will be provided to licensed nurses regarding medication administration.
- The DON/designee will complete medication pass competencies quarterly to ensure physician orders are followed including ensuring B/P's are not taken in restricted arm.
- The Unit Managers (UM)/Designee will conduct observations to ensure all licensed nurses are taking B/P and the licensed nurse is completing the dialysis communication sheets POST dialysis daily across all shifts.
- Results of observations will be reported by the Unit Manager (UM)/designee monthly to the Quality Improvement Committee (QIC) for any additional follow-up and or in-servicing until the issue is resolved, then randomly thereafter as determined by the QIC committee.
Duplicate Medication Administration Error in LTC Facility
Penalty
Summary
The facility failed to ensure that four residents were free from significant medication errors. On a specific date, these residents were administered their 8:00 AM medications twice due to incomplete medication administration documentation. This error occurred because an LPN, unfamiliar with the unit, attempted to pass the medications for the 8:00 AM med pass without realizing that she had not changed the shift time on her Medication Administration Record (MAR) to the correct med pass time. This led to the administration of duplicate doses of medications, which could have had adverse consequences for the residents involved. Resident #69, a man with a history of dementia, personality disorder, anxiety disorder, depression, alcohol abuse, congestive heart failure, atrial fibrillation, hyperglycemia, hypertension, and peripheral vascular disease, received duplicate doses of medications including Amlodipine, Metoprolol, Seroquel, Eliquis, and Divalproex. These medications could cause adverse effects such as hypotension, bradycardia, heart block, and increased risk of bleeding. Despite the potential risks, the resident's vital signs remained stable, and he did not experience any changes in mental status following the medication error. Resident #74, who had severe cognitive decline and a history of dementia, COPD, convulsions, cerebrovascular disease, traumatic hemorrhage of the cerebrum, hemiplegia/hemiparesis, bipolar affective disease, and anxiety disorder, was also affected. The resident received duplicate doses of medications such as Paroxetine, Potassium chloride, and Risperdal, which could lead to somnolence, elevated potassium levels, and hypotension. However, the resident remained stable with no changes in vital signs or mental status. Similarly, Resident #39 and Resident #108, both with complex medical histories, were administered duplicate doses of their medications, leading to emergency room evaluations. Despite the potential for serious adverse effects, both residents returned to the facility without significant changes in their conditions.
Removal Plan
- The licensed nurse conducted a change in condition with notification to the medical provider for all residents who received duplicate medication.
- The Nurse Practice Educator conducted an audit of all licensed nurses' medication administration competencies to ensure all licensed nurses are competent with medication administration with any correction action immediately upon discovery.
- The Unit Managers/designee conducted an audit for all residents' medication administration records to ensure free from medication errors with any corrective action immediately upon discovery.
- Re-education was provided by the Director of Nursing (DON)/Designee to all licensed nurses on safe medication administration practices including verification of correct patient, drug, route, dose, time, special consideration, and expiration date with a Post-test to validate understanding.
- Any licensed nurses not available during this time frame will be provided re-education, including post-test and return demonstration by DON/designee prior to the beginning of the next shift to work.
- New Licensed nurses will be provided education, including post-test during orientation by the DON/designee.
- Annual in-servicing will be provided to licensed nurses regarding medication administration.
- The Unit Managers (UM)/Designee will conduct observations to ensure all licensed nurses are passing medications according to Genesis medication administration policies including verification of right patient, drug, route, dose, time, special considerations, and expiration dates across all shifts including weekends and holidays, then 5 times a week, then 3 times a week, then randomly thereafter.
- Results of observations will be reported by the Unit Manager (UM)/designee to the Quality Improvement Committee (QIC) for any additional follow-up and or in-servicing until the issue is resolved, then randomly thereafter as determined by the QIC committee.
Dysfunctional Door Lock Leads to Resident Elopement
Penalty
Summary
The facility failed to maintain a safe environment for its residents by having a dysfunctional magnetic lock on the French doors leading to the outside through the activities office. This malfunction exposed residents to potential hazards, as the doors could be opened without triggering an alarm, which is supposed to alert staff to unauthorized exits. The issue was identified when a resident with severe cognitive deficits, as indicated by a Brief Interview for Mental Status (BIMS) score of 3, managed to elope from the facility. The resident was found outside by an EMS team and was unable to explain how she exited the building. The resident involved in the incident had been admitted for long-term care due to dementia, which rendered her family unable to provide adequate care. On the day of the elopement, the door leading into the activities office from the residents' hallway was left open, allowing the resident access to the French doors. These doors were not locked and lacked a wander guard alarm, which would have been crucial in preventing the resident from leaving the facility unsupervised. Interviews with the facility's staff, including the Administrator and the Maintenance Director, revealed that the magnetic lock system on the French doors was faulty. The system incorrectly indicated that the doors were locked even when they were not, due to a gap between the magnets. This failure in the locking mechanism, combined with the absence of a wander guard alarm, created a significant risk for residents, particularly those identified as wanderers, of which there were seven in the facility at the time.
Removal Plan
- Resident #58 was returned to the center and was re-assessed by the licensed nurse with no injuries identified.
- An updated wandering observation tool, pain observation tool, and fall risk observation tool were completed by the licensed nurse.
- Family and provider were notified.
- A full-scale elopement drill was completed with headcount with no additional concerns identified.
- The event was reported to OHFLAC.
- Signage was placed on the doors to ensure the staff made sure the door was fully secure.
- Three additional elopement drills were completed with staff education to validate staff response.
- All-staff education was started to include: Door is to be closed all the way so magnetic lock engaged. The door deadbolt is to be locked when no one is present in activities. Door is not to be used as an exit/egress by staff. Activities office door is to remain closed at all times unless there is a staff member in the activities room.
- A deadbolt lock was installed on the door.
- An activities aide/designated staff member was placed at the French doors in the activities room to monitor the doors with instruction that no one was to use the courtyard door to enter or exit the building as unintended egress.
- A keyed deadbolt was added to the Activities' French doors by the center maintenance director, verified by the Mobile ED to be securely closed to prevent residents from exiting the facility without supervision.
- A supplemental door open alarm was placed on the French doors, and verified to be functioning correctly by the center maintenance director.
- The activities aide/designated staff member is assigned to monitor the activities French doors until a self-closure device is installed on the door and to ensure the door appropriately closes and the maglock engages, with verification to be working appropriately by maintenance director.
- The supplemental door open alarm will remain in place until it is established that the magnetic lock on the French doors is correctly functioning with a self-closure device by the center maintenance director.
- If the magnetic lock cannot be repaired to manufacturer specifications it will be replaced and the supplemental door open alarm will remain in place until that time.
- An audit of all facility exiting doors was conducted to ensure all doors were securely latched, opening alarms were functioning properly and that self-closure devices are properly functioning with no additional findings of concern.
- An elopement drill was conducted by the center maintenance director and no additional concerns were noted.
- All staff present in the building are immediately being re-educated to not use the activities French doors to enter and exit the building and that the door will only be used for center specific activities when activities/designated staff are present for the duration of the activity with a door monitor assigned.
- All-staff not present will be educated upon return to work.
- Daily, maintenance will perform an audit to ensure all exit door self-closers and their magnetic locking components are working correctly and that the door is secured.
- The center maintenance director will immediately report findings of concern to the center administrator.
- Results of audits will be reported in the monthly Quality Assurance and Process Improvement meeting by the Center Maintenance Director for follow-up and in servicing needs to ensure compliance.
Dishwasher Temperature and Refrigerator Monitoring Deficiencies
Penalty
Summary
The facility failed to adhere to the manufacturer's instructions regarding the dishwasher temperature, which is crucial for maintaining a safe and sanitary food service environment. Observations and facility records revealed that the dishwasher was operating at temperatures significantly below the required levels since April 2024. Specifically, the wash and rinse cycles were both running at 110 degrees, whereas the operating manual specified a minimum of 120 degrees, with a recommended temperature of 140 degrees. An observation on June 3, 2024, confirmed that the dishwasher was only reaching 100 degrees. The Maintenance Director acknowledged awareness of the issue since April 2024 but indicated that the facility did not own the dishwasher, and the leasing company would need to address the malfunction. Additionally, the facility failed to monitor the temperature of a personal refrigerator in a resident's room, as there was no evidence of temperature checks being conducted per protocol. A CNA confirmed the absence of a temperature sheet for the refrigerator and expressed uncertainty about the procedure for ensuring daily temperature checks. A new order was placed in the electronic medical record on June 3, 2024, directing daily temperature checks to begin the following day. This oversight in monitoring refrigerator temperatures could potentially impact the safety and quality of food storage for the resident.
Removal Plan
- Dishwasher was taken out of use. Regional Maintenance Director contacted EcoLab for dishwasher service.
- Whole house audit completed by Director of Nursing/designee to ensure all plates, utensils and water pitchers were taken out of resident's rooms and not in use.
- All staff will be educated to use paper products for any food or fluid services until the dishwasher is repaired and working at recommended temperatures. Meal service and fluid pass will be observed three times a day to ensure disposable paper products are being used for residents until dishwasher is serviced by Ecolab. Once dishwasher is serviced, staff will be re-educated on manual instructions and machine operations, who to report to when systems are out of range and maintenance to escalate when needing service. Pots/pans and cooking utensils will continue to be cleaned and sanitized via three sink/compartment method.
- Nursing Home Administrator (NHA)/designee will bring results of audits to Quality Improvement Committee (QIC) for review monthly for any additional follow-up and/or in servicing until the issue is resolved and randomly thereafter as determined by QIC.
Failure to Prevent Abuse and Neglect in LTC Facility
Penalty
Summary
The facility failed to prevent abuse and neglect of residents, as evidenced by several incidents involving different residents. One resident, who was dependent on staff for wheelchair mobility, was left outside unattended in the facility courtyard following a smoking break. This resident reported being left outside alone on multiple occasions, unable to reenter the facility independently due to tremors and a history of falling from the wheelchair. The resident was left in the hot sun for an extended period without a means to notify staff, which was confirmed by a grievance form and medical records. Additionally, the facility failed to protect residents from verbal threats made by two other residents. One resident, with a history of paranoid schizophrenia, depression, and unspecified dementia, made several aggressive and threatening statements towards other residents and staff. These incidents were documented in the resident's progress notes, but there was a lack of proper notification to the physician and resident representatives, and the resident had not seen a psychiatrist as ordered. Another resident was reported to have verbally abused and threatened another resident, causing significant distress and anxiety. The facility's failure to address these issues placed residents in immediate jeopardy, as determined by the state agency. The incidents involving verbal threats and neglectful supervision of residents with mobility issues highlighted significant deficiencies in the facility's ability to protect residents from abuse and neglect.
Removal Plan
- Certified nursing aid suspended pending investigation. Administrator suspended pending investigation. Incident involving resident #29's allegation of being left outside in the sun for extended period reported to APS, Ombudsman and OHFLAC. Head to toe assessment performed on resident #29 to ensure no adverse effects. Incidents involving verbal threats by resident #61 reported to APS, OHFLAC and ombudsman. Resident #61 placed on one-on-one observation until see and cleared by psychiatric services. Incident involving Resident #11 allegation of verbal abuse reported to APS, OHFLAC and Ombudsman. Psychosocial follow up provided for resident #86. Resident #11 continues to follow with psych services as ordered.
- All residents residing in the facility have the potential to be affected. All capable residents will be interviewed to ensure no other allegations of abuse and all residents not able to be interviewed will have skin checks to ensure no sign or symptoms of abuse with corrective action immediately upon discovery. Whole house audit completed on residents having behaviors and ordered psychological services to ensure services provided with corrective action upon discovery.
- All staff will be re-educated on identifying, reporting, and preventing abuse or upon return to work. All staff will be re-educated on smoking policy to include staff supervising and assisting residents out and in during designated smoking times or upon return to work. Daily rounding audits completed by department heads regarding abuse and neglect concerns or transportation to and from smoking concerns with correct action immediately upon discovery.
- Nursing Home Administrator (NHA)/designee will bring results of audits to Quality Improvement Committee (QIC) for review monthly for any additional follow up and/or in-servicing until the issue is resolved and randomly thereafter as determined by QIC.
Facility Fails to Secure Hazardous Materials and Implement Fall Prevention
Penalty
Summary
The facility failed to maintain a safe environment by leaving the Central Supply room door open and the cabinet inside unlocked, exposing residents to potentially hazardous materials. During an observation, it was noted that the door to the Central Supply room was left open, and staff members did not take action to close it. Inside the room, various hazardous items such as disposable razors, rubbing alcohol, iodine prep solution, and syringes with needles were accessible to residents. This situation posed a significant risk to residents, particularly those identified as wanderers, who could potentially access these dangerous items. Interviews with staff revealed a lack of awareness and adherence to safety protocols. A nurse aide expressed uncertainty about whether the door was usually left open, while a licensed practical nurse suggested that maintenance might have left it open. The nurse also mentioned that the cabinet containing needles was likely left unlocked due to a nurse being distracted by other staff. This indicates a breakdown in communication and responsibility among staff members, contributing to the unsafe environment. Additionally, the facility failed to implement adequate fall prevention measures for a resident at risk of falls. Observations showed that fall mats were obstructed by furniture, and a bed alarm was not properly connected, rendering it ineffective. This oversight further highlights the facility's failure to ensure resident safety, as the necessary interventions to prevent falls were not consistently applied or monitored.
Removal Plan
- The administrator ensured that all razors, needles, scalpels, medicated powders, creams, and any other solution if consumed could be harmful was moved from the Central Supply Room to the East Wing Medication Room. All staff were informed that the items were relocated and even though those items are being placed elsewhere the Central Supply Room door is to remain closed at all times and locked.
- Video footage with full view of the Central Supply Room door was reviewed to ensure no residents entered the room for potential to have consumed any toxic substance with any corrective action immediately upon discovery.
- The administrator completed an in-service for all staff to ensure they are aware that the Central Supply Room door is to remain closed and locked at all times and the new location of the potentially harmful substances in the East Wing Medication Room. All staff will be in-serviced prior to their next shift, and virtually if need be.
- The Administrator will ensure adherence to the Keeping Residents Free from Potentially Harmful Substances and Items Policy and Procedure, ensure that staff keep all doors locked and all substances out of reach as appropriate. A monitoring log will be completed to ensure that all doors with locks are locked and all potentially harmful substances are kept in a safe area out of residents reach daily for 30 days, weekly for one month, and quarterly thereafter. To ensure continued compliance, the monitoring log will be re-evaluated at the Quarterly and Quality Assurance meeting.
Failure to Ensure Resident Safety During Fire and Drug Use Incidents
Penalty
Summary
The facility failed to ensure the resident environment remained as free of accident hazards as possible and that each resident received adequate supervision and assistance to prevent accidents. A structure fire resulted in the activation of the facility fire alarm system, but the staff did not begin evacuation after seeing smoke and hearing the fire alarm. A total of 18 minutes elapsed from the time the fire alarm activated and the time the facility began to evacuate, which only occurred after being instructed by emergency responders. This failure to follow the Fire Safety plan placed all residents at risk for serious bodily harm and/or death, creating an immediate jeopardy situation. Additionally, two residents were found using illegal substances, including opiates that were not prescribed, within the facility. These residents required Narcan due to overdose. The facility failed to take steps to protect other residents from the illegal drugs, exposing them to potential hazards. The residents involved had a history of substance abuse, and there were multiple instances where they left the facility unsupervised and returned under the influence of drugs. The facility did not adequately monitor or investigate these incidents, nor did they ensure the safety of other residents and staff. Interviews with staff revealed confusion and lack of training regarding the fire evacuation procedures. Staff members thought the fire alarm was a drill and did not take immediate action to evacuate residents. The Assistant Fire Marshall expressed concern over the facility's failure to evacuate upon sight of smoke, noting the potential for a complete disaster. The facility's policy on resident substance abuse was not effectively implemented, as evidenced by the repeated drug use incidents and the lack of proper investigation and protection for other residents. The facility's inaction in both the fire and drug use incidents placed all residents at immediate risk for serious harm or death.
Removal Plan
- All residents were interviewed for potential post event trauma by the Director of Nursing and designees. There were no negative findings with residents. All Responsible Parties were notified via a Caller Multiplier.
- All residents have the potential to be affected by the deficient practice. All staff were educated on the facility Fire Safety/Evacuation Plans to include triage evacuation and Disaster Response Coordinator by the Maintenance Director and RN Staff Educator.
- The Maintenance Director or designee will facilitate Facility Fire Drills weekly times two weeks, bi-weekly times two weeks then monthly to cover all shifts within a quarter with any Corrective Actions immediately upon discovery.
- Findings regarding the observations of Facility Fire Drills will be presented by the Director Nursing or designee in the Monthly Quality Assurance meeting for continued compliance as evidenced by meeting minutes.
- All residents with a diagnosis of illicit drug use were reviewed and assessed for signs and symptoms with no findings.
- All residents who have the potential to come into contact with illicit drug use while in the facility have the potential to be affected. DON/Designee will initiate all staff education on observing for signs and symptoms of being under the influence of drugs. In the event of occurrence, order will be on MAR to observe all residents for being under the influence of drugs.
- Residents will be monitored every 12 hours for 72 hours unless additional monitoring is deemed necessary.
- If staff visually notice any drugs or patients impaired this will be reported immediately to their supervisor.
- Staff educated not to touch drugs and for residents receiving Narcan will have increased observation until the resident is transported to an acute care facility.
- The facility will request a toxicology report prior to the resident returning to facility.
- Facility will notify local law enforcement and initiate an internal investigation.
- Resident will be educated on substance abuse and staff will attempt to provide substance abuse counseling.
- Center will update CP and educate the resident if found to be a repeat offender will be subject to further actions.
Failure to Prevent Physical Restraint and Abuse
Penalty
Summary
The facility failed to ensure that residents were free from physical abuse, as evidenced by two incidents involving physical restraint. In the first incident, a nurse aide held the head of a resident while a registered nurse performed a nasal swab for COVID testing. Multiple staff members and a resident witnessed the event, confirming that the resident was restrained against her will. Despite these accounts, the facility's investigation deemed the incident unsubstantiated, and the involved staff members remained employed without immediate corrective action. In the second incident, a resident became agitated, and a nurse locked the resident's wheelchair and physically held it to prevent the resident from leaving the room. This action was reported as possible involuntary seclusion. The facility's investigation again found the allegation unsubstantiated, despite statements from staff members who witnessed the event. The facility conducted an in-service training on abuse and neglect but did not take further immediate action against the involved staff. Both incidents placed the residents and others at risk for serious harm, as the facility did not take adequate measures to prevent future occurrences. The facility's failure to substantiate the allegations and take appropriate action contributed to an immediate jeopardy situation for all residents, highlighting a significant deficiency in ensuring resident safety and compliance with regulations regarding physical restraints.
Removal Plan
- Employee(RN) #40 will have extensive abuse and neglect training by the Regional Team Member.
- Employee (NA) #55 will have extensive abuse and neglect training by the Regional Team Member.
- Residents with BIMS scores of 12 and above were interviewed for potential physical abuse.
- Residents with BIMS scores of 11 or below had a skin assessment completed for potential physical abuse.
- Staff will be reeducated on the Abuse, Neglect, and Misappropriation Policy through in person, text blast will be physically educated with signatures. The training will be conducted by the Regional Team Member.
- There will be training for all staff on Resident Rights including the right to be free from any physical restraints imposed for purposes of discipline or convenience and not required to treat the resident medical symptoms. The training will be conducted by the Regional Team Member.
- Staff will be reeducated on restraint alternatives.
- There will be a team review of all reportable events to determine if physical abuse occurred, per state definitions. The team will include Social Services, Director of Nursing or Designee, and Executive Director.
- Audits will be conducted by the regional Director of Clinical Operations with correction upon discovery.
- Audit results will be reviewed by the QAPI Committee.
Delayed CPR Initiation Due to Lack of Code Status Documentation
Penalty
Summary
The facility delayed initiating Cardiopulmonary Resuscitation (CPR) for a resident who was found unresponsive with no pulse or respirations. The resident's medical record did not contain documentation of their code status or advance directives, which led to confusion among the staff about whether to initiate CPR. The standard of care dictates that in the absence of an advance directive, CPR should be administered. However, CPR was not initiated until 34 minutes after the resident was found unresponsive. The incident involved a resident with multiple medical conditions, including noninfective gastroenteritis, type 2 diabetes mellitus, and a malignant neoplasm of the esophagus. The resident was found unresponsive by a Certified Nursing Assistant (CNA) at approximately 6:45 AM, and the staff noted that the resident was still warm to the touch. Despite this, the Registered Nurse (RN) on duty did not initiate CPR immediately, citing uncertainty about the resident's code status and waiting for instructions from the Director of Nursing (DON). The delay in initiating CPR was compounded by the lack of a Physician Order for Scope of Treatment (POST) form in the resident's medical record. The RN on duty attempted to contact the resident's next of kin and the attending physician but did not proceed with CPR until instructed by the DON at 7:19 AM. Emergency medical personnel arrived shortly after and took over the code, but the resident was pronounced dead at 7:55 AM.
Removal Plan
- The Director of Nursing (DON/Designee) conducted an audit for all residents to ensure all residents had a code status listed in the Physician Orders.
- The DON conducted an audit for all licensed nursing staff including any non-licensed nursing personnel to validate their current Cardiopulmonary Resuscitation (CPR) certification with corrective action immediately upon discovery.
- Re-education was provided by the DON/Designee to all licensed nurses to ensure if there is no order for code status in the resident chart the resident is considered a full code and CPR to be initiated and documented on the CPR/AED flow sheet with a posttest to validate understanding.
- Any licensed nurses not available during this time frame will be provided re-education, including post-test during orientation by the DON/Designee.
- The unit managers (UM)/designee will monitor new admission/readmissions and/or change in resident advance directives order to ensure the resident has an order for code status and the CPR/AED flowsheet is utilized for all CPR daily including weekends and holidays, then five times a week, then three times a week then randomly thereafter.
- The nurse Practice Educator (NPE)/designee will conduct mock code drill daily across all shifts, then weekly, then monthly, then randomly thereafter.
- Results of monitors will be reported by the Director of Nursing (DON)/designee to the Quality Improvement Committee (QIC) for any additional follow up and or in servicing until the issue is resolved, then randomly thereafter as determined by the QIC committee.
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