Citations in West Virginia
Statistics, citations and compliance trends for long-term care facilities in West Virginia.
Statistics for West Virginia (Last 12 Months)
Financial Impact (Last 12 Months)
Compliance trends in West Virginia
Data through Mar 2026Comparisons below measure the most recent period Apr 2025 – Mar 2026 against the prior period Apr 2024 – Mar 2025 (two equal 12-month windows). The most recent 1 months are excluded because CMS is still publishing them.
Top tags by month · last 24 months
dashed = still reportingMonthly citation counts for the 5 most-cited tags. The dashed tail is the 1-month reporting lag.
Frequency movers
Biggest change in how often each tag is cited, as a rate per 100 inspections (so it isn't skewed by survey volume): Apr 2025 – Mar 2026 vs the prior period Apr 2024 – Mar 2025. Only tags with at least 20 citations in both periods are shown.
Severity movers
Tags whose average scope/severity shifted the most: Apr 2025 – Mar 2026 vs the prior period Apr 2024 – Mar 2025. The number is the average severity on the A–L scale (A=0…L=11); the letter is the band it falls in. A rise means the same tag is being cited at a more serious level — note the average can move enough to rank here while staying within the same letter. Same 20-citation minimum applies.
Care domain movers
Citations grouped into CFR care domains — F-tags by their §483 regulatory section (CMS State Operations Manual, Appendix PP) — measured as a rate per 100 inspections: Apr 2025 – Mar 2026 vs the prior period Apr 2024 – Mar 2025. Share is the domain's portion of citations this period; avg severity is the mean scope/severity letter and immediate jeopardy the percentage cited at J–L, both over the current period. Domains with at least 20 citations in both periods are shown; the sparkline tracks the last 12 months (left = oldest).
Immediate jeopardies · this period
Citations at the most serious scope/severity — J–L, immediate jeopardy, residents placed at risk of serious harm or death — over Apr 2025 – Mar 2026 vs the prior period Apr 2024 – Mar 2025. "Surveys with an IJ" counts distinct health inspections that had at least one.
Survey activity · by month
faded/dashed = still reportingCitations each month split into complaint-driven (unscheduled, triggered by grievances) vs standard surveys — bars, left axis — with the number of inspections as a line on the right axis. Rising inspections signal more scrutiny; a rising complaint share means more off-cycle surveys. The most recent 1 months are still being reported.
Deficiency-free survey rate
Share of health surveys that found zero deficiencies — the odds of a clean survey. Apr 2025 – Mar 2026 vs the prior period Apr 2024 – Mar 2025; the most recent 1 months are still being reported (dashed).
Penalties · by month
faded = still reportingTotal civil money penalty dollars imposed on the state's facilities each month — how hard the state is enforcing. The most recent 1 months are still being reported, and penalties often lag citations by several months.
Emerging tags
Tags that weren't established last period but surged — an early warning, distinct from movers (which track already-common tags). Criteria: fewer than 20 citations in the prior period, but at least 10 this period and 2.5× their prior volume. The sparkline shows monthly counts over the last 12 months (left = oldest).
Latest Citations in West Virginia
The facility failed to prevent accident hazards and adequately supervise residents when two residents obtained cannabis gummies and CBD products via DoorDash, kept them in a bedside box with vape pens and OTC medications, and offered gummies to another resident, resulting in altered mental status, red eyes, paranoia, and ER transfers without a documented thorough investigation by administration. In a separate incident, a resident with decision-making capacity reportedly used a vape in a room with an active oxygen concentrator and refused a room search, leaving a potential fire hazard unresolved. Additional observations showed that a resident care planned for bilateral fall mats was in bed with one mat propped against the wall instead of on the floor, and another high-fall-risk resident was in bed with the bed not in the lowest position as required by the care plan, with staff confirming these fall-prevention interventions were not in place.
Two residents were not protected from neglect when one was left overnight in a soiled brief despite requests for incontinence care, resulting in raw, excoriated skin to the sacrum and scrotum, and another was served a grilled cheese sandwich despite an order for a mechanical soft diet, causing coughing before the tray was replaced. Staff interviews and documentation confirmed that the first resident had not been changed during the night and that prior skin assessments showed no issues, while the second resident’s diet order and the facility’s nutrition manual identified grilled sandwiches as inappropriate for a mechanical soft diet; neither incident was entered into the facility’s reportables or grievance systems.
The facility failed to accurately post daily nurse staffing information, with incorrect dates, unclear corrections, and mismatched total hours worked on most reviewed days. The daily staffing sheet was not readily visible on entry and, when located, contained multiple discrepancies between posted staffing and actual time-punch records. During one night shift, the posted sheet listed more LPNs and NAs than were actually present, with one NA found sleeping and another conducting personal business on a laptop in the breakroom, while one NA was assigned 1:1 to a resident, leaving two NAs to care for the remaining residents. These issues were confirmed through record review, observation, and staff interviews.
The facility failed to ensure adequate nursing staff on all shifts, leading to prolonged call light response times and unmet care needs. Multiple residents reported waiting from 45 minutes to several hours for assistance, including toileting and incontinence care, and described staff leaving the floor during smoke breaks and meal tray pass, leaving minimal coverage. Staffing records showed nursing HPPD below required minimums on at least one reviewed day, and an external report flagged low weekend staffing. One resident reported being left overnight in a soiled brief while having diarrhea, later found with raw, red skin to the sacral and scrotal areas, and this incident was not documented as a grievance or reportable event. A night-shift observation also revealed fewer staff on duty than posted, with one NA sleeping and another conducting personal business, while only two NAs were left to care for more than fifty residents.
Surveyors found that residents were not provided a way to file anonymous grievances and reported fear of retaliation for making complaints. During a Resident Council meeting, multiple residents stated they had no anonymous grievance option and felt their concerns raised in council were not taken seriously. The Social Worker confirmed there was no anonymous grievance mechanism and that residents and families had to request grievance forms from nursing or department heads, despite a written policy stating that residents and representatives have the right to file grievances orally or in writing and that staff will make prompt efforts to resolve them.
Two residents did not receive care according to physician orders and professional standards. One resident with a documented right hand contracture had orders and a care plan directing splinting of the left, functional hand, and surveyors observed the contracted right hand tightly fisted without a splint in place; the OT and DON later confirmed the order should have been for the right hand. Another resident with an order for Humalog Kwikpen requiring the provider to be called for blood sugar (BS) readings over 400 had multiple BS values above 400 documented on the MAR, but there was no documentation that the provider was notified on those occasions, which was confirmed by an RN consultant.
Surveyors identified multiple failures to follow food safety and sanitation policies, including soiled food service equipment, outdated and improperly labeled food items, and inadequate documentation of manual ware washing procedures. Personal items such as employee coats were stored on bread racks, and trash bins were placed on the same shelves as milk containers on beverage carts used for residents. These observations showed that staff did not consistently maintain clean food preparation areas, properly label and date TCS foods, or separate trash and personal belongings from food and food-contact surfaces.
The facility did not follow its own food safety and sanitation policies requiring trash to be contained in covered, leak-proof containers. During a kitchen walkthrough with the Director of Dining Services (DDS), a surveyor observed an uncovered trash can next to the juice machine and another uncovered trash can in the dish room. The DDS confirmed that these trash receptacles lacked lids, contrary to Healthcare Services Group (HCSG) policies that require the DDS to ensure appropriate lids are provided for all containers.
Two residents reported and staff observed sexually inappropriate behavior by a male resident, including entering a resident’s room uninvited while naked from the waist down and pulling on her in bed, and placing his hands under another resident’s blanket and rubbing near and on her private area. Both residents described the contact as unwanted, and one was documented as cognitively intact with capacity. Despite staff corroboration and resident statements to clinical providers, the facility’s investigations concluded that sexual abuse was not substantiated, citing lack of physical harm and inconsistent statements, and failed to adequately assess or address whether the residents felt safe or to alleviate their expressed anxiety.
The facility failed to ensure food was palatable, attractive, and maintained at a safe and appetizing temperature, as shown by tray temperature checks and interviews with several residents and staff. At lunchtime, kitchen staff were not taking or recording temperatures for items on the always-available menu, including beef patties, hotdogs, and brown gravy, before meal service began. The DDS acknowledged that temperatures for these always-available menu items were not being monitored or documented.
Failure to Control Resident Access to Non-Prescribed Substances and Implement Fall-Prevention Measures
Penalty
Summary
The facility failed to maintain an environment as free from accident hazards as possible and did not provide adequate supervision to prevent accidents, particularly related to resident access to non-prescribed substances and implementation of fall-prevention measures. An anonymous resident reported that two female residents purchased cannabis gummies via DoorDash and offered them to another resident, who refused. These two residents were later sent to the hospital after one was noticeably impaired. Record review showed no investigation documented in the facility’s reportable or grievance logs regarding these residents’ changes in condition due to cannabis gummies being brought into the facility and offered to other residents. Nursing documentation for one of the involved residents described a change in condition with altered mental status, suspicion of substance abuse, and tachycardia, leading to transfer to the ER for evaluation and toxicology screening. A late-entry note indicated the resident was educated on facility policies prohibiting OTC medications and CBD products in the room. Another nursing note detailed that a CNA reported a resident had consumed a gummy given by another resident, then discarded the second gummy, which the CNA retrieved from the trash. On assessment, the resident was found lying in bed with reddened eyes, reporting feeling tired, and vital signs were obtained. The resident stated she had consumed “pot gummies” and allowed the nurse to inspect a wooden box at the bedside, which contained several red sugar-coated gummies, three vape pens (including a suspected CBD vape pen), a bottle of Benadryl, and several Imodium tablets. The resident reported purchasing the gummies and CBD vape pen from DoorDash, and the items were removed with her consent. Further documentation showed that another nurse was informed that two residents had consumed an unknown gummy-like substance. On assessment, one resident had very red eyes and reported feeling paranoid, with vital signs recorded. This resident stated she had received two gummies from another resident and that a third resident knew about the gummies. The nurse interviewed the third resident, who reported that the resident supplying the gummies had told her she had gummies and THC pens and planned to give gummies to another resident. The nurse also noted that as staff were going to check on the resident who supplied the gummies, a DoorDash delivery person arrived and handed a bag to the nurse containing a pack of cigarettes and a receipt showing two CBD purchases. Facility administration had no evidence that a thorough investigation into this incident had been completed, and only limited action was taken following the event, leading surveyors to identify an immediate jeopardy situation due to residents being susceptible to drug abuse from other residents. The facility also failed to address other accident hazards and fall-prevention interventions for additional residents. One resident, who had capacity to make her own medical decisions, was involved in an incident where she reportedly used a vape in her room while an oxygen concentrator was present and turned on. The resident was verbally educated by the Administrator about the dangers of vaping near oxygen equipment, the smoking policy requiring smoking paraphernalia to be stored by nursing staff, and the prohibition of vaping inside the facility. However, during the survey period it remained unknown whether the resident still had vape pens in her possession, and she refused a room search, leaving a possible serious fire hazard unresolved at the time of review. In separate observations related to fall prevention, one resident was observed lying in bed with a fall mat that was supposed to be in place on the floor instead leaned against the wall behind the headboard. Record review confirmed the care plan required fall mats on both sides of the bed while the resident was in bed, and an LPN acknowledged that the floor mat was not in place. Another resident, care planned as at risk for falls due to multiple factors including muscle weakness, cognitive impairment, incontinence, psychoactive medication use, recent hospitalizations, visual impairment, and a history of traumatic brain injury and multiple CVAs, was observed lying in bed with the bed not in the low position despite a care plan intervention specifying that the bed should be in the lowest position. A RN consultant confirmed that the bed was not in the lowest position while the resident was in bed.
Failure to Prevent Neglect in Incontinence Care and Diet Texture Management
Penalty
Summary
The deficiency involves failure to protect residents from neglect by not providing timely incontinence care and by not providing the correct diet texture. One resident reported during interview that he had been left overnight without his brief being changed while experiencing diarrhea, despite requesting to be changed. Two CNAs separately stated that when they saw the resident the following morning, he reported not having been changed all night, that aides had come in only to change his roommate and then left, and that his skin was "raw," "pretty bad," and red. Both CNAs reported the condition of his skin to an LPN, and an order was written later that day for wound care to excoriated sacrum and scrotum every shift. Prior skin assessments from earlier in the month documented no issues to the sacrum or scrotum, and the incident was not found in the facility’s reportables or grievances. The Administrator confirmed that, if accurate, this situation would constitute neglect under the facility’s abuse policy, which defines neglect as failure to provide necessary goods and services to avoid physical harm, pain, mental anguish, or emotional distress. A second deficiency concerns failure to provide the correct food texture to another resident who had an active diet order for mechanical soft texture. Progress notes document that this resident was served a grilled cheese sandwich on a dinner tray, which she began to eat before an NA noticed and removed the tray. The resident coughed a few times and then was fine, and the NA obtained another tray with food the resident could eat without problem. The resident’s diet order specified mechanical soft foods, and the facility’s Diet and Nutrition Care Manual lists grilled sandwiches as foods to avoid on a mechanical soft diet. A nurse consultant later confirmed that this incident occurred as documented and that it was not reported.
Failure to Accurately Post Daily Nurse Staffing Information
Penalty
Summary
The deficiency involves the facility’s failure to accurately post daily nurse staffing information in a prominent, accurate manner as required, with inaccuracies identified on 22 of 23 reviewed days. Upon surveyor entrance, the daily nurse staffing sheet was not readily visible and was ultimately located on a wall near the nurse’s station. Review of posted staffing sheets and time punch detail reports revealed multiple discrepancies, including incorrect dates on several postings and numerous errors in the total hours worked for various dates. On some days, corrections were written over original entries, making it impossible to clearly determine the actual number of nurse aides working or the correct total hours. In several instances, the posted total hours did not match the actual hours worked as shown on time detail reports, with both understatements and overstatements of staffing hours documented. During a nighttime observation, the posted staffing sheet listed two LPNs, three NAs, and zero RNs on duty, but a visual count showed only one LPN and two NAs actually present, with no RN. One NA was found sleeping on duty upon arrival, and another NA was in the breakroom with a makeshift office setup using a table, laptop, battery charger, and large rolling briefcase. It was later learned that one NA was assigned 1:1 to a resident, leaving two NAs to cover the remaining 56 residents. When questioned, an LPN stated that another LPN listed on the staffing sheet had called in sick due to pregnancy. These observations and documentation reviews were discussed with the Regional Director of Operations and an RN consultant, confirming that the posted staffing information did not accurately reflect the actual staffing levels and hours worked on multiple dates.
Insufficient Staffing Leading to Delayed Care and Resident Neglect
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff on all shifts to meet residents’ needs, resulting in delayed responses to call lights and inadequate incontinence care. During a resident council meeting, multiple residents reported waiting 1–3 hours for call lights to be answered, with staff sometimes stating they would return but not coming back for hours, and some residents reporting staff said they had been outside smoking with a resident. Individual resident interviews corroborated these concerns, with residents stating that night shift took a long time to answer call lights, that it could take 45 minutes to an hour or more to receive assistance, and that staff would delay changing residents during meal tray pass or after a scheduled smoke break when most aides and a nurse accompanied residents outside, leaving only one nurse to cover the floor. Staffing record reviews for specific dates showed Hours Per Patient Day (HPPD) below the minimum required 2.25 on at least one day, and the facility’s CASPER report triggered for low weekend staffing. A specific incident of neglect was identified for one resident who reported being left overnight in a soiled brief while experiencing diarrhea, despite requesting to be changed. Two CNAs independently stated that when they saw this resident the following morning, he reported not having been changed all night, and both described his skin as raw, bad, and red; one CNA stated she had changed him the previous day and that he reported no changes overnight, and both CNAs reported the condition to an LPN, who then notified an RN, leading to a wound care order for excoriation to the sacrum and scrotum. Prior skin assessments earlier in the month showed no issues in those areas, and the incident was not documented in reportables or grievances. Additionally, a night-shift observation found a discrepancy between the posted staffing sheet and actual staff present: the sheet listed two LPNs, three NAs, and no RNs, but only one LPN and two NAs were observed, with one NA found sleeping on duty and another engaged in personal business on a laptop, while a third NA was assigned 1:1 to a resident, leaving two NAs to cover 56 other residents. The administrator confirmed that the described incontinence incident would constitute neglect if accurate.
Failure to Provide Anonymous Grievance Process and Protect Residents From Fear of Retaliation
Penalty
Summary
Surveyors identified that the facility failed to honor residents’ rights to voice grievances without fear of reprisal and to provide a method for anonymous grievance submission. During a Resident Council meeting attended by 11 residents, residents reported they had no way to file an anonymous grievance, did not want to report complaints due to fear of retaliation, and felt that concerns raised in Resident Council were not taken seriously. An interview with the Social Worker confirmed there was no method for anonymous grievances and that residents and family members had to request a grievance form from a nurse or department head. Review of the facility’s Grievances/Complaints policy showed that residents and their representatives have the right to file grievances orally or in writing with facility staff or the designated agency, and that the Administrator and staff will make prompt efforts to resolve grievances, but the facility’s actual practice did not provide an anonymous option or alleviate residents’ fear of retaliation. This deficiency involved at least one identified resident (Resident #22) and the broader resident group, who reported barriers to exercising their grievance rights and lack of confidence that their concerns raised in Resident Council would be addressed, in contrast to the facility’s written grievance policy.
Failure to Follow Splinting and Blood Glucose Notification Orders
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards and physician orders for two residents. For one resident with a documented right hand contracture, surveyors observed that the right hand was tightly fisted and that no splinting device was in place. Record review showed active orders to apply and remove a splint to the left hand every night shift for mobility, and the care plan directed left hand splinting as ordered, despite the medical record listing a diagnosis of a right hand contracture. During interviews, the occupational therapist confirmed the splinting order should have been for the right hand, and the Director of Nursing confirmed that both the orders and care plan were written to place a splint on the resident’s functional hand instead of the contracted hand. For another resident with an order for Humalog Kwikpen, the physician’s order specified to hold the medication for blood sugar (BS) less than 100 and to call the provider for BS over 400. Review of the Medication Administration Record for March and April showed multiple dates on which the resident’s blood sugar exceeded 400. The facility was unable to provide documentation that the provider was contacted on those dates when the blood sugar was over 400, as required by the order. A registered nurse consultant confirmed that, according to the documentation, the provider was not notified when the resident’s blood sugar readings were over 400 on the identified dates.
Food Storage and Sanitation Deficiencies in Dietary Services
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with its own food safety and sanitation policies and professional standards. During an initial kitchen walkthrough, the surveyor, accompanied by the Director of Dining Services, observed multiple sanitation and storage issues, including a juice machine top soiled with debris, crumbs in the toaster tray, and a soiled microwave in the pantry. In the dry storage room, there was an opened, outdated brownie mix past its use-by date, and employee coats were found hanging on the bread rack. In the walk-in cooler, a case of bacon lacked an open or use-by date, and the meat slicer, though covered, had old food debris on and around the blade. The three-compartment sink log for that morning’s breakfast lacked recorded water temperature and sanitizer concentration, contrary to policy requirements for monitoring and documenting manual ware washing. Additional observations showed improper handling and storage of food and related items outside the main kitchen. A beverage in the pantry refrigerator was not labeled or dated. During a dining observation, beverage carts for two halls had trash bins placed on the same shelf as milk containers intended for residents. On a subsequent day, an employee’s coat was again found hanging on the bread rack, despite prior identification of this issue. These findings demonstrated that staff did not consistently follow facility policies requiring clean, sanitary food preparation and service areas, proper labeling and dating of TCS foods, and appropriate separation of personal items and trash from food and food-contact surfaces.
Uncovered Trash Receptacles in Food Service Areas
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional food safety standards and did not follow proper sanitation practices for food preparation equipment, with the potential to affect all 60 residents. Healthcare Services Group (HCSG) Policy #28 requires all trash to be contained in covered, leak-proof containers to prevent cross-contamination, and HCSG Policy #30 requires the Dining Services Director to ensure appropriate lids are provided for all containers. During an initial kitchen walkthrough with the Director of Dining Services (DDS), the surveyor observed that the trash can beside the juice machine had no lid and that the trash can in the dish room also had no lid. The DDS confirmed both observations and acknowledged that there was no lid available for the dish room trash can.
Failure to Substantiate and Address Resident Sexual Abuse Allegations
Penalty
Summary
The deficiency involves the facility’s failure to appropriately use investigation results and residents’ reports to determine and substantiate sexual abuse allegations involving one male resident and two female residents. In the first incident, a cognitively intact resident reported that she awoke in her bed to find a male resident in her room, uninvited, naked from the waist down and pulling on her leg, and stated she thought he was going to try to rape her. Staff responding to her yelling found the male resident in her room wearing only a t‑shirt, with no brief or pants, and the resident told staff to remove him from her room. During examination by an NP, she again reported that a man came into her room and pulled her down in bed. Despite these observations and statements, the facility’s Five‑Day Follow‑Up report concluded that allegations of sexual abuse were not substantiated, and the facility’s position, as verified by the Administrator, was that no physical harm was done, which was the basis for not substantiating sexual abuse. The facility did not adequately evaluate whether this resident felt safe or address her expressed anxiety about the incident. In the second incident, another cognitively intact resident with a BIMS score of 14 and a physician determination of capacity reported sexual abuse by the same male resident. A CNA witnessed the male resident’s hands under this resident’s blanket, rubbing close to her private parts, and when staff intervened and asked if he had touched her private area, she stated yes. During the facility’s investigation, the resident told the Social Worker and Administrator that the male resident rubbed her private area and that she believed the contact was intentional, and she also told her attending physician that he had touched her private area. When later seen by a psychologist, she voiced no recollection of the event. The facility’s Five‑Day Follow‑Up report stated that sexual abuse could not be substantiated due to inconsistency in statements, and the Administrator confirmed that the male resident had touched her but asserted it was accidental while rubbing her leg under the blanket. The facility failed to recognize and address this resident’s expression of anxiety about the unwanted touching and did not adequately evaluate whether she felt safe, leaving her and other residents vulnerable during and after the investigative process.
Failure to Monitor and Record Food Temperatures for Always-Available Menu Items
Penalty
Summary
The facility failed to ensure that food and drink were palatable, attractive, and maintained at a safe and appetizing temperature, as evidenced by food tray temperatures, resident interviews, and staff interviews involving four identified residents (#47, #33, #42, and #9) out of a census of 60. On 4/28/26 at 12:00 PM, it was observed that kitchen staff were not taking and recording temperatures for items on the always-available menu prior to the start of the lunch meal service. Specifically, beef patties, hotdogs, and brown gravy did not have recorded temperatures before meal service began. The Director of Dining Services acknowledged that temperatures for always-available menu items were not being taken or recorded. No additional medical history or specific clinical conditions of the involved residents were provided in the report.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
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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