The state of Ohio and the Centers for Medicare and Medicaid Services (CMS) conduct routine inspections and surveys at every nursing facility to identify serious concerns, violations, and deficiencies. Sometimes, in egregious cases, the underlying problems lead to a designation as a Special Focus Facility (SFF) where the nursing home must undergo additional inspections and unannounced investigations.
In 2014, nursing home regulators designated Manor at Whitehill as a Special Focus Facility (SFF) and added the Center to the National Medicare deficiency watch list. Some of those serious concerns, violations and deficiencies are listed below.
This Nursing Center is a ‘for profit’ facility providing services and cares to residents of Whitehall and Franklin County, Ohio. The 150-certified bed Long-Term Care Nursing Home is located at:
4805 Langley Avenue
Whitehall, OH 43213
(614) 501-8271
In addition to providing 24/7 skilled nursing care, the facility also offers:
The state of Ohio and Centers for Medicare and Medicaid Services are legally authorized to impose monetary penalties against any nursing facility identified with serious deficiencies and health violations. These fines are meant to discourage inferior performance.
Over the last three years, nursing home regulators have levied two monetary penalties against The Manor At Whitehall. These penalties include a $6,143 fine on 02/12/2015 and a $139,599 fine on 05/12/2016. During the same time, the regulators received twelve formally filed complaints that after investigations all resulted in citations.
The state of Ohio routinely updates their long-term care home database system to reflect all health violations, dangerous hazards, safety concerns, incident inquiries, opened investigations, and filed complaints. This publicly available information can be found on numerous sites including Medicare.gov.
Currently, The Manor At Whitehall maintains an overall one out of five stars compared to all nursing homes in the United States. This ranking includes one out of five stars for health inspections, two out of five stars for staffing issues, and one out of five stars for quality measures. Some of the major concerns, deficiencies, and violations involving this facility include:
In a summary statement of deficiencies dated August 31, 2015, the state investigator noted the facility “failed to ensure resident narcotics were not misappropriated.” The state surveyor reviewed the resident’s Medication Administration Records (MAR) involving the administration of narcotics. Documentation shows that there was a total of seven doses removed from a bubble pack prescription. However, the resident was sent to the hospital and readmitted to the facility. Even so, there was no evidence that the remainder of the narcotics in the bubble pack were destroyed as required by law.
In a summary statement of deficiencies dated February 12, 2015, the state investigator documented that the facility’s failure “to implement interventions to prevent the development of an avoidable pressure ulcer. This [deficiency] resulted in harm of [one resident] who developed an avoidable stage II pressure ulcer” on the heels. The deficient practice by the nursing staff “affected one of four residents reviewed for pressure ulcers.”
The incident involved observations of the resident “lying in his room on his left side at 1:20 PM on February 9, 2015 “facing the wall with his right inner heel lying directly on the mattress. Pillows were observed under the resident’s legs but were not preventing the heel from touching the surface.” The next day at 10:00 AM, the resident “was observed in his room lying on his back slightly turned toward the wall with his inner right heel directly touching the service of the mattress in the left out her heel directly touching the surface of the mattress.”
The resident was observed at 4:29 PM on February 10, 2015, while “lying on his left side facing the wall and his right in her heel was directly touching the surface of the bed.” Later that day at 4:55 PM, the resident “was observed up in the Broda chair [with] feet and heals resting against the firm plastic of the chair, and no cushion or padding was noted on the chair.” The next morning at 8:00 AM, the resident “was brought out of his room in the Broda chair to the dining room.” The surveyor observed the resident with “a pillow located on the bottom of the leg rest of the chair but no observed padding or protection from the back of the leg rest where the back and the inner right heel was resting on the surface.”
In a separate summary statement of deficiencies dated November 24, 2015, the investigator documented that the facility’s failure “to ensure skin conditions were comprehensively assessed to preventative measures implemented as ordered for [a resident].” An observation of the resident was made at 9:35 AM on November 24, 2015, who “was sitting at the Nurse’s Station in a wheelchair with the circular dark purple bruise to the left lower arm approximately 3.0 cm and scattered fading brown bruises to bilateral lower arms. The resident was wearing a short-sleeved shirt with no protective sleeves (Geri-sleeves).”
The investigator reviewed the resident’s monthly physician’s orders that instructed the nursing staff to provide care involving “Geri-sleeves or long sleeves… warn at all times.” Additionally, the resident’s Bleeding/Bruising Care Plan dated November 1, 2013, revealed the resident “was to be free of bleeding and bruising.” However, a review of interventions revealed no evidence of the Care Plan included that the resident was to wear Geri-sleeves or long sleeve shirts as ordered by the physician.”
In a summary statement of deficiencies dated November 24, 2015, the state investigator documented the facility’s failure “to provide services to restore bladder continence for [a resident] and failure to complete comprehensive bladder assessments for [two residents].”
The state investigator reviewed a resident’s evaluation for Continence and Retraining/Scheduling Toileting Assessment and medical records that “reveal no documented evidence of an incontinence assessment or interventions to restore bladder function between October 12, 2015, and November 24, 2015.” And an additional review of “an alteration in the elimination related to frequency incontinence Care Plan dated November 27, 2013 “revealed no interventions to restore or maintain bladder continence and no type of incontinence was identified.”
In a summary statement of deficiencies dated May 12, 2016, the state investigator documented the facility’s failure “to notify the physician of a resident with elevated blood glucose levels above ordered parameters and [a failure] to notify the physician that excess medication was found on the resident’s person.”
A review of the resident’s blood glucose test revealed that on April 7, 2016 “the result was 460 mg/dL.” Again at:
- 5:00 PM, the result was 421 mg/dL
- April 12, 2016 at 11:00 AM, the result was 551 mg/dL
- April 18, 2016 at 8:00 PM the result was 512 mg/dL
- April 26, 2016 a 4:00 PM, the result was 526 mg/dL
- May 1, 2016 at 11:00 AM the result was 405 mg/dL
However, reviewing the resident’s Progress Notes, assessments, and telephone orders for these dates “reveal no physician notification of the above abnormal blood glucose levels.”
In a summary statement of deficiencies dated May 12, 2016, the state investigator document at the facility’s failure “to ensure the least restrictive restraining device was used to treat [the resident’s] medical condition. The facility also failed to ensure the implementation of restraint reduction and ensure proper application of restraint for [a resident].” The incident involved a resident with clear speech who “understands others, makes himself understood and has both long- and short-term memory problems and has a severe cognitive impairment.”
The surveyor documented that the resident’s Minimum Data Set indicates “restraints were not utilized for the resident’s care.” However, reviewing the resident’s monthly physician’s orders and Restraint Enabler Decision Tree dated April 28, 2016 “reflected the use of the device. The device listed was the resident’s right side of the bed to be placed against the wall to ensure safety with care and transfers. The facility documented the resident’s right side of the bed against the wall would improve the resident’s functional status by making extra room in the resident’s room for transferring and mobility.”
The resident was observed on the late morning of May 2, 2016, while “sitting in his wheelchair with a split buddy (a positioning device) to his wheelchair foot pedals. The wheelchair foot pedals were elevated all the way up, causing the resident the inability to straighten out his legs.”
The next day at 9:40 AM, the resident was observed “lying on a low bed with a mat on the floor. A parameter mattress was observed on the resident’s bed with the body pillow position under the mattress elevating the left side of the mattress up and preventing the resident’s movement in bed.”
In a summary statement of deficiencies dated May 12, 2016, the state surveyor documented that the facility had failed to “identify staff burnout and encourage staff expressing frustration and burnout to continue to provide care to residents.” The deficient practice by the nursing staff “resulted in staff-to-resident physical and verbal abuse. This [failure] resulted in immediate jeopardy for [a resident].”
The incident involved physical and verbal abuse by a State-Tested Nursing Aide to a resident who “sustained actual harm when he was thrown into a chair and cursed at. This [failure] affected one [resident] reviewed for abuse and had the potential to affect all 141 residents.”
The state investigator informed the Administrator that an Immediate Jeopardy at the facility had begun “on April 26, 2016, at 10:30 PM, when a State-tested Nursing Aide reported to a Registered Nurse that she was frustrated and did not want to work at the facility.” The Registered Nurse persuaded the State-tested Nursing Aide, “who already exhibited signs of burnout on April 22, 2016, …when she was in the hallway yelling profanity at the nurse as observed by the Activity Director, to continue to work in providing care to residents. There was no evidence the Registered Nurse reported the State-tested Nursing Aide’s sign of burnout to the Administrator.”
Documents at the facility reveal that on that day at 5:55 AM, the resident reported to the Registered Nurse that the State-tested Nursing Aide “threw him into his chair …. At 6:15 AM, the [State-tested Nursing Aide] was laughing and giggling as she told the [Registered Nurse] she was leaving the facility because she went off on [a resident] and threw him into his chair.
In a summary statement of deficiencies dated May 12, 2016, the state investigator documented that the facility had failed to “revise or implement care interventions to ensure the resident was provided necessary treatment services to prevent new bedsore ulcers from developing.”
In a separate summary statement of deficiencies dated June 15, 2017, the state investigator documented that the facility had failed to “accurately assess and stage a pressure ulcer” involving one resident at the facility.” Medical Records reveal that the resident was admitted to the facility on May 4, 2017, “with the Stage III pressure ulcer” measuring 2.8 cm x 2.5 cm with no depth. However, the resident’s Progress Note, dated May 10, 2017, “revealed that she had a Stage II pressure ulcer [with a] size of 2.8 cm x 2.5 cm with no depth.
Further medical records reviews revealed that on May 17, 2017, there was documented evidence that she had a Stage II pressure ulcer with a size of 2.8 cm x 2.5 cm, with no depth.” The evidence revealed that “again on May 25, 2017, she had a Stage II pressure ulcer the size of 2.5 cm by 2.5 cm x 0.5 cm deep. By June 7, 2017, it was documented that the resident “had a healing Stage III pressure ulcer measuring 1.5 cm x 1.5 cm x 0.5 cm deep. By June 14, 2017, the pressure ulcer was documented as Stage II size of 1.3 cm x 1.5 cm x 0.8 cm deep.
However, during an interview conducted with the Director of Nursing, it was revealed that “the staging of [the resident’s] wound should not have been upgraded to a Stage II on May 11, 2017. It was always a Stage III. When asked why it was a Stage III instead of an unstageable when [the resident] first came to the facility, she stated, ‘there was slough all over it.” The Director stated later that morning that “[the resident’s] wound should have been staged as unstageable at the time of admission instead of a Stage III.”
In a summary statement of deficiencies dated May 12, 2016, the state surveyor noted that the facility had failed to “ensure hot water in the 100 hallway central shower system, central bathroom, and resident’s room was maintained at safe temperatures to prevent injury.” This deficiency by the nursing staff, Maintenance Director, and Administrator “resulted in the potential for serious harm which could result from burns from hot water.” The surveyor documented that an “Immediate Jeopardy occurred when the facility failed to adequately monitor water temperatures resulting in water temperatures between 123°F and 143°F.”
In a summary statement of deficiencies dated May 12, 2016, the state investigator identified a facility failure. The deficiency involved a failure “to maintain a comprehensive and effective infection control program [any failure] to ensure staff washes their hands after removing their gloves during resident care, [and a failure] to cleanse a glucometer according to disinfecting guidelines.”
In a separate summary statement of deficiencies dated January 11, 2017, the surveyor documented the facility’s failure “to ensure personal protective equipment was readily available for staff to use in the laundry or to prevent the spread of infection.” This deficient practice by the employees “had the potential to affect all 135 residents residing in the facility.”
If you have concluded that caregivers harmed your loved one while residing at The Manor At Whitehall, or any nursing facility, contacting a personal injury attorney can help. A lawyer working on your behalf can handle every aspect of your case from filing the complaint, gathering evidence, hiring investigators, and negotiating with claims adjusters or presenting evidence to a jury in a lawsuit trial.
No upfront payments are required because personal injury attorneys accept every wrongful death lawsuit, nursing home abuse case and medical malpractice for compensation with contingency agreements. This arraignment means all legal fees are paid only after the law firm has won your case at trial or negotiated an out of court settlement on your behalf.
Sources:
Attorney Nancy Iler
Licensed in Ohio
Chicago Nursing Home Injury Attorney Nursing Home Law Center LLC Home