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IMPORTANT BULLETIN
Immediate Jeopardy Issues
Third Quarter 2016
PLEASE BE SURE THAT FACILITY STAFF READ THIS
The Ohio Department of Health has provided OHCA Immediate Jeopardy data for all facilities surveyed during the third quarter of
2016. There was a total of thirty Immediate Jeopardy citations in seventeen facilities during nineteen separate surveys. The Ohio
Department of Health cited seventeen of these citations at a severity J; none at a severity K and thirteen at a severity L. There were
two IJ’s with an associated death. There were eight citations in three surveys in July, thirteen citations in ten surveys in August, and
nine citations in six surveys in June. Two facilities were cited by ODH for an IJ during two separate surveys. The agency cited F323
the most at nine times, F223 and F226 were both cited five times, F225 four times, F257 and F314 were both cited twice, and
F224/F309/F365 were all cited once. Six of the nineteen surveys had more than one Immediate Jeopardy citation: one facility had four
citations, three facilities had three IJ citations, and two had two IJ citations. One facility was cited for four IJ citations in one survey
and one IJ citation in another; and one facility had two separate surveys with one IJ citation during each survey.
Summaries of these citations are listed below, along with the Immediate Jeopardy Task Force’s comments and recommendations.
Facility A: F365 Food in Form to Meet Individual Needs (J) – Choking
8/26/2016 Complaint Investigation, Partial Extended Survey
The facility failed to ensure residents on mechanically altered diets were provided food in the correct texture assessed to meet their
individual needs. This resulted in Immediate Jeopardy for two of three residents reviewed for choking who experienced actual harm
when they were served the incorrect texture of food items at their meal and subsequently choked requiring staff intervention to
perform the Heimlich maneuver in an effort to remove the food bolus from the trachea where it was preventing air flow to and from
the lungs. The facility identified four residents who had choked within the last four months. Immediate Jeopardy began when a
resident was given a meal tray with a whole hot dog, contrary to the resident's physician order for a mechanical soft textured diet when
the resident was wearing dentures and with the order reading the diet was to be downgraded to a pureed diet if the resident did not
have dentures in place, which subsequently caused the resident to choke requiring the Heimlich maneuver to be performed by staff in
an attempt to clear the resident's airway. The Immediate Jeopardy continued when another resident, who had a physician order for
ground meat, nectar thick liquids and cream soups only, was observed to be served a bowl of chicken rice soup with the broth drained
and crackers added. That resident subsequently was observed to choke and required the Heimlich maneuver to be performed by staff
in an effort to clear the resident's airway.
Facility B: F323 Free of Accident Hazards/Supervision/Devices (J) – Elopement
9/29/2016 Complaint Investigation, Partial Extended Survey
The facility failed to timely assess a resident's elopement risk, and implement interventions and provide supervision to prevent his
elopement. This resulted in Immediate Jeopardy when the resident was determined missing from the facility, and no staff members
had observed him leaving the building. The potential for serious harm occurred as the resident had diagnoses including schizophrenia
and dementia; had a history of alcohol dependency and traumatic brain injury; required antipsychotic medications for his illness; and
was assessed by a psychiatric hospital as requiring 24 hour supervision to ensure his safety and prevent harm. Eight days later, the
resident was returned to the facility by the local transit system police department. This affected one of six residents reviewed who
were identified as an elopement risk.
Facility C: F223 Free from Abuse/Involuntary Seclusion (L) – Sexual Abuse (Staff to Resident)
F226 Develop/Implement Abuse/Neglect, Etc Policies (L) - Abuse Policy
9/14/2016 Complaint Investigation, Partial Extended Survey, Self-Reported Incident Investigation
The facility failed to protect one cognitively impaired resident from sexual abuse. The facility failed to implement their Abuse Policy
in the area of resident protection when they failed to protect one cognitively impaired resident from sexual abuse. This resulted in
Immediate Jeopardy for one resident when another resident, with a known history of inappropriate sexual behaviors, sexually
assaulted the resident. Actual harm occurred when the offending resident forcibly had sexual intercourse with the other resident
causing vaginal tearing and bleeding. In addition, the facility failed to protect another cognitively impaired female resident from the
offending resident when he was found lying on top of her trying to have sexual intercourse with her through her clothing. This placed
nine additional cognitively impaired female residents who resided on the same secure unit, at risk for the likelihood of serious harm
from sexual abuse. The facility care planned one to one supervision for the offending resident’s inappropriate sexual behaviors. There
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was no documented evidence this supervision was implemented by the facility, subsequently allowing the resident to have forcible
sexual penetration with another resident.
Facility D: F323 Free of Accident Hazards/Supervision/Devices (J) – Heat Stroke
8/25/2016 Complaint Investigation, Partial Extended Survey
The facility failed to appropriately supervise one cognitively impaired resident while he sat outside in extreme heat conditions from
suffering heatstroke. This resulted in Immediate Jeopardy for the resident who was found unresponsive in a chair outside in the facility
courtyard on a day when the heat index reached 90.2 degrees Fahrenheit. Actual harm occurred when the resident was found
unconscious and did not respond to verbal or tactile stimuli. The resident's skin was very warm and dry and he had blisters on both of
his upper arms. He did not respond to deep sternal rub. The resident was transferred to the hospital where he expired. This lack of
supervision of residents using the courtyard during high heat had the potential to affect all 16 residents who used the facility courtyard.
Immediate Jeopardy began when the resident was discovered unresponsive in a chair outside in the facility courtyard during extreme
heat conditions.
Facility E: F323 Free of Accident Hazards/Supervision/Devices (J) – Elopement
7/19/2016 Extended Survey, Amended Informal Dispute Resolution Completed on 08/23/2016
The facility failed to prevent one cognitively impaired resident, assessed at risk for elopement and falls, from wandering away from
the facility unsupervised. This resulted in Immediate Jeopardy for the resident who left the facility without staff knowledge and was
found by a neighbor approximately one mile from the facility. The resident sustained actual harm when he received abrasions to both
knees and his right shin, was incontinent of urine and his skin was cool to touch. This affected one of eight residents assessed to be at
risk for elopement. The resident was wearing a Wanderguard that should have caused an alarm to sound when the resident left the
facility. The alarm was intact and functioning when tested upon the resident's return to the facility, however, no one heard the alarm
sound when the resident left the building. There was no evidence that indicated the facility was able to determine how the resident
exited the building.
Facility F: F323 Free of Accident Hazards/Supervision/Devices (J) – Supervision
8/5/2016 Annual Survey, Extended Survey
The facility failed to provide adequate supervision for one cognitively impaired resident who was assessed to display behaviors of
unsafe wandering placing the resident at risk for physical harm. This resulted in Immediate Jeopardy when the resident was found in
another resident’s bed and the other resident was engaged in inappropriate touching of the resident who wandered. This affected one
of six cognitively impaired residents reviewed who displayed inappropriate behaviors.
Facility G: F223 Free from Abuse/Involuntary Seclusion (L) – Physical Abuse (Resident to Resident)
F225 Investigate/Report Allegations/Individuals (L) - Report Abuse
F226 Develop/Implement Abuse/Neglect, Etc Policies (L) - Abuse Policy
8/5/2016 Annual Survey, Extended Survey, Complaint Investigation, Self-Reported Incident Investigation
The facility failed to prevent resident to resident abuse resulting in Immediate Jeopardy when one resident verbally and/or physically
abused two residents and additional unidentified residents without evidence of safeguards being in place to protect the residents. The
facility failed to ensure staff prevented and reported a witnessed verbal and physical altercation between a resident who was alert and
oriented and a resident who was assessed to be severely cognitively impaired. The facility failed to ensure immediate reporting and
comprehensive investigations were completed involving the resident's physical and verbal abuse directed toward other residents
resulting in Immediate Jeopardy. Consequently, the facility failed to protect residents from further incidents involving physical and
verbal abuse from the resident and failed to ensure all incidents of physical and verbal abuse were reported to the State agency as
required. This affected five of six residents reviewed for abuse and had the potential to affect all 84 residents residing in the facility.
The resident was identified to be verbally abusive to (unidentified) residents in the facility, calling them names and cursing at them.
The resident was also verbally and physically abusive to his roommate and another resident. The offending resident, who was assessed
to be alert and oriented engaged in both a verbal and physical altercation, rising to the level of abuse with another resident, who was
assessed to be severely cognitively impaired.
Facility H: F323 Free of Accident Hazards/Supervision/Devices (J) – Elopement
9/19/2016 Complaint Investigation, Partial Extended Survey
The facility failed to ensure adequate supervision was provided to prevent the elopement of a resident who was assessed as being at
risk for elopement. This resulted in Immediate Jeopardy when the resident left the facility without staff knowledge and was found
unattended in his wheelchair in the middle of the state highway in front of the facility by a person driving by on the highway placing
the resident at risk for serious injury and/or death. The resident propelled his wheelchair through a delayed egress locking exterior
door which failed to activate or sound an audible alarm for the Secure Care transmitter on the resident's wheelchair. The facility was
unaware the resident was missing. The resident independently propelled his wheelchair approximately seventy-five yards into the
middle of the state highway in front of the facility. The resident was returned to the facility by the passerby. The resident was assessed
by nursing staff and no injury was discovered. The Immediate Jeopardy was removed when the Wander Guard/Secure Care Device
was relocated from the resident's wheelchair to the resident's right ankle, and all door alarms were checked to ensure they were
functionally operational.
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Facility I: F224 Prohibit Mistreatment/Neglect/Misappropriation (J) – Physical Abuse (Resident to Resident)
F225 Investigate/Report Allegations/Individuals (L) - Report Abuse
F226 Develop/Implement Abuse/Neglect, Etc Policies (L) - Abuse Policy
9/16/2016 Federal Monitoring Survey
The facility failed to ensure two residents reviewed for abuse, neglect, mistreatment, and misappropriation of property were free from
neglect and mental abuse. The facility failed to ensure an allegation of neglect and mental abuse from one resident was immediately
reported to the Administrator which resulted in the facility's failure to protect all residents from potential abuse or neglect by the
alleged perpetrator. The Immediate Jeopardy began when the STNA failed to provide necessary services to a resident who was at risk
for falls when the STNA refused to assist the resident to transfer from the chair to bed, and when the resident reported to the LPN and
the Activity Director that the STNA had refused to provide the resident with necessary care and services by refusing to assist the
resident during transfers. The LPN and the Activity Director failed to report this allegation of neglect and mental abuse to the
Administrator as required. The STNA continued to have contact with all residents for more than 35 days after the resident’s allegation
was made to facility staff. During this time the STNA mentally abused two residents by refusing to speak to them. Additionally, the
facility failed to develop an Abuse policy which included the specific federally required time frames for reporting of abuse and
injuries of unknown origin. This had the potential to affect all 85 residents in the facility. The Administrator was informed that
although the Immediacy was removed on, noncompliance remained at a lower level of no actual harm with the potential for more than
minimal harm that is not an Immediate Jeopardy due to the fact that sustained compliance could not yet be verified.
Facility J: F257 Comfortable & Safe Temperature Levels (L) – Temperature Levels
F309 Provide Care/Services for Highest Well-Being (L) – Necessary Care and Services
8/2/2016 Complaint Investigation, Partial Extended Survey
The facility failed to ensure comfortable and safe temperatures were maintained throughout the facility when temperatures exceeded
88 degrees Fahrenheit in resident rooms and common areas. Additionally, the facility failed to have an emergency contingency plan in
place related to excessive heat that directed staff what to do to ensure the health and safety of all residents in the facility. This resulted
in Immediate Jeopardy for two of seven residents reviewed for hospitalization due to experiencing actual harm resulting in
dehydration requiring treatment with IV fluids. Furthermore, the facility's failure to have developed and implemented an emergency
contingency plan placed the other 59 residents at risk for the likelihood of serious imminent harm by not monitoring resident's
individual room temperatures and monitoring the residents for signs and symptoms of heat related outcomes. Immediate Jeopardy
began when the facility first became aware that one of the two AC units had a broken compressor rendering it non-functional. The
facility had no emergency contingency plan for extreme heat and was not monitoring the temperatures of residents' individual rooms
or monitoring residents for any signs and symptoms of heat related concerns.
Facility K: F223 Free from Abuse/Involuntary Seclusion (L) – Physical Abuse (Staff to Resident)
F225 Investigate/Report Allegations/Individuals (L) - Report Abuse
F226 Develop/Implement Abuse/Neglect, Etc. Policies (L) - Abuse Policy
7/18/2016 Complaint Investigation, Partial Extended Survey, Self-Reported Incident Investigation
The facility failed to ensure one resident was free from abuse and five other residents were not mistreated and/or intimidated. This
resulted in Immediate Jeopardy for one resident when an STNA was verbally and physically abusive. The resident sustained actual
harm when she was found to have a 10 cm by 9 cm bruise to the forearm caused by an STNA and experienced a negative psychosocial outcome demonstrated by verbalization of recurrent anxiety and fear and preparations to move to another facility. This affected
six residents reviewed for abuse and had the potential to affect all 68 residents that resided in the facility. Immediate Jeopardy began
when the resident reported to a nurse that a bruise on her arm was caused by an STNA grabbing her left arm and pulling her out of the
recliner. The facility failed to implement their abuse policy and procedure to ensure the resident was free from abuse and that the other
residents were not mistreated and/or intimidated, because it failed to ensure the resident's allegation of abuse was thoroughly
investigated. It failed to interview other residents and staff about the aide in question before it unsubstantiated the allegation and
surveyor interviews of residents revealed that the aide had a history of being “mean” and “Not nice” and that other residents indicated
that they did not want the aide to care for them. This resulted in Immediate Jeopardy for one resident when the STNA resumed
working after the DON unsubstantiated an allegation of abuse without completing a thorough investigation.
Facility L: F323 Free of Accident Hazards/Supervision/Devices (J) - Elopement
8/1/2016 Complaint Investigation, Partial Extended Survey
The facility failed to provide adequate supervision to prevent the elopement of two residents, who were severely cognitively impaired,
independently mobile and assessed as being at a moderate risk for elopement and wandering. This resulted in Immediate Jeopardy
when the two residents were last seen in the facility prior to exiting the facility unsupervised. The potential for serious harm occurred
when the residents exited the secured dementia unit through a door with a key pad lock, which the residents figured out how to open
by watching others and which was not alarmed. The residents then walked through an electrical room and through the maintenance
work shop where multiple bio-hazard materials were stored and out the back door. This affected two of 20 residents assessed as being
at risk for elopement. Immediate Jeopardy began when two residents exited the secured dementia unit unsupervised and one of the
residents was subsequently found by the police wandering approximately 3/4 mile away from the facility and the other was found in
the kitchen.
Facility M: F323 Free of Accident Hazards/Supervision/Devices (J) – Choking
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9/26/2016 Annual Survey, Extended Survey, Complaint Investigation
The facility failed to provide adequate supervision during and after the dinner meal for one resident who was on a mechanically
altered diet with nectar thickened liquids to prevent choking. The resident experienced actual harm when he began to choke after
consuming a food item he should not have received (watermelon) during dinner requiring staff intervention to physically clear his
mouth and airway. Immediate Jeopardy resulted when the resident was returned to his room where he was later found unresponsive
requiring cardiopulmonary resuscitation. Emergency medical services (EMS) arrived and were unable to establish a patent airway due
to blockage by a plastic jelly packet. Immediate Jeopardy began on when the resident received watermelon contrary to physician
orders for a mechanical soft diet with nectar thick liquids and began to choke requiring staff intervention to clear his mouth and
airway. The resident was returned to his room without adequate supervision or assessment of his status. The nurse aides caring for the
resident was supposed to perform “frequent checks” after incident and noticed the resident had “weird” coloring and “raspy breathing”
and did not notify the nurse. The nurse did not assess the resident after the initial incident until the resident was noted to be
unresponsive by the aide.
Facility N(1): F223 Free from Abuse/Involuntary Seclusion (J) –Verbal Abuse (Staff to Resident)
F225 Investigate/Report Allegations/Individuals (J) - Report Abuse
F226 Develop/Implement Abuse/Neglect, Etc. Policies (J) - Abuse Policy
F257 Comfortable & Safe Temperature Levels (L) – Temperature Levels
7/28/2016 Complaint Investigation
The facility failed to ensure all residents were free from verbal and mental abuse and that allegations of abuse were reported
immediately to the Administrator of the facility and to the State survey and certification agency. The facility failed to implement the
Abuse policy and procedure in the areas of reporting allegations of abuse immediately to the administrator and State survey and
certification agency, thorough investigation of allegations of abuse, and protection from harm. The facility also failed to thoroughly
investigate all allegations of abuse and ensure that appropriate corrective action was taken, resulting in Immediate Jeopardy. This
resulted in psycho-social harm for one of five residents reviewed for resident abuse when a resident received verbal threats from his
roommate and was afraid to sleep at night due to the threats. Immediate Jeopardy began when an STNA was notified by the resident
that his roommate had threatened to kill him and that the resident was afraid of his roommate especially at night when they go to
sleep. There was no evidence of any interventions implemented at that time to protect the resident and they remained roommates. The
Immediate Jeopardy was removed when the resident was moved to a private room on another floor from his roommate and the facility
implemented corrective actions.
The facility failed to ensure a safe environmental temperature was maintained throughout the facility including all cottages. This
resulted in Immediate Jeopardy and the potential for serious harm to all 177 residents residing in the facility at the time of the
complaint investigation and specifically affected four residents who were sent to the hospital with heat related issues. Immediate
Jeopardy occurred when the facility failed to identify hot environmental temperatures throughout the building, failed to identify
residents who could be adversely affected by extreme temperatures, and failed to take immediate and effective steps to ensure
temperatures were monitored and safe temperatures restored when the air conditioning system failed. Immediate Jeopardy began when
the facility identified the AC units on the six cottages were non-functional and failed to implement the facility's extreme heat protocol.
The lack of adequate corrective actions posed a significant risk for serious illness to the residents residing in the facility with
temperatures elevating to 90 degrees Fahrenheit. The facility administration could not identify what the conditions would need to be in
the facility to determine an evacuation was necessary or provide a plan to determine when evacuation needed to occur. Interview with
the Administrator and Owner revealed they reported there was not a need to transfer residents out of the building and they could
manage it on-site. They felt the situation would be remedied by the end of the day. They could not identify what the conditions would
need to be in the facility to determine an evacuation was necessary or provide a plan to determine when evacuation needed to occur if
the temperatures remained elevated and measures to alleviate the conditions continued to be inadequate.
Facility N(2): F323 Free of Accident Hazards/Supervision/Devices (J) - Elopement
8/5/2016 Partial Extended Survey, Monitoring Visits
The facility failed to ensure adequate supervision was provided to prevent the elopement of a resident who was adjudicated to be
mentally incompetent and who had a history of leaving the facility unsupervised for periods of time. This resulted in Immediate
Jeopardy when the resident left refused to get into a facility transport van to go to another facility and began yelling at staff and then
left the facility grounds unsupervised. The potential for serious harm occurred when the facility failed to implement their facility's
elopement policy or call the police. The resident did not return to the facility for 17 hours.
Facility O: F314 Treatment/Services to Prevent/Heal Pressure Sores (J) – Pressure Injury
8/26/2016 Complaint Investigation, Partial Extended Survey
The facility failed to prevent the development of an avoidable Stage IV pressure ulcer for a resident using a splint device for
contractures. This resulted in Immediate Jeopardy when one resident suffered actual harm, caused by a hand splint which was
incorrectly applied by facility staff, and subsequently developed an avoidable Stage IV pressure ulcer to the left thumb, developing
pain and infection at the wound site requiring treatment with antibiotics. This affected one of four sampled residents reviewed for skin
integrity. Immediate Jeopardy began when the resident was observed by an STNA to have drainage coming from the dry disposable
wipes in her left hand. The STNA reported the drainage to the LPN who assessed the resident to have a Stage IV pressure ulcer of the
left palmar-medial interphalangeal joint (left thumb joint) from the inappropriate use of a staff applied splint device to the left hand.
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The LPN described the tissue surrounding the wound as macerated due to excess moisture related to contractures, with the wound bed
being dark red in areas with a hard white area exposed. Consequently, the resident developed an infection in the pressure ulcer and had
associated pain during treatment evidenced by the resident's grimacing and becoming red-faced.
Facility P: F314 Treatment/Services to Prevent/Heal Pressure Sores (J) – Pressure Injury
8/25/2016 Complaint Investigation, Partial Extended Survey
The facility failed to appropriately assess and treat an in-house acquired pressure ulcer for one resident. This resulted in Immediate
Jeopardy for the resident who did not receive a skin assessment on admission and who later developed an in-house acquired open area
on the sacrum and the facility failed to timely follow physician orders for the treatment and care of the resident. This resulted in actual
harm when the resident developed an unstageable pressure ulcer. The facility failed to implement physician orders to treat the
unstageable pressure ulcer. The resident was subsequently sent to the hospital for an elevated temperature and wound infection and
had an admitting diagnosis of Stage IV sacral decubitus ulcer. In addition, the facility failed to provide physician ordered pressure
ulcer treatments for the resident and failed to complete weekly skin assessments for another resident's pressure ulcer. This affected
three of four residents reviewed for pressure ulcers.
Facility Q(1): F223 Free from Abuse/Involuntary Seclusion (J) – Physical/Verbal Abuse (Staff to Resident)
8/8/2016 Complaint Investigation, Partial Extended Survey, Self-Reported Incident Investigation
The facility failed to protect residents from abuse after an STNA admitted to two LPNs that she hit a resident with a wet towel while
providing care. This resulted in Immediate Jeopardy when the STNA admitted to the LPNs that she hit a resident with a towel. The
potential for serious harm continued when the STNA was allowed to return to work and provide direct care to residents. This affected
one resident and had the potential to affect all residents in the facility. Immediate Jeopardy began when the STNA admitted to the
LPNs that she hit a resident with a wet towel when the resident was combative during care. The facility suspended the STNA. The
facility's investigation included written, signed statements by both LPNs regarding the STNA’s admission of abuse and the resident’s
allegation that "she beat me." The facility concluded that no abuse occurred and found the allegation unsubstantiated because the
Administrator stated that he believed there was no conclusive evidence to support the alleged abuse because the incident was not
witnessed and the LPNs may have misinterpreted what they saw and heard, so the STNA was permitted to return to work and provide
direct care to residents.
Facility Q(2): F323 Free of Accident Hazards/Supervision/Devices (J) - Elopement
9/15/2016 Complaint Investigation, Partial Extended Survey
The facility failed to provide adequate supervision to prevent the elopement of one resident, who had a court appointed guardian, had
a history of elopement, and diagnoses of insulin dependent diabetes and schizophrenia. This resulted in Immediate Jeopardy when the
resident was admitted with a known history of elopement from a previous facility and was not identified to be an elopement risk and
no elopement risk plan of care was initiated, and when the resident eloped from the facility the first time and no care plan was
implemented after that incident. Additionally, the facility staff failed to execute a proper search upon finding the resident was missing
from the facility after a second elopement. Serious harm and the potential of imminent life threatening danger occurred when the
resident was found lying on the ground, incoherent by police who called for emergency medical services to transport the resident to
the hospital. This affected one of eight residents assessed as being at risk for elopement.
Comments/Recommendations:
F365 – Choking (Failure to Provide Food to Meet Individual Needs)
 Ensure residents on altered diets are provided food in the correct texture assessed to meet their individual needs.
 If diet orders are written on contingencies such as dentures being in place, ensure that residents are assessed for these items prior
to serving food.
F323 – Choking (Failure to Supervise Resident During and After a Meal)
 Ensure residents do not have access to food they are not permitted to have and/or are supervised so they do not have access to
food they are not permitted to have.
 Ensure residents who experience a choking incident are appropriately monitored after the incident by a licensed nurse.
F323 – Elopement
 If a resident is assessed to require 24 hour supervision, ensure that the facility can provide this level of care prior to admission.
 If a residents care needs increase to a level the facility can no longer provide, emergency discharge may be appropriate.
 All staff must be aware of door and alarm protocol and respond to all alarms. No exceptions.
 If a facility cannot locate a resident during routine rounds, notify the supervisor immediately.
 Doors/exits that are alarmed should be activated and reset by the facility's policies. Staff must respond to ALL door alarms in
accordance with facility procedures.
 Ensure all doors through which a resident could potential exit are alarmed, even those with key pad exit locks.
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When a resident elopes, the facility must conduct a thorough investigation into the incident to ensure that appropriate
interventions are put in place to prevent recurrence.
If WanderGuard devices are placed on assistive devices (e.g., a walker or wheelchair), ensure that the device can be detected by
the door sensor.
Ensure staff report all exit-seeking behaviors to the nurse and the resident’s plan of care is revised accordingly.
F223 – Staff to Resident and Resident to Resident Abuse (Verbal, Physical, Sexual, Mental)
 If a resident is assessed to require 1:1 supervision due to abusive behaviors and it cannot be provided, facilities should consider an
immediate discharge.
 Once a resident commits one act of abuse toward a resident, a plan of care needs to be implemented to ensure it does not happen
again as subsequent incidents will likely be considered to be “foreseeable”. If a resident is verbally abusive or threating to another
resident, facility needs to ensure that the victim is not subject to ongoing abuse. This may require placing abusive resident in a
different room or on a different unit, or possible discharge.
F224 – Neglect
 A resident’s complaint that a staff member refused to provide any requested care or services that are part of the resident’s plan of
care should be considered an allegation of abuse or neglect and be investigated.
 Incidents where staff members ignore or fail to interact with residents during care may also constitute neglect.
F225 – Report/Investigate Abuse
 Facility must ensure all resident to resident incidents are reported and investigated and the investigation file is complete and
accurate.
 Investigations must be thorough, which means interviewing other residents when an allegation is made about a staff member and
interviewing additional staff members other than those directly involved with the incident. If an allegation is unsubstantiated by
the facility and ODH determines that the investigation was not thorough enough, the condition of immediate jeopardy will be ongoing.
F226 – Abuse Policy
 Policies should track the language in federal regulation and include specifically required reporting time frames as opposed to “in
accordance with state and federal law.”
F323 - Supervision for Inappropriate Behaviors
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Staff must report all instances and allegations of abuse and sexual conduct immediately. There is no exception to this.
If the facility cannot adequately protect residents from abuse from residents with behaviors; the facility should not admit or retain
the resident. If the resident’s behaviors escalate the facility should reassess to ensure that they can continue to meet the needs of
the resident while ensuring the safety of all residents.
If the facility chooses to admit a resident with a history of sexual abuse, misconduct, or known history of inappropriate sexual
behaviors, the facility needs to ensure they can protect other residents from this resident.
One on one supervision should not be used for extended periods of time in a nursing facility. If this is needed beyond a very short
period, the facility should assess if they can meet the needs of the resident or if emergency discharge is appropriate.
Full investigations must occur including resident and staff interviews.
F323 - Heat Stroke
 Residents must be assessed when outside temperatures are high or low and the residents spend time outdoors. This includes need
for sun protection.
 Cognitively impaired residents should be supervised or at minimum checked on periodically when outside to avoid over exposure
to sun, heat, or cold. Care plan should address increased supervision needs when outdoors to protect resident from the effects of
the weather (hot or cold).
F309 - Necessary Care and Services
F257 - Excessive Temperatures
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If the facility experiences issues with maintaining regulated temperature ranges in the facility, the facility should put an
emergency contingency plan in place related to excessive heat or cold that directs staff what to do to ensure the health and safety
of all residents in the facility. This plan should include a process for monitoring effectiveness and when evacuation is necessary.
This plan should also include monitoring resident's individual room temperatures using appropriate air temperature monitoring
devices designed to measure air temperature and not surfaces, and monitoring the residents for signs and systems of heat/cold
related outcomes.
Facilities should have a maintenance plan that includes periodic monitoring of the HVAC system so issues can be identified and
repaired ASAP.
F314 – Pressure Injury
 Residents with splints should be assessed for pressure points and proper fit/application with every application and removal.
 Residents at risk for pressure injury or those with current pressure injury or wound should regularly have assessment and
positioning and pressure reducing devices utilized as appropriate.
 The facility must ensure employees follow Medical Orders or amend/rescind with prescriber approval.
 Skin assessments should be done per facility policy, and by state and federal regulations. Documentation of these assessments is
necessary to demonstrate completion.
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If the facility admits a resident with a wound, the facility must have an immediate care plan in place and evidence of
implementation; if not there is a risk of an Immediate Jeopardy even if the wounds do not worsen.
General Comments/Recommendations:
If you have a negative occurrence in your facility, OHCA recommends that the facility has a plan of correction put into place and
documented specifically and clearly. If it is cited, the immediacy and completeness of the corrective action can be advantageous and
limit the time frame that one is out of compliance, or in an immediate jeopardy situation.
The IJ Task Force recommends that whenever a facility becomes aware that surveyors are considering or recommending an Immediate
Jeopardy, it is best to call for assistance. Resources that we recommend may include a long-term care specialty law firm, other longterm care regulatory consultants, and the association regulatory contact. It is important to forestall this development, or at a minimum,
keep the time frame minimal. OHCA provides frequent training on the subject of Immediate Jeopardies and how to prevent or mitigate
them.
The IJ Task Force cautions against affirming or verifying surveyor findings. Staff training on how to handle surveyor interviews, from
management level to direct care staff is vital to successful survey management. When surveyors interview management level staff
members, OHCA suggests that facilities try to have another witness present and take detailed notes regarding the discussion.
In cases with an Immediate Jeopardy (as well as other citations) where the IJ remains at the initial survey, requesting the state survey
agency to come out to abate the jeopardy is counted as one of the follow-up surveys, which are limited. It is critical to correct the
Jeopardy issue during the citation visit. Two revisits are permitted, at the State’s discretion, without prior approval from the regional
office; a third revisit may be approved only at the discretion of the regional office. Regional offices are limited to approving one
additional revisit. State Operations Manual Chapter 7-Survey and Enforcement Process for Skilled Nursing Facilities and Nursing
Facilities: http://www.cms.hhs.gov/surveycertificationgeninfo/.
In many cases, when surveyors remove the Immediate Jeopardy based on a facility’s corrective action, often the facility remains out of
compliance at Severity Level 2 (no actual harm with potential for more than minimal harm that is not Immediate Jeopardy) because
the facility has not provided in-service training to all appropriate staff.
7
Issues
2007 2008 2009 2010 2011 2012 2013
Falls
Elopements
Side rails
Necessary Care & Services – (CPR)
Necessary Care & Services - Other
Restraints
Hot Water/burns
Pressure Ulcers
Medication Errors
4
3
1
5
3
1
1
8
Accident Hazards/Supervision
Abuse / Neglect
Fail to protect after abuse
allegation
Fail to report abuse
Fail to develop/follow P&P for
Abuse
Suicide
Special Needs
Dietary Services (F365)
Unsupervised eating/Choking
Smoking/Fire
Rights
Tube
Paid feeding assistant
Quality of care
Quality Assurance
Food Sanitation F371
Infection Control
Safe Discharge
K tag
Weight Loss/Nutrition
Behaviors
Pain Management
Sufficient Staffing
Decreased ROM
Effective Administration
Medical Director
Excessive Temperature
1
4
2
11
1
1
1
7
1
4
3
5
2
6
2
1
1
1
4
7
4
2
2
1
5
3
3
1
5
2
5
2
1
2
2
2
1
1
1
1
1
5
2
6
5
3
2014 2015 2016
4
14
2
12
3
12
6
2
2
2
1
2
2
2
6
3
6
2
2
7
5
3
1
6
3
1
3
8
3
11
4
9
4
7
1
11
1
19
2
1
8
5
4
4
4
4
3
3
12
14
1
1
1
1
1
2
1
1
1
4
1
1
1
1
1
3
3
2
1
2
2
4
1
1
1
1
1
1
1
1
1
1
4
2
1
1
1
2
1
1
2
2
2
1
2
1
2
2
1
1
1
3
8
Immediate Jeopardies
Year
99 00
January
5
3
February
3
3
March
2
3
April
8
5
May
3
1
June
4
3
July
7
0
August
5
2
September 3
2
October
1
4
November 2
1
December 2
2
Total
45 29
Deaths Reported
Year
January
February
March
April
May
June
July
August
September
October
November
December
Total
01
3
3
6
2
4
2
1
6
3
2
1
2
35
02
0
0
3
7
2
3
1
0
7
1
1
1
26
03
1
0
0
1
3
2
6
1
1
5
1
2
23
04
2
0
0
2
4
2
4
2
3
2
5
1
27
05
6
1
3
3
4
2
3
2
1
2
0
0
27
06
2
3
3
3
5
0
2
2
5
0
1
5
31
07
2
2
3
0
1
1
6
5
3
3
1
4
31
08
2
3
6
12
3
3
4
2
1
3
3
4
46
09
3
2
5
4
5
2
3
2
1
3
3
2
35
10
1
1
4
1
3
1
2
3
2
0
1
3
22
11
1
2
1
4
1
4
6
7
6
2
1
3
38
12
2
5
7
1
0
1
3
13
11
6
5
2
56
13
3
4
3
4
2
2
5
8
11
4
5
5
56
14
1
3
1
2
2
5
12
8
2
3
8
12
59
15
8
4
8
5
4
5
3
6
6
4
4
4
61
16
6
20
3
20
10
15
8
13
9
104
99 00 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16
1
0
1
0
0
0
1
2
1
2
0
0
0
0
0
0
2
2
2
0
1
0
0
0
0
3
0
0
0
0
0
1
1
3
0
1
1
1
1
1
0
0
1
1
2
1
1
1
0
1
2
0
0
1
5
2
0
5
1
2
0
3
0
4
3
0
0
1
5
2
0
2
0
1
0
1
2
3
0
1
1
1
3
0
0
0
0
1
0
4
0
1
2
0
0
1
1
0
1
1
0
0
2
0
1
1
1
3
2
0
1
0
1
1
1
1
2
2
2
1
1
1
0
2
1
0
1
1
3
0
0
0
1
1
1
0
0
1
3
0
2
1
1
1
1
1
2
2
0
2
0
2
0
0
0
1
5
0
0
0
1
1
0
2
0
1
0
1
1
0
1
1
1
0
1
0
1
1
0
0
0
1
1
0
3
0
1
1
1
1
0
1
2
1
2
0
0
2
1
1
1
0
0
1
2
1
2
0
1
1
1
2
0
13 11 13 12 5
13 6
16 12 14 12 4
14 7
14 15 6
15
9