Failure to Ensure Driver Competency for Resident Transport Vehicle
Summary
The deficiency involves the facility’s failure to ensure that staff members who drive the facility’s transport vehicle were assessed and documented as competent to do so. During interviews, one facility staff member stated he had transported residents in the facility vehicle when asked by leadership, and employee file review showed another staff member also used the transport vehicle to transport residents. The DON confirmed that the facility provides transportation for residents to and from appointments and for activity outings. The DSD reported that facility staff, including two identified staff and activities staff, use the facility van for these purposes but stated there was no process in place to verify that these staff were competent and safe to operate the transport vehicle. The AD, who had worked at the facility for 15 years, stated that transporting residents on outings is part of her job and described the facility van as accommodating nine residents, including wheelchair-bound residents, with a hydraulic lift and wheelchair securement straps. She reported she had not been required to demonstrate competency or safety in driving the van. A concurrent observation with the DON confirmed the presence of a hydraulic lift and capacity for nine residents, including those who must remain in wheelchairs. The DON acknowledged that the facility had not completed competencies for staff who drive the transport vehicle. This practice was inconsistent with the facility’s written Competency Evaluation policy, which requires that all staff who provide care, treatment, or services be competent to perform their duties, with competency defined as the demonstrated knowledge and skill necessary to perform a task or job safely, successfully, and efficiently.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident with a right humerus fracture, lumbar fractures, and other comorbidities had a physician-ordered orthopedic follow-up appointment requiring accompaniment by medically trained staff. On the morning of the appointment, the resident was observed dressed, with arm in a sling and appointment papers in hand, waiting in the doorway and later still in the room, reporting that no one came to take him to the visit and that the appointment was missed. Review of records and appointment paperwork confirmed the scheduled follow-up and staff accompaniment requirement, and an RN acknowledged the resident was not transported due to miscommunication with the physician’s office.
A resident with Parkinson’s disease, muscle weakness, and intact cognition had physician-ordered podiatry appointments but repeatedly missed them because transportation was not properly arranged. Although the resident had Ohio managed Medicaid coverage that allowed multiple round-trip visits and required transport scheduling in advance, the insurer reported no transports were ever set up. The resident stated he missed two appointments due to the facility’s failure to arrange transportation, outside office staff reported multiple no-shows without cancellation or rescheduling, and an NP was not informed of any missed visits. An RN unit manager indicated transport confirmations were sent by text to the resident’s phone, while the resident reported his phone had been broken for two years, and the RN confirmed the resident was not transported to at least one scheduled appointment due to transportation issues.
A resident dependent on staff for ADLs and using a wheelchair missed multiple PMR appointments for pain management due to the facility's failure to arrange suitable transportation. Interviews and record reviews confirmed that transportation was either unavailable or could not accommodate the resident's wheelchair, resulting in several missed and rescheduled medical appointments.
A resident with multiple medical conditions, including cancer and undergoing chemotherapy, missed a scheduled Hematology and Oncology infusion appointment because transportation was not arranged during the responsible Unit Manager's vacation. Facility staff confirmed the oversight, and documentation showed the appointment was not entered into the transportation calendar or medical record, despite facility policy requiring assistance with transportation.
A resident with glaucoma was unable to attend a scheduled eye surgery due to the facility's failure to provide transportation. Despite the resident's need for supervision and the facility's policy to assist with transportation, staff were unavailable to accompany the resident. Interviews revealed a lack of communication and coordination between the Director of Nursing and the Transportation Coordinator, leading to the deficiency.
Failure to Transport Resident to Scheduled Orthopedic Appointment
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was transported to an outside orthopedic appointment as scheduled. The resident was admitted with multiple significant diagnoses, including a nondisplaced right humerus fracture, lumbar fractures at L1 and L2, morbid obesity, anxiety disorder, alcohol use, and a traumatic subdural hematoma from prior falls. The baseline care plan indicated the resident was alert and aware, non-weight bearing on the affected extremity, and was to receive physical and occupational therapy with the goal of discharge home, with social services coordinating services to achieve discharge goals. Physician orders documented an orthopedic follow-up appointment scheduled for 8:50 A.M. on 01/27/26, with instructions that staff accompaniment was required and that the accompanying staff needed to be medically trained. On the morning of the scheduled appointment, surveyor observation found the resident standing in the doorway with his right arm in a sling, wearing shoes and holding appointment papers, looking up and down the hallway shortly before the appointment time. In an interview, the resident stated he had been admitted about a week earlier, was supposed to have a follow-up with his orthopedic doctor that day, that his arm and sling were bothering him, and that no one had come to get him for the appointment. A later observation the same morning showed the resident still in his room with his arm in a sling, shoes on, and the appointment paperwork on the bedside table; he reported that no one ever came to get him and that he missed the appointment. Review of the appointment paperwork confirmed the scheduled orthopedic follow-up and the requirement for medically trained staff accompaniment. An RN interview verified the resident had not been transported to the appointment and attributed the missed appointment to miscommunication with the doctor’s office.
Failure to Arrange Transportation for Outside Podiatry Appointments
Penalty
Summary
The deficiency involves the facility’s failure to ensure transportation was adequately arranged for an insured resident’s outside podiatry appointments. The resident was admitted with Parkinson’s disease, muscle weakness, and a cognitive communication deficit, but the admission MDS showed intact cognition. Physician orders documented podiatry appointments on 12/04/25 at 11:15 A.M. and 01/08/26 at 2:15 P.M., and the resident was covered by an Ohio managed Medicaid plan that, per facility transportation guidelines, required transportation to be scheduled at least two days in advance and allowed up to 30 round trips per year. Despite these provisions, the insurance transportation representative reported that no transportation had been set up for any past or future appointments for this resident. The resident reported missing two appointments because the facility did not set up transportation in a timely manner. Outside office staff stated the resident was a no-show to multiple appointments due to transportation issues and that facility staff did not call to cancel or reschedule. The NP reported she was not notified of any missed appointments and confirmed transportation was a problem. The RN unit manager stated that confirmation for transport had been sent to the resident’s phone, but the resident reported his phone had been broken for two years and he could not receive texts. The RN unit manager confirmed the resident was not transported to the 01/08/26 appointment due to transportation issues. Facility transportation guidelines also indicated that routine or unrelated appointments should be canceled or rescheduled during a skilled stay, and that certain Medicare transports without secondary insurance would be billed to the resident at booking, but there was no evidence these guidelines were effectively implemented to ensure the resident’s ordered podiatry appointments were supported with appropriate transportation.
Failure to Provide Appropriate Transportation for Medical Appointments
Penalty
Summary
The facility failed to ensure appropriate transportation for a resident requiring outside medical appointments, specifically for follow-up care related to diabetes with neuropathy, hemiparesis, and pain management. The resident, who was dependent on staff for activities of daily living and used a wheelchair, missed multiple appointments with Physical Medicine and Rehabilitation (PMR) for evaluation and possible Botox injections due to pain and contractions. Documentation showed that transportation arranged by the facility was either not suitable for the resident's wheelchair or did not arrive as scheduled, resulting in several missed and rescheduled appointments. Interviews with the resident's family, PMR staff, and the Director of Nursing confirmed that the resident missed at least three appointments because transportation was either unavailable or inadequate. The facility's own policy required working with residents and families to secure appropriate transportation for off-site appointments, but there was no documentation explaining why some appointments were missed. The deficiency was identified through review of medical records, staff and family interviews, and policy review, affecting one resident out of three reviewed for outside medical appointments.
Failure to Arrange Transportation for Oncology Appointment
Penalty
Summary
The facility failed to ensure transportation was arranged for a resident to attend a scheduled Hematology and Oncology appointment for infusion therapy. The resident, who had diagnoses including malignant neoplasm of the right lung, cerebrovascular disease, and was receiving chemotherapy, was scheduled for an infusion appointment. Documentation showed that the appointment was missed due to a transportation error, specifically because the responsible Unit Manager was on vacation and the appointment was not scheduled on the transportation calendar. The resident's medical record did not contain a physician order for the missed appointment, and the facility's appointment calendar did not reflect the scheduled visit. Interviews with facility staff, including the Administrator, Unit Managers, Social Worker, and DON, confirmed that the missed appointment was due to a lack of transportation arrangements during the Unit Manager's absence. The facility's policy stated that assistance with arranging transportation would be provided as needed, but this was not followed in this instance. The deficiency was identified through review of records, interviews, and facility policy, and was substantiated by a resident grievance regarding the missed appointment.
Failure to Provide Transportation for Scheduled Surgery
Penalty
Summary
The facility failed to ensure transportation for a resident, identified as Former Resident #120, to a scheduled eye surgery appointment. The resident, who had diagnoses including schizophrenia, glaucoma, and non-compliance with medication regimen, was scheduled to leave the facility for laser eye surgery related to glaucoma. Despite having intact cognition and requiring supervision for activities of daily living, the resident was unable to attend the appointment due to the unavailability of staff to provide transportation. Interviews with the Director of Nursing (DON) and the Transportation Coordinator (TC) revealed a lack of communication and coordination regarding the resident's transportation needs. The DON was unaware of the missed appointment, and the TC acknowledged responsibility for tracking appointments but could not explain why the resident was not transported. The facility's policy stated that assistance would be provided for transportation to necessary services, but this was not adhered to in this instance, resulting in a deficiency noted under Complaint Number OH00161972.
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.
Trusted by long-term care providers and associations.
