Facility Lacks Qualified MDS Coordinator
Summary
The facility failed to ensure that qualified staff were employed to accurately encode, transmit, and implement assessments and care plans. The Minimum Data Set (MDS) Coordinator position, responsible for completing all MDS and Care Area Assessments (CAAs), scheduling and leading Care Plan Conferences, and transmitting completed MDS assessments to the state, was vacant after the previous coordinator left on 08/14/2024. The Director of Nursing (DON), who lacked training in MDS, was temporarily assigned these duties with assistance from an MDS Consultant. However, the consultant was not available for interviews, and the DON admitted to not being familiar with the MDS process. The Administrator acknowledged that the workload assigned to the Assistant Director of Nursing (ADON), who was also handling admissions, infection prevention, assessments, and other duties, was unrealistic for long-term success. The facility was in the process of hiring new staff to fill the DON and MDS positions, but at the time of the survey, the ADON was overwhelmed with responsibilities, and the facility was not in compliance with state regulations requiring qualified staff for MDS tasks.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A facility allowed an Interim DON to serve and practice as a Registered Nurse with a lapsed and inactive license, despite reminders and assistance from HR to renew. The license remained inactive due to incomplete renewal, and both the Administrator and HR were unaware of the lapse until it was confirmed during a complaint investigation.
A certified medication aide/tech who had not completed required training administered narcotic medication and insulin to two residents with complex medical histories. Facility records, interviews, and policy review confirmed the aide/tech was not qualified to give these medications, in violation of facility policy requiring administration by licensed or legally authorized staff.
A facility failed to ensure all nurses had active licenses, resulting in an LPN working with an expired license. The issue was discovered during a complaint investigation, and the IDON confirmed the LPN worked post-expiration. An assessment of residents and medication audits showed no issues.
The facility did not verify an LPN's active and unrestricted nursing license before hiring. The absence of documented evidence of license verification was confirmed by the Administrator. Although the LPN's license was later confirmed to be active and unrestricted, this verification happened post-hire.
Two STNAs administered medications with expired CRMA licenses, affecting 21 residents. The issue was identified through a review of medical and staffing records, revealing multiple instances of noncompliance. Interviews confirmed the oversight, which was investigated under a specific complaint number.
Interim DON Practiced with Lapsed RN License
Penalty
Summary
The facility failed to ensure that nursing staff were licensed in accordance with state laws, specifically allowing an individual to serve as Interim Director of Nursing (DON) while her Registered Nurse (RN) license was inactive and had lapsed. The Interim DON assumed the role in October 2025 after the previous DON resigned. Verification on the Ohio e-licensure website confirmed that the Interim DON's license had expired as of 10/31/25 and was not renewed. Despite reminders posted at the time clock and direct assistance from Human Resources (HR) to complete the renewal application, the license remained inactive due to incomplete renewal. Interviews with the Administrator and HR revealed that both were unaware the Interim DON's license was still inactive, even after attempts to prompt renewal. HR had assisted the Interim DON with the application process, but did not follow up to ensure completion. The deficiency was identified during a complaint investigation and had the potential to affect all 83 residents in the facility, as the Interim DON continued to practice without an active nursing license.
Unqualified Staff Administered Narcotics and Insulin
Penalty
Summary
Certified Medication Aide/Tech #3 administered narcotic medication and insulin to two residents without being qualified or trained to do so. One resident, with multiple diagnoses including diabetes, cerebrovascular disease, and cognitive impairment, received hydrocodone-acetaminophen, a class II narcotic, on two occasions as documented in the medication administration record and controlled drug log. Another resident, with a history of diabetes, COPD, hemiplegia, and other conditions, received insulin aspart via Flex pen on two separate occasions, also administered by the same unqualified staff member. Documentation confirmed that the aide/tech had not completed the required training and was not authorized to administer these medications at the time of administration. Interviews with facility staff, including the administrator and a registered nurse, confirmed that the aide/tech was unqualified to administer narcotics and insulin. Review of the personnel file showed no evidence of completed training or qualification for medication administration. Facility policy requires that medications be administered by licensed nurses or staff legally authorized to do so, which was not followed in these instances. The deficiency was identified through review of records, interviews, and policy documents, affecting two residents out of 32 with narcotic and/or insulin orders.
Expired Nursing License Deficiency
Penalty
Summary
The facility failed to ensure that all nurses providing care to residents had active licenses, as required by state law. Specifically, a Licensed Practical Nurse (LPN) was found to have an expired license while continuing to work at the facility. The Ohio Board of Nursing License Verification database confirmed that the LPN's license had expired, and the facility's daily nursing schedules showed that the LPN was scheduled to work after the expiration date. The Human Resource Manager confirmed that the LPN worked with an expired license on her last day of work. The Interim Director of Nursing (IDON) verified that the LPN had worked after her license expired and stated that the issue was discovered and addressed by management. The IDON conducted an assessment of all residents cared for by the LPN and found no issues or concerns with the nursing care provided. Additionally, an audit of medications administered by the LPN revealed no errors. The deficiency was identified during a complaint investigation related to specific complaint numbers.
Failure to Verify LPN License Before Hire
Penalty
Summary
The facility failed to ensure that an LPN had an active and unrestricted nursing license prior to being hired. This deficiency was identified during a review of personnel files, where it was found that there was no documented evidence of license verification for the LPN before their hire date. The issue was confirmed during an interview with the Administrator, who acknowledged the absence of licensure verification documentation in the LPN's file. A subsequent review of a document titled 'License Look Up' confirmed that the LPN did have an active and unrestricted nursing license, but this verification occurred after the hire date.
Expired CRMA Licenses Lead to Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure that licensed staff were administering medications, which affected 21 residents out of 24 reviewed for medication administration. The issue arose when two State Tested Nursing Assistants (STNAs), identified as #433 and #407, administered medications with expired Certified Registered Medication Aide (CRMA) licenses. This noncompliance was discovered through a review of medical records, medication administration records, staffing assignments, and CRMA licenses. The expired licenses of STNA #433 and STNA #407 were identified during the survey, revealing that they had administered medications on multiple occasions with expired certifications. Interviews with the facility's Administrator and Regional Clinical Support Registered Nurse (RCSRN) confirmed the oversight and the subsequent identification of the issue. The facility census at the time was 56, and the deficiency was investigated under Complaint Number OH000154300.
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