Accord Care Community Orrville Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Orrville, Ohio.
- Location
- 1980 Lynn Drive, Orrville, Ohio 44667
- CMS Provider Number
- 366123
- Inspections on file
- 32
- Latest survey
- December 4, 2025
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Accord Care Community Orrville Llc during CMS and state inspections, most recent first.
The facility failed to ensure timely wound care interventions for two residents. One resident did not receive a wound clinic referral or ordered lab tests as directed by a practitioner, resulting in unmanaged pressure ulcers. Another resident, dependent on staff for ADLs and at risk for skin breakdown, was found in bed without required heel protector boots, a lapse confirmed by both the resident and an LPN.
A resident with quadriplegia and hand contractures did not receive prescribed rolled washcloths or splints to both hands as ordered, and staff confirmed the absence of a restorative program to maintain or improve range of motion after therapy services ended. Observations and staff interviews verified that the resident's contracture interventions were not in place, and no system existed to prevent further decline in functional abilities.
Surveyors found that several residents had dirty bedding, missing thermostat covers, and detached bathroom sink molding in their rooms. These issues were confirmed by an LPN and the housekeeping supervisor, while the regional facilities manager was unaware of the problems due to the recent resignation of the maintenance director. The deficiency had the potential to impact all residents.
A resident's personal funds were not refunded to their spouse within the required 30-day period following the resident's death. Despite multiple contacts and assistance from the Ombudsman, the refund check was delayed for several months, and facility staff confirmed the delay without providing a reason. The resident had multiple serious medical conditions at the time of death.
A resident with multiple vascular wounds on her lower extremities did not receive adequate pain management in a timely manner. Despite having a care plan, the facility failed to assess and treat the resident's pain effectively, particularly during dressing changes. The resident frequently reported high levels of pain, but pain assessments and timely administration of pain relief were lacking, as confirmed by staff interviews and observations.
The facility failed to administer the COVID-19 vaccine to residents who had consented, leading to several residents contracting the virus during an outbreak. Despite consent, the facility did not schedule a vaccine clinic or order vaccines, leaving residents unprotected. One resident required hospital treatment for COVID-19 and pneumonia, while another experienced symptoms after testing positive.
A staffing shortage at a facility left only one LPN, one RN in training, and one CNA to care for 53 residents, including those in a memory care unit. The CNA, new to the facility, was unable to access care plans or clean linens, resulting in inadequate care. The facility's policy requiring shift-to-shift reports was not followed, and the Administrator acknowledged the staffing issues.
A facility failed to ensure staff wore the correct PPE when entering a COVID-19 positive resident's room. An Agency CNA and the Maintenance Director entered the room without the required PPE, despite the resident being on droplet isolation precautions. The facility's Director of Nursing confirmed the PPE requirements, which were not followed. Education records showed the staff had not received recent PPE training.
A facility failed to ensure comprehensive and routine assessment of a resident's non-pressure related skin issues, leading to a deficiency. The resident, with a history of COPD and diabetes, had an abrasion on the right lower extremity that was initially assessed and treated, but subsequent monitoring was not consistently documented. The wound later progressed to a non-pressure chronic ulcer with fat layer exposure, as classified by an outside wound healing center. Despite being prescribed antibiotics and scheduled for follow-up, the resident was unable to attend due to an acute illness, and the facility did not ensure continued wound monitoring.
A facility failed to implement fall prevention interventions and update care plans for a resident at high risk for falls. The resident, with severe cognitive impairment, experienced two falls. The first fall investigation lacked documentation of witness statements and whether interventions like elbow protectors were used. The care plan was not updated with new interventions. The second fall resulted in visible bruising and a head injury, again lacking documentation of interventions. Staff confirmed the deficiencies in documentation and care plan updates.
The facility did not maintain food at palatable temperatures, affecting 54 residents. Several residents complained about cold and unpalatable food. Observations showed that while food was initially hot, it cooled significantly by the time it was served. A test tray confirmed the food was too cold, and the facility lacked a policy on required food temperatures at service.
A facility failed to maintain a medication error rate below five percent, resulting in a 6.67% error rate. An LPN did not prime insulin pens before administering doses to a resident with diabetes, contrary to manufacturer's guidelines. This oversight had the potential to affect additional residents receiving insulin injections, as confirmed by the DON.
The facility failed to meet the dietary preferences of four residents, including serving orange juice to a resident who disliked it and not providing milk to two residents who requested it. These actions were contrary to the facility's policy on therapeutic diets.
A resident with dementia had conflicting advanced directives in their medical records, with one indicating Full Measures and another indicating DNR-CC. The facility's policy required consistent documentation, but the directives in the hard chart and electronic record were not aligned. An LPN and the Administrator confirmed the inconsistency, which could lead to confusion in emergency situations.
A resident with significant cognitive and physical impairments was found with a bruise on the forehead, but the facility failed to promptly notify the resident's POA, who discovered the injury herself. The facility's policy required immediate notification of changes in a resident's condition, which was not followed in this instance.
A resident with dementia and muscle weakness sustained a forehead bruise of unknown origin, which was not reported to the State agency as required. The injury was discovered by an LPN during breakfast, and the resident's Power of Attorney was informed but not given an explanation. Observations suggested the bruise might have been caused by contact with the bed's side rail, contrary to initial suggestions of a mechanical lift incident.
A resident with multiple dependencies was found with a forehead bruise, but the LTC facility failed to conduct a thorough investigation. Initial observations suggested the injury might have been caused by a Hoyer lift, but further examination indicated it could have been from a bed rail. The facility did not follow its policy for reporting and investigating such injuries, leading to a deficiency.
A facility failed to provide appropriate treatment for a resident's moisture-associated dermatitis (MASD), leading to inadequate healing. The resident, with Alzheimer's and diabetes, had an intervention for incontinence care, but the zinc cream treatment was not consistently ordered or documented. Staff interviews revealed the resident sometimes refused care, and a 4-N-1 Skin Protectant was used instead, which was not a treatment for MASD. Observations confirmed MASD presence, and the physician's order was not initially in the electronic health record.
A resident with severe cognitive impairment and incontinence was left sitting in a common area with a strong odor of urine and a stained chux pad, indicating a lack of timely care. Despite the resident's care plan requiring regular incontinence care, staff failed to address the issue promptly, resulting in the resident's brief, pants, chux pad, and wheelchair cushion being saturated with urine.
A facility failed to investigate an allegation of verbal abuse involving a resident with intact cognition who required substantial assistance for ADLs. The resident reported an inappropriate comment made by an STNA during care, but the facility did not document or investigate the incident as required by their policy. The DON was aware but did not conduct a thorough investigation, and the interim administrator was not informed of the incident.
The facility failed to honor food preferences for three residents, serving them items they disliked despite clear documentation on their diet tray tickets. The Dietary Manager acknowledged the errors and mentioned plans to update preferences and audit diet tickets.
The facility did not complete required 90-day and annual performance evaluations for several STNAs, potentially affecting all 58 residents. This issue was confirmed by the Business Office Manager during a complaint investigation.
Failure to Provide Timely Wound Care and Maintain Preventative Devices
Penalty
Summary
The facility failed to maintain proper wound care for two residents. For one resident with multiple complex diagnoses, including a sacral pressure ulcer, a Certified Nurse Practitioner ordered a referral to a wound clinic and laboratory tests for a comprehensive metabolic panel. However, the facility did not follow through with these orders, as the referral was not made and the laboratory tests were not obtained. This was confirmed by both the practitioner and the Regional Director of Clinical Operations, and wound documentation later showed the presence of an unstageable pressure ulcer. For another resident with diabetes, chronic kidney disease, and polyneuropathy, the care plan required the use of heel protector boots while in bed to prevent skin breakdown. Despite this, the resident was observed in bed without the boots, which were found lying against the wall. The resident stated the boots should have been on, and this was verified by an LPN present at the time, who acknowledged the boots should have been in use.
Failure to Maintain Restorative Program and Hand Contracture Interventions
Penalty
Summary
The facility failed to implement a restorative program to prevent the decline of residents' functional abilities, specifically for a resident with contractures of both hands. The resident had multiple diagnoses, including quadriplegia and contractures, and physician orders directed that rolled washcloths be applied to both hands twice daily. The care plan also included this intervention. However, observations revealed that the resident's hands were clenched in a tight-fisted position without the prescribed splints or washcloths in place. This absence was verified by nursing staff during the survey. Interviews with facility staff, including LPNs and the Therapy Director, confirmed that there was no restorative program in place to address range of motion exercises or to implement therapy recommendations after therapy services were discontinued. The Therapy Director acknowledged that residents who had received therapy services were at risk for functional decline due to the lack of restorative follow-up. The Assistant Director of Nursing also verified the absence of a restorative program and the failure to maintain the resident's hand splints as ordered.
Failure to Maintain Clean and Safe Resident Environment
Penalty
Summary
Surveyors observed that the facility failed to maintain a clean, sanitary, and safe environment for its residents. During observations, three residents were found with dirty bedding, and multiple rooms had missing thermostat covers. Additionally, strips of molding that should have been attached to bathroom sinks were found detached and leaning against the wall in some resident bathrooms. These conditions were verified by both nursing and housekeeping staff at the time of observation. Interviews revealed that the Regional Facilities Manager was unaware of the missing thermostat covers and detached molding, attributing the oversight to the recent resignation of the maintenance director without notice. The deficiency was identified during investigations under two complaint numbers and had the potential to affect all residents in the facility.
Failure to Timely Refund Resident Personal Funds After Death
Penalty
Summary
The facility failed to convey a resident's personal funds and provide a final accounting to the resident's representative within 30 days of the resident's death, as required by facility policy. Record review showed that the resident, who had diagnoses including Alzheimer's Disease, dementia, severe protein-calorie malnutrition, congestive heart failure, and type 2 diabetes mellitus with diabetic neuropathy, expired in the facility. The resident's spouse reported not receiving the refund check for the resident's personal funds until several months after the resident's death, despite contacting the Ombudsman for assistance. Interviews with the Business Office Manager and the Administrator confirmed that the refund check was not issued within the required 30-day timeframe, and no explanation was provided for the delay. The Ombudsman also confirmed being contacted by the resident's spouse and subsequently speaking with the Administrator, who stated they were working on the issue. Documentation showed that the refund check for $759.00 was eventually issued to the resident's spouse, but not in a timely manner as stipulated by facility policy.
Inadequate Pain Management for Resident with Vascular Wounds
Penalty
Summary
The facility failed to implement an effective pain management program for a resident with multiple vascular wounds on her lower extremities. The resident, who was cognitively intact, had a history of peripheral vascular disease, major depressive disorder, type two diabetes, and heart failure. Despite having a care plan that included administering analgesia and monitoring pain, the facility did not adequately assess or treat the resident's pain prior to wound care treatments. The resident's medical records revealed multiple instances where pain assessments were not conducted, and pain medication was not administered in a timely manner. The resident frequently reported pain, especially during dressing changes, but there was no documented evidence of pain assessments or administration of pain relief prior to these procedures. The resident's pain was often rated high on a scale of zero to ten, yet the facility failed to provide consistent pain management. Interviews with staff and observations confirmed that the resident experienced significant pain, particularly during wound care. Staff members acknowledged the resident's complaints of pain and the ineffectiveness of the current pain management approach. The facility's policy on administering pain medications emphasized the importance of assessing pain and recognizing non-verbal signs, but these guidelines were not followed, leading to inadequate pain management for the resident.
Failure to Administer COVID-19 Vaccine to Consenting Residents
Penalty
Summary
The facility failed to ensure that residents who had consented to receive the COVID-19 vaccination were administered the vaccine. This deficiency affected several residents, including four specific individuals who had consented to the vaccine but did not receive it. The failure to administer the vaccine was due to the facility's inability to schedule a COVID-19 clinic or order the vaccines from the pharmacy in a timely manner. As a result, these residents were left unprotected during a COVID-19 outbreak within the facility. One resident, who had consented to the vaccine upon admission, tested positive for COVID-19 and was transferred to the emergency room with symptoms of shortness of breath, low oxygen saturation, and chest pain. The resident was diagnosed with COVID-19 and pneumonia and required ongoing hospital treatment. Another resident, who also consented to the vaccine, tested positive for COVID-19 and experienced symptoms such as congestion and malaise. This resident had not been provided the vaccine prior to contracting the virus. The facility's infection control log revealed that multiple residents tested positive for COVID-19 during the outbreak. Interviews with facility staff, including the Administrator, confirmed that the residents who had consented to the vaccine were not administered it due to a failure to schedule a clinic and order the vaccines. The facility's COVID-19 policy emphasized the importance of vaccination, but the lack of timely action resulted in residents being exposed to and contracting the virus.
Staffing Shortage Leads to Inadequate Resident Care
Penalty
Summary
The facility failed to ensure sufficient staffing levels to provide timely care to all 53 residents, including those in a locked memory care unit. On the morning of 02/03/25, the facility was left with only one LPN, one RN in training, and one CNA after multiple staff members called off. This left the memory care unit unattended for a period, and the remaining staff were unable to provide adequate care, including timely incontinence care and repositioning of residents. Agency CNA #208, who was new to the facility, was the only CNA present and was directed to the memory care unit without receiving a proper report or access to care plans. She found residents in need of care, including one covered in bowel movement, and was unable to access clean linens due to a locked laundry area. The CNA expressed concerns about resident safety and her ability to provide adequate care under these conditions. Interviews with staff confirmed the lack of coverage and the absence of a shift-to-shift report. The facility's policy requires CNAs to complete a walkthrough and provide a detailed report to the oncoming shift, which did not occur. The Administrator acknowledged the staffing shortage and the failure to ensure proper coverage, noting that the facility's memory care unit should be staffed 24 hours a day.
Failure to Adhere to PPE Protocols for COVID-19 Positive Resident
Penalty
Summary
The facility failed to ensure that staff donned and doffed the correct personal protective equipment (PPE) when entering and exiting the room of a resident who was COVID-19 positive. This deficiency was observed when an Agency Certified Nursing Assistant (CNA) and the Maintenance Director entered the room of a COVID-19 positive resident without wearing the required PPE, which included gloves, an N95 respirator mask, gowns, and face shields. The resident was on droplet isolation precautions, and a sign indicating this was posted outside the room. Despite this, the staff members only wore surgical masks and did not adhere to the facility's infection control protocols. The incident occurred during a COVID-19 outbreak in the facility, where 20 residents had tested positive. The facility's Director of Nursing confirmed the PPE requirements for entering a COVID-19 positive room, which the staff failed to follow. A review of the facility's recent education records revealed that the CNA and Maintenance Director had not signed off on receiving education related to PPE and droplet precautions. The facility's policy on transmission-based precautions was also reviewed, which outlined the necessary protective measures for staff entering rooms of residents with infections transmitted by droplets.
Failure to Monitor Non-Pressure Related Skin Issues
Penalty
Summary
The facility failed to ensure comprehensive and routine assessment of non-pressure related skin issues for a resident, leading to a deficiency. Resident #10, who had a medical history including chronic obstructive pulmonary disease, type two diabetes mellitus with diabetic neuropathy, and peripheral vascular disease, was admitted with an abrasion on the right lower extremity. The wound was initially assessed and treated, but subsequent monitoring was not consistently documented. The wound was described as an abrasion on 01/03/25 and 01/16/25, but no further wound monitoring was recorded after the latter date. The resident's wound was later classified as a non-pressure chronic ulcer with fat layer exposure by an outside wound healing center, indicating a progression in the wound's severity. Despite being prescribed antibiotics for a wound infection and being scheduled for follow-up at the wound center, the resident was unable to attend due to an acute illness. The facility's failure to ensure continued wound monitoring after the resident's visit to the wound center on 01/16/25 was confirmed by Compliance Specialist #206. This deficiency was investigated under Complaint Numbers OH00161733 and OH00161732.
Failure to Implement Fall Prevention and Update Care Plans
Penalty
Summary
The facility failed to implement documented fall prevention interventions and did not update care plans in a timely manner to prevent repeat falls for a resident. The resident, who was severely cognitively impaired and at high risk for falls, experienced two falls within a short period. The first fall occurred when the resident was found on the floor between beds, likely rushing to the bathroom. The investigation lacked documentation of witness statements, the resident's last toileting, and whether the resident was wearing elbow protectors and non-skid socks. The care plan was not updated to include new interventions after this fall. The second fall happened two days later, with the resident found on the floor with visible bruising and a closed head injury. Again, there was no documentation regarding the use of elbow protectors or the resident's last toileting. The facility's policy required monitoring and documentation of residents' responses to interventions, which was not followed. Interviews with staff confirmed the lack of documentation and timely updates to the care plan, contributing to the deficiency.
Food Temperature Deficiency
Penalty
Summary
The facility failed to ensure that food was served at palatable temperatures, affecting 54 residents who received meals. During the annual survey, several residents reported that their food was cold and not palatable. Observations of the tray line revealed that while food was initially above 165 degrees Fahrenheit, by the time it was served, the temperature had dropped significantly. A test tray showed that the chicken thigh was at 108 degrees Fahrenheit and the peas at 115 degrees Fahrenheit, which the Dietary Manager acknowledged as too cold. The facility did not have a policy specifying the required food temperatures at the point of service.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a rate of 6.67% due to two errors in 30 opportunities. This deficiency was identified during a review of medication administration for a resident with type two diabetes mellitus and diabetic chronic kidney disease. The resident required insulin administration as part of their care plan. However, the Licensed Practical Nurse (LPN) responsible for administering the insulin did not follow the manufacturer's guidelines for priming the insulin pen before injection. This oversight occurred during the administration of both insulin lispro and insulin glargine, leading to potential inaccuracies in the insulin dosage administered. The LPN admitted to not priming the insulin pen and was unaware of the correct procedure, as evidenced by their question, "How do you do that?" This lack of knowledge and adherence to proper medication administration protocols had the potential to affect not only the resident in question but also an additional 13 residents who received insulin injections. The Director of Nursing confirmed that the LPN worked with residents throughout the facility, further highlighting the potential widespread impact of this deficiency.
Failure to Accommodate Resident Dietary Preferences
Penalty
Summary
The facility failed to provide meals that accommodated the preferences of four residents, as observed during a survey. Resident #3, who has severe cognitive impairment due to dementia and Alzheimer's disease, was served orange juice despite a documented dislike for it. Similarly, Resident #8, who has intact cognition and is on a no added salt diet, was served cake instead of the prescribed fruit for dessert. These discrepancies were confirmed by staff during the survey. Additionally, Resident #16, who has moderately impaired cognition and requires a consistent carbohydrate diet, was not provided with the requested eight ounces of milk with their meal. Resident #34, who also has moderately impaired cognition and is on a regular diet with double portions, was similarly not given milk as per their preference. These failures to adhere to dietary preferences and orders were verified by staff and are in violation of the facility's policy on therapeutic diets, which mandates that diets be prescribed in accordance with residents' goals and preferences.
Inconsistent Advanced Directives for a Resident
Penalty
Summary
The facility failed to ensure that the advanced directives for a resident were accurate and consistent across different records. Resident #108, who was not cognitively intact due to conditions such as dementia, insomnia, and hypertension, had conflicting advanced directives in their medical records. The hard copy chart contained two different directives: one indicating Full Measures, requiring all life-saving measures, and another indicating Do Not Resuscitate - Comfort Care (DNR-CC), which specified that CPR should not be initiated in case of cardiac or respiratory arrest. Both forms were dated the same day, and the electronic medical record indicated the resident's directive as DNR-CC. During an interview, an LPN and the Administrator confirmed the presence of two different advance directives in the hard chart and stated that in the event of a cardiac or respiratory arrest, staff would follow the directive in the hard chart. They acknowledged that the directives in the electronic record and the hard copy chart should be consistent, but they were not for Resident #108. The facility's policy required that information about advance directives be prominently displayed in the medical record and reviewed annually with the resident or their representative, but this was not adhered to in this case.
Failure to Notify POA of Resident Injury
Penalty
Summary
The facility failed to timely notify the Power of Attorney (POA) of Resident #25 about an injury of unknown origin. Resident #25, who was readmitted with diagnoses including age-related physical debility, dementia, and Parkinson's disease, was found with a bruise on the forehead. The resident was dependent on staff for various activities and was rarely or never understood, indicating significant cognitive and physical impairments. On the morning of the incident, a Licensed Practical Nurse (LPN) noticed the bruise while feeding the resident in the dining room, but the POA was not informed until later, despite being present at the facility. Interviews revealed that the POA, who worked as a receptionist at the facility, discovered the injury herself when she visited her mother. The POA was not notified by the staff and had to inquire about the injury upon noticing it. The facility's policy required prompt notification of changes in a resident's condition to the resident, their physician, and their representative, which was not adhered to in this case. This deficiency was identified during an investigation under Complaint Number OH00158226.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin to the State agency, affecting a resident who was reviewed for abuse. The resident, who was readmitted with diagnoses including dementia and muscle weakness, was dependent on staff for all activities of daily living. A bruise was discovered on the resident's forehead, which was not reported as required by the facility's policy on abuse, neglect, and injuries of unknown origin. The injury was first noted by an LPN during breakfast, who observed a bruise with an open area on the resident's forehead. The resident's Power of Attorney, who also worked at the facility, noticed the injury later that morning and was informed by the nurse that the cause was unknown. Despite the facility's policy requiring immediate reporting of such injuries, no Facility Reported Incident (FRI) was completed for this case. Interviews and observations revealed inconsistencies in the explanation of how the injury occurred. While the Director of Nursing suggested the injury might have been caused by a mechanical lift, observations indicated that the bruise's location and shape were consistent with contact with the bed's side rail. The facility's policy mandates that all injuries of unknown origin be reported to the appropriate authorities, but this was not done in this instance.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate an injury of unknown origin for a resident, identified as Resident #25, who was dependent on staff for all activities of daily living due to multiple diagnoses including dementia and Parkinson's disease. The resident was found with a bruise on the forehead, which was not present the previous day. The bruise was initially noted by an LPN during breakfast, but no immediate investigation was initiated to determine the cause of the injury. Interviews with staff revealed inconsistencies in the accounts of how the injury might have occurred. The Director of Nursing (DON) and other staff speculated that the injury could have been caused by contact with a Hoyer lift bar during a transfer, but observations and further interviews suggested that the injury's location was more consistent with contact with the bed's side rail. Despite these observations, the facility did not conduct a comprehensive investigation, as required by their policy, which mandates interviewing all staff who had contact with the resident during the period of the alleged incident. The facility's policy on reporting and investigating injuries of unknown origin was not followed, as the injury was not reported to the necessary authorities, and the investigation was not documented thoroughly. The DON confirmed that only two staff members and the resident's Power of Attorney were interviewed, and no other staff or residents were questioned. This lack of thorough investigation and documentation represents a deficiency in the facility's compliance with its own policies and regulatory requirements.
Inadequate Treatment for Moisture-Associated Dermatitis
Penalty
Summary
The facility failed to ensure appropriate treatment for moisture-associated dermatitis (MASD) for a resident, leading to inadequate healing. The resident, who had Alzheimer's disease, dementia, and diabetes, was admitted to the secured memory care unit. An intervention was in place to provide incontinence care and apply barrier cream after each episode. However, the zinc cream treatment for MASD was discontinued on a specific date, and there was no evidence of the treatment being ordered or provided for a period thereafter. The resident's skin condition was documented as improving, but the treatment was not consistently documented in the medical records. Interviews with staff revealed that the resident sometimes refused care, which contributed to the inconsistency in treatment. The Director of Nursing indicated that a 4-N-1 Skin Protectant barrier cream was used during the period when the zinc cream was not ordered, but a manufacturer representative clarified that this product was not a treatment for MASD. Observations confirmed the presence of MASD on the resident's buttocks, and it was noted that the physician's order for treatment was not initially entered into the electronic health record. This deficiency was investigated under a specific complaint number.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care for a resident, identified as Resident #15, who was admitted with diagnoses including diffuse traumatic brain injury, lack of coordination, and schizoaffective disorder. The resident's care plan indicated they were incontinent of bowel and bladder, requiring regular assessment and incontinence care, including the application of barrier cream after each episode. Observations revealed that the resident was left sitting in a common lounge area in a wheelchair with a strong odor of urine and a visibly stained chux pad, indicating a lack of timely care. Further observations showed that the resident remained in this condition for an extended period, as staff members, including the Medical Records/Activity Director, did not address the issue. An interview with a State tested Nurse Aide (STNA) revealed that the resident was last changed after breakfast and before lunch, but the STNA could not specify the exact time. Eventually, another STNA confirmed that the resident's incontinence brief, pants, chux pad, and wheelchair cushion were saturated with urine, highlighting the facility's failure to adhere to its Perineal Care policy, which aims to ensure cleanliness, comfort, and infection prevention.
Failure to Investigate Alleged Verbal Abuse Incident
Penalty
Summary
The facility failed to complete an investigation of an allegation of potential staff-to-resident verbal abuse involving Resident #51. The resident, who had intact cognition and required substantial assistance for activities of daily living, reported an incident where a State tested Nursing Assistant (STNA) made an inappropriate comment during care. Despite the resident stating that they did not feel it was abuse and felt safe, the facility did not document or investigate the incident as required by their Abuse Prevention Policy. Interviews revealed that the Director of Nursing (DON) was aware of the incident but did not conduct a thorough investigation or document any findings. Additionally, the Regional Director of Operations, who was the interim administrator at the time, was not informed of the incident and stated that she would have investigated it. The facility's failure to investigate and document the incident represents noncompliance with their policy to identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property.
Failure to Honor Resident Food Preferences
Penalty
Summary
The facility failed to honor food preferences for three residents, which was identified through observation, interview, and record review. Resident #15, who had intact cognition and required setup for eating, was served peas despite having a documented dislike for them on her diet tray ticket. Similarly, Resident #18, who also had intact cognition and required setup for eating, was served an egg bake for breakfast, although her diet tray ticket indicated a dislike for eggs. The Dietary Manager acknowledged the error, stating that the ticket was not updated. Resident #44, with intact cognition and requiring substantial assistance for eating, was also served an egg bake despite her diet tray ticket indicating a dislike for eggs. The resident confirmed that she frequently received eggs and had to request alternatives if she was still hungry. The Dietary Manager, who was recently employed, admitted to the kitchen being disorganized and mentioned plans to update residents' preferences and audit diet tickets. This deficiency was investigated under Complaint Number OH00155428.
Failure to Conduct Required STNA Evaluations
Penalty
Summary
The facility failed to conduct required 90-day and annual performance evaluations for state tested nursing assistants (STNAs), affecting five out of six STNAs whose personnel files were reviewed. This deficiency was identified during a complaint investigation and had the potential to impact all 58 residents in the facility. Specifically, STNAs hired on various dates in 2024 and earlier did not have their 90-day or annual evaluations completed as required. The Business Office Manager confirmed the absence of these evaluations for the identified STNAs.
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Surveyors found that multiple hazardous storage areas, including a closet near medical records, a beauty salon used to store chemical cases, a supply room in one nursing station, a room leading to a smoking area, a housekeeping room near therapy, and a lobby storage room, lacked required self-closing or automatic-closing doors. These conditions did not comply with NFPA 101 requirements for hazardous area enclosure and had the potential to affect all residents and staff in an emergency.
Surveyors found that the facility did not conduct fire drills on every shift each quarter and did not vary drill conditions as required by NFPA 101. Record review showed that one shift lacked a documented drill for an entire quarter, and the pattern of drill times and dates did not demonstrate varied conditions. The Maintenance Director confirmed the incomplete and noncompliant fire drill schedule, which affected all residents and staff emergency preparedness.
Surveyors found that the facility did not maintain clear egress corridors as required by NFPA 101, with a TV/video cart plugged into a corridor outlet and multiple unsecured chairs placed in the hallway near resident rooms and the secured unit dining room, including directly in front of a fire extinguisher. These items projected about 29 inches into an approximately eight-foot-wide corridor and were located in front of the handrail, potentially affecting 28 residents and staff’s ability to assist in an emergency. The Maintenance Director confirmed these corridor obstructions during the survey.
A resident with intact cognition receiving Medicare Part A skilled services for metabolic encephalopathy had services discontinued while benefit days remained, but the facility did not issue the required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN). The Social Services Director later confirmed that no SNF ABN was provided and reported she believed only a Notice of Medicare Non-Coverage (NOMNC) was needed when all skilled services were stopped. This practice conflicted with the facility’s written policy, which required SNF ABNs to be issued when extended care items or services were initiated, reduced, or terminated due to expected non-coverage by Medicare.
Surveyors identified that the facility exceeded the acceptable medication error rate when two residents with type 2 DM received insulin doses that were not administered according to orders or manufacturer instructions. In two separate observations, an LPN administered Novolog and another LPN administered insulin glargine and insulin lispro without priming the insulin pens, and the insulin lispro and Novolog were given after the residents had already consumed a significant portion of their breakfast meals, despite orders for administration before meals. Manufacturer information for both insulin products required priming before each injection to ensure accurate dosing, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and specified time frames.
The facility failed to maintain accurate and complete crash cart audits for multiple full-code residents. Surveyors, accompanied by the DON, found that daily crash cart checks did not include verification of supply expiration dates, and that an extension cord documented as present on several audit dates was not actually in the cart. Audit logs also conflicted with the cart’s contents by indicating that required items such as eye protection, saline, and clear plastic were present when they were not. These findings were inconsistent with the facility’s policy requiring the crash cart to be checked every 24 hours and after each use, with prompt replacement of equipment and supplies.
A resident with chronic respiratory failure on supplemental O2, COPD, and cognitive risk factors was repeatedly documented as non-compliant with the smoking policy, including going out to smoke outside designated times and retaining cigarettes and lighters provided by family. Despite prior assessments identifying this resident as unsafe to smoke without supervision, a later assessment classified the resident as safe to smoke independently without documented rationale or care plan update. The resident subsequently went outside alone with an O2 nasal cannula in place, lit a cigarette, and sustained facial burns when the cannula ignited, as observed by staff and confirmed by EMS and ED records. In a separate case, another cognitively impaired resident with a history of falls had a care-planned intervention for non-skid strips in front of a recliner, but observation and staff confirmation showed the strips were not present, despite remaining on the active fall-risk care plan.
Multiple dependent residents did not receive scheduled showers, bed baths, or shaving as outlined in their care plans and the facility’s routine care policy. One resident recovering from spinal surgery missed numerous scheduled showers over several months. Another resident who relied on staff for self-care repeatedly requested shaving but was not shaved, and visible facial hair was observed after a recent shower. A resident with chronic respiratory failure and a tracheostomy, requiring substantial/maximal assist with personal hygiene, had no documented showers for an extended period and was observed with long facial hair, which staff acknowledged should be removed during bathing or as needed. A cognitively impaired resident with ESRD and CHF, scheduled for twice-weekly showers, had multiple undocumented or missed showers and reported not getting showers despite asking aides who said they lacked time. Another cognitively intact resident with hemiplegia and multiple comorbidities, also scheduled for twice-weekly showers, had several dates where documentation showed no shower/bath/bed bath provided or no entry at all, and she reported feeling unclean and unimportant when her showers were missed.
A resident with an indwelling urinary catheter for urinary retention, and care plan interventions requiring the drainage bag to be properly secured with a dignity cover, was observed seated in a chair with the catheter drainage bag uncovered and containing visible dark yellow urine that could be seen from the hallway. Later, an LPN confirmed the catheter bag was lying directly on the floor without a dignity cover. This situation occurred despite facility policy requiring care to be provided in a manner that respects and enhances each resident’s dignity and personal privacy.
A cognitively intact resident with chronic orthopedic pain had a PRN oxycodone order, but multiple doses were signed out on the narcotic log by an RN without corresponding entries on the MAR or documented pain assessments. A CNA/med tech reported frequent problems with this RN’s narcotic counts and documentation, describing erratic behavior when handling narcotic keys. The resident reported taking oxycodone only once or twice daily and otherwise using Tylenol, which conflicted with the number of oxycodone doses signed out. The facility’s investigation found it was inconclusive whether narcotics were misappropriated or whether there was a failure of documentation, but confirmed there was no evidence that all signed-out doses were administered.
Failure to Maintain Self-Closing Doors for Multiple Hazardous Storage Areas
Penalty
Summary
Surveyors identified a deficiency related to hazardous area protection and door requirements under NFPA 101, 2012 Edition. During facility tours, they observed that multiple hazardous storage areas did not have self-closing or automatic-closing doors as required for hazardous areas such as combustible storage and chemical storage. These areas included a closet next to medical records, a beauty salon being used to store cases of chemicals, a supply room in Station #2, and the room leading to the smoking area in Station #3. On a subsequent tour, surveyors observed additional hazardous areas without self-closing doors. The housekeeping room across from therapy and the lobby storage room were both noted to lack self-closing door mechanisms. The facility census at the time was 59 residents, and the surveyors stated that this deficient practice had the potential to affect all residents and staff's ability to assist in an emergency. The Maintenance Director verified these findings at the time they were observed.
Plan Of Correction
K 0321 This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be admissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as its allegation of substantial compliance as of 06/12/2026 K-0321 Doors with Self-Closing Devices Corrective action for resident/s: 1. The closet door next to medical records was lacking a self-closing door on 5/19/2026. Maintenance director to add self-closing device to closet door next to medical records on or before 06/12/2026 in accordance with applicable code. 2. The beauty salon had chemicals stored in it on 5/19/2026. Maintenance director moved chemicals from beauty salon on 05/20/2026 in accordance with applicable code. 3. The supply room on station 2 was lacking a self-closing door on 5/19/2026. Maintenance director to add self-closing door to supply room on station 2 on or before 06/12/2026 in accordance with applicable code. 4. The room to the smoking area on station 3 was lacking a self-closing door on 5/19/2026. Maintenance director to add a self-closing door to the smoking are on station 3 on or before 06/12/2026 in accordance with applicable code. 4. The housekeeping room across from therapy was lacking a self-closing door on 5/19/2026. Maintenance director to add a self-closing door to the housekeeping room across from therapy gym on or before 06/12/2026 in accordance with applicable code. 5. The lobby storage room was lacking a self-closing door on 5/19/2026. Maintenance director to add a self-closing door to the lobby storage room on or before 06/12/2026 in accordance with applicable code. Identification of other residents who may be affected: LNHA and Maintenance director/designee completed a full facility audit for doors with self-closing devices on 05/26/2026. Any corrective action, including, doors identified as needing self-closures will be added on or before 06/09/2026 in accordance with applicable code. Measures for systemic change: LNHA educated Maintenance Director on 05/26/2026 regarding NFPA 101-2012 sections 19.3.2.1 and 19.3.5.9 specifically regarding doors with self-closing devices. How Corrective Action will be monitored Ongoing "Doors with Self-Closing device audit" to be completed weekly x 2 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 06/12/2026
Failure to Conduct Required Quarterly Fire Drills on All Shifts
Penalty
Summary
The facility failed to conduct fire drills in accordance with NFPA 101, 2012 Edition, sections 19.7.1 through 19.7.1.8, specifically by not holding drills every shift each quarter and not varying drill conditions as required. Record review on 06/09/25 at approximately 10:32 A.M. showed there was no fire drill conducted for the first shift during the third quarter. The documented first-shift fire drills occurred on 01/30/26 at 2:42 P.M., 04/30/26 at 1:51 P.M., and 10/31/25 at 10:58 A.M., indicating a missed quarter. Second-shift fire drills were recorded on 02/26/26 at 5:20 P.M., 06/03/25 at 4:35 P.M., 08/29/25 at 3:46 P.M., and 11/25/25 at 5:09 P.M., and third-shift drills on 02/28/26 at 11:47 P.M., 05/30/25 at 12:18 A.M., 07/22/25 at 11:34 P.M., 09/26/25 at 11:40 P.M., and 12/15/25 at 5:17 A.M. The surveyor determined that drills were not conducted under varied conditions and that the required quarterly drill on each shift was not consistently performed. The Maintenance Director confirmed these findings at the time they were identified, and the deficiency had the potential to affect all 59 residents and staff response in an emergency. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency related to facility-wide emergency preparedness practices and documentation of fire drills.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 05/29/2026 K-0712 Fire Drills Corrective action for resident/s: There were no records of a fire drill for the first shift of the third quarter of 2025. First shift fire drill completed on 5/24/2026 by maintenance director/designee with no findings or corrective action necessary. Identification of other residents who may be affected: On 5/26/2026 Maintenance director/designee completed 100% audit of the scheduled fire drills to ensure a drill is scheduled quarterly each shift with no findings or corrective action necessary. Measures for systemic change: LNHA educated Maintenance Director on 05/26/2026 regarding NFPA 101-2012 section 19.7.1.4 through 19.7.1.7. specifically including fire drill frequency requirements. How Corrective Action will be monitored Ongoing "Fire Drill Audit" to be completed weekly x 2 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 05/29/2026
Obstructed Egress Corridors Due to Equipment and Chairs
Penalty
Summary
The facility failed to maintain required clear egress widths in corridors in accordance with NFPA 101, 2012 Edition, sections 19.2.3.4 through 19.2.3.5 and 7.3.2 through 7.3.2.3, creating projections into the egress corridor that exceeded allowable limits. Surveyors observed that on one day in Station #3, a cart with a television and video equipment was plugged into an outlet in the corridor by room 38, and five activity room chairs were placed in the corridor near the secured unit dining room directly in front of a fire extinguisher. On the following day, surveyors again observed chairs in the Station #3 corridor, with four by room 35 and four by the activities room, and the same television cart still in the corridor; the chairs were not secured. The corridor was approximately eight feet wide, and the projections extended approximately 29 inches into the corridor in front of the handrail. These conditions had the potential to affect 28 residents in the facility and the staff’s ability to assist in an emergency, and the Maintenance Director confirmed the observations at the time of discovery. No specific resident medical histories or conditions were described in the report, only that 28 residents were potentially affected and the facility census was 59.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be subsequent remedial measures and should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 05/29/2026 K-0232 Clear path of egress Corrective action for resident/s: 1. On 05/18/2026 station 3 had a cart with a television parked in the corridor by room 38 that exceeded allowable limits. Maintenance director/designee moved the TV cart into the activity room, out to the corridor on 05/18/2026 in accordance with applicable code. 2. On 5/18/2026 station 3 had 5 chairs in the corridor near the dining room directly in front of the fire extinguisher. Maintenance director/designee moved the chairs into the dining room, out of the corridor on 5/18/2026 in accordance with applicable code. 3. On 5/19/2026 station 3 had 4 chairs by the activity room and 4 by room 35. In addition, the TV cart was in the corridor. The maintenance director/designee moved the chairs and TV cart into the dining room, out of the corridor on 5/19/2026 in accordance with applicable code. Identification of other residents who may be affected: Maintenance director/designee completed a 100% facility audit for clear paths of egress on 5/26/26 with no findings or corrective action necessary. Measures for systemic change: Maintenance Director/designee educated staff on 5/26/2026 regarding NFPA 101-2012 section 19.2.3.4 and 19.2.3.5 specifically including maintaining a clear path of egress. How Corrective Action will be monitored Ongoing "Path of Egress Audit" to be completed weekly x 2 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 05/29/2026
Failure to Issue Required SNF ABN When Discontinuing Medicare Part A Services
Penalty
Summary
The deficiency involves the facility’s failure to issue a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) when Medicare Part A services were discontinued for a resident who still had available benefit days. The resident was admitted with a diagnosis of metabolic encephalopathy and had intact cognition per the Minimum Data Set assessment. The facility’s own SNF Beneficiary Notification Review documented that Medicare Part A skilled services began on 02/11/26 and the last covered day was 03/11/26, and that the facility initiated discharge from Medicare Part A services before the resident’s benefit days were exhausted. Despite this, no SNF ABN was provided to the resident or the resident’s representative. During interviews, the Social Services Director stated that the SNF ABN was issued hours prior to the last covered day but, upon reviewing her files, confirmed that no SNF ABN had actually been issued for this resident. She further explained that she believed an SNF ABN was only required if one skilled service remained and that if all skilled services were being discontinued, only the Notice of Medicare Non-Coverage (NOMNC) needed to be issued. The Administrator, however, stated that a resident should always receive both a SNF ABN and a NOMNC when Medicare Part A services are discontinued and benefit days remain. Review of the facility’s written policy dated 03/28/23 showed that the facility was required to issue SNF ABNs for initiation, reduction, or termination of extended care items or services when Medicare payment was not expected, which did not occur in this case.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as its allegation of substantial compliance as of 05/29/2026 F-0582 Corrective action for resident/s: On 5/14/26 Resident #34 was informed of rights and responsibilities related to Advanced Beneficiary Notice and voiced understanding of information for future reference by administrator. Identification of other residents who may be affected: Any resident receiving skilled services from nursing or therapy services. The Administrator audited all residents who were discharged from skilled services in the past 30 days to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary Notice on 5/29/26. No non-compliance was noted. Measures for systemic change: On 5/14/2026 Business Office Manager, Director of Rehab, Minimum Data Set nurse, Director of Nursing and Social Services Director were educated on proper procedure of issuing of Notice Of Medicare Non Coverage and Advanced Beneficiary Notice by administrator. All upcoming discharges from skilled services will be reviewed weekly at Utilization Review meeting to ensure notices will be delivered timely. How Corrective Action will be monitored: Administrator or designee to complete audits of all residents being discharged from skilled services to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 5/29/26
Insulin Administration Errors and Failure to Prime Insulin Pens
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5%, with surveyors identifying 3 errors out of 28 medication administration opportunities, resulting in a 10.71% error rate. For one resident with type 2 diabetes mellitus and moderate cognitive impairment, the physician’s order directed Novolog insulin 10 units via subcutaneous pen-injector to be given before meals. During an observed medication pass, the LPN administered 10 units of Novolog insulin without priming the pen and did so after the resident had already consumed approximately 50% of the breakfast meal. The LPN later confirmed she did not prime the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer instructions for the Novolog FlexPen specified that an air shot (priming) must be performed before each injection to ensure proper dosing. Another resident, also diagnosed with type 2 diabetes mellitus and with intact cognition, had orders for insulin glargine 35 units subcutaneously twice daily and insulin lispro 20 units subcutaneously before meals, plus 12 units subcutaneously if blood glucose was between 251 mg/dL and 300 mg/dL. During an observed medication administration, an LPN administered 35 units of insulin glargine and 32 units of insulin lispro without priming the insulin pens and after the resident had consumed approximately 90% of the breakfast meal, despite orders for insulin lispro to be given before meals. The LPN later stated she could not remember if she had primed the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer information for insulin lispro stated that the pen must be primed before each injection to confirm insulin delivery and remove air, and that failure to prime could result in too much or too little insulin. The DON confirmed the expectation that insulin be administered as ordered, including priming each pen with two units before dialing the prescribed dose, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and required time frames.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 5/29/2026. F-0759 Corrective action for resident/s: Residents #21 and #22 were assessed and evaluated by nurse and Director of Nursing 5/14/26. Resident #21 and #22 both denied any adverse effects and none were noted upon assessment by the Director of Nursing on 5/14/2026. Notification made to physician on 5/14/2026. LPN # 2 competency Eval on insulin administration with the Director of Nursing completed 5/14/2026. Identification of other residents who may be affected: Diabetic residents on assignment of LPN #2/station 2 have the potential to be affected and were assessed by the DON/Designee on 5/14/26 and found to be within normal limits. Measures for systemic change: All Nurses were educated by the Director of Nursing on the steps for Insulin administration per competency, diabetes clinical protocol policy, Medication and treatment orders policy, administering medications policy, and Obtaining fingerstick Glucose Level policy On 5/14/2026. How Corrective Action will be monitored: Director of Nursing and Assistant Director of Nursing will complete insulin administration audits on 5 nurses. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance: 5/29/2026
Inaccurate Crash Cart Audits and Missing Emergency Equipment
Penalty
Summary
The facility failed to ensure accurate and complete crash cart audits for residents requiring basic life support, affecting eighteen of thirty-five residents who were designated as full code. During an observation of the crash cart with the DON, surveyors found that the daily audit documentation for the month did not include verification of expiration dates for crash cart supplies. Review of the crash cart audit logs showed that an extension cord was documented as being in the cart on multiple dates, but the extension cord was not present in the cart at the time of inspection. Additionally, the audit documentation indicated that required items, including eye protection, saline, and clear plastic, were not present in the crash cart, yet they were documented as being in the cart. The facility’s undated “Emergency Crash Cart” policy stated that the crash cart is to be checked every 24 hours and after every use, and that equipment and supplies are to be noted and replaced promptly, but the observed documentation and contents of the cart did not match these requirements. This deficiency was verified with the DON at the time of the survey and was cited under the requirement that personnel provide basic life support, including CPR, to residents requiring emergency care, subject to physician orders and advance directives, and was investigated under Complaint Number 2687380.
Plan Of Correction
Cridersville Care Center Provider Number:366171 Survey Type: Complaint Survey Survey Date: 04/29/26 This Plan of Correction (PoC) outlines the actions completed by the facility with regards to the deficiency citation. This Plan of correction does not constitute any admission of guilt or liability by the facility and is submitted only in response to the regulatory requirements. Please accept the following as the facility's credible allegation of compliance as of 4/30/26. F678 CPR All Full Code residents #18 have the potential to be affected by the alleged deficiency. On 4/27/26 the DON/ADON re-stocked the crash cart per the inventory sheet for all missing items. Crash cart inventory sheet updated and new one will go into effect on 5/1/26. All licensed nursing staff provided with training related to crash cart inventory being a daily audit review using inventory sheet on 4/27/26 per DON/designee. The DON/designee will conduct clinical rounds and conduct a random audit of crash cart three times per week for 4 (four) weeks to ensure compliance. The results of the audit will be documented. The facility conducted an Ad-Hoc QAPI meeting on 4/27/26 and discussed the alleged deficiency and corrective actions. Date when corrective action will be completed: 4/30/26
Unsafe Smoking Practices with Oxygen and Missed Fall-Prevention Interventions
Penalty
Summary
The deficiency involves the facility’s failure to provide a safe smoking environment, adequate supervision, and appropriate implementation of its smoking policy for a resident who used oxygen and smoked, as well as failure to implement fall-prevention interventions as care planned for another resident. One resident had multiple relevant diagnoses, including chronic respiratory failure with hypoxia, COPD, end-stage renal disease, dependence on supplemental oxygen, diabetes, and necrotizing fasciitis. Her care plans identified impaired visual function, risk for respiratory complications related to a history of smoking, and risk for cognitive decline, with interventions including use of oxygen per order and observation for understanding. A smoking-related care plan created earlier documented that she wished to use smoking products, had been assessed as safe to smoke "with supervision," and was non-compliant with the smoking policy, with family continuing to provide smoking supplies despite education and a verbal warning for non-compliance. Smoking assessments and progress notes showed a pattern of non-compliance and inconsistent classification of this resident’s smoking safety. Multiple smoking observation/assessments completed earlier in March documented that she had no cognitive loss, visual deficits, or dexterity problems but was unsafe to smoke without supervision because she did not return smoking materials and did not follow designated smoke times. Progress notes described her going out to smoke multiple times by herself or with family, including sneaking out next door with a cigarette and going out multiple times in one evening, with staff documenting that she was "reeducated" and that family brought in cigarettes and lighters which she did not return to staff. Despite this history, a smoking assessment completed after a three-day hospital stay assessed her as safe to smoke without supervision, with no documentation explaining how this conclusion was reached or evidence that her care plan was updated accordingly. On the day of the incident, the resident reported she had cigarettes and a lighter on her person after returning from dialysis and stated she "could not find a nurse" and went outside to smoke, saying she "guessed" she forgot she had her oxygen on. A CNA observed her outside and saw a flame coming through the resident’s oxygen nasal cannula tubing, turned off the oxygen tank, removed the tubing, and patted out sparks on the resident’s shirt sleeve. The resident’s face and hands appeared black in color, and EMS documented first-degree burns to the head and face, with the resident stating she lit a cigarette with her nasal cannula on, causing the burn. The hospital record described her face as black from smoke and her lips and mouth as "burnt and charred," with a recommendation for intubation that she refused. The facility’s incident report recorded that she went outside with oxygen on to smoke without notifying staff, that staff witnessed the occurrence as she walked through the dining room door to the courtyard, and that she stated she thought she had turned her oxygen off. The facility’s smoking policy required interdisciplinary evaluation to determine safe versus unsafe smokers, staff maintenance of all smoking paraphernalia for both safe and unsafe smokers, and progressive consequences for policy violations. A separate deficiency involved another resident at risk for falls whose care plan included use of non-skid strips on the floor in front of her recliner as a fall-prevention intervention. This resident had severe cognitive impairment, used a walker and wheelchair, required supervision or touching assistance for transfers and ambulation, and had experienced two or more falls without injury since the prior assessment. The fall-risk care plan, initiated at admission, specified non-skid strips in front of the recliner beginning in November. However, nursing staff interviewed were not familiar with all of the resident’s fall-prevention interventions without checking the record, and observation of the room showed two recliners with no non-skid strips on the floor in front of them. An LPN confirmed that the non-skid strips were not present despite the intervention remaining active in the care plan, and moving the recliners did not reveal any strips. The facility’s fall management policy required identification of hazards and risk factors, implementation of interventions to minimize falls and injuries, and development and implementation of a care plan based on interdisciplinary evaluation, with interventions related to identified risk factors.
Plan Of Correction
Smoking: On 03/21/26 at 3:16 P.M. 911 response was activated for Resident #11 and Medical Director #601 was notified by Registered Nurse (RN) #322. On 03/21/26 at 3:18 P.M. on-call Nurse/Social Services #423 immediately notified the Administrator and Director of Nursing (DON) #304 of the incident involving Resident #11. On 03/21/26 at 3:22 P.M. Emergency Medical Services (EMS) arrived onsite. At 3:30 P.M. Resident #11 was transported to the emergency room. On 03/21/26 at 3:30 P.M. RN #322 completed a smoking re-assessment of Resident #11 assessing the resident to be an unsafe smoker requiring supervision due to failure to remove oxygen prior to entering designated smoking area. On 03/21/26 from 3:38 P.M. through 7:57 P.M. Licensed Practical Nurse (LPN) #337, #336, #335, #338; RN #334, and DON #304 re-assessed residents (who smoke). This included Resident #22, Resident #3, Resident #47, Resident #50, Resident #60, Resident #150, Resident #86, and Resident #10 to determine smoking safety (via smoking assessment). Each resident was re-educated regarding the facility smoking policy and staff verified there were no smoking materials on their person. The residents' smoking materials would be maintained by facility staff and distributed per policy. On 03/21/26 at 4:30 P.M. DON #304 responded to facility and an Ad Hoc (not scheduled) Quality Assurance (QA) meeting was held via telephone with the Administrator, DON #304 and Medical Director #601 to review investigative findings and plan of action. A root cause analysis was completed and determined Resident #11 had smoking materials on her person (believed to be obtained from family without staff knowledge) and failed to remove her oxygen. The QA team discussed a corrective action plan. On 03/21/26 from 5:00 P.M through 03/22/26 at 3:00 P.M. 26 RNs, 13 LPNs, one medical technician (MT), 54 Certified Nursing Assistants (CNA) four activities staff, one central supply staff, 11 dietary staff, 12 housekeeping staff, three laundry staff, one medical records staff, two social designees, two maintenance staff, nine administrative staff, and 19 therapy staff (158 staff at the time of the incident) were provided education regarding the facility smoking policy by DON #304 and the Administrator. This was completed via 1:1, small group in-services or via phone. Newly hired staff would receive education during general orientation regarding the facility's smoking policy. On 03/21/26 at 5:00 P.M. DON #304 completed an audit of all residents who smoke (Resident #22, Resident #3, Resident #47, Resident #50, Resident #60, Resident #150, Resident #86, and Resident #10) to verify smoking evaluations and plans of care accurately reflected the residents' smoking safety needs. The residents were educated on the facility smoking policy, and smoking materials were to be maintained at the nurses' station. An audit was completed which included verification of required safety measures present in designated smoking areas, including an ash can, fire extinguisher, fire blanket, ash trays and no oxygen signs. There were no identified concerns or changes made because of the audits. On 03/21/26 at 8:55 P.M. Resident #11 returned from the ED. LPN #332 verbally educated the resident regarding the facility smoking policy which included the need for supervision, a smoking apron (to be worn) and the facility smoke times. LPN #332 verified no smoking materials were on the resident's person or in her room at this time. On 03/23/26 at 11:00 A.M. the Interdisciplinary Team (IDT) (Administrator, DON #304, Medical Director #601, RN #302, Social Services #427, Social Services #423, DON #300, and Maintenance #436) met in-person to review the plan of action with DON #304/designee to complete weekly monitoring of residents who smoke and designated smoking areas weekly for four weeks with Housekeeping responsible to complete the cleaning. Housekeeping staff were responsible for cleaning ashtrays and the designated smoking area daily. Audits to be reviewed and any further actions required to be directed by the Quality Assurance and Performance Improvement (QAPI) Committee during scheduled meetings. The IDT also reviewed all current smoking assessments and care plans for residents who smoke. Resident #50 required a change in supervision levels with smoking due to cognition levels and her plan of care as well as Resident #11's plan of care was updated to reflect supervision/safety. On 03/23/26 from 3:45 P.M. to 8:55 P.M. Social Services #423 re-educated residents who smoke (Resident #22, Resident #3, Resident #47, Resident #50, Resident #60, Resident #150, Resident #86, Resident #10) and responsible parties, if applicable regarding the facility smoking policy and supervision levels. On 03/23/26 at12:13 P.M. Social Services #427 contacted Resident #11's family member (#602) to schedule a care conference. Family member #602 and Family Member #603 were not available to meet until 03/27/26. On 03/23/26 at 1:00 P.M. staff education related to smoking areas, removal of oxygen prior to entering smoking area and maintaining smoking materials at the nurses' station for residents who smoke was initiated by DON #304 and the Administrator via 1:1, small group in-services or via phone call. Education was completed for all 158 staff by 03/24/26 at 1:00 P.M. Newly hired staff would be educated during general orientation regarding the facility's smoking policy. The facility does not utilize agency staff. On 03/27/26 at 11:00 A.M. a care conference was held with Resident #11 and Family Members #602 and #603, the Administrator, Social Services #423 and Social Services #427. The facility smoking policy was reviewed. The resident and family were informed an involuntary discharge would be initiated should the resident exhibit non-compliance moving forward and supervision would be increased beyond the two-hour standard of care to monitor more closely for non-compliance with the facility smoking policy. Family Member #602 stated he educated his siblings as well. On 04/10/26 at 2:00 P.M. DON #304 initiated education with 26 RNs and 13 LPNs (100% of nurses educated) regarding completion of the smoking evaluation via 1:1, small group in-services, or phone. The education was completed by 6:00 P.M. on 04/10/26. A new resident who smokes must remain supervised until the interdisciplinary team (IDT) reviews and determines smoking safety, at which time the care plan is developed and resident and family education is provided. The communication through the staff would be the care plan. Newly hired staff receive education during general orientation regarding the facility's smoking policy and completion of smoking evaluation via Point Click Care (PCC). On 04/10/26 at 4:29 P.M. DON #304 initiated an order in PCC for the nurse to verify, each shift, that Resident #11's smoking materials were maintained at the nurses' station. On 04/13/26 at 5:30 P.M. DON #304 initiated orders in PCC for nurses to verify, each shift, that all residents who smoke would have smoking materials maintained at the nurses' station. An updated list of smokers included: Resident #60, Resident #50, Resident #11, Resident #86, Resident #113, and Resident #151. On 04/13/26 at 5:45 P.M. DON #304 initiated questionnaires for staff regarding the smoking policy with re-education provided as needed via 1:1 and small group in-services for staff currently in the facility with all staff to be questioned/educated prior to working their next scheduled shift. Falls: On 4/9/26, Maintenance Director placed non-skid strips on the floor in front of Resident #12's recliner. Like Residents are identified as residents who have had a fall within the facility. Utilizing the Fall Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, an audit of falls and appropriate interventions for the past 30 days will be completed by the Director of Nursing or designee to ensure fall interventions are in place per plan of care. This audit along with identified corrections will be completed on or F 0689 before 5/13/26. The Director of Nursing or designee will re-educate licensed nurses and STNA/CNAs on the Fall Management Policy to include fall interventions to be in place per the care plan. This education will be completed on or before 5/13/26. Utilizing the Fall Management Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, the Director of Nursing or designee will complete an audit of new admissions, new readmissions and residents who experience a fall within the last 7 days, weekly for four weeks, beginning 5/14/26 to ensure fall safety interventions are in place per plan of care. Current fall interventions found to not be in place will be corrected with all intervention in place per plan of care. Negative findings to be addressed immediately and negative trends or system wide issues will be reported to the QAPI committee, and the action plan will be adjusted as needed.
Removal Plan
- Activated 911 response for Resident #11 and notified the Medical Director.
- On-call Nurse/Social Services immediately notified the Administrator and DON of the incident.
- EMS arrived onsite and Resident #11 was transported to the emergency room.
- Completed a smoking re-assessment of Resident #11, determining the resident was an unsafe smoker requiring supervision due to failure to remove oxygen prior to entering the designated smoking area.
- Re-assessed all residents who smoke (Residents #22, #3, #47, #50, #60, #150, #86, and #10) to determine smoking safety via smoking assessment.
- Re-educated residents who smoke regarding the facility smoking policy and verified there were no smoking materials on their person.
- Implemented that smoking materials would be maintained by facility staff and distributed per policy.
- Held an ad hoc QA meeting to review investigative findings and plan of action.
- Completed a root cause analysis determining Resident #11 had smoking materials on her person and failed to remove oxygen.
- Developed a corrective action plan.
- Provided facility-wide education to staff on the facility smoking policy.
- Implemented that newly hired staff would receive smoking policy education during orientation.
- Completed an audit of all residents who smoke to verify smoking evaluations and plans of care accurately reflected smoking safety needs.
- Ensured smoking materials were maintained at the nurses’ station.
- Audited designated smoking areas for required safety measures (ash can, fire extinguisher, fire blanket, ash trays, and no-oxygen signs).
- Provided verbal education to Resident #11 on smoking policy (supervision, smoking apron, smoke times).
- Verified no smoking materials were on Resident #11’s person or in her room.
- Conducted an in-person IDT meeting to implement weekly monitoring of residents who smoke and designated smoking areas weekly for four weeks.
- Assigned housekeeping to clean ashtrays and the designated smoking area daily.
- Directed audits to be reviewed by QAPI.
- Reviewed all current smoking assessments and care plans for residents who smoke.
- Updated Resident #50’s supervision level.
- Updated Resident #11’s plan of care to reflect supervision/safety.
- Re-educated residents who smoke and responsible parties (as applicable) regarding the facility smoking policy and supervision levels.
- Contacted Resident #11’s family to schedule a care conference.
- Initiated additional staff education regarding smoking areas, removal of oxygen prior to entering smoking area, and maintaining smoking materials at the nurses’ station.
- Held a care conference with Resident #11 and family to review smoking policy.
- Informed resident/family that involuntary discharge would be initiated for future non-compliance.
- Increased supervision beyond the two-hour standard of care to monitor more closely for non-compliance.
- Provided education to all nurses regarding completion of the smoking evaluation.
- Implemented that new residents who smoke must remain supervised until IDT review determines smoking safety and care plan/education are completed.
- Entered an order in PCC for nursing to verify each shift that Resident #11’s smoking materials were maintained at the nurses’ station.
- Entered orders in PCC for nursing to verify each shift that all residents who smoke have smoking materials maintained at the nurses’ station.
- Initiated staff questionnaires regarding the smoking policy with re-education as needed.
- Required all staff to be questioned/educated prior to working their next scheduled shift.
Failure to Provide Scheduled Bathing and Shaving Assistance for Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide scheduled and needed bathing and shaving assistance to multiple dependent residents in accordance with their care plans, preferences, and the facility’s routine care policy. One resident with spinal stenosis and recent L2–L5 decompression fixation fusion was care planned for substantial/maximal assistance with shower/bath and toileting hygiene and was scheduled for showers on Tuesdays and Fridays. Electronic documentation from early January through early April showed this resident did not receive a shower or bed bath on 11 identified scheduled days, and the DON confirmed these missed bathing events. Another resident with dysphagia and developmental issues, who required assistance with self-care and mobility, reported that she asked staff to shave her but they did not, which bothered her. During an observation following a recent shower, she stated she had not been shaved and that the hair "itched"; small gray hairs were visible on her chin. A CNA confirmed the presence of gray chin hairs and acknowledged the resident needed shaving, stating it would be addressed with the next scheduled shower. A further resident with chronic respiratory failure, tracheostomy status, heart failure, moderate intellectual disabilities, anxiety, depression, and PTSD required substantial/maximal assistance with personal hygiene and had a care plan for assistance with self-care, including personal hygiene. Her shower schedule called for showers on Monday and Thursday nights, with complete shaves for men and women. Review of documentation showed her last recorded shower/bath was nearly a year earlier, with no indication of additional personal hygiene or facial hair removal on that date. Observations on two separate days showed long white hairs on her chin and jaw line, which a CNA later confirmed, stating facial hair removal should occur with baths/showers or as needed. A resident with end stage renal disease, respiratory failure, hyperlipidemia, and congestive heart failure, who had impaired cognition and required partial/moderate assistance with bathing and personal hygiene, was scheduled for showers on Wednesdays and Saturdays. Review of shower documentation from admission through early April revealed no showers provided or refusals documented on at least ten scheduled shower days. In interviews, this resident reported not receiving scheduled showers, was unsure of his shower days, and stated he could use a good scrub down, adding that he had asked aides who told him they did not have time. A CNA explained that shower days appear on shower sheets and in the computer and that CNAs are supposed to document daily, with nurses checking the documentation; the DON verified the resident had not received showers per schedule or preference. Another resident with a fracture of the lower end of the left humerus, hemiplegia and hemiparesis after cerebral infarction, rheumatoid arthritis, hypertensive heart disease, urinary retention, and osteoarthritis was care planned as non–weight bearing to the left upper extremity and requiring substantial/maximal assistance with showering/bathing. Her electronic record showed she was scheduled for showers on Wednesdays and Saturdays. The shower task question "did the resident receive a shower/bath/bed bath?" was documented as "no" on three dates, indicating no shower/bath/bed bath was completed, and left unanswered on three additional dates. The DON confirmed that one missed shower was due to an outside appointment, that on two dates the "no" response meant no bathing of any type occurred, and that on three dates there was no documentation at all. The resident, who was cognitively intact, reported that missing showers made her feel unimportant compared to others and that she did not feel clean when her shower was missed. Facility policy on routine resident care stated that showers, tub baths, and shampoos are to be scheduled according to person-centered care or state guidelines, with additional showers given upon request, but the documented and observed care did not reflect consistent provision of scheduled bathing and shaving for these residents.
Plan Of Correction
1. Resident #5 received a shower by the STNA on 4/13/26. Resident #8 received a shower by the STNA on 4/8/26. Resident #9 received a shower and had their chin shaved by the STNA on 4/14/26. Resident #70 received a shower by the STNA on 4/13/26. Resident #76 received a shower and had their chin shaved by the STNA on 4/15/26. 2. Like residents are identified as residents who need assistance with showering and shaving. Utilizing the Shower Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, an audit of like residents will be completed by the Director of Nursing or designee to ensure that showers and resident shaving are completed. This audit along with identified corrections will be completed on or before 5/13/26. 3. The Director of Nursing or designee will re-educate licensed nurses and STNA's on the Routine Resident Care Policy to include bathing and shaving residents. This education will be completed on or before 5/13/26. 4. Utilizing the Shower Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, the Director of Nursing or designee will complete an audit of 4-6 residents weekly for four weeks, beginning 5/14/26 to ensure that showers and resident shaving are completed. Noncompliance found during audits will be addressed and assistance with showers and/or shaving provided. Negative findings to be addressed immediately and negative trends or system wide issues will be reported to the QAPI committee, and the action plan will be adjusted as needed.
Uncovered Urinary Catheter Drainage Bag Compromises Resident Dignity
Penalty
Summary
The facility failed to maintain a resident’s right to privacy and dignity related to management of an indwelling urinary catheter. A resident admitted with malignant neoplasm of the esophagus and type II diabetes mellitus had a care plan identifying risk for urinary tract infection and catheter-related trauma due to an indwelling catheter for urinary retention. The care plan interventions included ensuring the catheter tubing was secured and the drainage bag was properly secured with a dignity cover in place. Physician orders directed that the resident’s 16 French indwelling urinary catheter be changed every 30 days and as needed, and the comprehensive MDS documented that the resident had an indwelling catheter and was cognitively intact. During observation, the resident was seen seated in a chair with the urinary catheter drainage bag hanging from the chair without a dignity cover, and dark yellow urine was visible in the bag from the hallway. In a later observation and interview, an LPN confirmed that the catheter bag was lying directly on the floor and did not have a dignity cover. Attempts to interview the resident to confirm cognitive status were unsuccessful, as the resident was unable to answer screening questions. Review of the facility’s “Resident Dignity & Personal Privacy” policy stated that the facility should provide care in a manner that respects and enhances each resident’s dignity, individuality, and right to personal property, which was not followed in this instance when the catheter drainage bag was left uncovered and visible.
Plan Of Correction
The Laurels of Athens wishes to have this plan of correction submitted as our written allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission to nor agreement with, either the existence of, or the scope and severity of, any of the cited deficiencies or conclusions set forth in the statement of deficiencies. This plan is prepared and/or executed to ensure continuing compliance with regulatory requirements. Our alleged date of compliance is 5/13/2026. 1. On 4/6/26, Resident #92's catheter bag was removed from the floor, the bag changed and covered for dignity by the licensed nurse. Resident #92 discharged from the facility on 4/11/26. 2. Like Residents are identified as residents who utilize urinary catheters. An audit will be completed by the Director of Nursing or designee for like residents utilizing the Urinary Catheter Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC to ensure catheter bags are covered for dignity and not laying directly on the floor. This audit along with identified corrections will be completed on or before 5/13/26. 3. The Director of Nursing or designee will re-educate licensed nurses on the Indwelling Urinary Catheter Policy as well as Resident Dignity & Personal Privacy Policy to include privacy covers are in place for urinary catheters and that the catheter is not laying on the floor. This education will be completed on or before 5/13/26. 4. Utilizing the Urinary Catheter Audit Tool which was created on 4/20/26 by the Director of Nursing for purpose of this POC, the Director of Nursing or designee will complete an audit of all residents with catheters weekly for four weeks, beginning 5/14/26 to ensure catheter bags are covered for dignity and not laying directly on the floor. Any catheters found to be touching the floor or uncovered will be removed from the floor, the bag changed and covered for dignity. Negative findings to be addressed immediately and negative trends or system wide issues will be reported to the QAPI committee, and the action plan will be adjusted as needed.
Failure to Prevent Possible Misappropriation and Poor Documentation of PRN Narcotics
Penalty
Summary
The deficiency involves failure to prevent potential misappropriation of a resident’s narcotic medication and failure to ensure accurate documentation of controlled substance administration. A cognitively intact resident with chronic pain related to an internal orthopedic device and left knee pain had an order for oxycodone 5 mg PO every four hours PRN for pain and a care plan directing staff to administer medications as ordered and observe for effectiveness and side effects. The resident’s MDS showed she rated her pain as 7/10 and received opioid medication. However, review of the February MAR and the narcotic log revealed multiple discrepancies between narcotic sign-outs and documented administration. On several occasions, oxycodone doses were signed out on the narcotic log by an RN without corresponding documentation on the MAR. Specifically, oxycodone was signed out on one evening at 9:30 p.m. with no MAR entry, and again on a subsequent night at 1:30 a.m. and 5:30 a.m. with no MAR entries for those times. Another dose was signed out at 9:00 p.m. while the MAR reflected administration at 10:16 p.m., and a later dose at 5:30 a.m. was documented on both the narcotic log and MAR. There was also no documentation of pain assessments before or after PRN opioid administration. These documentation gaps meant there was no evidence that all narcotic doses signed out were actually administered to the resident. Staff interviews further highlighted concerns about the handling of narcotics. A CNA/med tech reported frequently taking the narcotic keys from the RN and described the RN’s behavior as erratic, with repeated problems involving incorrect narcotic counts and missing documentation on both the MAR and narcotic log. The resident stated she did not receive oxycodone more than once or twice a day, preferring to take Tylenol the rest of the time, which conflicted with the number of oxycodone doses signed out. When questioned, the RN gave inconsistent explanations about how often she pulled and administered PRN narcotics and acknowledged struggling with the new system, while also suggesting the resident may have received PRN tizanidine instead of remembering oxycodone. The facility’s investigation concluded that evidence was inconclusive as to whether misappropriation occurred or whether the issue was solely lack of documentation, but confirmed there was no evidence the resident received all doses signed out on the narcotic log.
Plan Of Correction
1. Resident #99 had a Self-Reported Incident submitted and investigated via the EIDC on 3/2/26. The investigation was inconclusive as we could not prove that misappropriation occurred. On 2/24/26, Resident #99 was interviewed and pain assessed by Director of Nursing and resident had no ill effects related to the inconsistent documentation in the medical record as it relates to her controlled substance pain medication. 2. Like Residents are identified as residents who utilize controlled substance PRN pain medications. An audit will be completed by the Director of Nursing or designee for like residents utilizing the Controlled Substance Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC to ensure PRN controlled substance pain medications that are signed off the control sheet are documented in the resident medical record as well. This audit along with identified corrections will be completed on or before 5/13/26. 3. The Director of Nursing or designee will re-educate licensed nurses on the Controlled Substances Policy to include appropriate documentation of controlled substances. In addition, the licensed nurses will be re-educated by the Director of Nursing or designee on the Abuse Prohibition Policy to include misappropriation of resident property. This education will be completed on or before 5/13/26. 4. Utilizing the Controlled Substance Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, the Director of Nursing or designee will complete an audit three controlled substance sheets from each of the nine medication carts for a total of twenty-seven sheets weekly for four weeks, beginning 5/14/26 to ensure PRN controlled substance pain medications that are signed off the control sheet are documented in the resident medical record as well. Inconsistencies noted from the audit will be investigated for misappropriation. Negative findings to be addressed immediately and negative trends or system wide issues will be reported to the QAPI committee, and the action plan will be adjusted as needed.
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