Adams County Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in West Union, Ohio.
- Location
- 10856 State Route 41, West Union, Ohio 45693
- CMS Provider Number
- 366143
- Inspections on file
- 15
- Latest survey
- March 26, 2026
- Citations (last 12 mo.)
- 18
Citation history
Health deficiencies cited at Adams County Manor during CMS and state inspections, most recent first.
Surveyors found multiple food safety violations involving improper storage, labeling, dating, and temperature control of food items in the main kitchen, adjacent kitchenette, and a therapy gym refrigerator/freezer used for resident food. Numerous items, including dried onion flakes, tortillas, milkshakes, lettuce, cheese, hamburgers, lunchmeats, chicken fingers, juices, strawberries, and baked goods, were observed unsealed, open to air, spoiled, expired, or lacking required labels and dates. A freezer used to store juices and baked goods was operating at 48°F despite product instructions requiring temperatures below 38°F, and the Administrator was unaware that food and beverages were being stored in that malfunctioning unit. In the therapy area, resident food items such as meat, crackers, a premade salad, a partially consumed milkshake, and ice cream were also found open, unnamed, and undated, with both the DM and Therapy Manager confirming these items were not in compliance and should have been discarded.
Surveyors found that the facility failed to maintain safe, functional shower floors, resulting in pooled water and damaged tile surfaces in multiple resident bathrooms. Observations showed cracked, broken, and missing tiles, missing grout, and uneven surfaces, with water not draining properly and pooling after showers. A resident and a CNA confirmed that the tiles were damaged and drainage was poor, while facility policy stated that the environment should be homelike and comfortable.
A cognitively intact resident with multiple medical conditions, including acute kidney failure and adult failure to thrive, was care planned as being at risk for self-care deficits and scheduled for twice-weekly showers on the night shift. Over a 30‑day period, documentation showed the resident received only two showers or bed baths, with no refusals recorded, despite her stated preference for at least twice-weekly bathing with hair washing. On multiple observations, her hair appeared greasy and unwashed, and she confirmed in interviews that she had not received showers or hair washing as preferred. The DON verified that residents should receive showers and hair care per their scheduled preferences and that staff must document this care, and facility policy required provision of ADL assistance to maintain grooming and personal hygiene.
Surveyors found that the facility failed to identify and monitor target behaviors for two cognitively intact residents receiving antipsychotic medications. One resident with psychotic and mood-related diagnoses was given Abilify at bedtime for psychotic disorder with hallucinations, and another resident with Wernicke’s encephalopathy, alcohol abuse, psychotic disorder with hallucinations, and dementia was given Zyprexa at bedtime. In both cases, medical record reviews showed no documented target behaviors or behavior monitoring related to the antipsychotic use, and the ADON and DON each confirmed that staff had not established or tracked target behaviors for these medications.
Surveyors found that MDS assessments were inaccurately coded for two residents. For one resident with dementia and mood and anxiety disorders, bed handrails ordered and used for mobility were coded on the MDS as a daily physical restraint, despite no restraint assessment or care plan documentation and observation showing the rails did not restrict movement. For another resident with Wernicke’s encephalopathy, psychotic disorder with hallucinations, and dementia, documentation showed the pneumococcal vaccine was offered and declined, but the MDS recorded that the resident was not up to date because the vaccine had not been offered. Facility nursing leadership and the MDS nurse confirmed both MDS assessments were coded inaccurately.
A resident with type 2 DM, depression, mood disorders, osteomyelitis, and moderately impaired cognition had a new diagnosis of bipolar disorder type two added to the medical record, but the facility did not obtain an updated PASARR to reflect this qualifying mental health condition. The existing PASARR did not include the bipolar diagnosis, and this lack of PASARR update was confirmed by the corporate DON during surveyor interview.
A resident with multiple diagnoses, including type 2 DM, depression, mood disorders, and osteomyelitis, and with moderately impaired cognition, was receiving continuous supplemental O2 per a physician order specifying 2–3 L/min via nasal cannula on day and night shifts to maintain O2 saturation above 90%. Despite this ongoing O2 therapy, the resident’s comprehensive care plan, last revised shortly before the O2 order, contained no problem, goals, or interventions related to supplemental oxygen or its use. The Corporate DON confirmed that no care plan had been developed to address the resident’s supplemental O2 needs, resulting in a deficiency under the comprehensive care plan requirements.
A resident with adult failure to thrive, COPD, and protein calorie malnutrition had a physician order for weights three times weekly at a specific time, but staff did not obtain or document these weights on multiple ordered days, and there was no documentation of refusals. The DON confirmed the missing weights and lack of refusal documentation. Facility policy required that ordered and additional weights be obtained as indicated by diagnoses or providers and recorded in the EMR, but this was not followed for the identified dates.
A resident with dementia, Wernicke's encephalopathy, and psychotic disorder was care planned as being at risk for pain and had scheduled Tylenol ordered for left hip pain, with an MDS indicating occasional pain that interfered with sleep. Despite a facility policy requiring every-shift pain monitoring documented on the MAR flow sheet and the DON’s expectation that all residents have a set day for pain assessments, the resident’s MARs for multiple months contained no order for routine pain monitoring and no documented pain assessments after a specific date. The resident reported fluctuating but manageable pain controlled by scheduled medication, but staff failed to consistently assess and record pain levels as required by the care plan and facility policy.
Surveyors found that the facility did not perform and/or document required monthly and annual inspections of battery back-up emergency and exit lighting in accordance with NFPA 101 standards. During record review, no evidence was available to show that emergency lights throughout the building had been tested for the required 90-minute annual duration, despite multiple requests for documentation. The Maintenance Director confirmed that the documentation could not be produced, and this deficiency potentially affected all residents in the facility.
Surveyors found that the facility failed to maintain and document its fire alarm system in accordance with NFPA 101 and NFPA 72, potentially affecting all residents. The only annual fire alarm record provided was a single page without a device list, and there was no documentation of required semi-annual visual inspections or sensitivity testing of devices. During the tour, surveyors observed multiple fire alarm breakers in various electrical panels that were not marked in red, not secured from unauthorized access, and in one case left in the off position, with panel labeling insufficient to identify the presence of a fire alarm breaker. These findings were confirmed with the Maintenance Director.
Surveyors identified that the facility failed to maintain required inspection and testing of its automatic sprinkler system in accordance with NFPA standards. Record review showed only one documented sprinkler inspection within the prior year, and no additional inspection records were produced despite multiple requests during the survey. The Maintenance Director confirmed that no other sprinkler inspection documentation was available, indicating that ongoing required inspections were not documented for all residents in the facility.
Surveyors identified that the facility’s electrical system was not maintained according to NFPA 101 and NFPA 70. In the kitchen electrical panel, breakers labeled for the dishwasher were in the off position while the dishwasher continued to run with power. In generator sub panel B, a breaker was labeled for a sprinkler pump even though no sprinkler pump existed, and there was an open breaker position without a blank cover. These issues were confirmed by the Maintenance Director and had the potential to affect all residents.
Surveyors determined that the facility did not maintain required documentation showing that fire dampers had been inspected and tested in accordance with NFPA 101, NFPA 90A, and NFPA 80 standards. During record review, no inspection or testing records were produced despite multiple requests, even though fire dampers were observed throughout the building. The Maintenance Director confirmed that the documentation was not available, and this deficiency had the potential to affect all 69 residents.
Surveyors found that the facility did not have documentation showing that a required quarterly fire drill was conducted for one month, despite multiple requests for records during the survey. The missing documentation related to a specific quarter and was confirmed by the Maintenance Director, and this lapse had the potential to affect all 69 residents in the facility.
Surveyors observed that generator annunciator panels at two nurses’ stations had no functional indicator lights and had their key switches in the off position, contrary to NFPA 99 requirements for essential electrical systems. An MD reported that he only becomes aware of generator problems by physically checking the generator displays, and testing showed the key controlled an audible signal when the generators were running, confirming the annunciators were not being used to indicate emergency power source alarm conditions.
Surveyors found that the facility failed to maintain required documentation showing that its three generators were tested monthly and inspected and tested annually in accordance with NFPA 99 and NFPA 110. Despite multiple requests, no records of these tests or inspections were provided. During the facility tour, surveyors also observed that none of the three generators were equipped with remote manual stop buttons, and this was confirmed by the Maintenance Director. This deficient practice had the potential to affect all residents in the facility.
Surveyors found that the facility failed to maintain the kitchen fire suppression system in accordance with NFPA standards, with only one documented kitchen hood inspection in the prior year and no additional inspection records available despite multiple requests. During the kitchen tour, surveyors also observed that gas-fired appliances lacked restraints to prevent overextension of gas lines when moved for cleaning or service, a finding confirmed by the Maintenance Director. This deficiency had the potential to affect 22 of the 69 residents in the facility.
Improper Food Storage, Labeling, and Temperature Control in Dietary and Therapy Areas
Penalty
Summary
Surveyors identified a deficiency related to food safety and storage practices in the facility’s dietary and ancillary food storage areas, affecting all 69 residents who received food from the kitchen. During observations, an unsealed, open-to-air bag of dried onion flakes was found, and the Dietary Manager (DM) confirmed it was not properly sealed and should have been discarded. In stand-up freezer #1, surveyors observed an undated, open bag of flour tortillas and an undated, unlabeled milkshake, which the DM acknowledged were not dated, not properly sealed, and should have been discarded. In a kitchenette refrigerator next to the main kitchen, surveyors found visibly spoiled lettuce, a package of cheese, and a box of hamburgers, all unlabeled and undated; the DM confirmed these items should have been discarded. In stand-up refrigerator #1, a bag of turkey lunchmeat and a bag of ham lunchmeat were found unsealed and open to air, and the DM again confirmed they were not properly sealed and should have been discarded. Further observations showed additional food safety issues. Stand-up freezer #2 contained two thermometers reading 48°F while storing individually packaged orange, prune, and apple juices labeled to be kept below 38°F, along with boxes of individually wrapped dinner rolls and doughnuts; the DM confirmed the elevated temperature and that the juices’ storage instructions required temperatures below 38°F. The Administrator later confirmed awareness that the freezer was under consideration for repair or replacement but was unaware that food and beverages were being stored in it. In stand-up refrigerator #4, an unsealed bag of cheese and a bag of thawed frozen strawberries dated as opened on 03/07/26 were found, and the DM confirmed the cheese was not properly sealed and the strawberries had expired. In freezer #3, a bag of chicken fingers was found unsealed and open to air, which the DM stated should have been discarded. In the therapy gym refrigerator and freezer used to store resident food, surveyors found meat and crackers labeled only with a resident name but undated, a premade salad in a takeout container unnamed and undated, a partially consumed milkshake open to air with no name or date, and an opened, unnamed, undated half-gallon container of vanilla ice cream; the Therapy Manager confirmed these items were not properly labeled and dated and should have been discarded.
Plan Of Correction
F 0812 F 0812 No resident experienced negative effects related to the unsealed box of dried onion flakes observed on 03/23/2026 @ 09:21 am. No resident experienced negative effects related to the undated bag of flour tortillas that were open-to-air and undated, observed in stand-up freezer #1 on 03/23/2026 @ 09:23 am. No resident experienced negative effects related to the undated and unlabeled milkshake that was observed in stand-up freezer #1 on 03/23/2026 @ 09:23 am. No resident experienced negative effects related to the unlabeled and undated visibly spoiled lettuce, package of cheese, and box of hamburgers observed in the kitchenette next to the main kitchen refrigerator on 03/23/2026 @ 09:27 am. No resident experienced negative effects related to the unsealed and open-to-air bag of turkey lunchmeat and bag of ham lunchmeat observed in stand-up refrigerator #1 on 03/23/2026 @ 09:39 am. No resident experienced negative effects related to the individually packaged servings of orange juice, prune juice, and apple juice; as well as individually wrapped dinner rolls and doughnuts observed in stand-up freezer #2 which contained two thermometers reading 48 degrees Fahrenheit, on 03/23/2026 @ 09:42 am. No resident experienced negative effects related to the unsealed bag of cheese and gag of thawed frozen strawberries with an open date of 03/07/2026, observed in the stand-up refrigerator #4, on 03/23/2026 @ 09:39 am. No resident experienced negative effects related to the unsealed bag of chicken fingers observed in freezer #3 on 03/23/2026 @ 09:50 am. No resident experienced negative effects related to the labeled [R] [R] meat & crackers which was undated; and a premade salad in a takeout container unnamed and undated, observed in the therapy gym refrigerator on 03/26/2026 @ 12:16 pm. No resident experienced negative effects related to the partially consumed milkshake that was open-to-air with no name of date and a half-gallon container of vanilla ice cream that was opened, unnamed and undated, observed in the therapy gym freezer. LNHA notified Medical Director on 04/06/2026 of the findings noted during Annual Survey that involved inappropriately stored foods/drinks and that no negative effects were identified in any resident related to the inappropriately stored foods/drinks. No new orders were received from Medical Director. LNHA/Designee will educate licensed and unlicensed personnel in the following: §483.60(i)(1)(2) Food Procurement, Store/Prepare/Serve-Sanitary §483.60(i) Food safety requirements. The facility must - §483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities. (i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations. (ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices. (iii) This provision does not preclude residents from consuming foods not procured by the facility. §483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety. LNHA/Designee will complete daily rounds, observing food storage areas, ensuring that all items are labelled, dated, unexpired, and stored appropriately (i.e., appropriate temperature levels in refrigerators (<41 degrees Fahrenheit), freezers (at or below 0 degrees Fahrenheit). Issues will be addressed upon recognition of issue. Also, LNHA/Designee educated Dietary Manager & Therapy Director on 03/26/2026 that staff foods/drinks must be stored in separate refrigerators/freezers than residents. Further, all items in the resident's refrigerators/freezers must be dated/labeled and expiration date(s) observed. Any expired, unlabeled, or undated items are to be discarded straight away. Dietary Manager also educated on 03/26/2026 that refrigerators storing food and beverages must meet the temperature threshold of <41 degrees Fahrenheit (refrigerator) or 0 degrees or less (freezer). Freezer that was being utilized as a refrigerator was removed from service on 03/26/2026. Juices were moved to an actual storage refrigerator, within acceptable temperature range. There is adequate storage space for refrigerated and frozen items, so replacement of malfunctioning freezer is not necessary, but on or before 04/30/2026, the interdisciplinary team (IDT) will meet and discuss benefits of purchasing a new refrigerator/freezer and determine necessity. If necessary, quotes will be obtained by LNHA and purchase made. Dietary Staff will observe & record refrigerator and freezer temperatures every shift, at least twice daily to ensure temperatures are within acceptable limits (refrigerator < 41 degrees Fahrenheit and freezer at or below 0 degrees Fahrenheit). Any failing equipment will be removed from service immediately and reported to Maintenance for corrective action. Dietary Manager will be responsible for ensuring this occurs. Compliance will be determined by daily review of Dietary staff documentation by Dietary Manager. Dietary Manager audited refrigerators located in the kitchen, kitchenette, and Therapy gym on 03/26/2026. Undated, unlabeled, and expired items were discarded. Dietary Manager also verified that all refrigerators and freezers in use in the kitchen, kitchenette, and Therapy gym were within appropriate temperature range(s) (< 41 degrees refrigerator & at or below 0 freezer) on 03/26/2026. LNHA/Designee will complete audits that determine if foods & drinks are being appropriately stored and that Dietary staff are consistently and appropriately monitoring refrigerator and freezer temperatures (below 41 degrees Fahrenheit). Inappropriately stored items will be addressed straight away. These audits will be completed on at least 3 refrigerators/freezers every week x4; then as determined by QAA.
Failure to Maintain Safe and Properly Draining Shower Floors
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to maintain resident shower floors in good repair, resulting in unsafe and non-homelike bathroom conditions for multiple residents. Observation of the shared bathroom for Residents #10 and #11 showed a large amount of water pooled on top of the shower tiles, with several tiles cracked, grout missing between multiple tiles, and an uneven tile surface. A separate observation of the bathroom used by Residents #35 and #38 revealed multiple broken and/or missing shower floor tiles and an uneven tile surface. Resident #35 confirmed that multiple tiles on the shower floor were missing or broken and that the water did not drain well. A CNA also confirmed that the shower floors in the bathrooms used by Residents #10, #11, #35, and #38 had missing, cracked, and broken tiles and that water did not drain correctly, causing pooling after residents’ showers. Review of the facility’s undated “Homelike Environment” policy showed the facility encouraged personalization and comfort of a home-like environment, but the observed shower conditions did not align with this policy. This deficiency represents noncompliance investigated under Complaint Number 2647177.
Plan Of Correction
DON completed a head-to-toe physical assessment/observation on Resident #10, #11, #35, & #38 on 04/06/2026. It was determined that there were no negative effects related to the shower tiles not being in good repair identified during Annual Survey. LNHA notified Resident #10, #11, #35, & #38's primary care provider on 03/26/2026, of findings noted during Annual Survey and that no negative effects were identified during head-to-toe assessment/observation. Primary care provider acknowledged that the resident's shower floor was not in good repair (broken uneven tile) and that there were no negative effects related to the shower floors' lack of good repair. No new orders received from primary care provider. Maintenance Director replaced shower floor tiles in room #106 on 04/17/2026. Maintenance Director will replace shower floor tiles in room #203 (resident # 11 & #12) & 206 (resident #35 & 38) on or before 04/24/2026. On or before 04/30/2026, LNHA/Designee will observe shower rooms' flooring in the rooms of like residents (all shower floors in facility) to ensure that tile is in good repair. Any tile identified flooring that is not in good repair will be repaired/replaced also on or before 04/30/2026. On or before 04/30/2026, LNHA/Designee will educate Maintenance Director as follows: §483.10(i)(1)-(7) Safe/Clean/Comfortable/Homelike Environment §483.10(i) Safe Environment. The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. The facility must provide- §483.10(i) A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. (i) This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk. (ii) The facility shall exercise reasonable care for the protection of the resident's property from loss or theft. §483.10(i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior; §483.10(i)(3) Clean bed and bath linens that are in good condition; §483.10(i)(4) Private closet space in each resident room, as specified in §483.90 (e)(2)(iv); §483.10(i)(5) Adequate and comfortable lighting levels in all areas; §483.10(i)(6) Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990 must maintain a temperature range of 71 to 81°F; and §483.10(i)(7) For the maintenance of comfortable sound levels. On or before 04/30/2026, LNHA/Designee will review room monitoring procedures and expectations with the interdisciplinary team (IDT). This review will observe what tasks/reviews/observations are being completed during weekly room rounds. LNHA/Designee will ensure that shower room flooring observation is specifically listed on the weekly room rounds. Additionally, when a floor is found to not be in good repair, a Maintenance Request will be submitted for Maintenance to observe/address the issue noted. Such requests will be monitored electronically by the LNHA/Designee ongoing. LNHA/Designee will complete audits. The audit will observe 5 shower floors every week x4 weeks; then as determined by QAA, to determine if the floors are in good repair. Any floors observed to not be in good repair will be repaired/replaced.
Failure to Provide Scheduled Bathing and Hair Care for Dependent Resident
Penalty
Summary
The facility failed to provide timely bathing and hair washing assistance to a dependent resident in accordance with her care plan, stated preferences, and facility policy. The resident was admitted with diagnoses including acute kidney failure, adult failure to thrive, and depression, and an MDS assessment documented that she was cognitively intact. Her care plan identified a risk for self-care deficit with bathing, dressing, and feeding, with interventions to encourage participation in planning day-to-day care, evaluate her ability to perform self-care, minimize environmental stimuli, and provide ADL assistance as needed. The shower task list scheduled her to receive showers on the night shift on Sundays and Thursdays. However, review of shower documentation over a 30‑day period showed she received only two showers or bed baths, on 03/06/26 and 03/22/26, with no additional showers documented and no refusals recorded. During observations on two separate days, the resident’s hair appeared greasy and unwashed. In interviews conducted immediately following these observations, the resident stated she preferred to have a shower or bed bath at least twice a week with hair washing on those days, and she reported that she had not had her hair washed in weeks and was not receiving bathing at the frequency she preferred. A subsequent observation again showed her hair to be greasy and unwashed, and she confirmed she still had not received a shower or hair washing. The DON confirmed that residents were to receive showers and hair washing per their scheduled preferences and that staff were required to document this care in the medical record, and also confirmed that this resident had documentation of only two showers or bed baths in the 30‑day review period with no documented refusals. Facility policy stated that residents unable to carry out ADLs independently would receive services necessary to maintain grooming and personal hygiene, which was not met in this case.
Plan Of Correction
DON performed a physical, head-to-toe assessment/observation of Resident #8 on 03/26/2026. This assessment/observation revealed that no negative outcomes were experienced by Resident #8 regarding the missing shower documentation, greasy hair, or concern of lacking episodes of bathing/showering/hair care identified during Annual Survey. LNHA notified Resident #8's primary care provider on 03/26/2026 of missing shower documentation, greasy hair, and concerns for lacking episodes of bathing/showering/hair care identified during Annual Survey and that a physical, head-to-toe assessment/observation was completed, revealing no negative outcomes. Primary care provider acknowledged these findings and provided no new orders. Responsible Nurse reviewed Resident #8's bathing/shower schedule 04/09/26 to ensure shower/bed bath was scheduled appropriately. Resident previously moved rooms and bathing/shower scheduled was not updated, resulting in the above-described findings. Responsible Nurse adjusted Resident #8's bathing/shower schedule on 04/09/2026 to reflect her new room assignment with an associated bathing/shower schedule of every Tuesday and Saturday during dayshift (7a-7p). Resident #8 agreeable. DON added Resident #8's new bathing/shower schedule to Point-of-Care documentation on 04/09/2026 so that CNAs will be required to document bathing/showering episodes on Tuesdays, Saturdays, and as needed or requested. On or before 4/30/2026, DON/Designee will educate licensed and unlicensed nursing staff on the following: § 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. §483.24(a)(2) A resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene; Also, on or before 04/30/2026, DON/Designee will educate licensed and unlicensed nursing personnel regarding the importance and requirement of providing bathing/showering per shower schedules. On or before 04/30/2026, DON/Designee will review residents' bathing/shower schedules to ensure residents are listed on shower schedules as appropriate. DON/Designee will complete weekly audits x5 medical records x4 weeks; then as determined by QAA. This audit will list the resident identifier (facility's identifier), when their bathing/shower episodes are scheduled, if the bathing/shower episode(s) have been documented as completed or at least offered per schedule, and if the resident appeared clean and well kept.
Failure to Monitor Target Behaviors for Residents on Antipsychotic Medications
Penalty
Summary
The deficiency involves the facility’s failure to identify and monitor target behaviors for residents receiving antipsychotic medications, as required for appropriate use and monitoring of psychotropic drugs. For one resident admitted with diagnoses including acute kidney failure, psychotic disorder, anxiety disorder, and bipolar disorder, the physician ordered Abilify 10 mg by mouth at bedtime for psychotic disorder with hallucinations. The resident’s MDS assessment indicated the resident was cognitively intact and received antipsychotic medication. However, review of the medical record showed no documentation of target behaviors or behavior monitoring related to the administration of Abilify. In an interview, the Assistant Director of Nursing confirmed that staff had not identified or monitored target behaviors associated with this antipsychotic use. A second resident, admitted with diagnoses including Wernicke’s encephalopathy, alcohol abuse, psychotic disorder with hallucinations, and dementia, had a physician’s order for Zyprexa 7.5 mg by mouth at bedtime related to Wernicke’s encephalopathy. The MDS assessment for this resident also showed that the resident was cognitively intact and received antipsychotic medication. Review of this resident’s medical record likewise revealed no documentation of target behaviors or monitoring of behaviors related to the administration of Zyprexa. In an interview, the Director of Nursing confirmed that facility staff had not identified or monitored target behaviors for this resident’s antipsychotic medication.
Plan Of Correction
DON completed a head-to-toe physical assessment/observation on Resident #6 on 03/26/2026. It was determined that there were no negative effects related to the lack of behavioral monitoring identified during Annual Survey. LNHA notified Resident #6's primary care provider on 03/26/2026, of findings noted during Annual Survey and that no negative effects were identified during head-to-toe assessment/observation. Primary care provider acknowledged the missing behavioral documentation and that there were no negative effects related to the lack of behavioral monitoring. No new orders received from primary care provider. DON completed a head-to-toe physical assessment/observation on Resident #20 on 03/26/2026. It was determined that there were no negative effects related to the lack of behavioral monitoring identified during Annual Survey. LNHA notified Resident #20's primary care provider on 03/26/2026 of findings noted during Annual Survey and that no negative effects were identified during head-to-toe assessment/observation. Primary care provider acknowledged the missing targeted behavioral documentation and that there were no negative effects related to the lack of behavioral monitoring. No new orders received from primary care provider. On or before 04/30/2026, DON/Designee will review other residents' diagnosis list. Any resident with a mental health diagnosis, will have a medication review completed to ensure that targeted behavioral observations are added to treatment administration record (TAR) so that nurses will review/document any specific experienced behaviors on their shift accordingly. On or before 04/30/2026, DON/Designee will educate licensed nursing personnel of the following: 483.10(e)(1),483.12(a)(2),483.45(c)(3)(d)(e) Right to be Free from Chemical Restraints §483.10(e) Respect and Dignity. The resident has a right to be treated with respect and dignity, including: §483.10(e)(1) The right to be free from any . . . chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms, consistent with §483.12(a)(2). §483.12 The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. §483.12(a) The facility must- §483.12(a)(2) Ensure that the resident is free from . . . chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms. §483.45(c)(3) A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories: (i) Anti-psychotic; (ii) Anti-depressant; (iii) Anti-anxiety; and (iv) Hypnotic. §483.45(d) Unnecessary drugs-General. Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used- (1) In excessive dose (including duplicate drug therapy); or (2) For excessive duration; or (3) Without adequate monitoring; or (4) Without adequate indications for its use; or (5) In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or (6) Any combinations of the reasons stated in paragraphs (d)(1) through (d)(5) of this section. §483.45(e) Psychotropic Drugs. Based on a comprehensive assessment of a resident, the facility must ensure that-- §483.45(e)(1) Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record; §483.45(e)(2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs; §483.45(e)(3) Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; and §483.45(e)(4) PRN orders for psychotropic drugs are limited to 14 days. Except as provided in §483.45(e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order. §483.45(e)(5) PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication. Additionally, licensed nursing personnel will be educated on policy review / adjustment as well as expectations for monitoring targeted behavior as noted in the following paragraph: On or before 04/30/2026, LNHA/Designee will review facility's policy & procedure regarding targeted behavioral monitoring. During this review, IDT will ensure that all residents with mental health, intellectual diagnoses or who are taking antipsychotic medications have specific targeted behavioral monitoring tasks placed/implemented, so that licensed nursing personnel are documenting behaviors or lack of behaviors that occur during their shift. This will include every shift documentation by licensed nursing personnel. DON/Designee will complete an audit of 5 residents' medical records weekly x4; then as determined by QAA. This audit will include the patient's identifier (facility's patient identifier), any behaviors were indicated and documented (will also reflect if no behaviors occurred), interventions to any behaviors that were documented. New procedure will include behavioral monitoring for those who suffer from mental health/intellectual disabilities and also those who do not.
Inaccurate MDS Coding for Restraint Use and Pneumococcal Immunization
Penalty
Summary
The deficiency involves inaccurate completion of Minimum Data Set (MDS) assessments related to restraint use and immunization status. For one resident with dementia, mood disorder, and anxiety disorder, the medical record showed a physician’s order for bilateral handrails to promote bed mobility due to weakness, with checks every shift. The MDS assessment section P for this resident coded bed rails as a physical restraint used daily. However, the care plan did not document any restraint use, and the medical record did not contain a restraint assessment. Observation showed the bed had two small handrails at the top on each side, used for bed mobility, which did not inhibit the resident’s movement in or out of bed or otherwise restrain the resident. Facility staff, including the ADON and MDS nurse, confirmed the handrails were ordered for mobility and were not assessed as restraining the resident, indicating the MDS coding was inaccurate. For another resident with Wernicke’s encephalopathy, psychotic disorder with hallucinations, and dementia, the vaccine consent form documented that the resident was offered and declined the pneumonia vaccine. Despite this, the MDS assessment indicated the resident was not up to date with the pneumonia vaccine because it had not been offered. During interview, the ADON and MDS nurse confirmed that the pneumonia vaccine had been offered and declined, and that the MDS assessment had been coded inaccurately. These findings show that the facility failed to ensure MDS assessments accurately reflected the residents’ status regarding both restraint use and immunization history, as required by the accuracy of assessments regulation.
Plan Of Correction
DON completed a head-to-toe physical assessment/observation on Resident #11 on 03/26/2026. It was determined that there were no negative effects related to the lack of "Side Rail Assessment"/Grab Bar Evaluation. DON completed an assessment for the need and use of bilateral handrails to promote bed mobility due to weakness on 03/26/2026. It was determined that the bedrail is being used for promoting bed mobility not being used in a way that prevents or restrains Resident #11 from normal daily functioning. LNHA notified Resident #11's primary care provider on 03/26/2026, of findings noted during Annual Survey and that no negative effects were identified during assessment/observation related to the lack of "Side Rail Assessment"/Grab Bar Evaluation documentation. MDS Nurse corrected Resident #11's MDS on 03/20/2026 to reflect that his bed rails were no longer being used. On or before 4/30/2026, DON/Designee will ensure that other residents residing in the facility and using bedrails have a "Side Rail Assessment"/Grab Bar Evaluation completed to verify that bedrails are being utilized to promote mobility and in no way prevent/restrain a person from from normal daily function(ing). Assessment/evaluation by nursing/therapy will establish the use of which side or bilateral grab bars for mobility purposes. All residents will have care plan in place reflecting the accurate use of grab bar for mobility purposes. DON completed a head-to-toe physical assessment/observation on Resident #20 on 03/26/2026. It was determined that there were no negative effects related to the lack of documentation or related to the documentation discrepancy regarding the Pneumococcal vaccination (nursing documentation reflects that the vaccine was refused, but the MDS documentation describes that it was not offered) identified during Annual Survey. LNHA notified Resident #20's primary care provider on 03/36/2026, of findings noted during Annual Survey and that no negative effects were identified during assessment/observation related to the documentation discrepancy regarding the Pneumococcal vaccination (nursing documentation reflects that the vaccine was refused, but the MDS documentation describes that it was not offered). Primary care provider acknowledged the documentation discrepancy pertaining to the Pneumococcal vaccination. No new orders were provided. On or before 4/30/2026, DON/Designee will review the medical records of like residents residing in the facility to ensure that consents and care plan documentation aligns and that Pneumococcal vaccinations are administered per orders. On or before 04/30/2026, DON/Designee will provide education to licensed nursing personnel (including MDS nursing staff) regarding the following: 483.20(g)(h)(i)(j) Accuracy of F 0641 Assessments §483.20(g) Accuracy of Assessments. The assessment must accurately reflect the resident's status. §483.20(h) Coordination. A registered nurse must conduct or coordinate each assessment with the appropriate participation of health professionals. §483.20(i) Certification. §483.20(i)(1) A registered nurse must sign and certify that the assessment is §483.20(i) (2) Each individual who completes a portion of the assessment must sign and certify the accuracy of that portion of the assessment. §483.20(j) Penalty for Falsification. §483.20(j) (1) Under Medicare and Medicaid, an individual who willfully and knowingly- (i) Certifies a material and false statement in a resident assessment is subject to a civil money penalty of not more than $1,000 for each assessment; or (ii) Causes another individual to certify a material and false statement in a resident assessment is subject to a civil money penalty or not more than $5,000 for each assessment. Also, on or before 04/30/2026, DON/Designee will provide education to licensed nursing personnel (including MDS nursing staff) explaining that: DON/MDS/Designee will review nursing documentation when completing MDS assessments to ensure that accurate coding is reflected in the MDS coding, specifically when a resident is using grab bars as a mobility device (not a restraint) and/or Pneumococcal vaccinations are offered/provided/declined. Discrepancies should be addressed with the Director of Nursing prior to coding by the MDS coordinator. On or before 04/30/2026, DON/Designee will compile a list of like residents who have bed rails. On or before 04/30/2026, DON/Designee will review the compiled list of like residents who have bed rails and ensure there is a current and accurate "Side Rail Assessment" documented. On or before 04/30/2026, DON/Designee will ensure that care plans and physician orders accurately reflect the use of bedrails and results from the "Side Rail Assessment." On or before 04/30/2026, DON/Designee will review MDS assessment for residents using bedrails to ensure accurate data has been coded and reported regarding the use and reasoning of use of bedrails. On or before 04/30/2026, DON/Designee will compile a list of residents, and their Pneumococcal vaccination status is. On or before 04/30/2026, DON/Designee will complete a complete audit to ensure that Pneumococcal vaccination statuses are accurately reflected in the medical record (i.e. consents, care plans). On or before 04/30/2026, DON/Designee will perform a complete audit to review most recent MDS assessment to ensure that MDS assessment accurately reflects the resident's Pneumococcal vaccination status. QAA. This audit will list the resident identifier (facility identifier), if they utilize bedrails, date of their last "Side Rail Assessment" why they utilize bed rails, and ensure accurate documentation is reflected in physician orders, care plan, and the recent MDS assessment. QAA. This audit will list resident identifier (facility identifier), the status of their Pneumococcal vaccination (offered, administered, declined, etc.), and ensure that this information is accurately reflected in the care plan and recent MDS assessment.
Failure to Update PASARR After New Bipolar Disorder Diagnosis
Penalty
Summary
Surveyors identified a deficiency in the facility’s coordination of PASARR with resident assessments and care planning when a required PASARR update was not completed after a new qualifying mental health diagnosis was added. Resident #66 was admitted on 05/14/23 with diagnoses including type 2 diabetes mellitus, depression, mood disorders, and osteomyelitis. The most recent PASARR for this resident, dated 06/08/23, did not include a diagnosis of bipolar disorder type two. The resident’s diagnosis list showed that bipolar disorder type two was added as a new mental health diagnosis on 08/20/25, and an MDS assessment dated 01/12/26 documented moderately impaired cognition. Despite this new serious mental health diagnosis, the facility did not complete a new PASARR for the resident, which was confirmed in an interview on 03/25/26 at 11:43 a.m. with the Corporate Director of Nursing, who verified that no updated PASARR had been obtained following the addition of the bipolar disorder diagnosis.
Plan Of Correction
DON completed a head-to-toe physical assessment/observation on Resident #66 on 03/26/2026. It was determined that there were no negative effects related to the missing Pre-Admission Screening & Resident Review (PASARR) identified during Annual Survey. On or before 04/30/2026, LNHA/Designee will a PASAR referral for Resident #66. The facility will ensure receipt and incorporation of PASARR findings into the resident's medical record, care plan, and service upon completion, as appropriate. LNHA notified Resident #66's primary care provider on 03/26/2026 of findings noted during Annual Survey and that no negative effects were identified during head-to-toe assessment/observation. Primary care provider acknowledged the missing Pre-Admission Screening & Resident Review (PASARR) and that there were no negative effects related to the lack of behavioral monitoring. No new orders received from primary care provider. On or before 04/30/2026, LNHA/Designee will review other residents' medical records to ensure that current residents have a Pre-Admission Screening & Resident Review (PASARR) on file. Also, on or before 04/30/2026, LNHA/Designee will evaluate list of residents and their diagnosis list(s). LNHA/Designee will evaluate diagnoses and Pre-Admission Screening & Resident Reviews (PASARR) to ensure that any diagnosis of a mental disorder and/or intellectual disability have been captured on a Pre-Admission Screening & Resident Reviews (PASARR). Any missing Pre-Admission Screening & Reviews (PASARRs) will be completed. On or before 04/30/2026, LNHA/Designee will educate Social Service Designee (SSD) in the following: 483.20(e)(2) Coordination of PASARR and Assessments §483.20(e) Coordination. A facility must coordinate assessments with the pre-admission screening and resident review (PASARR) program under Medicaid in subpart C of this part to the maximum extent practicable to avoid duplicative testing and effort. Coordination includes: §483.20(e)(1)Incorporating the recommendations from the PASARR level II determination and the PASARR evaluation report into a resident's assessment, care planning, and transitions of care. §483.20(e)(2) Referring all level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status assessment. Also, on or before 04/30/2026, LNHA/Designee will also educate Social Service Designee (SSD) that a Pre-Admission Screening & Resident Review (PASARR) is required with all new admissions and with any new mental health or intellectual disability diagnoses. LNHA/Designee will complete audits x5 residents/medical records weekly x4 weeks; then as determined by QAA. The audits will ensure that PASARR referrals are made when a resident: • Newly admits to the facility • Have a new diagnosis of serious mental illness, intellectual disability (ID), or related condition, and/or • Have had a significant change in status indicating a potential PASARR Level II trigger, and/or The audit will include: • Review of admission records • Diagnosis lists • Psychiatric consults MDS Section P Existing PASARR documentation Any resident lacking a required PASARR or with incomplete PASARR documentation will be referred immediately for PASARR review. Company policy/procedure was reviewed and no additional changes are required at this time. Education and ongoing monitoring is sufficient in ensuring regulatory compliance.
Failure to Care Plan for Resident Receiving Continuous Supplemental Oxygen
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan addressing the use of supplemental oxygen for a resident who was receiving continuous oxygen therapy. The resident was admitted with diagnoses including type 2 diabetes mellitus, depression, mood disorders, and osteomyelitis, and had moderately impaired cognition per a recent MDS assessment. Review of the resident’s care plan, last revised on 03/07/26, showed no care plan interventions or goals related to supplemental oxygen or oxygen use, despite the resident’s ongoing need for this treatment. Further review of the medical record revealed a physician’s order dated 03/09/26 for oxygen at 2–3 L/min via nasal cannula, to be administered on day and night shifts to maintain oxygen saturation above 90%. This order demonstrated that the resident was to receive continuous supplemental oxygen, yet no corresponding care plan was developed to address this treatment and related care needs. During an interview, the Corporate DON confirmed that the facility did not create a care plan for the resident’s supplemental oxygen and oxygen use, verifying the absence of required care planning for this service.
Plan Of Correction
DON completed a physical head-to-toe assessment/observation of Resident #66 on 03/26/26. No negative effects were identified related to care plan issues identified during the Annual Survey. LNHA notified Resident #66's primary care provider on 03/26/2026 of missing documentation regarding care plan and notified there was no harm or negative effects to the resident regarding this lack of documentation. Primary care provider acknowledged the missing care plan documentation related to care required while using oxygen, and no harm or negative effects. No new orders currently. Resident #66 passed away (was on hospice - not related to oxygen use or misuse) and his care plan was not updated prior to his passing. On or before 04/30/2026, DON/Designee will educate licensed nursing personnel regarding the following: §483.21(b) Comprehensive Care Plans §483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following - (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and (ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6). (iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record.(iv) In consultation with the resident and the resident's representative(s)- (A) The resident's goals for admission and desired outcomes. (B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose. (C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section. §483.21(b)(3) The services provided or arranged by the facility, as outlined by the comprehensive care plan, must- (iii) Be culturally-competent and trauma-informed. On or before 04/30/2026, DON/Designee will complete an audit of residents currently residing in the facility. This audit will include the resident identifier (facility identifier); reflect if a physician's order is in place for oxygen use; and if the care plan accurately reflects the use of oxygen. Don/Designee will complete weekly audits x5 medical records per week x4; then as determined by QAA. This audit will include the resident identifier (facility identifier); reflect if a physician's order is in place for oxygen use; and if the care plan accurately reflects the use of oxygen.
Failure to Obtain and Document Physician-Ordered Weights
Penalty
Summary
The deficiency involves the facility’s failure to obtain and document ordered weights for a resident in accordance with physician orders and facility policy. The resident was admitted with diagnoses including adult failure to thrive, COPD, and protein calorie malnutrition, and had a physician order dated 02/02/26 to be weighed every Monday, Wednesday, and Friday at 6:00 A.M. due to COPD. The resident’s MDS assessment indicated severely impaired cognition. Review of the weight records for February and March 2026 showed multiple missing weight entries on ordered days, with no documentation that the resident refused to be weighed on those dates. During an interview, the DON confirmed that the resident had an active order for thrice-weekly weights at 6:00 A.M. and acknowledged that there were no documented weights or refusals for the specified dates in February and March 2026. Review of the facility’s undated Weights Policy and Procedure showed that staff were to weigh all residents upon admission, weekly for four weeks, and then monthly unless specific diagnoses indicated a need for more frequent weights, and that additional weights could be ordered by the physician, dietitian, or nursing staff. The policy also required that all resident weights be recorded in the weight/vital section of the electronic medical record, which did not occur for the identified dates for this resident.
Plan Of Correction
DON performed a head-to-toe physical assessed Resident #12 on 03/26/26. There were no negative effects related to the residents' missing weight documentation that were identified during the Annual Survey. LNHA notified Primary care provider of missing weight documentation on 03/26/26. Primary care provider gave new orders to change weight frequency to weekly. On or before 4/30/26, DON/Designee will review residents' weight orders and ensure weights are scheduled in Point Click Care, per physician's orders. On or before 4/30/2026, licensed and unlicensed nursing staff will be educated on: § 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices. Also, on or before 04/30/026, licensed and unlicensed nursing staff will be educated on: the importance and procedure of following weight order/care plan and ensuring proper documentation. DON/Designee will perform audits x5 medical records weekly x4 weeks; then as determined by QAA. This audit will list a resident identifier (facility identifier), current weight order, and if the weight(s) were obtained per current physician's orders. Negative findings identified during the audits will be investigated / verified. PCP alerted for reporting/review/intervention, and responsible party alerted of any negative findings and/or new orders or concerns.
Failure to Routinely Monitor and Document Resident Pain Levels
Penalty
Summary
The deficiency involves the facility’s failure to ensure routine monitoring and documentation of pain levels for a resident who required pain management. The resident was admitted with diagnoses including Wernicke's encephalopathy, psychotic disorder with hallucinations, and dementia, and had a care plan dated 05/15/25 identifying the resident as at risk for pain/discomfort. Care plan interventions included administering medications as ordered, monitoring for effectiveness, and assessing and documenting the resident’s pain location, duration, frequency, intensity, and negative findings. A physician’s order dated 07/23/25 directed Tylenol 325 mg, two tablets every six hours for left hip pain, and an MDS assessment dated 12/22/25 documented that the resident was cognitively intact and experienced occasional pain that made it hard to sleep on several days during the review period. Review of the MARs for February and March 2025 showed no order for routine pain monitoring and no documentation of any pain assessment after 02/25/26. The DON confirmed that all residents should have a set day for pain assessments, that this resident’s record lacked a physician’s order for routine pain monitoring, and that the MARs contained no documented pain assessments since 02/25/26. The resident reported that pain levels fluctuated but were manageable and that scheduled pain medication was typically effective. Facility policy titled “Pain Management and Assessments” stated that all residents would be monitored for pain every shift by nursing staff, with this information tracked on the pain section of the MAR flow sheet, which was not done in this case.
Plan Of Correction
F 0697 DON assessed Resident #20 on 03/26/2026. There were no negative effects related to the resident's lack of Pain Assessment completion that was identified during the Annual Survey. LNHA notified Primary care provider of lack of Pain Assessment completion on 03/26/2026. Primary care provider has no new orders currently. On or before 04/30/2026, DON/Designee will meet with interdisciplinary team (IDT) to review facility policy & procedure regarding monitoring pain. At this time, the IDT will ensure that the facility's policy & procedure requires all like residents' pain be monitored by licensed nursing staff every shift. On or before 04/30/2026, licensed nursing staff will be educated on: §483.25(k) Pain Management. The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. Also, on or before 4/30/2026, licensed nursing staff will be educated on the requirement that pain observation & documentation must occur every shift for all like residents. DON/Designee will perform Pain Assessment audits of x5 medical records x4 weeks; then as determined by QAA to ensure proper documentation is complete. The audit will list identifier (facility identifier), current pain observation reflected in physician's order; pain observation completion; and follow-up interventions completed for any reports of pain
Failure to Perform and Document Required Emergency and Exit Lighting Tests
Penalty
Summary
The facility failed to perform and document required monthly and annual inspections of emergency and exit lighting in accordance with NFPA 101, 2012 Edition, sections 19.2.9.1 and 7.9.3.1.2, affecting all 69 residents in the building. During record review on 03/25/26 beginning at 8:45 A.M., surveyors found no documentation verifying that the battery back-up emergency lights located throughout the facility had been tested for the required 90-minute annual duration. Documentation of these tests was requested at the entrance conference at 8:40 A.M., and again at 9:35 A.M. and 10:10 A.M., but no records were provided by the time of exit. The Maintenance Director confirmed during interview that the requested documentation was not available, verifying the deficiency in required emergency lighting testing and recordkeeping. No specific residents, medical histories, or clinical conditions were described in the report beyond the statement that 69 residents were potentially affected.
Plan Of Correction
1.Based on record review and staff interview, no residents experienced negative outcomes related to failure to perform and document required emergency lighting testing. 2.The Medical Director was notified on 03/26/2026 by LNHA that the facility failed to provide documentation verifying battery back-up emergency lights were tested annually for 90 minutes as required. 3.Emergency lighting testing [for 90 minutes] will be completed by Maintenance Director/designee on or before 04/30/2026. Testing will be added to an annual automatically recurring schedule by Administrator/designee. 4.Documentation will be maintained and reviewed. Compliance will be reviewed in QAPI quarterly and as needed. 5. LNHA educated Maintenance Director on 03/26/2026 regarding the requirements for maintaining emergency lighting.
Failure to Maintain and Document Fire Alarm System per NFPA Requirements
Penalty
Summary
Surveyors identified that the facility failed to maintain and document its fire alarm system in accordance with NFPA 101 and NFPA 72 requirements, potentially affecting all 69 residents in the building. During record review, the only annual fire alarm documentation provided consisted of a single page without a device list. No documentation was available to verify that the required semi-annual visual inspections of the fire alarm system had been completed, and there was also no documentation confirming that fire alarm devices in the facility had undergone the required sensitivity testing. Documentation was requested multiple times throughout the survey period, including at the entrance conference and later in the morning, but none was produced by the time of exit. During the physical tour of the facility, surveyors observed multiple issues with fire alarm breakers in electrical panels. In electrical panel PP-5, the fire alarm breaker was found in the off position and was neither marked in red nor secured from unauthorized access. Another fire alarm breaker located in the generator main A panel was also not marked in red or secured, and the panel itself had no label indicating that a fire alarm breaker was inside. Additionally, in the electrical panel labeled generator sub-A at the front of the building, the fire alarm breaker was not marked in red or secured from unauthorized access. These observations were confirmed in an interview with the Maintenance Director.
Plan Of Correction
1. Based on observation, record review, and staff interview, no residents experienced negative outcomes related to fire alarm system testing and maintenance deficiencies. The facility failed to provide complete annual fire alarm documentation listing (only one page with no device list provided during survey), failed to provide documentation of required semi-annual visual inspections, and failed to provide documentation of required device sensitivity testing. Additionally, observations identified fire alarm breakers that were in the off position, not marked in red, not secured from unauthorized access, and not properly labeled within electrical panels. 2. The Medical Director was notified by LNHA on 03/26/2026 of the deficiency, including incomplete fire alarm system documentation, lack of required inspections and testing, and electrical breaker deficiencies identified during survey. 3. Fire alarm system inspection, testing, and documentation will be completed by a contracted fire protection vendor on or before 04/30/2026. This will include: (a) completion of a full annual inspection with a complete device list, (b) completion and documentation of semi-annual visual inspections, and (c) completion and documentation of sensitivity testing of all required devices. All missing documentation will be obtained and maintained onsite. Electrical deficiencies will be corrected by Maintenance Director/designee or licensed electrician on or before 04/30/2026, including: (a) ensuring all fire alarm breakers are in the correct position, (b) marking all fire alarm breakers in red, (c) securing breakers from unauthorized access, and (d) labeling all panels to clearly identify fire alarm circuits including those located within generator panels. All required inspections, testing, and maintenance will be placed on an an automatically recurring schedule per NFPA 72 requirements by Administrator/designee on or before 04/30/2026. 4. Documentation of all fire alarm system inspections, testing, and maintenance will be maintained onsite and readily available. The Maintenance Director/designee will audit compliance monthly. Compliance will be reviewed in QAPI every quarter and as needed to ensure ongoing systemic compliance. 5. LNHA educated Maintenance Director on 03/26/2026 regarding maintenance of the facility's fire alarm equipment/system, including listing out all devices.
Failure to Maintain Required Sprinkler System Inspection Documentation
Penalty
Summary
The facility failed to properly maintain its automatic sprinkler system in accordance with NFPA 101 (2012) and NFPA 25 (2010), affecting all 67 residents in the building. During record review on 03/25/26 beginning at 8:45 A.M., surveyors found only one documented sprinkler inspection within the previous 12 months, dated 04/23/25. Additional documentation of required inspections was requested at the entrance conference at 8:40 A.M., and again at 9:35 A.M. and 10:10 A.M., but no further records were provided by the time of exit. An interview with the Maintenance Director confirmed that there were no other sprinkler inspection records available, verifying the lack of documented ongoing inspection and maintenance of the sprinkler system. No specific resident medical histories or conditions at the time of the deficiency were described in the report.
Plan Of Correction
1.Based on record review, observation and interview, no residents experienced negative outcomes related to sprinkler system deficiencies. The facility failed to ensure sprinkler system inspection, testing, and maintenance were completed and documented in accordance with NFPA 25. Findings included lack of complete inspection documentation within the required timeframe and identified physical deficiencies (including missing escutcheon plates). 2.The Medical Director was notified by LNHA on 03/26/2026 that the facility failed to ensure sprinkler system inspections, testing, and maintenance were completed and documented in accordance with NFPA 101 and NFPA 25 requirements. 3.Sprinkler system inspection, testing, and maintenance will be completed by a contracted fire protection vendor on or before 04/30/2026. This will include implementation of a full Inspection, Testing, and Maintenance (ITM) program in accordance with NFPA 25 (2010 Edition), including but not limited to: Completion of a full annual sprinkler system inspection in accordance with NFPA 25 §13.6.2.1. Quarterly testing of waterflow alarm devices and supervisory signals. Monthly and/or weekly inspection of control valves, gauges, and system condition as applicable. Five-year internal pipe inspection (obstruction investigation) if due. Inspection of all sprinkler heads to ensure no damage, corrosion, paint, loading, obstruction, or missing escutcheon plates. Verification that all components are installed correctly and maintained in reliable operating condition. All identified physical deficiencies (including missing escutcheon plates and any additional deficiencies discovered during inspection) will be corrected on or before 04/30/2026. A comprehensive facility-wide sprinkler system inspection will be completed to ensure no additional deficiencies exist. All inspection, testing, and maintenance activities will be placed on an automatically recurring schedule by Administrator/designee to ensure ongoing compliance. 4.Documentation of all sprinkler system inspection, testing, and maintenance activities will be maintained onsite and readily available at the time of survey. The Maintenance Director/designee will conduct routine audits to verify completion of required inspection, testing, and maintenance (ITM) activities. Compliance will be reviewed in QAPI every quarter and as needed to ensure ongoing systemic compliance. 5.LNHA educated Maintenance Director on 03/26/2026 regarding the requirements for maintaining the facility's fire suppression equipment, as well as ensuring required completion of backflow device testing; and required escutcheon plates to sprinkler heads.
Improperly Labeled and Maintained Electrical Panels
Penalty
Summary
Surveyors found that the facility failed to maintain its electrical system in accordance with NFPA 101-2012 and NFPA 70-2011, potentially affecting all 69 residents. During a tour of the facility, surveyors observed in the kitchen electrical panel that the breakers labeled for the facility’s dishwasher were in the off position while the dishwasher itself was running and had power. Later, in generator sub panel B, surveyors noted a breaker labeled as a sprinkler pump even though the facility did not have a sprinkler pump, as well as an open breaker space without a blank installed. The Maintenance Director confirmed these findings at the time they were discovered. No specific residents, medical histories, or clinical conditions were mentioned in relation to these deficiencies.
Plan Of Correction
1.Based on observation and staff interview, no residents experienced negative outcomes related to electrical system deficiencies. The facility's kitchen dishwasher breakers were in the off position; the dishwasher was running and had power. It was also noted that in generator sub panel B there was a breaker listed as sprinkler pump as well as an open breaker that has no blank, while the facility has no sprinkler pump. 2.The Medical Director was notified by LNHA on 03/26/2026 of deficiencies including improper breaker configuration and labeling. 3.Electrical deficiencies will be corrected by licensed electrician on or before 04/30/2026. 4.Monthly inspections will be conducted and compliance reviewed in QAPI. 5.LNHA educated 03/26/2026 regarding the requirements for maintaining the facility's electrical equipment, including the requirements for the facility's kitchen dishwasher breakers' requirements in power being active and breaker reflecting that it is on, and vice versa. Also, Maintenance Direct was educated in the importance of ensuring the appropriate labeling of breakers.
Lack of Required Inspection and Testing Documentation for Fire Dampers
Penalty
Summary
Surveyors found that the facility failed to maintain its fire dampers in accordance with NFPA 101 (2012 Edition) sections 19.5.2 and 9.2.1, NFPA 90A (2012 Edition) sections 5.4.5.2 through 5.4.6.2 and 5.4.8.1, and NFPA 80 (2010 Edition) sections 19.4.1 through 19.4.11. During record review on the survey date beginning at 8:45 A.M., there was no documentation available to verify that the facility’s fire dampers had been inspected and tested as required by code. Documentation of fire damper inspection and testing was requested at the entrance conference at 8:40 A.M., and again at 9:35 A.M. and 10:10 A.M., but no records were provided by the time of survey exit. During the physical tour, surveyors observed that fire dampers were present throughout the building, and the Maintenance Director confirmed that the requested documentation could not be produced. This deficiency had the potential to affect all 69 residents in the facility. No specific resident medical histories or conditions at the time of the deficiency were described in the report, only that 69 residents could potentially be affected.
Plan Of Correction
1. Based on observation, record review and interview, no residents experienced negative outcomes related to the missing fire damper inspection. 2. The Medical Director was notified by LNHA on 03/26/2026 that the facility failed to ensure fire dampers were inspected and tested. 3. Fire damper inspection will be completed by contracted vendor on or before 04/30/2026. 4. Compliance will be reviewed in QAPI quarterly and as needed. 5. LNHA educated Maintenance Director on 03/26/2026 regarding the requirements of maintaining the facility's smoke/fire dampers, ensuring required scheduled inspections/testing.
Failure to Conduct and Document Required Quarterly Fire Drill
Penalty
Summary
The deficiency involves the facility’s failure to conduct and document required fire drills on each shift at least quarterly in accordance with NFPA 101 – 2012 Edition, Section 19.7.1. Surveyors reviewed facility records on 03/25/26 beginning at 8:45 A.M. and found no documentation to verify that a fire drill had been conducted in May 2025. Documentation of fire drills was requested at the entrance conference at 8:40 A.M., and again at 9:35 A.M. and 10:10 A.M., but no records were provided by the time of exit. The survey identified that this failure to document a quarterly fire drill had the potential to affect all 69 of the 69 residents in the facility. Interview with the Maintenance Director at the time of observation confirmed that there was no documentation available to show that the required fire drill had been conducted for that period.
Plan Of Correction
1. Based on record review and staff interview, no residents experienced negative outcomes related to fire drill documentation deficiencies. 2. The Medical Director was notified by LNHA on 03/26/2026 that the facility failed to provide documentation verifying a fire drill was conducted in May 2025. 3. Fire drill schedule has been implemented and documentation will be maintained for all required drills. 4. Compliance will be reviewed in QAPI quarterly and as needed. 5. LNHA educated Maintenance Director on 03/26/2026 on the requirements for conducting fire drills on every shift every quarter.
Nonfunctional Generator Alarm Annunciators at Nurses’ Stations
Penalty
Summary
Surveyors found that the facility failed to maintain required generator alarm annunciators in accordance with NFPA 99, Sections 6.4.1.1.17 through 6.4.1.1.17.5, potentially affecting all 69 residents in the building. During a tour, the generator annunciator panel at the East nurses’ station was observed with no functional indicator lights and the key switch on the side of the box in the off position. The generator annunciator at the front nurses’ station was observed in the same condition, with no lights illuminated and the key in the off position. In an interview, the Maintenance Director stated that the only way he knows if there is a problem with the generators is by going to the generators themselves and checking their displays. When the Maintenance Director started the generators, it was determined that the key controlled an audible signal that sounded when the generator was running, confirming that the annunciators were not being used as intended to indicate alarm conditions of the emergency power source.
Plan Of Correction
1.Based on observation and staff interview, no residents experienced negative outcomes related to annunciator deficiencies. The generator annunciator panel at the East nurse's station had no lights functional and the provider key on the side of the box was in an off position. Additionally, the generator annunciator at the front nurse's station having no functional lights and the provider key on the side of the box was in an off position. 2.The Medical Director was notified of non-functional annunciator panels. 3.Annunciator repairs will be completed by contracted vendor on or before 04/30/2026. 4.Monthly monitoring will be conducted and reviewed in QAPI. 5. LNHA educated Maintenance Director regarding having a generator annunciator that is functioning appropriately, and maintenance of the same.
Failure to Maintain and Document Required Generator Testing and Safety Features
Penalty
Summary
Surveyors identified a deficiency related to the testing and maintenance of the facility’s essential electrical system and generators. During record review, they found no documentation to verify that the facility’s three generators were tested monthly as required by NFPA 99 and NFPA 110. Additionally, there was no documentation provided to show that the three generators were inspected and tested annually as required by code. Documentation of these tests and inspections was requested at the entrance conference and again later in the morning, but no records were produced by the time of survey exit. During the physical tour of the facility, surveyors observed that none of the three generators had remote manual stop buttons. An interview with the Maintenance Director confirmed the absence of these remote manual stop buttons at the time of observation. These findings were determined to be out of compliance with NFPA 99 – 2012 Edition, Section 6.4.4 through 6.5.4.2 and NFPA 110 – 2010 Edition 5.6.5, and the deficient practice had the potential to affect all 69 residents in the facility.
Plan Of Correction
1.Based on record review, observation, and staff interview, no residents experienced negative outcomes related to the facility's failure to test and maintain the essential electrical system in accordance with NFPA requirements. Findings identified during the survey included: • The facility failed to provide documentation verifying that the three generators were tested monthly as required. • The facility failed to provide documentation verifying that the three generators were inspected and tested annually as required. • During observation on 03/25/2026, it was identified that the facility's three generators did not have remote manual stop buttons installed. 2.The Medical Director was notified by LNHA on 03/26/2026 of the deficiency, including failure to perform and document required generator testing, lack of annual inspection documentation, and absence of required remote manual stop devices. 3.Generator system inspection, testing, and maintenance will be completed by a contracted generator service provider and/or Maintenance Director/designee on or before 04/30/2026. Corrective actions will include: • Completion of monthly generator testing under load conditions, including verification of automatic transfer within 10 seconds. • Completion of annual generator inspection and testing, including full system evaluation in accordance with NFPA 110 requirements. • Installation of remote manual stop buttons for all three generators in accordance with code requirements. • Verification that all generator components, transfer switches, and associated equipment are functioning properly. • Establishment of a comprehensive generator testing and maintenance program, including weekly inspections, monthly load testing (20–40 day intervals), and required periodic extended testing. • All generator testing, inspection, and maintenance activities will be placed on an automatically recurring schedule by Administrator/designee on or before 04/30/2026. Documentation logs will be implemented and maintained onsite. 4.Documentation of all generator inspections, testing, and maintenance will be maintained onsite and readily available. The Maintenance Director/designee will conduct weekly and monthly audits to ensure compliance with NFPA 99 and NFPA 110 requirements. Compliance will be reviewed in QAPI every quarter and as needed to ensure ongoing systemic compliance 5.LNHA educated Maintenance Director on 03/26/2026 regarding the requirements for maintaining the facility's generators, including inspection and testing.
Failure to Maintain Kitchen Hood Inspections and Gas Appliance Restraints
Penalty
Summary
The deficiency involves the facility’s failure to maintain the kitchen fire suppression system and related equipment in accordance with NFPA 101, NFPA 96, NFPA 17A, NFPA 10, and NFPA 54 requirements. During record review, surveyors determined that only one kitchen hood inspection had been documented in the previous 12 months, with the sole inspection dated 04/23/25. Additional documentation of required inspections was requested multiple times during the survey, including at the entrance conference and later in the morning, but no further records were provided by the time of exit. During the physical tour of the facility’s kitchen, surveyors observed that the gas-fired kitchen appliances were not equipped with restraints to prevent overextension of the gas lines if the appliances were moved for service or cleaning. The Maintenance Director confirmed the absence of these restraints at the time of observation. This deficient practice had the potential to affect 22 of the 69 residents residing in the facility.
Plan Of Correction
1. Based on record review, observation and staff interview, no residents experienced negative outcomes related to failure to maintain kitchen fire suppression system and equipment safeguards. 2. The Medical Director was notified by LNHA on 03/26/2026 of the deficiency including incomplete hood inspection frequency and lack of appliance restraints. 3. Hood inspection will be completed by Grexen (contracted company) on or before 04/30/2026. Appliance restraints will be installed by Maintenance Director/designee on or before 04/30/2026. Hood inspections will be added to an every six (6) month automatically recurring schedule by Administrator/designee. 4. Compliance will be reviewed in QAPI every quarter and as needed. 5. LNHA educated Maintenance Director on 03/26/2026 regarding the requirements for maintaining the kitchen hood and kitchen equipment.
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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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