Altercare Of Nobles Pond, Inc
Inspection history, citations, penalties and survey trends for this long-term care facility in Canton, Ohio.
- Location
- 7006 Fulton Drive, Nw, Canton, Ohio 44718
- CMS Provider Number
- 366298
- Inspections on file
- 24
- Latest survey
- March 19, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Altercare Of Nobles Pond, Inc during CMS and state inspections, most recent first.
A resident with multiple medical conditions, including metabolic encephalopathy and Generalized Anxiety Disorder, was started on BuSpar 10 mg BID following a psychiatric evaluation, but the responsible party was not properly informed of this new psychotropic medication order. Nursing notes lacked documentation of the psychiatrist’s assessment or any notification to the responsible party, even though the MAR showed the resident received two doses. The responsible party later reported learning of the medication only during an in-person visit and expressed concern due to the resident’s prior adverse reactions to psychotropic drugs. Conflicting accounts from two ADONs about when and how the responsible party was notified, combined with the absence of required documentation, demonstrated noncompliance with the facility’s policy on notifying and documenting changes in a resident’s condition or treatment.
A resident with impaired ability to perform ADLs and requiring assistance with toileting reported that her bedpan smelled terrible and was not cleaned by staff after use. During observation, surveyors found two unlabeled, unbagged orange bedpans in the bathroom, one in the toilet bowl and one on the floor between the wall and toilet, both with apparent barrier cream residue. A CNA confirmed the bedpans were stored inappropriately, demonstrating a failure to maintain a clean, comfortable, and homelike environment consistent with the facility’s resident rights policy.
The facility failed to provide appropriate and timely care in several areas. A resident with urinary retention, a Foley catheter, and ongoing hematuria continued to receive an anticoagulant while experiencing large blood clots and low Hgb, with delayed practitioner response and no documented timely family notification, until critically low labs led to hospital transfer. Another resident with a right hip arthroplasty had a hip dressing in place but no wound care orders or care plan interventions. A third resident with a stage 4 pressure ulcer also had an undocumented and untreated skin tear on the posterior inner thigh, despite a dated dressing being present. A fourth resident with obesity, DM, and cardiac monitoring needs had multiple missed daily weights despite a physician order and care plan interventions, with no documentation explaining the omissions.
Two residents did not receive consistent, professionally managed pressure ulcer care. One resident was admitted with a wound noted on assessment, but for weeks the only documented wound was a skin tear, there were no wound-care orders, and facility staff denied any buttock wounds despite a family photo and an outside RN’s documentation of open buttock areas and a stage 1 coccyx ulcer. Another resident with a care-planned stage 4 sacral pressure injury and specific MD orders for Aquacel AG and foam dressings every other day had multiple missed or unrecorded treatments on the TAR, and reported that dressings were not changed consistently and that only two nurses regularly performed the care. The regional RN verified the missing treatment entries, while the ADON, who stated an outside wound center managed the wound, was unaware of the missed treatments, contrary to the facility’s wound care policy requiring adherence to professional standards of practice.
A resident with acute kidney failure, kidney stones, UTI, moderate cognitive impairment, and severe left hip osteoarthritis experienced inadequate pain management when PRN acetaminophen and later PRN oxycodone were not used or escalated in a timely and consistently effective manner. On one occasion, the resident was documented as yelling with pain rated 9/10, initially receiving only Tylenol because narcotics were noted as not due, and although oxycodone was later increased and administered, the resident was again observed yelling in pain that same afternoon. A family member reported the resident screaming in pain on another day, being told that Tylenol would not be available for some time, and that the nurse would not call the NP or physician, instead waiting for the NP’s next visit and only leaving a log-book message. These events occurred despite facility policies requiring prompt physician notification for changes in condition and pain management consistent with professional standards.
A resident with multiple comorbidities, including DM, CKD, morbid obesity, and mobility impairment, had a PRN order for Hydroxyzine Pamoate 25 mg. The consulting pharmacy later recommended discontinuation of this drug, and the physician signed to discontinue it, but nursing staff continued to administer the medication and the order remained active on the MAR for several weeks afterward. This resulted in the resident receiving doses of Hydroxyzine despite the documented decision to stop the medication, contrary to facility policy requiring medications to be administered in accordance with prescriber orders.
A resident without documented psychiatric diagnoses or anxiety symptoms was started on BuSpar and Trazodone following a psychiatric evaluation that relied on the resident’s self-reported sadness, anxiety, and sleep issues, while depression was still being ruled out. Nursing notes did not document the psychiatrist’s assessment or the new psychotropic orders on the day they were made, and there was no clear documentation that the responsible party was notified when BuSpar was initiated. The MAR showed BuSpar was entered and administered twice before being discontinued, and the responsible party later reported not understanding why the medications were started and expressed concern due to the resident’s prior adverse reactions to psychotropics. Interviews with ADONs revealed inconsistent accounts of when and how the responsible party was informed and showed that the rationale for Trazodone was not discussed, contrary to facility policy requiring immediate notification and documentation when there is a change in the resident’s status or treatment.
Surveyors found that food items were stored without required labels or dates, the oven was not kept clean, and a dietary aide handled ready-to-eat food with bare hands, all in violation of facility policies. These deficiencies had the potential to affect nearly all residents receiving food from the kitchen.
Multiple residents did not receive physician-ordered fortified nutritional treats or their preferred food and beverage items during meals, including cases where allergies and dietary orders were not accommodated. Staff and resident interviews, as well as direct observation, confirmed that meal trays were missing required supplements and selected items, and that substitutions were made without honoring resident preferences.
A resident with multiple medical conditions and intact cognition was unable to summon assistance because the call light in their room was not working due to the cord being pulled out of the wall. The resident, who was at risk for falls and required help with transfers, was observed needing assistance and reported the issue. Facility policy required timely response to call lights, but the malfunction prevented the resident from receiving needed support.
A resident with hemiplegia and muscle weakness did not consistently receive a physician-ordered left palm protector as required to prevent skin breakdown and deformity. Observations and staff interviews revealed the device was not always in place during the day, and some CNAs were unaware of the correct timing for its removal. The facility also lacked a policy on palm protector use.
A resident who required tube feeding due to dysphagia and gastrostomy status was given a different enteral formula than what was ordered by the physician, despite the correct formula being available in the facility. Staff did not obtain physician or dietitian approval for the substitution, and facility policy requiring administration of prescribed enteral nutrition was not followed.
A resident with type 1 diabetes and significant physical limitations did not receive consistent staff assistance with carbohydrate counting or insulin pump operation as ordered, resulting in missed or incorrect insulin administration. Staff lacked training on the insulin pump, care plans were not updated to reflect current interventions, and documentation of insulin boluses and carbohydrate counts was incomplete, leading to significant medication errors.
A resident with multiple chronic conditions experienced a fall that was inconsistently documented in the facility's records. Two separate incident reports were created for the same event, both marked as falls with injury, yet both stated there was no injury or pain, despite clinical notes indicating a head abrasion and thigh pain. Staff interviews confirmed discrepancies in the documentation and notification times, and the DON acknowledged the reports did not match.
A resident with multiple medical conditions and a fall risk was unable to summon assistance because the call light in their bathroom was not working due to the cord being pulled out of the wall. The resident attempted to use the call light for help with positioning, but it failed to activate the electronic message board, contrary to facility policy requiring timely response to call lights.
A long-term care facility failed to protect residents from the misappropriation of narcotic medications, affecting several residents. Discrepancies in medication administration records and narcotic count sheets led to missing medications. Incidents included missing oxycodone for a resident post-discharge, premature destruction of another resident's medication, and false documentation of narcotic waste by an LPN. These deficiencies highlight lapses in medication management and documentation procedures.
Failure to Notify Responsible Party of New Psychotropic Medication Order
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s responsible party was fully informed of and understood a change in the resident’s medication regimen. A resident admitted with metabolic encephalopathy, peripheral vascular disease, urinary tract infection, kidney calculus, and osteonecrosis of the left femur underwent an admission psychiatric evaluation by a consulting psychiatrist, who diagnosed Generalized Anxiety Disorder and ordered BuSpar 10 mg orally twice daily. The nursing progress notes for the period surrounding this evaluation contained no documentation of the psychiatrist’s assessment or of any notification to the resident’s responsible party about the new BuSpar order. The MAR showed the BuSpar order was entered and that the resident received two doses. The facility’s policy required immediate notification of the resident and authorized representative, with documentation in the medical record, when there was a change in the resident’s mental, physical, or psychosocial status. The resident’s responsible party reported that the facility started the resident on BuSpar and Trazodone for reasons unknown to her, and that she did not learn about the BuSpar until a nurse mentioned it during a visit. She stated the resident had previously experienced adverse reactions to psychotropic medications and that she did not want him on medications that cross the blood-brain barrier. One ADON stated she believed another ADON had notified the responsible party by phone and that she later met in person with the responsible party to discuss the BuSpar order, acknowledging the resident received two doses before discontinuation. The other ADON, however, stated she did not notify the family by phone, that all communication with the responsible party was in person, and that she discussed the BuSpar order with the responsible party at the next in-person visit and believed the resident did not receive any doses. There was no documentation in the medical record of timely notification to the responsible party about the initiation of BuSpar, contrary to facility policy.
Failure to Maintain Clean and Homelike Environment for Bedpan-Dependent Resident
Penalty
Summary
Surveyors identified that the facility failed to maintain a clean and homelike environment for Resident #58. The resident was admitted on 11/04/25 with diagnoses including need for personal care, difficulty walking, muscle weakness, and repeated falls, and had a care plan dated 01/21/26 indicating an impaired ability to perform or participate in ADLs, with interventions to assist with toileting and provide incontinence care as needed. During an interview and observation on 03/16/26 at 11:40 A.M., the resident reported that her bedpan smelled terrible and that staff did not clean the bedpan after use. At that time, two unlabeled and unbagged orange bedpans were observed in the bathroom, one inside the toilet bowl and one on the floor between the wall and toilet, both appearing to have barrier cream residue on them. At 11:42 A.M., CNA #615 confirmed that the two bedpans were stored inappropriately. Review of the facility’s resident rights policy dated 05/01/25 stated the facility would make every effort to assist each resident in exercising their rights to be treated with respect, kindness, and dignity. This deficiency was cited under Complaint Number 2807084. The deficiency centers on the facility’s failure to ensure that the resident’s bedpan was cleaned after use and that bedpans were properly labeled, bagged, and stored, resulting in a bathroom environment that was not clean, comfortable, or homelike as required by the facility’s own resident rights policy.
Failure to Provide Timely Medical Response, Wound Management, and Ordered Daily Weights
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate medical treatment and timely response to a change in condition for a resident with hematuria and anemia, as well as failures in wound care management and completion of ordered daily weights for other residents. One resident with acute kidney failure, urinary retention, and a Foley catheter had ongoing hematuria and blood clots while receiving Eliquis. Laboratory results showed low red blood cell and hemoglobin levels, and nursing notes documented large blood clots and bloody drainage from the penis on multiple occasions. Although nursing staff paged the nurse practitioner and notified the urologist, there were significant delays in response to the change in condition, and the medical record lacked evidence of timely family notification. The resident continued to receive Eliquis through multiple days of documented bleeding and low hemoglobin until an order was finally obtained to hold the anticoagulant and repeat labs, after which a critically low hemoglobin prompted transfer to the emergency department. Another deficiency involved a resident admitted with a displaced right femur fracture and right hip arthroplasty who had a dressing to the right hip but no corresponding wound care orders or care plan interventions. Observation confirmed the presence of a right hip dressing without any documented wound care orders in the medical record. The DON confirmed that the resident did not have orders or a care plan for wound care and interventions related to the right hip surgical site, despite the presence of a dressing. A further deficiency concerned a resident with a history including surgical aftercare for digestive system surgery, muscle weakness, and malignancies of the liver and colon, who had a documented stage 4 pressure ulcer but also had an additional skin tear on the left posterior inner thigh. The quarterly MDS did not reflect the skin tear, and the physician orders contained no assessments or treatments for this wound. During wound care observation, a dressing dated several days earlier was noted on the left posterior inner thigh, and the DON confirmed that the medical record did not contain documentation of or orders to treat this skin tear, contrary to the facility’s wound care policy requiring verification of physician orders for wound procedures. Additionally, the facility failed to obtain daily weights as ordered for another resident with morbid obesity, type II diabetes mellitus, and cardiac-related monitoring needs. This resident had an order for daily weights and a care plan that included monitoring for edema and obtaining vital signs as ordered. Review of treatment administration records showed multiple missed daily weights in both February and March, with no documentation in the progress notes explaining why the weights were not completed. An LPN confirmed that some of the required daily weights had not been obtained as ordered, despite the facility’s policy that residents’ weights be monitored and recorded in the electronic medical record to evaluate nutritional status within the parameters of their medical condition.
Failure to Provide and Document Consistent Pressure Ulcer Care
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate care and treatment for existing pressure ulcers and to prevent new ulcers from developing for two residents. One resident was admitted with multiple medical conditions, including peripheral vascular disease and osteonecrosis, and the admission assessment and baseline care plan noted the presence of a wound without documenting its location. From admission through several weeks, nursing progress notes contained no documentation of any wounds other than a skin tear, and there were no physician orders for wound care. Despite this, the resident’s responsible party reported pressure wounds on the buttocks, provided a photograph showing two open reddened areas near the gluteal fold, and stated that the facility was not providing wound care. A urology RN later documented two open skin areas on the left medial buttock and a stage 1 pressure ulcer on the coccyx when the resident presented for a procedure, while facility nursing leadership and staff continued to deny the presence of any buttock wounds beyond the documented skin tear. The second resident had an existing care plan for a sacral pressure injury related to impaired mobility, urinary incontinence, and cancer, with interventions including performing ordered treatments and completing preventive measures. The resident’s MDS indicated cognitive intactness, need for assistance with rolling, frequent urinary incontinence, a colostomy, and one stage 4 pressure ulcer. Physician orders specified cleansing the sacrum with soap and water, patting dry, filling the wound and undermining with Aquacel AG rope, and applying a foam dressing every other day and as needed. However, review of the Treatment Administration Records showed multiple dates in two consecutive months when the ordered sacral wound treatments were not recorded as completed. The resident with the sacral pressure ulcer reported that dressings were not being changed consistently and attributed the development of the wound to not being repositioned, though she was unsure whether it originated in the facility or the hospital. She further stated that only two nurses regularly changed her sacral dressing. The regional RN confirmed the missing treatment entries on the TAR, and the ADON, who indicated that an outside wound center managed the resident’s wound care and had recently changed the treatment frequency, was unaware that treatments were not being completed and suggested agency nursing staff usage as a possible factor. The facility’s own wound care policy required that wound care be provided using professional standards of practice, which was not followed as evidenced by the lack of documented and consistently provided wound care for both residents’ pressure ulcers.
Failure to Provide Timely and Effective Pain Management for a Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate pain management for a resident with multiple medical issues, including acute kidney failure, kidney stones, urinary tract infection, and primary osteoarthritis of the left hip. The resident had moderate cognitive impairment and reported pain in multiple areas, including his hip, arms, legs, and teeth. Physician orders initially included PRN acetaminophen 325 mg every four hours for pain, which was later discontinued, and then PRN oxycodone 2.5 mg every eight hours for pain. Documentation showed that on one date the resident received acetaminophen for a pain level of six, which was not effective, followed by another dose that was effective. An orthopedic note documented the resident’s left hip pain and the plan for further interventions, including urology and dental evaluations. On another date, the resident’s pain escalated significantly. At approximately midday, the resident was documented as yelling out with pain rated 9/10. At that time, narcotics were noted as “not due,” and Tylenol was administered while the NP was notified. Shortly thereafter, the NP ordered an increase in oxycodone to 5 mg every eight hours PRN, and a dose was administered. The MAR and controlled drug record indicated that the oxycodone dose was effective at a later assessment, with the resident resting; however, an observation later that same afternoon found the resident in bed yelling out that he was in pain. The ADON later stated she did not hear the resident if he hollered out after the oxycodone administration. Family interviews revealed additional concerns about pain management on an earlier date. A family member reported that the resident was screaming in pain and that staff told her Tylenol would not be available for another 40 minutes. The family member stated she had to locate staff to assist the resident and provide pain medication, and that the LPN on duty said the NP would not be in until the next day and would not address the resident’s pain, and that the nurse would not call the physician. The LPN later confirmed she was aware of the family’s concerns, gave Tylenol, did not recall if the resident was hollering in pain, and did not call the NP because the NP preferred to see residents in person for narcotic pain medications, instead leaving a message in the log book for the physician. These actions and inactions occurred despite facility policies requiring notification of the physician and representative upon changes in condition and administration of pain medications in accordance with professional standards of practice.
Failure to Timely Implement Pharmacy and Physician Discontinuation of PRN Hydroxyzine
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely implementation of pharmacy recommendations to discontinue a medication after physician approval. A resident admitted with diagnoses including a displaced right humerus fracture, gait and mobility abnormalities, type II diabetes mellitus, morbid obesity, and chronic kidney disease had a physician order dated 01/27/26 for Hydroxyzine Pamoate 25 mg to be given orally once daily as needed. The five-day admission MDS showed a BIMS score of 10, indicating moderate cognitive impairment, and documented that the resident was receiving a diuretic, opioid, antiplatelet, and antidepressant. On 02/16/26, the consulting pharmacy recommended discontinuation of Hydroxyzine Pamoate 25 mg, and on 02/20/26 the physician reviewed and agreed with this recommendation, signing to discontinue the medication. Despite the physician’s discontinuation decision, review of the February and March 2026 MARs showed that the Hydroxyzine Pamoate order remained active and the medication continued to be administered. The MAR for February 2026 documented administration of Hydroxyzine Pamoate 25 mg on 02/25/26, and the March 2026 MAR documented administrations on 03/06/26 and 03/11/26. The order itself was not discontinued until 03/16/26. During an interview on 03/17/26, the Regional Nurse confirmed that the pharmacy recommendation to discontinue the medication was made on 02/16/26, the physician signed to discontinue it on 02/20/26, but the medication continued to be given on the above dates and the order remained in place until mid-March. Facility policy on medication administration stated that medications are to be administered in accordance with prescriber orders, which did not occur in this case.
Failure to Ensure Appropriate Indication and Notification for New Psychotropic Medications
Penalty
Summary
The facility failed to ensure a resident’s drug regimen was free from unnecessary medications by not establishing and documenting appropriate indications for new psychotropic drugs. A resident admitted with metabolic encephalopathy, peripheral vascular disease, urinary tract infection, kidney calculus, and osteonecrosis of the left femur had no documented history of generalized anxiety disorder, depression, or other psychiatric conditions in the medical record. Review of progress notes over several days showed no signs or symptoms of anxiety and no documentation of referral to psychiatric services. During an admission psychiatric evaluation, the consulting psychiatrist documented the resident’s self-reported sadness, depression, poor sleep, anxiety, and restlessness, diagnosed generalized anxiety disorder, ordered BuSpar 10 mg orally twice daily for anxiety, and Trazodone 25 mg orally every evening while depression was still being ruled out and not listed as a confirmed diagnosis. The nursing documentation did not reflect the psychiatrist’s assessment or the new orders for BuSpar and Trazodone on the date they were made, and there was no documentation of notification of the resident’s responsible party regarding the initiation of BuSpar. The MAR showed the BuSpar order was entered the day after the psychiatric evaluation, and the resident received two doses before discontinuation. The responsible party later reported that the medications were started for an unknown reason, stated the resident had prior adverse reactions to psychotropic medications, and did not want medications that cross the blood-brain barrier. Interviews with the ADONs revealed conflicting accounts about whether and when the responsible party was notified of the new orders, with one ADON stating she did not notify the family by phone and that all communication was in person, and acknowledging that nothing was discussed regarding the rationale for Trazodone. The facility’s policy required immediate notification of the resident and authorized representative, consultation with the practitioner, and documentation in the medical record when there is a change in mental, physical, or psychosocial status, which was not consistently followed in this case.
Deficient Food Storage, Sanitation, and Handling Practices
Penalty
Summary
Surveyors observed multiple deficiencies in the facility's food storage, preparation, and service practices. During a kitchen tour, open bags of cake mix and instant mashed potatoes were found in the dry goods storage room without labels or dates indicating when they were opened. In the walk-in freezer, frozen french toast sticks and an opened bag of biscuits were also found without labels or dates. Additionally, the oven in the preparation area had visible food residue and splatter, indicating it was not maintained in a clean and sanitary condition. During lunch meal service, a dietary aide was seen handling a deli sandwich with bare hands, removing it from a sandwich bag and placing it on a plate for a resident, contrary to facility policy requiring glove use for food handling. Facility policies reviewed by surveyors specified that all open food items must be labeled with the opened date, expiration date, and food item name, and that gloves must be worn when handling food. These deficiencies had the potential to affect 68 out of 69 residents who received food from the kitchen, with one resident not affected due to being NPO (nothing by mouth).
Failure to Provide Physician-Ordered Supplements and Honor Resident Meal Preferences
Penalty
Summary
The facility failed to provide meals that accommodated resident allergies, physician-ordered supplements, and stated preferences for multiple residents. For one resident with COPD, failure to thrive, and dementia on hospice, the physician ordered a regular diet with a four-ounce fortified nutritional treat at lunch. However, observation revealed that the fortified treat was not included on the lunch tray, and this omission was confirmed by both a CNA and review of the meal ticket. Another resident with systemic lupus and recent significant weight loss had a physician order for a regular diet with no bananas or seafood due to allergies and a daily fortified nutritional treat at lunch. Observation and interviews confirmed that the fortified treat was missing from the lunch tray, despite being indicated on the meal ticket. Additional deficiencies were observed regarding resident meal preferences. One resident with anorexia and moderate cognitive impairment was supposed to receive apple juice according to the meal ticket but was instead given cranberry juice and, on another occasion, lemonade. These errors were verified by both staff and the resident, who expressed dissatisfaction with the incorrect beverage. Another resident with chronic respiratory failure and muscle wasting selected specific breakfast items, including a hash brown patty and cranberry juice, but did not receive the hash brown and was given orange juice instead. Staff confirmed the kitchen had run out of hash browns. A further resident with COPD and moderate cognitive impairment also did not receive a selected hash brown patty for breakfast, as the kitchen had run out. Across these cases, the facility did not consistently provide food and beverages according to physician orders, resident allergies, and stated preferences, as evidenced by direct observation, record review, and staff interviews. These failures affected five of six residents reviewed for food and drink, out of a facility census of 69.
Failure to Ensure Functioning Call Light for Resident Needing Assistance
Penalty
Summary
A deficiency was identified when a resident with diagnoses including pancytopenia, diabetes mellitus, and atherosclerotic heart disease, and who exhibited intact cognition, was observed needing assistance and reported that the call light was not working. The resident's care plan indicated a risk for falls and included an intervention to encourage the use of the call light for transfer and ambulation assistance. During observation and interview, it was confirmed that the call light did not activate the electronic message board, and further inspection revealed the call light cord was pulled out of the wall, rendering it nonfunctional. The facility's policy required timely response to call lights to meet residents' needs.
Failure to Implement Physician-Ordered Palm Protector for Resident with Limited Mobility
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident's left palm protector was implemented as ordered to prevent skin breakdown and deformity. The resident, who had a history of hemiplegia and hemiparesis following a cerebral infarction affecting the left non-dominant side, muscle weakness, and vascular dementia, had a physician's order for a left palm protector to be applied in the morning and removed at bedtime, with skin integrity checks twice daily. Documentation in the medical record indicated the palm protector was applied as ordered, and the care plan included this intervention. However, during observation, the resident was found with a contracted left hand and no palm protector in place, and the resident confirmed that the device was supposed to be worn during the day. A CNA also confirmed the palm protector was not in place as ordered and applied it at that time. Further interviews revealed that staff were not consistently aware of the timing for removal of the palm protector, with one CNA stating she was unaware it was to be removed at bedtime. Additionally, the facility did not have a policy regarding the use of palm protectors.
Failure to Administer Prescribed Enteral Feeding Formula
Penalty
Summary
A deficiency occurred when a resident with a history of dysphagia, aphasia, and gastrostomy status, who was dependent on staff for activities of daily living and received the majority of their nutrition and hydration via tube feeding, was not provided the prescribed enteral feeding formula. The physician's order specified continuous administration of Isosource 1.5 at 55 ml per hour, but instead, Vital 1.5 formula was administered. This substitution was observed during a survey, and the medication administration record indicated the feeding was signed as administered according to the order, despite the actual formula being different. Interviews with nursing and dietary staff confirmed that no physician order or dietitian consultation had been made to authorize the substitution of the enteral formula. The supply room was found to have the prescribed Isosource 1.5 formula available at the time of the incident, and the medical records coordinator was unable to explain why the incorrect formula was used. Facility policy required that enteral nutrition be administered as prescribed, in accordance with professional standards, which was not followed in this instance.
Failure to Ensure Proper Insulin Pump Management and Carbohydrate Counting
Penalty
Summary
The facility failed to ensure that a resident with type 1 diabetes mellitus, spastic quadriplegic cerebral palsy, and a recent right humerus fracture received proper assistance with insulin pump management and carbohydrate counting as ordered by the physician. The resident was dependent on staff for all activities of daily living, including eating, and was unable to independently calculate or enter carbohydrate counts into the insulin pump due to physical limitations. Despite physician orders specifying that staff should assist with carbohydrate counts and insulin pump operation, there was no evidence in the medical administration records that this assistance was consistently provided across multiple meals and days. Staff interviews revealed a lack of knowledge and training regarding the resident's insulin pump and carbohydrate counting. Several nurses and LPNs admitted they were unfamiliar with the insulin pump's operation, did not know they were responsible for providing carbohydrate counts, or relied on the resident to guide them through the process. Documentation showed that staff did not consistently record carbohydrate counts or verify that insulin boluses were administered as ordered. Additionally, there was a transcription error regarding insulin dosage, and the nurse involved was unaware of the correct dose to administer, further contributing to medication errors. The resident's care plan did not reflect current physician orders related to carbohydrate counting and insulin pump management. The facility did not provide staff education on the use, care, or maintenance of the insulin pump, nor did it assess the resident for self-administration of medication. The lack of updated care plans, staff training, and proper documentation led to significant medication errors, including missed or incorrect insulin administration and inadequate monitoring of blood glucose levels.
Inaccurate Documentation of Fall and Investigation
Penalty
Summary
The facility failed to accurately document the details of a fall and the subsequent fall investigation for one resident. The medical record review revealed inconsistencies in the documentation of the fall event, including conflicting dates and times of the incident, discrepancies in the reporting of injuries, and inconsistent notification times for the nurse practitioner and resident representative. Two separate fall investigation reports were completed for the same incident, both indicating the fall was classified as 'with injury,' yet both reports stated there was no injury and no pain. Additionally, the progress note from the nurse practitioner described a small abrasion on the back of the resident's head and right thigh pain, which was not reflected in the fall investigation reports. The care plan identified the resident as being at risk for falls due to multiple medical conditions and medications, but the documentation of the actual fall event and related assessments was not consistent or accurate. The resident involved had multiple diagnoses, including osteoarthritis, atrial fibrillation, diabetes, COPD, bipolar disorder, hypertension, and impaired mobility. The resident self-reported the fall, stating she hit her head and hurt her arm, but the incident reports did not document these injuries. Interviews with facility staff confirmed the existence of two incident reports for the same event and acknowledged that the information in the reports did not match. The Director of Nursing confirmed that the fall was classified as a fall with injury, despite the incident reports indicating otherwise, and explained that the duplication occurred because the first report was accidentally closed before completion.
Non-Functioning Call Light in Resident Bathroom
Penalty
Summary
A deficiency was identified when a resident, admitted with pancytopenia, diabetes mellitus, and atherosclerotic heart disease, was found to have a non-functioning call light in their room. The resident, who was assessed as having intact cognition and was at risk for falls, reported using the call light to request assistance for positioning prior to lunch, but the device did not work. Observation confirmed that the call light failed to activate the electronic message board, and further inspection with the Administrator revealed the call light cord was pulled out of the wall, rendering it inoperable. The facility's policy required timely response to call lights to meet resident needs, but this was not met in this instance.
Misappropriation of Narcotic Medications in LTC Facility
Penalty
Summary
The facility failed to protect several residents from the misappropriation of narcotic medications, affecting five residents who were prescribed such medications. The incidents involved discrepancies in medication administration records (MAR) and narcotic count sheets, leading to missing medications. For instance, Resident #70's oxycodone was reported missing after discharge, prompting a facility-wide search and drug testing of nurses, which returned negative results. Similarly, Resident #22's narcotic medication was found to be destroyed prematurely, with the facility unable to verify the receipt of medications due to missing records. Resident #21 experienced issues with medication administration documentation, where an LPN failed to record the administration of narcotic medication in the MAR, leading to a policy violation write-up. Resident #64's records showed discrepancies between the MAR and the narcotic sheets, with more administrations recorded on the narcotic sheets than in the MAR. This was discovered during routine medication audits, indicating a lack of proper documentation and accountability. Resident #71's case involved an LPN who falsely documented the wasting of narcotic medication, claiming a witness who later denied involvement. This led to the termination of the LPN and further investigation by the facility. The facility's policies on medication administration and narcotic handling were not adequately followed, resulting in these deficiencies. The incidents highlight lapses in the facility's procedures for narcotic medication management and documentation.
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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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