Arbors At Oregon
Inspection history, citations, penalties and survey trends for this long-term care facility in Oregon, Ohio.
- Location
- 904 Isaac Streets Drive, Oregon, Ohio 43616
- CMS Provider Number
- 365523
- Inspections on file
- 37
- Latest survey
- January 5, 2026
- Citations (last 12 mo.)
- 9 (1 serious)
Citation history
Health deficiencies cited at Arbors At Oregon during CMS and state inspections, most recent first.
A resident with multiple medical conditions and intact cognition, who required extensive assistance for ADLs and transfers, requested help from a CNA to clear personal items from the bed so that an RN could perform ordered dressing changes. The CNA did not assist the resident, reported to the RN that the resident had made a mess and should clean it up, and the dressing changes were not completed. The RN viewed the CNA’s conduct and statement as inappropriate and reported the incident by text to the ADON, who did not consider it verbal abuse and did not promptly notify the DON or the state agency or initiate an investigation, contrary to the facility’s abuse reporting policy requiring immediate reporting of alleged violations.
A resident with multiple medical conditions and dependence on staff for ADLs was not assisted into bed for ordered dressing changes after a CNA allegedly refused to help clean off the bed and made an inappropriate comment about the resident cleaning the bed herself. An RN reported this allegation of verbal abuse and refusal of care to the ADON by text, but the ADON did not consider it verbal abuse, did not notify the DON, and did not initiate an investigation as required by facility policy. The resident’s dressing change was not completed as ordered, and there was no documentation of the alleged incident in the medical record during the period reviewed.
Two residents with diabetes received insulin via pen-injectors from an LPN who did not prime the pens before administration, contrary to manufacturer instructions and facility policy. For one resident, the LPN attached the needle, dialed the ordered dose of long-acting insulin, and injected it without priming. For another resident, the LPN similarly dialed the ordered dose of rapid-acting insulin and administered it without priming. The LPN later confirmed believing priming was unnecessary, despite manufacturer directions requiring priming before each injection to remove air and ensure accurate dosing. These observations contributed to a medication error rate above 5%.
Surveyors found that an LPN failed to prime insulin pens before administering ordered doses of Degludec and Lispro to two residents with diabetes and other comorbidities. For each resident, the LPN attached the needle, dialed the full ordered dose, and injected the insulin without first expelling air or confirming a drop of insulin, despite manufacturer instructions and facility policy requiring priming before each injection to ensure accurate dosing.
An LPN failed to follow infection control standards and facility policy by touching oral medications with bare hands and administering them after they had contacted contaminated surfaces. For one resident with multiple chronic conditions and moderately impaired cognition, the LPN dropped two tablets onto the medication cart, picked them up with a bare hand, then handled the cart and computer before giving the pills to the resident, who swallowed them with water. For another resident with complex medical issues, the LPN dropped a Flomax tablet onto the cart and between items on the cart, retrieved it with a bare hand, and also punched multiple other medications from cards into a bare hand before placing them into a medication cup and administering them. The LPN later confirmed this was his usual practice, despite facility policy directing staff not to touch medications with bare hands when removing them from their source.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents, as observed by surveyors.
An unattended and unlocked medication cart was found near two halls, with a cup containing two used oral syringes that had been used to administer morphine sulphate. An LPN confirmed the cart was left unsecured and the syringes were not properly disposed of, stating they were left by the previous shift. This incident had the potential to affect several cognitively impaired, independently mobile residents in the area.
Surveyors found expired milk and juice, as well as multiple unlabeled and undated food items in kitchen and pantry areas. Food brought in by families or visitors was not consistently labeled or discarded according to policy, and food debris was observed on the floor. Staff confirmed these findings and acknowledged inconsistent cleaning and maintenance practices.
A resident with a diabetic foot ulcer did not have wound measurements completed for over a month, despite having physician orders and a care plan for wound care. Review of records and staff interview confirmed the absence of documented wound measurements, which was not in accordance with the facility's wound management policy requiring ongoing assessment.
The facility failed to ensure proper IV catheter care for three residents, leading to deficiencies in treatment. A resident with multiple medical conditions had a midline catheter without timely dressing changes. Another resident's catheter remained in place beyond the ordered duration, with inadequate dressing maintenance. A third resident's central line dressing was not changed as scheduled. These issues were confirmed through staff interviews and record reviews, indicating non-compliance with physician orders and facility policies.
The facility failed to provide adequate pressure ulcer care, resulting in harm to three residents. One resident developed an unstageable ulcer due to inconsistent care plan implementation, another developed a stage III ulcer without timely intervention, and a third was admitted with untreated wounds, leading to hospitalization. The facility's lack of timely assessment and treatment contributed to these outcomes.
The facility failed to provide adequate personal hygiene care for residents requiring assistance with activities of daily living. Several residents were observed with unclean nails, unwashed hair, and unshaven faces, despite being scheduled for regular showers and personal care. Staff interviews revealed neglect due to fear of resident behaviors and missed scheduled care, violating facility policies on maintaining proper hygiene.
A resident with Alzheimer's and severe cognitive impairment had significant dental issues, including decayed and missing teeth, which were not addressed in her care plan. Despite the resident's refusal of dental interventions and expressed difficulty eating, the facility did not update the care plan to include supports for her dental needs, contrary to their policy requiring comprehensive care plans.
A resident with severe cognitive impairment and multiple medical conditions was not provided with alternative communication methods as indicated in their care plan. Despite recommendations for a communication sheet, staff were unaware and untrained in its use, leaving the resident to rely on gestures and nods for communication.
The facility failed to implement ordered interventions for two residents to promote range of motion and limit contractures. One resident was observed without the prescribed lap tray for safe arm positioning, and another was without rolled washcloths in their hands, despite orders. Staff interviews confirmed the absence of these interventions, indicating non-compliance with care plans.
The facility failed to enforce its smoking policy, allowing two residents to retain smoking materials and smoke in non-designated areas. One resident was found with cigarettes and observed smoking in a prohibited area, while another had burn marks on his clothing from unsafe smoking practices. Despite the facility's policy, these residents were initially allowed to keep their cigarettes, leading to potential safety hazards.
The facility failed to involve a cognitively intact resident in care planning and did not update another resident's care plan to reflect a change in smoking status. One resident expressed a desire to participate in care planning but had not been included since readmission. Another resident, who was a smoker, had his cigarettes removed due to safety concerns, but his care plan lacked updates to address unsafe smoking. The DON confirmed the absence of a smoking care plan.
A resident with multiple health conditions, including diabetes and chronic respiratory failure, was found to have undetected skin integrity issues, including a diabetic foot ulcer, despite having a care plan and orders for regular skin assessments. The facility failed to identify and report these issues in a timely manner, leading to a deficiency.
A resident with conductive hearing loss and impacted earwax did not receive timely audiology services despite being highly hearing impaired and lacking hearing aids. The resident, who was cognitively intact, communicated through written questions and expressed the need for ear cleaning and audiology services. The facility delayed contacting audiology for approximately three months after the resident's admission, leading to a deficiency investigation.
A resident, who was continent and required assistance for toileting due to left side weakness, experienced an episode of incontinence after the night staff failed to respond to his call light. Despite being cognitively intact and dependent on staff for toileting, the resident was left unattended, resulting in soiling himself. This incident highlights a failure to adhere to facility policies on maintaining residents' toileting abilities.
A resident with multiple health issues, including hemiplegia and depression, did not receive adequate grooming and hygiene care in an LTC facility. The resident, dependent on staff for ADLs, had only three documented showers over a month and had untrimmed fingernails with a black/brown substance. Staff interviews confirmed the lack of grooming and missed showers, and the DON acknowledged the failure to adhere to the resident's care schedule.
A resident with multiple medical conditions and frequent bowel incontinence was not provided timely care, resulting in the resident being found with dried stool upon hospital admission. Despite a care plan requiring regular checks, staff failed to perform necessary incontinence monitoring.
Failure to Timely Report Allegation of Verbal Abuse to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to timely report an allegation of verbal abuse to the state agency as required by policy. A resident with intact cognition, admitted with diagnoses including cervical spinal stenosis, osteomyelitis, type II diabetes mellitus, and muscle weakness, was care planned to require assistance of two staff for bed mobility and mechanical lift transfers. On the date in question, an RN requested that a CNA transfer the resident to bed so wound dressings could be changed. Later, the CNA reported to the RN that the resident refused to get into bed and that the resident had asked for help to clean off her bed so she could be transferred. The CNA also reported telling the resident, "you made the mess on the bed, you can clean it up," and did not assist the resident with cleaning the bed or transferring her, resulting in the ordered dressing changes not being completed that day. The RN considered the CNA’s statement and failure to assist as inappropriate and reported this information by text message to the ADON that evening. The ADON received the RN’s text describing the CNA’s refusal to help and the statement made to the resident but did not consider it verbal abuse and took no further action at that time. The ADON did not report the allegation to the DON and did not initiate an investigation until two days later, at which time the DON was informed. Interviews confirmed that the resident did not recall the specific alleged statement but did recall that the CNA said she would return after answering another call light and did not come back, and that the dressing change was not completed as ordered. The facility’s abuse, neglect, and exploitation policy required that alleged violations be reported immediately, but not later than two hours if involving abuse or serious bodily injury, and not later than 24 hours otherwise, to the Administrator, state agency, adult protective services, and other required agencies. The failure of the ADON to promptly report the allegation and initiate an investigation, and the lack of timely reporting to the state agency, constituted non-compliance with the facility’s abuse reporting policy.
Failure to Investigate Alleged Verbal Abuse and Missed Dressing Change
Penalty
Summary
The deficiency involves the facility’s failure to investigate an allegation of verbal abuse toward a resident and related failure to provide ordered care. The resident had diagnoses including cervical spinal stenosis, osteomyelitis, type II diabetes mellitus, and muscle weakness, with intact cognition and dependence on staff for toilet hygiene, personal hygiene, and transfers requiring two-person assistance and a mechanical lift. On the date in question, an RN asked a CNA to transfer the resident to bed for dressing changes. The RN later reported that the CNA told her the resident refused to get into bed and that the CNA stated she told the resident, "you made the mess on the bed, you can clean it up," and did not assist the resident in cleaning off the bed or transferring to bed. As a result, the resident’s dressing changes were not completed as ordered that day. The RN texted this information to the ADON that evening, reporting the CNA’s alleged statement and refusal to help. The ADON acknowledged receiving the text, stated she did not feel the statement was verbal abuse, and took no further action at that time, including not reporting the concern to the DON and not initiating an investigation. The facility’s abuse policy required an immediate investigation when there is suspicion or a report of abuse, neglect, or exploitation, including identifying and interviewing all involved persons and documenting the investigation. The DON later confirmed that the allegation of verbal abuse should have been promptly reported and investigated. Review of the resident’s record showed no progress notes regarding the alleged verbal abuse during the relevant period, and the resident confirmed her dressing was not changed as ordered on the date in question.
Failure to Prime Insulin Pens Resulting in Medication Administration Errors
Penalty
Summary
The facility failed to maintain a medication administration error rate below 5%, with surveyors identifying 2 errors out of 36 observed opportunities, resulting in a 5.5% error rate. For one resident with traumatic brain injury, type II diabetes mellitus, muscle weakness, depression, and dysphagia, the care plan directed that medications and insulin be administered as ordered. The physician’s order specified a morning subcutaneous dose of 15 units of insulin Degludec via pen-injector. During continuous observation, an LPN prepared the Degludec insulin pen by attaching the needle, dialing the pen to 15 units, and administering the insulin subcutaneously without priming the pen beforehand. A second resident, with diagnoses including acute and chronic respiratory failure with hypoxia, type II diabetes mellitus, peripheral vascular disease, chronic kidney disease, and hypertension, also had a care plan directing administration of medications and insulin as ordered. The physician’s order required 4 units of insulin Lispro via pen-injector to be given subcutaneously before meals and at bedtime. Observation showed the same LPN dialed the Lispro pen to 4 units and administered the insulin without priming the pen. In a subsequent interview, the LPN confirmed that he did not prime the insulin pens for either resident and stated there was no need to do so. Manufacturer instructions for both the Degludec and Lispro pen-injectors, as well as facility policy, required medications to be administered in accordance with manufacturer specifications, including priming the pens before each injection to remove air and ensure correct dosing.
Failure to Prime Insulin Pens Before Administration
Penalty
Summary
The deficiency involves the facility’s failure to ensure insulin pens were primed prior to insulin administration, contrary to manufacturer instructions and facility policy, resulting in significant medication errors for two residents. For one resident with traumatic brain injury, type II diabetes mellitus, muscle weakness, depression, and dysphagia, the care plan directed staff to administer insulin per physician orders. The physician ordered Degludec insulin via pen-injector, 15 units subcutaneously in the morning. During continuous observation of a medication pass, an LPN attached a needle to the Degludec pen, dialed the pen directly to 15 units, entered the resident’s room, and administered the insulin subcutaneously without priming the pen. The second affected resident had diagnoses including acute and chronic respiratory failure with hypoxia, type II diabetes mellitus, peripheral vascular disease, chronic kidney disease, and hypertension, and also had a care plan intervention to administer insulin per physician orders. The physician ordered Lispro insulin via pen-injector, 4 units subcutaneously before meals and at bedtime. During observed medication administration, the same LPN dialed the Lispro pen directly to 4 units and administered the insulin without priming. In a subsequent interview, the LPN confirmed that he did not prime the insulin pens for either resident and stated there was no need to do so. Manufacturer instructions for both Degludec and Lispro pens, as well as facility policy, required priming the pen (dialing 2 units, expelling air until a drop of insulin appears) before each injection to remove air and ensure correct dosing, and noted that not priming may result in too much or too little insulin being delivered.
Improper Handling of Oral Medications During Preparation and Administration
Penalty
Summary
The deficiency involves failure to maintain infection control standards during medication preparation and administration. For one resident with traumatic brain injury, type II diabetes, muscle weakness, depression, dysphagia, and moderately impaired cognition, an LPN prepared morning medications including Celexa and Vimpat. During preparation, the LPN dropped the Celexa tablet onto the top of the medication cart, where it bounced multiple times, then picked it up with a bare hand and placed it into the medication cup. The same process occurred with the Vimpat tablet, which was also dropped on the cart and then picked up with a bare hand and placed into the cup. After preparing all medications, the LPN handled the medication cart drawers and computer mouse, then picked up the medication cup and handed it to the resident, who ingested the pills with water. For a second resident with acute and chronic respiratory failure with hypoxia, type II diabetes, peripheral vascular disease, chronic kidney disease, hypertension, and moderately impaired cognition, the same LPN prepared multiple morning medications including Flomax, buspar, carvedilol, clopidogrel, ferrous sulfate, folic acid, lasix, levothyroxine, protonix, potassium chloride, and seroquel. The LPN dropped the Flomax tablet on the top of the medication cart, where it bounced and landed between the narcotic book and a tray holding water and medication supplies, then picked it up with a bare hand and placed it into the medication cup. The LPN then repeatedly punched each of the remaining medications from their cards into one bare hand before transferring them into the medication cup. After returning the punch cards to the cart drawer and using the computer mouse, the LPN carried the medication cup to the resident’s room and observed the resident take all pills with water. In an interview, the LPN confirmed touching the pills with bare hands, including the dropped Flomax, and stated that he usually punches residents’ pills into his bare hands because he drops them when attempting to punch them directly into the cup. Facility policy on medication administration stated that staff should take care not to touch medications with a bare hand when removing them from the source.
Failure to Maintain Safe Environment and Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and staff did not implement sufficient measures to monitor or protect residents from these risks. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Unattended and Unlocked Medication Cart with Improper Disposal of Oral Syringes
Penalty
Summary
Surveyors observed an unattended and unlocked medication cart near the C and D Halls of the facility during early morning hours. On top of the cart, there was a clear plastic drinking cup containing two small oral syringes, which had been used to administer morphine sulphate. Small droplets of an unknown clear substance were present on the syringes and inside the cup. No staff were present in the area at the time of observation. Shortly after, an LPN exited a resident's room at the far end of the D Hall and confirmed that the medication cart was left unlocked and unattended. The LPN stated that the syringes were left by the night shift and that she was attempting to clean up the mess, noting that shift change had occurred approximately one hour prior. The facility's policy on medication storage, revised in January 2024, requires that all medications be stored securely and that medication carts remain locked or under direct observation during medication passes. The failure to secure the medication cart and properly dispose of used oral syringes was found to have the potential to affect seven residents identified as cognitively impaired and independently mobile, all residing on the C and D Halls. This deficiency was identified during a complaint investigation.
Expired and Unlabeled Food Items Found in Facility Storage
Penalty
Summary
Surveyors observed that the facility failed to properly store and discard food items in accordance with professional standards and facility policy. During a kitchen inspection, expired food items were found, including 38 cartons of one percent milk past the expiration date, two unopened thickened orange juice containers with an expiration date several months prior, and an unopened thickened apple juice with an expiration date in the future. The Dietary Manager confirmed the presence of these expired items. In the east pantry, food brought in by residents or visitors was found unlabeled or past the date, including a fast-food bag and a container of potato salad, as well as food debris on the floor. The Licensed Practical Nurse verified these findings and stated that dietary staff maintained temperature logs and cleaned the refrigerator two to three times per month, but all staff were responsible for its maintenance. Further inspection of the west pantry revealed additional issues, such as unlabeled and undated grocery bags of unknown food, undated restaurant boxes, and an expired carton of milk. The Medical Records Clerk confirmed these findings. Review of facility policies showed that all foods should be labeled, dated, and stored according to safe food handling practices, and food brought in by families or visitors must be labeled, dated, and consumed within three days or discarded. The facility failed to follow these policies, resulting in improper storage and retention of expired and unlabeled food items, potentially affecting all residents except those identified as receiving no food by mouth.
Failure to Complete Wound Measurements for Ongoing Assessment
Penalty
Summary
The facility failed to ensure that wound measurements were completed for ongoing assessment of a resident's diabetic foot ulcer. Medical record review showed that the resident, who had multiple diagnoses including diabetes mellitus, end stage renal disease, and dependence on renal dialysis, was admitted with a diabetic foot ulcer and had a physician's order for daily wound care. The care plan included interventions to complete wound treatment as prescribed. However, review of the skin and wound assessments from mid-June through late July revealed that no measurements of the diabetic wound were documented during this period. An interview with a registered nurse confirmed that the resident's wound was not measured between the specified dates. The facility's policy on wound treatment management required ongoing assessment of wounds, including monitoring the effectiveness of treatments. The lack of wound measurements was not in accordance with the facility's policy and current wound standards of practice, as ongoing assessment is necessary to monitor healing and determine if modifications to treatment are needed.
Deficiencies in IV Catheter Care and Documentation
Penalty
Summary
The facility failed to ensure proper care and maintenance of intravenous (IV) catheters for three residents, leading to deficiencies in their treatment. Resident #1, who had multiple complex medical conditions including respiratory failure and diabetes, had a midline catheter inserted with a physician's order for dressing changes every seven days. However, documentation showed that the dressing was not changed after a certain date, and the Assistant Director of Nursing confirmed the lack of documentation for the required dressing changes. Resident #2, who was dependent on a ventilator and had chronic respiratory failure, had a midline catheter placed for a one-day antibiotic therapy. Despite the order to remove the catheter after one day, the catheter remained in place with no current orders for its care. An observation revealed the dressing was peeling and there was dried blood at the insertion site, indicating a lack of proper maintenance and documentation. Resident #3, who was in a persistent vegetative state and had a central line, also experienced a lapse in care. The central line dressing was not changed as per the seven-day schedule, and the facility's policy required documentation of catheter care, which was not adequately maintained. These findings were confirmed through staff interviews and medical record reviews, highlighting the facility's failure to adhere to physician orders and its own policies for IV catheter care.
Failure to Provide Adequate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevention, resulting in actual harm to three residents. Resident #79 was admitted with multiple health conditions, including cerebral infarction and diabetes, and was at risk for impaired skin integrity. Despite having a care plan that included interventions such as the use of an air mattress and regular repositioning, the facility did not consistently document or implement these measures. Resident #79 developed an unstageable pressure ulcer, which was not identified or treated in a timely manner, leading to the resident's hospitalization. Resident #40, who had a history of chronic respiratory failure and was dependent on staff for daily living activities, developed a stage III pressure ulcer. The facility failed to implement hospital-recommended skin treatments upon the resident's return from a hospital stay. There was a lack of documentation and timely intervention for the resident's skin condition, and the family expressed concerns about the timeliness of care, including repositioning and incontinence care. Resident #184 was admitted with multiple wounds, including unstageable pressure ulcers and a deep tissue injury, but did not receive any treatments for these conditions while at the facility. The facility's records did not reflect the presence of these wounds, and the resident was eventually sent to the hospital with a necrotic area on the coccyx, sepsis, and respiratory failure. The facility's failure to assess and treat the resident's wounds promptly contributed to the resident's deteriorating condition.
Deficiency in Providing Adequate Personal Hygiene Care
Penalty
Summary
The facility failed to provide adequate and timely care for residents who required assistance with activities of daily living, specifically in maintaining personal hygiene, including nail care, bathing, and shaving. This deficiency affected four residents out of the seven reviewed. The facility's policies on activities of daily living and bathing were not adhered to, resulting in residents not receiving the necessary services to maintain good grooming and hygiene. Resident #16, who was severely cognitively impaired and dependent on staff for all activities of daily living, was observed with long, unclean fingernails, oily and uncombed hair, and dried food on his shirt. Staff interviews revealed that many were afraid of the resident due to his behaviors, leading to neglect in providing nail care and showers. Despite being scheduled for showers twice a week, the resident had not been showered in a long time, receiving only daily bed baths instead. Resident #15, with intact cognition and dependent on staff for activities of daily living, reported not having received a shower since May, only a couple of bed baths. The resident's hair was greasy and matted, and the facility's documentation confirmed missed showers on scheduled days. Similarly, Resident #19, who was dependent on staff for mobility and activities of daily living, was observed with unshaven whiskers, despite being scheduled for regular bed baths. Resident #185, who was ventilator-dependent and required assistance with bathing and personal hygiene, also reported not receiving regular showers or shaving assistance, with documentation confirming missed bathing days.
Failure to Address Dental Needs in Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan that addressed the dental needs of a resident, which was identified during a review of medical records, observations, and interviews. The resident, who was admitted with multiple diagnoses including Alzheimer's disease and chronic kidney disease, was found to have significant dental issues, including three decayed teeth, one missing tooth, and six root tips, as noted in a dental appointment. Despite these findings, the resident's care plan did not include supports or interventions for these oral health concerns. The resident, who was severely cognitively impaired, expressed difficulty eating due to her dental condition, which was observed during an interview. The resident had refused dental extractions and other interventions, and the facility was aware of these refusals. However, the care plan was not updated to reflect the resident's dental needs or to provide alternative supports. The facility's policy on comprehensive care plans requires that they include measurable objectives and timeframes to meet all of a resident's needs, but this was not adhered to in this case.
Failure to Provide Alternative Communication Methods
Penalty
Summary
The facility failed to provide alternative methods of communication for a resident with severe cognitive impairment and multiple medical conditions, including cerebral infarction with left side hemiplegia and hemiparesis. The resident was dependent on staff for activities of daily living and had impaired communication due to a cerebral vascular accident. Although the nursing plan of care was revised to address the resident's impaired communication, no formal communication tool or technique was established. Observations noted the resident attempting to communicate through gestures and eye contact, but no communication board or alternate means of communication was available in the room. Interviews with staff, including a Speech Language Pathologist (SLP) and nursing aides, revealed a lack of awareness and training regarding the use of a communication sheet that was previously recommended for the resident. The SLP confirmed that a communication sheet was implemented but did not provide additional staff training. Staff members, including a State Tested Nurse Aide (STNA) and a Licensed Practical Nurse (LPN), were unaware of the communication sheet's existence or its intended use. The communication sheet was found on the resident's dresser, unused, while the resident continued to rely on gestures and nods for communication.
Failure to Implement ROM Interventions for Residents
Penalty
Summary
The facility failed to implement ordered interventions to promote range of motion and limit contractures for two residents. Resident #24, who has severe cognitive impairment and is dependent on staff for activities of daily living, was observed without the prescribed left half lap tray for safe arm positioning. Despite physician orders and documentation indicating the tray was applied, observations revealed it was missing, and the resident's left arm was resting in her lap with a closed fist. Staff interviews confirmed the absence of the tray and the presence of jagged plastic edges on the wheelchair armrest. Resident #19, with multiple diagnoses including chronic respiratory failure and contractures, was observed without the ordered rolled washcloths in both hands, which were intended to manage contractures. Despite documentation indicating compliance, observations showed the resident's hands were tightly clenched without washcloths. Staff interviews revealed uncertainty about the absence of the washcloths, and attempts to place them were met with resistance and difficulty, indicating the intervention was not being followed as required. The facility's policy on activities of daily living emphasizes maintaining the highest practicable outcomes for residents, yet the observations and interviews indicate a failure to adhere to prescribed interventions for these residents. This lack of compliance with physician orders and care plans resulted in deficiencies in the care provided to residents #24 and #19, potentially impacting their range of motion and contracture management.
Failure to Enforce Smoking Policy and Secure Smoking Materials
Penalty
Summary
The facility failed to adhere to its policy regarding the secure storage of smoking materials and ensuring residents smoked only in designated areas. This deficiency was observed in two residents, both of whom were cognitively intact and had been assessed for smoking safety. Resident #70 was found with cigarettes in his possession and was observed smoking in a non-designated area, despite the facility's policy prohibiting smoking on the premises. Interviews confirmed that Resident #70 was aware of the smoking rules but continued to keep his smoking materials with him and smoke in unauthorized areas. Resident #13, who also had cigarettes in his possession, was found with burn marks on his clothing, indicating unsafe smoking practices. Despite the facility's policy, Resident #13 was initially allowed to keep his cigarettes, but they were later confiscated after staff observed him falling asleep while smoking and burning holes in his clothes. The Director of Nursing confirmed that Resident #13 was reassessed and deemed unsafe to smoke independently, leading to the removal of his smoking materials. The facility's Smoking/Non-Smoking Policy, which prohibits smoking on any facility property and the retention of smoking materials by residents, was not effectively enforced. This resulted in residents smoking in non-designated areas and retaining smoking materials, posing potential safety hazards. The policy was not consistently applied, as evidenced by the differing treatment of the two residents involved.
Deficiencies in Resident Care Planning and Smoking Status Updates
Penalty
Summary
The facility failed to ensure that residents and/or their representatives participated in care planning, affecting one resident who was cognitively intact and expressed a desire to be involved in his care plan development. Despite being readmitted to the facility, there was no record of a care plan meeting held with the resident, and the resident confirmed he had not participated in any care planning meetings since his return. The facility's administrator verified the absence of care conference information for this resident. Additionally, the facility did not update a resident's care plan to reflect a change in smoking status, affecting another resident who was cognitively intact and had a history of smoking. The resident was observed with burn marks on his clothing and reported that his cigarettes were taken and returned by staff. The resident's cigarettes were removed again after being found falling asleep while smoking, but the care plan had not been updated to address unsafe smoking. The Director of Nursing confirmed the lack of a smoking care plan and stated it would be updated.
Failure to Timely Identify and Assess Skin Integrity Issues
Penalty
Summary
The facility failed to identify, report, and timely assess an alteration in skin integrity for a resident, leading to a deficiency. The resident, who had multiple diagnoses including chronic respiratory failure, type 2 diabetes mellitus, and was at risk for skin breakdown, was observed to have two darkened scabbed areas on the left foot during personal care. Despite having a care plan that included interventions for skin integrity, such as frequent repositioning and pressure-relieving devices, the facility did not detect these skin issues in a timely manner. The resident's medical record indicated that weekly skin assessments were ordered, but observations revealed dark crusty areas on the toes that were not previously documented. A podiatry note later confirmed the presence of small eschars on the right foot, and a skin wound evaluation identified a new diabetic foot ulcer on the right great toe. The facility's clinical protocol required prompt intervention for at-risk residents, but the deficiency was noted under complaint investigations, indicating a lapse in adherence to these protocols.
Delayed Audiology Services for Resident with Hearing Concerns
Penalty
Summary
The facility failed to provide timely audiology services for a resident with identified hearing concerns. Resident #70, who was admitted with diagnoses including conductive hearing loss and impacted earwax, was cognitively intact and required assistance with certain activities of daily living. Despite being highly hearing impaired and lacking hearing aids, the resident's care plan included interventions for impaired communication and an audiology referral as needed. However, the resident had not been seen by an audiologist since admission, and no appointment had been scheduled, even though the resident had authorized audiology services. Interviews revealed that the resident was unable to hear and communicated through written questions, expressing the need for ear cleaning and audiology services. The resident reported a history of needing regular earwax removal due to past eardrum repairs, which was not addressed by the facility. The Social Services Director confirmed that the first contact with audiology was made approximately three months after the resident's admission, indicating a significant delay in addressing the resident's hearing needs. This deficiency was investigated under a specific complaint number.
Failure to Assist Continent Resident Leads to Incontinence Episode
Penalty
Summary
The facility failed to provide adequate and timely care to prevent an episode of incontinence for a resident who was continent of bowel and bladder. Resident #69, who was admitted with diagnoses including hemiplegia, hemiparesis, stroke, and benign prostatic hyperplasia, was cognitively intact and dependent on staff for toileting due to left side weakness. Despite being always continent and not on a toileting program, Resident #69 required assistance to use the bathroom, especially at night due to medication effects. An incident occurred when Resident #69 activated the call light during the night shift, needing assistance to use the bathroom. The night staff turned off the call light but did not return to assist, resulting in the resident soiling himself. This was confirmed by a State tested Nursing Assistant (STNA) who found the resident in this condition during the first shift. The facility's policies on Activities of Daily Living and Incontinence, which emphasize maintaining a resident's ability to toilet, were not adhered to, leading to this deficiency.
Failure to Provide Adequate Grooming and Hygiene
Penalty
Summary
The facility failed to provide adequate grooming and hygiene for a resident who was dependent on staff for activities of daily living (ADLs). The resident, who had a history of cerebral infarction with hemiplegia and hemiparesis, was admitted with multiple diagnoses including hypertension, peripheral vascular disease, and depression. The resident required substantial to maximal assistance with transfers, was incontinent, and was at risk for pressure ulcer development. Despite these needs, the facility did not consistently provide scheduled showers or maintain the resident's personal hygiene, as evidenced by long, jagged fingernails with a black/brown substance underneath. Observations and interviews revealed that the resident did not receive showers as scheduled, with only three documented showers over a 30-day period. The resident reported that their fingernails had not been trimmed since admission, and staff interviews confirmed the lack of grooming and missed showers. The Director of Nursing verified the resident's shower schedule and acknowledged the failure to provide the necessary care. This deficiency was investigated under two complaint numbers, indicating a pattern of non-compliance in the facility's care practices.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely and sufficient care for a resident who was dependent on staff for activities of daily living and experienced frequent bowel incontinence. The resident, who had multiple medical conditions including atrial fibrillation, congestive heart failure, and diabetes, was assessed to have intact cognition and was at risk for pressure ulcers due to moisture-associated skin damage. Despite a care plan that required regular checks and incontinence care, the resident was found covered in dried stool upon admission to the hospital emergency room. On the day of the incident, a State tested Nurse Aide (STNA) and a Licensed Practical Nurse (LPN) were responsible for the resident's care. The STNA did not perform incontinence checks, relying on the resident to call out for assistance, and the LPN did not assess the resident for bowel incontinence during her shift. The Director of Nursing confirmed that the resident required incontinence monitoring every two hours, which was not provided, leading to the deficiency noted in the report.
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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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