Arbors West
Inspection history, citations, penalties and survey trends for this long-term care facility in West Jefferson, Ohio.
- Location
- 375 West Main Street, West Jefferson, Ohio 43162
- CMS Provider Number
- 365426
- Inspections on file
- 26
- Latest survey
- March 26, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Arbors West during CMS and state inspections, most recent first.
A cognitively intact resident with Huntington’s disease and other conditions was participating in chair exercises when a CNA used a personal cellphone to record the resident lifting her leg above her head, without any signed photo release or consent from the resident’s POA. Two other CNAs watched the event and did not report it. Other staff later observed the CNAs laughing and viewing the image on the phone. Review of incident reports, staff statements, and the facility’s social media policy confirmed that the recording was taken in the work area using a personal device and that facility policy prohibits taking or sharing resident photos or videos without prior written permission.
The facility failed to maintain proper hand hygiene during food service, affecting all residents. A staff member contaminated food by using a soiled glove while taking food temperatures. Additionally, a soiled scoop was used during tray line service, contrary to facility policy requiring clean utensils. The facility's policy mandates adherence to federal guidelines for meal service.
The facility failed to maintain clean and safe grounds, with significant litter of cigarette butts observed along the sidewalk to the smoking area. Two residents confirmed the issue, noting that residents did not use the provided dispensing devices. An LPN confirmed the litter and identified potential fire hazards due to piles of debris mixed with cigarette butts. The facility's policy indicated maintenance was responsible for maintaining safe grounds.
The facility failed to conduct interdisciplinary care conferences for three residents, affecting their involvement in care planning. A resident was not invited to any conferences, while another's family was rarely invited. Additionally, a resident's care plan lacked updates for anticoagulant use, despite receiving the medication. These deficiencies were confirmed by staff interviews and record reviews.
The facility failed to timely address pharmacy recommendations for four residents, leading to delays in medication changes. Recommendations for obtaining a TSH level, discontinuing Lorazepam and Megace, and reducing doses of Zoloft and Trazodone were not acted upon promptly. The facility's policy requires timely action on MRR irregularities, which was not followed.
The facility failed to prepare pureed food to the required consistency for residents with dietary needs. A staff member was observed preparing pureed peas, which contained lumps and pieces despite repeated blending. The Regional Dietary Contractor confirmed the improper consistency, which was corrected only after surveyor intervention. The facility's policy mandates a pudding mousse-like consistency for pureed foods.
The facility failed to ensure resident fund authorization forms were properly witnessed, affecting two residents. One resident, cognitively impaired, had an illegible signature without witness signatures, while another, cognitively intact, had a legible signature but also lacked witness signatures. The Business Office Manager was unaware of the requirement for witness signatures, contrary to facility policy.
The facility failed to provide required spenddown notifications to two residents whose account balances exceeded $1800. One resident, with a BIMS score of 4, had balances consistently over the threshold, reaching $3707.29. Another resident, with a BIMS score of 00, had balances over $19,000. Despite the facility's policy requiring notifications when balances reach $1800, these were not consistently provided, as confirmed by the Business Office Manager.
A facility failed to create a comprehensive care plan for a resident with PTSD, despite the resident's severe cognitive impairment and multiple diagnoses. Interviews with the DON and a social worker confirmed the absence of a care plan addressing PTSD, contrary to the facility's policy requiring person-centered care plans for all residents.
The facility failed to communicate with the dialysis center for a resident with end-stage renal disease, diabetes, heart failure, and cognitive communication deficit. The LPN confirmed that no documentation was sent to the dialysis center, and the DON acknowledged the lack of communication, as the dialysis center stopped completing their part of the form. The facility's policy required coordination and reporting to the dialysis provider, which was not followed.
A facility failed to provide trauma-informed care for a resident with PTSD, who was severely cognitively impaired and had multiple diagnoses. Despite receiving psychiatric services, the resident's medical record lacked documentation of preferences, trauma triggers, or interventions to prevent re-traumatization. Interviews confirmed the absence of an independent PTSD assessment, as residents were referred to psychiatric services without further facility assessment.
A resident was prescribed Quetiapine Fumarate (Seroquel) for insomnia despite not having a psychotic disorder, which is necessary for such medication. The facility failed to act on a pharmacist's recommendation to discontinue the medication, resulting in its continued use without an appropriate diagnosis.
A medication error occurred when a nurse administered Lisinopril and Propranolol to a resident with a systolic blood pressure of 105 mmHg, despite orders to hold these medications if the systolic blood pressure was below 110 mmHg. The nurse was unaware of the parameters, leading to a medication error rate of 6.45% in the facility.
A resident receiving hospice care had incomplete medical records, with the last hospice note being from a care team meeting. The hospice communication notebook at the nurses' station was also missing visit documentation. Interviews with staff confirmed the absence of hospice notes, affecting the facility's record-keeping for the resident.
A facility failed to prevent contamination during medication administration when an RN handled medications with bare hands before placing them in a medication cup. The RN was unaware of the proper procedure to avoid touching pills directly, which was contrary to the facility's policy requiring medications to be administered in a manner preventing contamination or infection.
A facility failed to follow ordered parameters for blood pressure medication administration for a resident. An RN administered Lisinopril and Propranolol despite the resident's blood pressure being below the prescribed threshold for withholding these medications. The RN was unaware of the hold parameters, contrary to the facility's medication administration policy.
A former LPN misappropriated pain medications from three residents, affecting their prescribed regimens. The facility discovered discrepancies in medication counts and surveillance footage confirmed the LPN's actions. Despite policies requiring controlled substance counts, the misappropriation occurred, impacting resident care.
Two residents experienced significant delays in call light responses, with one resident waiting over an hour for incontinence care and another waiting 20 minutes for assistance with tube feeding. Staff interviews confirmed that long wait times were typical, and observations noted several staff members, including the DON and Unit Manager, walking past activated call lights without responding. Facility policy emphasized the importance of timely responses, highlighting the deficiency in care.
A resident in a LTC facility was observed without a sheet on her mattress over several days, despite being cognitively intact and requiring assistance with daily living activities. After moving rooms, the resident requested a sheet but was denied. Staff confirmed that the bed should have had a sheet, indicating a failure to maintain a homelike environment.
A resident with multiple medical conditions did not receive scheduled showers, resulting in an unkempt appearance. Despite being cognitively intact and requiring assistance, the resident's shower schedule was inconsistently documented, and staff reported frequent refusals and inadequate staffing. The DON was unaware of schedule discrepancies and missing documentation.
A resident with multiple health conditions, including diabetes and respiratory issues, did not receive a full and nutritious meal as per their carb-controlled diet plan. The meal provided was incomplete, missing key components like soup and bread, leading the resident to order additional food. Staff interviews revealed a lack of awareness and adherence to the resident's dietary preferences and facility policy, resulting in non-compliance.
Unauthorized Cellphone Recording of Resident Without Consent
Penalty
Summary
The facility failed to ensure the confidentiality and privacy of a resident’s personal and medical information when a CNA used a personal cellphone to record the resident without consent. The resident, admitted with diagnoses including Huntington’s disease, anxiety, and protein calorie malnutrition, was cognitively intact with a BIMS score of 13 and required one-person assistance with ADLs. During a chair exercise activity in the dining room, the CNA observed the resident lifting her leg above her head and took out her cellphone to take a picture/video of the resident. Two other CNAs stood nearby, watched the resident performing the exercises, and witnessed the recording being made but did not report it. The resident’s POA later confirmed that she had not given authorization for any photos or videos to be taken of the resident. Multiple staff interviews and document reviews corroborated that the recording occurred and that it involved the resident’s image being captured without prior authorization. The Activities Director and Business Office Manager both observed the three CNAs outside the dining room laughing and looking at a cellphone image of the resident with her leg pointed straight up. Review of the incident reports and staff statements confirmed that the recording was made on a personal cellphone in the work area. The Admissions Coordinator verified that there was no signed photo release authorization for the resident, and review of the facility’s Social Media Policy showed that employees are prohibited from using personal electronic devices in the work area without written approval and from taking or sharing resident photos or videos without prior written permission from the resident or authorized agent. Observation of the video by the Administrator and DON further confirmed that the resident had been recorded without authorization, constituting a breach of confidentiality and privacy.
Failure to Maintain Proper Hand Hygiene During Food Service
Penalty
Summary
The facility failed to maintain proper hand hygiene during food service, which had the potential to affect all residents. During an observation, a staff member was seen taking temperatures of food items and inadvertently contaminating the food. The staff member placed a thermometer in mashed potatoes, getting a piece of potato on her thumb and pointer finger. Without changing gloves, she submerged her soiled fingers into the gravy, confirming that her dirty glove was in the gravy mixture. In another instance, a staff member was observed scooping augratin potatoes when the scooper fell into the pan and became soiled. Despite this, a Regional Dietary Contractor picked up the soiled scoop and continued to use it for tray line service, handling other food items with it. The staff member acknowledged that if a scoop or service item falls into the food, it should be replaced with a clean one. The facility's policy on meal distribution and infection control, dated February 2023, mandates that meal service should follow federal guidelines.
Facility Grounds Littered with Cigarette Butts
Penalty
Summary
The facility failed to maintain the grounds in a clean and safe manner, specifically regarding the accumulation of cigarette butts on the property. Observations on two separate occasions revealed significant litter of cigarette butts along the sidewalk from the east hall exit to the designated smoking area, with hundreds of cigarette butts visible. Interviews with two residents confirmed that the smoking area, sidewalk, and grass area outside the fence were littered with cigarette butts, as residents did not use the dispensing devices provided and instead tossed their cigarette butts anywhere. An LPN confirmed the presence of hundreds of cigarette butts along the sidewalk and behind the fence, noting that the yard company was responsible for picking up trash and cigarette butts. The LPN also identified piles of dead plant debris mixed with cigarette butts, which could pose a fire hazard next to the wooden fence. The facility's policy on Preventative Maintenance indicated that maintenance was responsible for ensuring the building and grounds were maintained in a safe and operable manner.
Deficiencies in Care Conferences and Care Plan Updates
Penalty
Summary
The facility failed to ensure that interdisciplinary quarterly care conferences were completed for three residents, affecting their involvement in care planning. Resident #7, who was cognitively intact, reported not being invited to any care conferences in the previous year, despite documentation indicating a conference was held. Similarly, Resident #9's family expressed that they were only invited to a care conference once in the last year, although the facility's records showed a conference was held. Interviews with regional staff confirmed the lack of evidence for completed care conferences for these residents. Resident #36, who was moderately cognitively impaired, also did not have documented care conferences. The resident expressed a desire to be more involved in their care, but the facility only documented a quarterly mood evaluation by the social worker without a summary of care discussions or participant details. The social worker confirmed the absence of documented care plan meetings, indicating that the resident's care discussions were informal and not part of a structured conference. Additionally, the facility failed to update the care plan for former Resident #51 regarding the use of an anticoagulant medication. Despite receiving Eliquis for embolism and thrombosis, the resident's care plan lacked focus, goals, or interventions related to the medication. The Director of Nursing confirmed this oversight, which was inconsistent with the facility's policy to develop comprehensive care plans that address residents' medical needs.
Delayed Response to Medication Regimen Reviews
Penalty
Summary
The facility failed to timely respond to monthly medication regimen reviews (MRR) for four residents, leading to deficiencies in addressing pharmacy recommendations. For Resident #53, the pharmacist recommended obtaining a thyroid stimulating hormone (TSH) level on 02/05/25, but the provider did not address this until 03/18/25, with the TSH level ordered on 03/25/25. The Director of Nursing (DON) confirmed that the expectation is for recommendations to be addressed by the provider on the next visit, which occurs at least weekly. Resident #62's MRR on 02/05/25 included recommendations to discontinue Lorazepam and reduce doses of Zoloft and Trazodone. The provider agreed to these changes on 03/18/25, but the interdisciplinary team did not meet to review these recommendations until 03/25/25, delaying the implementation of the medication changes. Similarly, for Resident #73, a recommendation to discontinue Megace due to the risk of deep vein thrombosis was made on 02/05/25, but the provider did not respond until 03/18/25, and the medication was not discontinued until 03/25/25. Resident #32's MRR on 02/05/25 recommended discontinuing Seroquel, which was being used for sleep in a patient with dementia. The physician agreed to discontinue the medication on 03/18/25, but it was not acted upon until 03/24/25. The facility's policy requires MRR irregularities to be reported and acted upon within 10 working days, but this was not adhered to, resulting in delayed responses to pharmacy recommendations for these residents.
Improper Consistency of Pureed Food
Penalty
Summary
The facility failed to ensure that pureed food was prepared to the proper consistency, as required for residents with specific dietary needs. During an observation, a staff member was seen preparing pureed peas by adding broth to the mixture in a roboku blender. Despite repeated blending and tasting, the mixture contained significant amounts of food on the sides, including visible lumps and pieces of peas. The Regional Dietary Contractor confirmed the presence of chunks and full skins of peas in the mixture. The facility's policy requires pureed foods to be made to a pudding mousse-like consistency, which was not achieved until after surveyor intervention.
Failure to Witness Resident Fund Authorizations
Penalty
Summary
The facility failed to ensure that resident fund authorization forms were properly witnessed, affecting two residents out of seven authorizations reviewed. Resident #12, who was cognitively impaired with a BIMS score of six, had an authorization form dated 04/24/24 with an illegible signature and no witness signatures. Resident #36, who was cognitively intact with a BIMS score of 12, had an authorization form dated 04/20/23 with a legible signature but also lacked witness signatures. The facility's policy requires that authorization forms be signed by the resident or responsible party and witnessed by an individual not associated with the facility when required by the state. During an interview, the Business Office Manager (BOM) confirmed that the authorizations for both residents were not witnessed. The BOM was unaware that witness signatures were necessary, believing they were only required if the resident was unable to sign. This oversight indicates a lack of adherence to the facility's policy regarding resident fund authorizations, which mandates witness signatures to ensure the proper management of residents' financial affairs.
Failure to Provide Spenddown Notifications
Penalty
Summary
The facility failed to provide spenddown notifications to residents when their account balances exceeded $1800, as required by their policy. This deficiency affected two residents, both of whom had account balances over the threshold. Resident #17, who was cognitively impaired with a BIMS score of 4, had a personal fund balance that consistently exceeded $1800 from January 2024 to March 2025, reaching as high as $3707.29. Despite the high balances, spenddown letters were not consistently provided monthly, as required. Resident #43, also cognitively impaired with a BIMS score of 00, had a personal fund balance that significantly exceeded the threshold, with balances over $19,000 for several months in 2024. The resident's balance remained above the $1800 threshold into 2025, yet spenddown notifications were not provided monthly. The facility's policy required that residents be notified when their account balance reached $1800, but this was not adhered to. An interview with the Business Office Manager confirmed that spenddown letters were not provided monthly for residents who were over-resourced. The facility's policy, dated February 2018, stated that residents should be notified when their account balance reaches $1800, but this was not consistently followed, leading to the deficiency.
Failure to Develop Comprehensive Care Plan for PTSD
Penalty
Summary
The facility failed to develop an accurate and comprehensive care plan for a resident diagnosed with Post Traumatic Stress Disorder (PTSD). The resident, who was admitted with multiple diagnoses including cerebral infarction, hemiplegia, type two diabetes mellitus, fibromyalgia, dementia, depression, and PTSD, was found to have no documented care plan addressing PTSD or potential triggers. The annual minimum data set (MDS) indicated severe cognitive impairment and psychiatric/mood disorders, yet the care plan lacked specific interventions for PTSD. Interviews with the Director of Nursing (DON) and a social worker confirmed the absence of a care plan for the resident's PTSD. The facility's policy mandates the development of a comprehensive person-centered care plan for each resident, which includes measurable objectives and timeframes to address medical, nursing, and psychosocial needs identified in the resident's comprehensive assessment. However, this policy was not adhered to in the case of the resident with PTSD, as evidenced by the lack of a care plan for this specific condition.
Failure to Communicate with Dialysis Center for Resident Care
Penalty
Summary
The facility failed to ensure proper communication with the dialysis center for a resident requiring dialysis services. This deficiency affected a resident with end-stage renal disease, diabetes, heart failure, and cognitive communication deficit. The medical record review revealed that the facility did not maintain a dialysis communication binder, and all documentation was located in the electronic medical record. The Licensed Practical Nurse (LPN) confirmed that the facility did not send any documentation to the dialysis center and believed the center did not have access to the facility's medical records. The Director of Nursing (DON) confirmed the lack of communication with the dialysis center, stating that the center had stopped completing their part of the communication form, leading the facility to cease sending it. The pre and post-dialysis assessments in the electronic record were not specific to dialysis sessions, as they were based on vitals taken every 12 hours rather than immediately before and after dialysis. The facility's policy required coordination between the facility and the dialysis provider, including providing a report to the dialysis provider on each treatment day, which was not adhered to in this case.
Lack of Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide individualized trauma-informed care for a resident diagnosed with Post Traumatic Stress Disorder (PTSD). The resident, who was admitted with multiple diagnoses including cerebral infarction, hemiplegia, type two diabetes mellitus, fibromyalgia, dementia, depression, and PTSD, was found to be severely cognitively impaired with a BIMS score of five out of 15. Despite receiving psychiatric services and medications for depression and PTSD, the medical record lacked documentation of the resident's preferences, trauma triggers, or interventions to prevent re-traumatization. Interviews with the Director of Nursing and a social worker confirmed the absence of an independent PTSD assessment, as residents with PTSD were referred to psychiatric services without further facility assessment.
Inappropriate Use of Antipsychotic Medication
Penalty
Summary
The facility failed to ensure that a resident had an appropriate diagnosis for the use of an antipsychotic medication, specifically Quetiapine Fumarate (Seroquel). The resident, who was admitted with diagnoses including malnutrition, Alzheimer's disease, heart failure, muscle weakness, and atrial fibrillation, was prescribed Seroquel for insomnia. However, the resident did not have a psychotic disorder, which is necessary for the use of such medication. Despite recommendations from a pharmacist to evaluate and discontinue the medication due to the lack of an appropriate diagnosis, the medication was continued until it was eventually discontinued on 03/25/25. The Director of Nursing confirmed that the medication regime review was not acted upon in a timely manner, and the resident continued to receive Seroquel without a warranted diagnosis. The facility's policy states that psychotropic drugs should only be administered when necessary to treat a specific condition, as diagnosed and documented in the clinical record. The failure to adhere to this policy resulted in the unnecessary administration of an antipsychotic medication to a resident without a proper diagnosis.
Medication Administration Error Due to Unawareness of Parameters
Penalty
Summary
The facility failed to ensure medications were administered as ordered, resulting in a medication error rate of 6.45%. This deficiency affected one resident out of three observed for medication administration. During an observation, a registered nurse prepared and administered seven medications to a resident, including Lisinopril and Propranolol, both of which were to be held if the resident's systolic blood pressure was less than 110 mmHg. The resident's blood pressure was recorded at 105/69, yet the medications were administered. The nurse confirmed she was unaware of the parameters to hold the medication, despite the facility's policy requiring the person administering medications to obtain and record vital signs and hold medications for vital signs outside the physician's prescribed parameters.
Incomplete Hospice Documentation for Resident
Penalty
Summary
The facility failed to maintain an accurate and complete medical record for a resident who was receiving hospice services. The resident, who had multiple diagnoses including dementia and chronic kidney disease, was unable to be interviewed due to communication difficulties. The review of the resident's electronic medical record showed that the last hospice note was from an interdisciplinary team meeting, and there were no subsequent hospice notes uploaded. Additionally, the hospice communication notebook at the nurses' station, which should have contained visit documentation, was found to be incomplete with only an admission face sheet and blank sections for hospice team communication. Interviews with facility staff, including a Registered Nurse and the Director of Nursing, confirmed the absence of hospice communication notes in the hospice binder. The Director of Nursing acknowledged that the nursing staff relied on the binder for hospice communication and verified that the last note in the electronic medical record was from the care team meeting. This deficiency affected the facility's ability to maintain accurate and complete records for the resident receiving hospice care.
Medication Administration Deficiency Due to Improper Handling
Penalty
Summary
The facility failed to ensure medications were administered in a manner to prevent contamination or infection, affecting one resident during medication administration observations. On the morning of March 26, 2025, a Registered Nurse (RN) prepared seven medications for a resident using a unit dose dispensing system. The RN removed each medication from its package and placed it into her ungloved hand before dropping it into a medication cup. During an interview, the RN confirmed that she was unaware that she should not touch the pills with her bare hands and should either place the pills directly into the cup or wear gloves. A review of the facility's Medication Administration policy, last reviewed on January 17, 2023, confirmed that medications are to be administered as prescribed by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection.
Failure to Follow Blood Pressure Medication Parameters
Penalty
Summary
The facility failed to adhere to the ordered parameters for administering blood pressure medications to Resident #240. During an observation, RN #136 prepared and administered seven medications, including Lisinopril and Propranolol, to the resident. The resident's blood pressure was recorded at 105/69, which was below the prescribed threshold of 110 mmHg for withholding these medications. Despite this, RN #136 administered the medications, later confirming she was unaware of the hold parameters. The facility's medication administration policy, last reviewed on 01/17/23, requires staff to obtain and record vital signs and hold medications if vital signs fall outside the physician's prescribed parameters.
Medication Misappropriation by LPN
Penalty
Summary
The facility failed to protect three residents from misappropriation of their pain medications by a former Licensed Practical Nurse (LPN). The residents involved had various medical conditions requiring pain management, including multiple sclerosis, chronic obstructive pulmonary disease, and paraplegia. The care plans for these residents included administering medications as ordered and monitoring their effectiveness. However, discrepancies in medication counts were discovered, indicating that the prescribed Gabapentin was not administered as documented. The incident came to light when the Director of Nursing noticed inaccuracies in the medication counts for the affected residents. Surveillance footage revealed that the former LPN diverted medication by removing pills from blister packs and placing them into a generic container. This misappropriation was confirmed when the LPN admitted to the missing medications during an inquiry by the facility's administrator. The facility's policy required controlled substances to be counted at the end of each shift, with discrepancies reported immediately. Despite this policy, the misappropriation occurred, affecting the residents' medication regimens. The facility's failure to adhere to its own procedures allowed the LPN to misappropriate medications, impacting the care of the residents under her supervision.
Delayed Call Light Response in LTC Facility
Penalty
Summary
The facility failed to respond to call lights in a timely manner, affecting two residents. Resident #35, who was cognitively intact and required assistance with various activities of daily living, had her call light activated for incontinence care from approximately 8:00 A.M. until 9:25 A.M. on the day of observation. Interviews with the resident and CNAs revealed that long wait times for call light responses were typical, with staff often too busy to respond promptly. The resident reported that requests for showers or incontinence care were often delayed by one to two hours, or staff would not return after initially acknowledging the request. Resident #49, who was also cognitively intact and had a feeding tube, experienced a delay in response to his call light, which had been activated for about 20 minutes due to concerns about his tube feeding. Observations noted several staff members, including nursing staff, CNAs, the DON, and the Unit Manager, walking past the room without responding to the call light. An LPN confirmed that the call light had been on for a long time and acknowledged that all staff were responsible for answering call lights, with an expectation of a response within about five minutes. The facility's policy and protocol emphasized the importance of timely responses to call lights, indicating that failure to do so could be considered neglect.
Failure to Provide Linens for Resident's Bed
Penalty
Summary
The facility failed to ensure a comfortable and homelike environment for Resident #35 by not providing linens on her bed. Resident #35, who was cognitively intact and required assistance with various activities of daily living, was observed multiple times over three days without a sheet on her mattress. Instead, she had only one sheet/blanket covering her while she slept. This lack of proper bedding was confirmed through observations and interviews with the resident and staff. Resident #35 had recently moved rooms, and it was noted by Certified Nursing Aides that she had a sheet on her bed in her previous room. However, since the move, the mattress on her bed had been without sheets. The resident had requested a sheet, but her request was denied. A Licensed Practical Nurse confirmed that the type of bed and mattress used by the resident should have a sheet, and acknowledged that staff should have placed a sheet on the mattress.
Failure to Provide Scheduled Showers
Penalty
Summary
The facility failed to ensure that a resident received showers as scheduled, affecting one resident out of three reviewed for Activities of Daily Living (ADLs). The resident, who was cognitively intact, required assistance with showering and personal hygiene due to multiple medical conditions, including diabetes, spinal muscular atrophy, and functional quadriplegia. Despite being scheduled for showers on specific days, records showed inconsistencies in documentation, with several instances where showers were not recorded as provided or refused. Observations revealed the resident appeared unkempt, with greasy hair and dirty nails, indicating a lack of proper hygiene care. Interviews with the resident and staff revealed discrepancies in the shower schedule and a lack of adequate staffing to provide the necessary care. The resident expressed a preference for bed baths and reported receiving showers less frequently than scheduled. Staff confirmed the resident's disheveled appearance and noted frequent refusals of ADL care. The Director of Nursing was unaware of the discrepancies in the shower schedule and acknowledged missing documentation for several shower instances. This deficiency was investigated under multiple complaint numbers.
Failure to Provide Nutritious Meal to Resident
Penalty
Summary
The facility failed to provide a full and nutritious meal to a resident, identified as Resident #35, who was part of a group reviewed for nutritious meals. Resident #35, who was cognitively intact and required setup assistance for eating, had a medical history that included diabetes, spinal muscular atrophy, chronic myeloid leukemia, respiratory failure with hypoxia, pulmonary fibrosis, and bipolar disorder. The resident was on a carb-controlled diet, and the menu for the dinner meal included lentil soup, whole wheat crackers, tuna salad on wheat bread, marinated tomato salad, and a half slice of dessert. However, the resident received a meal consisting only of shredded lettuce with tomato and onion salad and two slices of lunch meat, missing several components of the planned meal. Interviews with staff revealed discrepancies in meal preparation and delivery. A CNA confirmed the resident received an incomplete meal, and the Director of Nursing was unaware of the missing items. The Kitchen Manager acknowledged the resident's preferences and confirmed that the resident was not given half of her meal, which led to the resident frequently ordering food from DoorDash. The resident expressed a preference for wraps instead of open-faced sandwiches and confirmed ordering additional food due to insufficient meals. The facility's policy on menus and adequate nutrition was not followed, as the resident's nutritional needs were not met, leading to non-compliance under a complaint investigation.
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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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