Autumnwood Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Tiffin, Ohio.
- Location
- 670 E Sr 18, Tiffin, Ohio 44883
- CMS Provider Number
- 365380
- Inspections on file
- 24
- Latest survey
- July 8, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Autumnwood Care Center during CMS and state inspections, most recent first.
A resident who was transferred to the hospital did not receive a required bed hold notice prior to or during the transfer. The resident, who was private pay and cognitively intact, only signed the bed hold agreement several days after returning, and reported not being informed about the policy or charges beforehand. Staff interviews confirmed the notice was delayed due to staff absence, contrary to facility policy requiring advance notification.
A resident with a history of hypokalemia received the wrong medication due to an incomplete verbal order and transcription error by the ADON. The LPN administered Kayexalate instead of potassium, leading to the resident's hospitalization for hypokalemia treatment. The facility lacked a policy for clarifying incomplete orders.
The facility failed to maintain kitchen sanitation and proper food storage, affecting 77 residents. The dishwasher did not reach the required 180°F for sanitization, and staff were unaware of the machine type. Soy sauce was improperly stored, a scoop was left in a cereal container, and an open box of omelets was found in the freezer. Facility policies on food storage and dishwasher use were not followed.
The facility failed to maintain the dishwashing machine in a safe operating condition, affecting 77 residents. The dishwasher, labeled as a high temperature machine, did not reach the required rinse temperature of 180°F. Despite attempts to fix the machine, it continued to provide inaccurate temperature readings, and the three sink system was not consistently used for sanitation. The facility's policy required immediate correction of inadequate temperatures, which was not effectively implemented.
The facility failed to maintain cleanliness in the laundry room, with lint accumulation behind industrial dryers, and did not address a long-standing brown stain on the ceiling in a resident room. The stain was due to a past leak, and although the leak was repaired, the ceiling was not repainted. These issues were confirmed by staff and residents.
A resident with intact cognition and multiple diagnoses was not provided showers as per their care plan, receiving bed baths instead due to the unavailability of a shower bed. The facility's DON was unaware of the issue, despite having two shower beds available. The facility's policy on Resident Rights was not upheld, as the resident's preference for showers was not honored.
A resident with intact cognition and multiple diagnoses, including diabetes and Parkinson's, did not receive quarterly statements for her personal funds, as required by the facility's policy. Despite authorizing the facility to manage her funds, there was no documentation of statements being provided, which was confirmed by both the resident and the Business Office Manager.
The facility failed to timely notify the physician and resident representative of a change in condition for two residents. A resident with multiple diagnoses reported ankle pain after an incident, but the physician and representative were not notified until weeks later, delaying an x-ray. The facility's policy required prompt notification, which was not followed.
A facility failed to maintain comfortable sound levels in the dining room on a secured unit due to sticky floors causing loud squeaking noises. This affected a resident with Alzheimer's and potentially impacted 12 others. Staff and resident interviews confirmed the noise was disruptive and agitating, with attempts to reduce it proving ineffective.
A facility failed to ensure a comprehensive care plan for a resident, who required compression stockings as per a physician's order. The care plan lacked goals or interventions for the stockings, and the resident reported them being too tight, informing several aides and nurses. The DON confirmed the care plan omission, contrary to the facility's policy for comprehensive, person-centered care plans.
A resident with multiple medical conditions, including lymphedema, was not provided with physician-ordered compression stockings due to them being too tight. Despite informing staff, the issue persisted, and the resident was observed without the stockings on multiple occasions. Staff interviews confirmed the oversight, and the DON was unaware of the problem.
A resident with multiple medical conditions, including dysphagia and moderate cognitive impairment, was not receiving tube feeding at the physician-ordered rate. Observations showed the feeding was set at incorrect rates on two occasions, with no justification documented. A nurse confirmed the error and adjusted the rate to the correct setting.
A resident was found with unsecured medications in their room, including Imodium and stomach chews, which they were using to manage diarrhea. The resident was not permitted to self-administer medications, and staff confirmed that all medications should be administered by a nurse. The facility's policy requires medications to be stored in locked compartments, which was not followed in this case.
A resident with multiple health conditions, including lymphedema, did not have physician-ordered compression stockings applied due to them being too tight. Despite the resident's refusal and communication of the issue to staff, the nursing staff falsely documented daily application in the Treatment Administration Record. The DON was unaware of the issue, and the facility's documentation policy was not followed.
The facility failed to maintain catheter bags in a sanitary manner for two residents, with one bag dragging on the floor and another improperly placed on a trash can. Additionally, a nurse administered medications to two residents using bare hands, violating infection control procedures. These actions were contrary to the facility's policies on catheter care and medication administration.
A resident with an implanted defibrillator experienced a deficiency in care when their cardiac transmitter device was misplaced during a room move and remained missing for several weeks. The facility lacked a policy for defibrillator monitor care, leading to inadequate monitoring and a delay in addressing the issue, which was only discovered during a cardiology appointment.
A resident with Alzheimer's and other health issues was transferred to a psychiatric facility without proper documentation or justification. The facility failed to provide a discharge notice, leaving the resident without a place to return. Interviews revealed inconsistencies in the reported behavior and the decision to transfer, with hospital staff describing the situation as patient dumping.
A resident with Alzheimer's and other conditions was transferred to a psychiatric facility without receiving the required discharge notice. The facility initially held the resident's bed but later refused re-admission without notifying the resident or their representative, leading to the resident remaining at the hospital.
A resident with Alzheimer's and other medical conditions was not allowed to return to the facility after a therapeutic leave to a psychiatric hospital, exceeding the bed-hold policy. Despite the resident's desire to return and lack of documented aggressive behavior, the facility did not provide a required discharge notice, leading to confusion and distress for the resident and family. Hospital staff perceived the situation as patient dumping.
Failure to Provide Timely Bed Hold Notice to Resident During Hospital Transfer
Penalty
Summary
The facility failed to provide a required bed hold notice to a resident who was transferred to the hospital. The resident, who was private pay and cognitively intact, was sent to the emergency room after being found on the bathroom floor in pain. Documentation in the medical record confirmed the transfer and subsequent return from the hospital, but there was no evidence that the resident received a bed hold notice at the time of transfer. The bed hold notice was only signed by the resident several days after returning to the facility, and not prior to or during the hospital stay. Interviews with facility staff and the resident confirmed that the bed hold agreement was not discussed or signed before the hospital transfer. The social worker stated that the agreement was not obtained until after returning from time off, and the resident reported being unaware of the bed hold policy or any associated charges until after her return. Facility policy requires that residents and their representatives be informed of bed hold rights and payment policies prior to transfer, but this was not followed in this instance.
Medication Error Due to Incomplete Order
Penalty
Summary
The facility failed to ensure a medication order was complete and accurate, leading to a significant medication error involving Resident #10. The Assistant Director of Nursing (ADON) received a verbal order via text from a Certified Nurse Practitioner (CNP) to administer potassium to Resident #10 due to critically low potassium levels. However, the ADON misinterpreted the order and entered an incorrect medication order into the electronic medical record, resulting in the administration of sodium polystyrene sulfonate (Kayexalate), a medication used to remove potassium from the blood, instead of potassium replacement. The error was compounded when the Licensed Practical Nurse (LPN) administered the incorrect medication without verifying the laboratory results or questioning the order, despite being aware of the resident's history of hypokalemia and regular potassium supplementation. The LPN was informed by the ADON that the resident's potassium was high, which led to the administration of Kayexalate. Shortly after administration, the ADON realized the mistake, but it was too late to prevent the medication from being given. As a result of the medication error, Resident #10 experienced hypokalemia and required emergency hospital treatment, including oral and intravenous potassium replacement. The facility lacked a policy for clarifying incomplete orders from CNPs and physicians, contributing to the error. The deficiency was identified during a complaint investigation, highlighting the facility's failure to ensure residents are free from significant medication errors.
Kitchen Sanitation and Food Storage Deficiencies
Penalty
Summary
The facility failed to maintain the kitchen in a safe and sanitary manner, which had the potential to affect 77 residents. During an observation, it was found that the dishwasher, labeled as a high-temperature machine, was not reaching the required 180 degrees Fahrenheit for the rinse cycle. Instead, the highest temperature recorded was 154 degrees Fahrenheit. Dietary Staff #534 was unaware of the type of dishwasher being used, and the Dietary Director #601 confirmed the issue and instructed staff to use the three-sink system for sanitation. A review of the Dishwasher Temperature Record for December 2024 showed that the rinse temperature did not reach 180 degrees Fahrenheit on 20 out of 24 occasions. Additionally, the dry storage area was found to have a one-gallon bottle of soy sauce that was open and stored on a dry shelf, despite being labeled to refrigerate after opening. The Dietary Manager #601 verified this and disposed of the soy sauce. Further inspection revealed a scoop left inside a bulk rice puff cereal container, which should have been stored outside the container. In the reach-in freezer, an open box containing cheddar cheese omelets was found, with the Dietary Manager confirming that the box was left open and not in use. The facility's policies on food storage and dishwasher use were not adhered to, contributing to the deficiencies observed.
Dishwasher Temperature Deficiency
Penalty
Summary
The facility failed to maintain the dishwashing machine in a safe operating condition, which had the potential to affect 77 residents. The issue was identified when a dietary staff member was observed running dishes through the dishwasher without knowing whether it was a high temperature or chemical machine. The dishwasher was labeled as a high temperature machine, requiring a final rinse temperature of 180 degrees Fahrenheit. However, observations showed that the rinse temperature gauge did not move off the 100-degree mark, and an internal temperature gauge puck confirmed the highest temperature reached was only 154 degrees Fahrenheit. Further investigation revealed that the dishwasher had been experiencing issues with temperature gauges for a couple of months. Although the facility had been using a puck to ensure proper temperatures, they stopped using it after the gauges were reportedly repaired at the end of November. However, the dishwasher continued to fail to reach the required rinse temperature, and the three sink system was not utilized from December 1 to December 9, despite the temperature logs showing multiple instances where the dishwasher did not reach the proper rinse temperature. Subsequent observations and interviews confirmed that the dishwasher's temperature gauge was providing inaccurate readings, indicating higher temperatures than what was actually achieved. Despite attempts to fix the machine, the dishwasher continued to fail to reach the necessary rinse temperature of 180 degrees Fahrenheit. The facility's policy required that inadequate temperatures be reported and corrected immediately, but this was not effectively implemented, leading to the deficiency.
Facility Maintenance Deficiencies in Laundry and Resident Room
Penalty
Summary
The facility failed to ensure the dryers in the laundry room were cleaned appropriately, as observed on 12/10/24, when the walk-in vent area behind the facility's three industrial dryers was found covered in lint. Laundry staff confirmed that the Maintenance Supervisor only cleaned the lint once per year, which could potentially affect all residents in the facility. Additionally, the facility did not maintain a well-kept environment for two residents. In the room shared by these residents, a large brown stain was observed on the ceiling above one of the beds. The residents confirmed the stain had been present for a long time, and although they made light of it by imagining shapes, they expressed a desire for the ceiling to be painted. The Maintenance Supervisor acknowledged the stain, attributing it to a past leak that had been repaired, though he could not recall when the repair occurred.
Failure to Honor Resident's Shower Preferences
Penalty
Summary
The facility failed to honor a resident's shower preferences, affecting a resident with intact cognition and multiple diagnoses, including bipolar disorder and diabetes. The resident's care plan specified a preference for showers three times a week, but documentation from 10/12/24 to 12/11/24 showed no record of showers being provided, only bed baths. Interviews with the resident and CNAs confirmed that the resident was not receiving showers as preferred, with CNAs citing the unavailability of a shower bed as the reason. The Director of Nursing was unaware of the issue and revealed that the facility had two shower beds available, contradicting the CNAs' statements. The facility had recently implemented shower sheets to track whether residents received showers or baths, but there were no records for the resident from 10/12/24 to 11/29/24. The facility's policy on Resident Rights, revised in 2016, states that residents have the right to participate in decision-making regarding their care, which was not upheld in this case.
Failure to Provide Quarterly Personal Fund Statements
Penalty
Summary
The facility failed to provide quarterly statements for personal funds to a resident, which is a requirement as per their policy. The deficiency was identified during a review of the medical record, staff and resident interviews, and policy review. The affected resident, admitted on 09/11/17, had diagnoses including type two diabetes mellitus, bipolar disorder, Parkinson's disease, and hypertension, and was noted to have intact cognition according to a recent MDS assessment. The resident had authorized the facility to manage her personal fund account, but there was no documentation that she received quarterly statements. During an interview, the resident confirmed that she had not been provided with a copy of her quarterly statement in the past year. The Business Office Manager verified the absence of documentation for the quarterly statements, which is contrary to the facility's policy revised in 04/2017.
Failure to Timely Notify Physician and Representative of Resident's Condition Change
Penalty
Summary
The facility failed to timely notify the physician and resident representative of a change in condition for two residents. Resident #30, who had diagnoses including chronic obstructive pulmonary disease, heart failure, dementia, and anxiety, reported pain in her right ankle and foot after moving it wrong in the middle of the night. Despite the resident's complaint of pain and request for an x-ray, there was no documentation that the physician or resident's representative were notified at the time of the incident on 11/17/24. The nurse's note indicated that the resident had wrapped her own foot with an elastic bandage, and the nurse provided a leg pedal for the wheelchair but did not notify the physician or representative. It was not until 12/09/24 that the physician was notified, and an x-ray was ordered, which revealed no fracture or acute disease. The Director of Nursing confirmed the lack of timely notification and the delay in obtaining an x-ray. The facility's policy, revised in 05/2017, required prompt notification of changes in a resident's condition to the resident, attending physician, and representative, which was not adhered to in this case.
Disruptive Noise Levels in Dining Room Due to Sticky Floors
Penalty
Summary
The facility failed to maintain comfortable sound levels in the dining room on the secured unit, affecting one resident and potentially impacting 12 others. The issue was identified through observations and interviews with staff and residents. The floors in the dining room were clean but sticky, causing loud squeaking noises as staff and residents walked across them. This noise was disruptive and agitating to the residents, particularly those with cognitive impairments. Resident #59, who has Alzheimer's disease, anxiety disorder, muscle weakness, and dementia, was notably affected by the noise. The resident, who is moderately cognitively impaired and requires assistance with daily activities, expressed that the squeaking noises were very noisy and bothersome. Staff interviews confirmed that the noise was a regular occurrence and that attempts to reduce it, such as mopping the floors or walking outside in the rain, were ineffective.
Incomplete Care Plan for Compression Stockings
Penalty
Summary
The facility failed to ensure a comprehensive care plan was complete and current for a resident, affecting one of two residents reviewed for comprehensive care planning. The resident, who was admitted with diagnoses including bipolar disorder, chronic obstructive pulmonary disease, chronic respiratory failure, ataxia, Parkinson's, schizoaffective disorder, and lymphedema, required maximum assistance for lower body dressing and oxygen therapy. A physician's order was in place for compression stockings to be applied in the morning and removed at bedtime. However, the care plan did not include goals or interventions for the use of these stockings. An observation revealed that the resident did not have the compression stockings applied, and during an interview, the resident stated that the stockings were too tight and had informed several aides and nurses about this issue. The Director of Nursing confirmed that the care plan failed to include information about the compression stockings. The facility's policy required a comprehensive, person-centered care plan with measurable objectives and timetables to meet the resident's needs, which was not implemented in this case.
Failure to Provide Physician-Ordered Compression Stockings
Penalty
Summary
The facility failed to provide a resident with compression stockings as ordered by the physician. The resident, who had a medical history including bipolar disorder, chronic obstructive pulmonary disease, chronic respiratory failure, ataxia, Parkinson's, schizoaffective disorder, and lymphedema, was observed without the prescribed compression stockings on two separate occasions. The resident required maximum assistance for lower body dressing and was on oxygen therapy. The care plan included monitoring for lower extremity swelling, and there was a physician's order for compression stockings to be applied in the morning and removed at bedtime. Despite the physician's order, the resident did not have the compression stockings applied because they were too tight, as reported by the resident. The resident had informed several aides and nurses about the issue, but the problem persisted. Interviews with staff, including an LPN and the DON, confirmed the oversight, with the DON being unaware of the resident's inability to wear the stockings. The deficiency was identified through observations and interviews, highlighting a lapse in following the physician's orders and addressing the resident's needs.
Failure to Administer Tube Feeding at Ordered Rate
Penalty
Summary
The facility failed to ensure that a resident's tube feeding was administered at the physician-ordered rate. The resident, who was moderately cognitively impaired and required maximal assistance with daily activities, had a medical history that included Parkinson's Disease, dysphagia, and moderate protein calorie malnutrition. The resident's care plan indicated that they were on a no food by mouth (NPO) status and received more than half of their total calories through tube feeding. The physician's order specified that the resident should receive 55 ml of Nepro Carb Steady oral liquid supplement via gastrostomy tube every shift, with a water flush of 240 ml every four hours. Observations on two consecutive days revealed that the resident's tube feeding was running at rates of 59 ml per hour and 50 ml per hour, rather than the ordered 55 ml per hour. There was no documentation or justification for these deviations from the prescribed rate in the resident's progress notes or electronic Medication Administration Record (eMAR). A registered nurse confirmed that the tube feeding was set incorrectly and adjusted it to the correct rate. The facility's policy on enteral nutrition, revised in November 2018, stated that adequate nutritional support should be provided as ordered, which was not adhered to in this instance.
Resident Medications Found Unsecured in Room
Penalty
Summary
The facility failed to ensure that resident medications were kept secured, affecting one resident. The resident, who was cognitively intact and required maximal assistance with daily activities, was found to have a blister pack of white pills and loose multicolored tablets in a baggie in the drawer of his overbed table. The resident confirmed that he was keeping Imodium and stomach chews at his bedside to manage his diarrhea, despite not having permission to self-administer medications. Interviews with facility staff, including a CNA and an RN, confirmed that the resident was not permitted to self-administer medications and that all medications should be administered by a nurse. The RN observed and removed the unsecured medications from the resident's room, acknowledging the breach in protocol. The facility's policy on medication storage, which requires all drugs and biologicals to be stored in locked compartments, was not adhered to in this instance.
Failure to Accurately Document Compression Stocking Application
Penalty
Summary
The facility failed to ensure accurate documentation regarding the application of compression stockings for a resident diagnosed with multiple conditions, including lymphedema. The resident, who required maximum assistance for lower body dressing, had a physician's order for compression stockings to be applied in the morning and removed at bedtime. However, observations revealed that the resident did not have the stockings applied, and the resident reported that the stockings were too tight and had not been worn for months. Despite this, the nursing staff documented in the Treatment Administration Record (TAR) that the stockings were applied daily. Interviews with the resident and staff confirmed that the compression stockings were not applied as ordered. The resident had informed several aides and nurses about the issue, but no new stockings were provided. The Director of Nursing was unaware of the situation and verified that the staff had falsely documented the application of the stockings. The facility's policy on charting and documentation requires that medical records be objective, complete, and accurate, which was not adhered to in this case.
Infection Control and Medication Administration Deficiencies
Penalty
Summary
The facility failed to maintain catheter collection bags in a safe and sanitary manner for two residents with indwelling catheters. Resident #39's catheter bag was observed dragging on the floor as a CNA pushed her wheelchair to the dining room. The CNA was unaware of the issue until it was pointed out, acknowledging it as an infection control problem. Similarly, Resident #56's catheter bag was found hanging on the side of a trash can and partially touching the floor, with the privacy bag cover being rolled over by a bedside table wheel. Despite being aware of the improper placement, staff did not consistently reposition the bag to prevent contact with the floor. The facility also failed to ensure medications were administered in a sanitary manner. During medication administration, RN #545 was observed handling medications for Resident #56 and Resident #69 with bare hands, contrary to the facility's infection control procedures. The nurse admitted to directly touching the medications without gloves, and the Director of Nursing confirmed that this practice was against policy. The facility's policies on urinary catheter care and medication administration were not adequately followed, leading to these deficiencies. The urinary catheter care policy did not explicitly state the requirement to keep catheter bags off the floor, while the medication administration policy required adherence to infection control procedures, which were not followed by the staff.
Failure to Monitor Cardiac Defibrillator
Penalty
Summary
The facility failed to adequately monitor the placement of a resident's cardiac defibrillator external heart monitor, affecting a resident with congestive heart failure, coronary artery disease, atrial fibrillation, and an implanted defibrillator. The resident had a moderately impaired cognitive level and required maximum assistance for transfers. The resident's care plan required monitoring of the implanted defibrillator to ensure the resident remained free from signs and symptoms of pacemaker malfunction or failure. However, during a room move, the resident's cardiac transmitter device was misplaced and not discovered until a cardiology appointment revealed the resident had been defibrillated due to ventricular tachycardia. The facility did not have a policy related to the care of defibrillator monitors, and the monitor was missing for at least four weeks. During this time, the facility was unable to connect the transmitter device to the internet, requiring an adaptor to be ordered. The issue was identified when the resident's cardiologist noted the defibrillator had successfully defibrillated the resident without their awareness. The facility's failure to monitor the defibrillator device and ensure it was properly connected led to the deficiency.
Failure to Provide Adequate Documentation and Justification for Resident Transfer and Discharge
Penalty
Summary
The facility failed to provide the required documentation and justification for the transfer and discharge of a resident, identified as Resident #76, to a hospital. The resident, who had a history of Alzheimer's disease, spinal stenosis, congestive heart failure, and ischemic heart disease, was transferred to an acute geriatric psychiatric facility on a 72-hour involuntary hold. The transfer was initiated by a Certified Nurse Practitioner (CNP) following an incident where the resident was verbally aggressive and allegedly attempted to strike another resident, although no physical contact was made. The facility did not provide a 30-day or emergency discharge notice to the resident or their representative, and there was no adequate documentation of behaviors that would justify the transfer. Interviews with various staff members, including the Administrator, Director of Nursing (DON), and Social Services Director, revealed inconsistencies in the documentation and communication regarding the resident's behavior and the decision to transfer. The CNP who authorized the transfer later acknowledged that the initial report of the resident's behavior was inaccurate, as the resident did not physically assault another resident. Despite this, the facility did not allow the resident to return after the hospital stay, and no formal discharge notice was provided, leaving the resident without a place to return to. The facility's actions were further scrutinized through interviews with hospital staff and the Long Term Care Ombudsman, who indicated that the facility refused to accept the resident back and did not provide the necessary discharge documentation. The hospital staff described the situation as patient dumping, as the resident was left without a long-term care option. The facility's policy on permitting residents to return after hospitalization was not followed, as the discharge was not justified by the resident's health or behavior, and the facility failed to meet the regulatory requirements for a facility-initiated discharge.
Failure to Provide Discharge Notice
Penalty
Summary
The facility failed to provide the appropriate written notice of discharge to a resident and their representative, which is a requirement when a resident is transferred or discharged. The resident, who had medical diagnoses including Alzheimer's disease and congestive heart failure, was transferred to an acute, inpatient geriatric psychiatric facility on an involuntary hold due to a behavioral incident. Despite the transfer, the facility did not issue a 30-day or emergency discharge notice to the resident or their representative, as confirmed by interviews with the hospital staff, family members, and facility administrators. The facility initially held the resident's bed but later decided not to allow the resident to return without notifying the resident or their representative. The hospital social worker attempted to coordinate the resident's return, but the facility refused to accept the resident back and did not provide a formal discharge notice. This lack of communication and failure to follow proper discharge procedures led to the resident remaining at the hospital, despite their desire to return to the facility.
Failure to Allow Resident Return After Therapeutic Leave
Penalty
Summary
The facility failed to allow a resident to return after a therapeutic leave to an acute, inpatient, geriatric psychiatric facility, which exceeded the bed-hold policy. The resident, who had Alzheimer's disease, spinal stenosis, congestive heart failure, and ischemic heart disease, was transferred to the psychiatric facility on a 72-hour involuntary hold due to perceived aggressive behavior. However, the facility did not provide a 30-day or emergency discharge notice to the resident or their representative, which is required when a facility-initiated discharge occurs. Interviews with various staff members and hospital workers revealed discrepancies in the documentation and communication regarding the resident's behavior and the decision not to readmit them. The facility's Administrator and Director of Nursing acknowledged that the resident did not physically assault another resident, contrary to what was documented on the pink slip form. Despite the resident's desire to return to the facility, the facility's social worker indicated an intention to avoid readmitting the resident, and the resident's belongings were removed from the facility without a formal discharge notice. The facility's policy on permitting residents to return after hospitalization or therapeutic leave was not followed, as the facility did not meet the necessary requirements for a facility-initiated discharge. The facility's actions were perceived as patient dumping by hospital staff, and the resident was left without a clear plan for returning to the facility or an alternative placement, leading to confusion and distress for the resident and their family.
Latest citations in Ohio
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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