Beavercreek Health And Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Beavercreek, Ohio.
- Location
- 3854 Park Overlooke Drive, Beavercreek, Ohio 45431
- CMS Provider Number
- 366400
- Inspections on file
- 44
- Latest survey
- February 19, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Beavercreek Health And Rehab during CMS and state inspections, most recent first.
Surveyors found that the facility did not maintain hot water temperatures within the policy range of 105–120°F in multiple resident rooms and spa areas, with readings both above 120°F and as low as the 50s and 60s. A CNA reported that water in one spa room was not warm enough to provide showers, and a resident stated she received a cold shower in her room. The Director of Maintenance acknowledged that water temperatures were expected to be within the specified range and confirmed that temperatures were not consistently maintained according to the facility’s water temperature safety policy.
A resident with multiple complex medical conditions was injured during a transfer when a Hoyer lift pad broke, resulting in fractures to both femurs and the spine. Staff interviews revealed that concerns about the poor condition of Hoyer pads had been reported to administration for months without action, and there was no routine inspection plan in place. Only one staff member was actively assisting during the transfer, contrary to policy requiring two, leading to the resident's fall and subsequent hospitalization.
A resident with quadriplegia and polyneuropathy, dependent on staff for care and identified as at risk for pressure ulcers, developed an unstageable pressure ulcer on the left foot. Despite existing care plan interventions, no new measures were implemented after the wound was found, and staff did not conduct further assessment or therapy evaluation to address the pressure source.
Two residents did not receive Repatha injections as ordered due to inconsistent pharmacy deliveries and staff practices of discontinuing and rewriting orders to prompt medication delivery. The DON confirmed that only a portion of the prescribed doses were administered, despite facility policy requiring medications to be given as prescribed.
A resident with multiple chronic conditions was discharged for non-payment without proper documentation of discharge planning, including missing nursing discharge notes and incomplete recapitulation of stay forms. Staff interviews confirmed that required discharge documentation and planning details were not completed or available in the medical record.
A resident with severe cognitive impairment and multiple medical conditions was admitted with deep tissue injuries to the left heel and left outer ankle. Although physician orders for wound care were written several days after admission, staff did not initiate treatment for the pressure ulcers until that time, resulting in a delay of care.
Staff failed to timely report, assess, and investigate a fall involving a resident with dementia and impaired mobility, as required by facility policy, and did not implement fall prevention interventions per the care plan for another resident with hemiplegia. One resident was found on the floor and not properly assessed or reported, while another was left without a required fall mat and with the bed in a high position, contrary to care plan instructions.
A resident with severe cognitive impairment and multiple medical conditions developed a pressure ulcer on the left knee due to the facility's failure to timely assess and treat a newly identified skin issue. Despite being at high risk for skin breakdown, the facility did not document required skin checks or follow through with prescribed wound care. Physical therapy noted a scab and redness, but the knee brace continued to be used until the area became necrotic. The facility's policy on pressure injury prevention was not followed, leading to inadequate treatment of the ulcer.
A resident with severe cognitive impairment and multiple medical conditions did not receive prescribed doses of Morphine Sulfate as ordered. An LPN documented the administration of the medication on the MAR, but the Controlled Drug Record lacked supporting documentation for several doses. The LPN admitted to not administering the medication because the resident was resting, contrary to the facility's policy requiring proper documentation.
A resident with multiple medical conditions, including MRSA, was under Contact Precautions, but a State tested Nursing Assistant (STNA) failed to wear PPE and perform hand hygiene as required by the facility's policy. The STNA mistakenly believed the resident was on Enhanced Barrier Precautions. This breach was identified during a complaint investigation.
The facility failed to serve dairy products at the appropriate temperature, affecting 68 residents. Milk was observed at 46.6°F, above the required 41°F. Dietary staff did not replace the milk on trays already prepared, and these were delivered to residents. A resident noted the milk could have been colder.
The facility failed to store and prepare food under sanitary conditions, affecting 68 residents. Mold was found in the walk-in cooler, and cucumbers were leaking onto potatoes. The walk-in freezer had unsealed food, and the hood vents and sprinklers were coated in a dark gray substance. Facility policies on cleanliness were not followed.
The facility failed to document and follow up on resident concerns raised during Resident Council meetings, affecting several residents. Issues such as snacks not being distributed at night, delayed call light responses, and incomplete showers were consistently raised, but the facility did not provide evidence of discussions or plans to address them. Interviews confirmed that the facility did not follow up timely on these concerns, and management instructed staff not to include detailed notes in meeting minutes.
The facility failed to ensure accurate code status documentation for three residents, leading to discrepancies between paper charts and EMRs. One resident's paper chart indicated a DNR-CCA status, while the EMR showed Full Code. Another resident's paper chart showed DNR-CC, but the EMR listed Full Code. A third resident had mismatched DNR statuses between the EMR and paper chart. These inconsistencies were confirmed by an LPN and the DON.
A facility failed to maintain a safe and homelike environment for a resident with multiple health conditions, including COPD and heart failure. A large hole was found in the drywall behind the resident's bariatric bed, which the Maintenance Director confirmed had not been reported. The damage was significant, requiring more than a simple patch to repair.
The facility failed to notify three residents and their representatives of the reasons for hospital transfers, as required by policy. One resident with multiple complex diagnoses and two others with serious health conditions were transferred without documented notification. Staff interviews confirmed the lack of written notifications, despite the facility's policy mandating timely notice before transfers.
The facility failed to provide timely bed hold notifications to residents upon hospital transfer, affecting three residents. A resident with osteomyelitis and heart failure, another with cerebral palsy and diabetes, and a third with acute respiratory failure and multiple sclerosis were all given bed hold notices only after their hospital stays. The DON and Business Office Manager confirmed this practice, which was against the facility's policy requiring notification within 24 hours of emergency transfer.
A resident with dementia and oropharyngeal dysphagia was not provided with a lid for their provale cup, despite it being ordered and indicated on the meal ticket. The Dietary Manager confirmed the absence of the lid, stating it was not typically provided as the resident did not like using it. The facility's policy required that adaptive devices be provided for residents who need them.
The facility failed to maintain resident dignity, affecting two residents. One resident, who required assistance with eating, was left without lunch while others ate, and another resident had a full foley catheter bag visible from the hallway without a dignity cover. These incidents were confirmed by staff interviews and violated the facility's dignity policy.
A resident was refused re-admission to a facility after hospitalization despite being deemed stable by the ER. The facility's DON and staff cited critical lab results as the reason for refusal, leading to the resident's return to the hospital. Interviews revealed inadequate documentation and communication regarding the decision, contrary to facility policy.
A resident with a history of falls was found on the floor by an STNA, claiming to have sat down intentionally. The RN did not report or document the incident, leading to a lack of monitoring. Later, the resident reported hip pain, and an X-ray revealed a fracture, requiring hospital evaluation and surgery.
Failure to Maintain Consistent Safe Hot Water Temperatures
Penalty
Summary
The facility failed to maintain hot water temperatures within its policy range of 105 to 120 degrees Fahrenheit in resident rooms, spa rooms, and common bathing areas, based on multiple observations over several days. On 02/17/26, surveyors measured water at 99.2°F in the Red spa room and above 120°F in several resident rooms (105, 108, 205, 216, 307, 308, 310, and 315). The Director of Maintenance stated that water temperatures were expected to be kept between 105°F and 120°F throughout the facility. On 02/18/26, additional observations showed inconsistent temperatures, including resident rooms with water at 106°F, 116°F, 110°F, 82°F, and 52°F. The Red spa room sink measured 110°F and its shower 98°F, while the Blue spa room sink measured 80°F and its shower 65°F. On 02/18/26, a CNA confirmed that water temperatures in the Blue spa room were not warm enough to provide showers and reported that maintenance had been working on the issue all day. On 02/19/26, a resident reported receiving a cold shower in her room. Subsequent measurements that same day showed water temperatures of 57°F in one resident room, 88.1°F in the Blue spa shower and 82°F in its sink, and 62°F and 59°F in additional resident rooms. In a follow-up interview on 02/19/26, the Director of Maintenance verified that water temperatures were not consistently maintained within the safe and appropriate range throughout the building. Review of the facility’s “Safety of Water Temperatures” policy dated 12/2009 confirmed that water supplies to resident rooms, bathrooms, common areas, and tub/shower areas were to be maintained between 105°F and 120°F. This deficiency was investigated under Complaint Number 2724861.
Failure to Maintain Safe Transfer Equipment Resulting in Resident Injury
Penalty
Summary
The facility failed to ensure a safe transfer for a resident using a mechanical Hoyer lift, resulting in actual harm. The incident occurred when a staff member attempted to transfer a resident with significant medical needs, including cerebral palsy, diabetes with polyneuropathy, morbid obesity, and heart failure. During the transfer, the Hoyer pad strap broke, causing the resident to fall and sustain bilateral femur fractures and an L1 compression fracture, which required hospitalization and surgical intervention. Multiple staff interviews confirmed that the Hoyer pads were in poor condition prior to the incident, with several staff members having reported their concerns to administration over a period of months. Despite these repeated reports, no action was taken by management to replace the defective equipment until after the resident's fall. Staff also confirmed that the facility did not have a routine inspection plan in place for the Hoyer pads before the incident occurred. Facility policy required that two nursing assistants be present for mechanical lift transfers and that all equipment be in good condition. On the day of the incident, only one staff member was actively assisting with the transfer, while the second was present in the room but not directly involved at the time of the fall. The lack of timely equipment maintenance and failure to follow established safety protocols directly contributed to the resident's injury.
Failure to Assess and Implement Interventions After Discovery of Pressure Ulcer
Penalty
Summary
The facility failed to assess and implement new interventions after an unstageable pressure ulcer was discovered on a resident's left foot. The resident, who was admitted with diagnoses including quadriplegia and polyneuropathy, was dependent on staff for bathing, dressing, and positioning, and was identified as being at risk for pressure ulcers. Despite care plan interventions such as weekly skin checks, floating heels, turning and repositioning, and use of pressure-reducing devices, a wound was found on the ball of the resident's left foot during a bed bath. Documentation indicated instructions to relieve pressure and contact the primary care provider, and the resident reported that the wheelchair footrest may have caused the wound due to lack of sensation in her legs. Observations and interviews revealed that no new interventions were implemented to alleviate pressure from the affected foot after the ulcer was found. The resident was seen in her wheelchair without a pillow under her foot, and both nursing and administrative staff confirmed that neither a therapy evaluation nor additional interventions had been initiated. There was also uncertainty among staff regarding the cause of the wound, with suggestions that either the bed bolsters or the wheelchair foot pedals could be responsible. The facility's policy required assessment and documentation of significant risk factors for pressure sores, but this was not followed after the wound was identified.
Failure to Administer Medications per Physician Orders Due to Pharmacy Delivery Issues
Penalty
Summary
The facility failed to administer medications according to physician orders for two residents who were prescribed Repatha (Evolocumab) for hyperlipidemia and hypertriglyceridemia. For one resident with diagnoses including type II diabetes mellitus with foot ulcer and chronic heart failure, physician orders specified Repatha injections every three weeks, but review of the Medication Administration Records (MAR) and pharmacy delivery slips showed that only five of thirteen ordered doses were administered between March and November. The Director of Nursing (DON) confirmed that the medication was not consistently delivered by the pharmacy as ordered, and when the medication was unavailable, staff would sometimes discontinue and rewrite orders to prompt delivery. Only eight doses were documented as delivered by the pharmacy during this period. Another resident with multiple diagnoses, including respiratory failure, diabetes with polyneuropathy, and chronic heart failure, was ordered Repatha injections every two weeks. Review of records indicated that only four of eleven ordered doses were administered, with only five doses documented as delivered by the pharmacy. The DON confirmed that the medication was not administered as ordered due to delivery issues, and similar to the first case, staff would discontinue and rewrite orders to facilitate delivery. Facility policy required medications to be administered safely, timely, and as prescribed, but this was not followed in these cases.
Failure to Document Discharge Planning and Required Notifications
Penalty
Summary
The facility failed to document discharge planning for a resident who was admitted with multiple diagnoses, including chronic obstructive pulmonary disease, atherosclerotic heart disease, anxiety disorder, hypertension, osteoarthritis, and depression. The resident was admitted for a short-term stay and expressed a desire to return home safely, as reflected in her care plan. Despite a 30-day discharge notice being issued due to non-payment and a physician's order for discharge to home with hospice care, there was no documentation in the progress notes regarding the resident's discharge. Additionally, the recapitulation of stay form was incomplete, with only the sections on mobility and activities of daily living filled out, and no nursing discharge note was present in the medical record. Interviews with facility staff confirmed that required documentation was missing. The Assistant Director of Nursing acknowledged that a nursing discharge note and a fully completed recapitulation of stay form should have been present. The Administrator confirmed the resident was discharged to her sister's home but was unsure about the discharge planning process. The former Social Worker stated she was not present at the time of discharge and was uncertain about the arrangements made for home health care and therapy, as she was no longer employed at the facility when the discharge occurred.
Delayed Pressure Ulcer Treatment
Penalty
Summary
A deficiency occurred when staff failed to timely initiate treatment for pressure ulcers in a resident with multiple medical conditions, including a stage four pressure ulcer, stroke, liver cirrhosis, and depression. The resident was admitted with deep tissue injuries to the left heel and left outer ankle, both measuring two centimeters in length and width, but the depth was not measured. Although physician orders to cleanse the wounds and apply skin prep every shift were written on the third day after admission, treatment was not started until that time, resulting in a delay of care. Staff confirmed that the prescribed treatment for the pressure ulcers was not initiated upon admission, despite the resident's dependence on staff for activities of daily living and severely impaired cognition. Online clinical guidance indicates that immediate treatment is required once a pressure ulcer develops.
Failure to Report, Assess, and Prevent Resident Falls
Penalty
Summary
The facility failed to ensure timely reporting, assessment, and investigation of resident falls, as well as implementation of fall prevention interventions according to resident care plans. For one resident with multiple comorbidities including dementia, chronic pain, and impaired balance, video footage showed the resident on the floor beside her bed, with a CNA attempting to lift her back onto the bed without reporting the fall to a nurse. The resident was wearing socks, which contributed to difficulty in the transfer. The incident was not reported by staff, and the facility's investigation was incomplete, lacking a statement from the involved CNA and unable to determine the circumstances due to delayed reporting. The facility's policy required staff to evaluate and document falls, and for nurses to assess and document injuries and circumstances, which was not followed in this case. Another resident with hemiplegia, weakness, and impaired balance was found in bed with the bed in the highest position and without a required fall mat on one side, contrary to the care plan interventions. Staff were unsure about the need for fall mats on both sides and confirmed the absence of the mat. These failures affected two of three residents reviewed for falls and demonstrate noncompliance with accident hazard prevention and supervision requirements.
Failure to Timely Assess and Treat Pressure Ulcer
Penalty
Summary
The facility failed to provide timely assessment and treatment for a newly identified skin issue in a resident, leading to the development of a pressure ulcer. The resident, who had severe cognitive impairment and was dependent on staff for all activities of daily living, was admitted with multiple medical diagnoses including nontraumatic intracerebral hemorrhage and vascular dementia. Initially, the resident did not have a pressure ulcer, but a physician's order was in place to monitor the skin on the left knee due to the use of a knee brace. However, the facility did not document the completion of skin checks on several occasions in October, despite the resident being at high risk for skin breakdown. Physical therapy notes indicated that a scab and redness were observed on the resident's left knee as early as mid-October, and the nurse was notified. Despite this, the facility continued to apply the knee brace until the end of October, when the area was noted to be more inflamed and necrotic. Weekly skin assessments failed to identify any issues until the end of October, when an unstageable pressure ulcer was documented. The facility's Treatment Administration Record for November also lacked documentation of wound care on multiple dates, indicating a failure to follow through with the prescribed treatment regimen. Interviews with facility staff confirmed the lack of documentation and awareness of the resident's skin breakdown until after the end of October. The facility's policy on the prevention of pressure injuries emphasized the importance of daily skin inspections and careful selection and monitoring of medical devices to prevent tissue damage. However, the facility did not adhere to these guidelines, resulting in the development and inadequate treatment of a pressure ulcer on the resident's left knee.
Failure to Administer Medications as Ordered
Penalty
Summary
The facility failed to ensure medications were administered as ordered for Resident #75, who was affected by this deficiency. Resident #75 had multiple medical diagnoses, including chronic obstructive pulmonary disease, heart failure, atrial fibrillation, dementia with psychosis, paranoid schizophrenia, and diabetes mellitus. The resident was enrolled in Hospice services and had severe cognitive impairment, requiring substantial assistance for daily activities. A physician order was in place for Morphine Sulfate (MSO4) to be administered three times daily for pain or shortness of breath. However, the Medical Administration Record (MAR) indicated that the MSO4 was documented as administered, but the Controlled Drug Record lacked documentation to support the administration of the 2:00 P.M. doses on several specified dates. Licensed Practical Nurse (LPN) #155 confirmed during an interview that she documented the administration of the 2:00 P.M. doses of MSO4 on the MAR, despite not actually administering the medication because the resident was usually sleeping or resting comfortably at those times. The facility's policy on medication administration required that medications be administered as prescribed and documented appropriately if withheld or refused. The LPN acknowledged not documenting the reason for not administering the medication in a progress note, which was contrary to the facility's policy. This deficiency was investigated under Complaint Number OH00158451.
Infection Control Breach for Resident on Contact Precautions
Penalty
Summary
The facility failed to adhere to infection control procedures for a resident under Contact Precautions, affecting one out of three residents reviewed for wound care. The resident, who was cognitively intact, had multiple medical diagnoses including alcoholic cirrhosis of the liver, chronic obstructive pulmonary disease, chronic Hepatitis C, and was a carrier or suspected carrier of MRSA. The resident had physician orders for Contact Precautions and specific wound care treatments due to vascular ulcers on various parts of the body. Despite these precautions, a State tested Nursing Assistant (STNA) entered the resident's room without donning personal protective equipment (PPE) and failed to perform hand hygiene after exiting, which was against the facility's policy for Contact Precautions. The STNA mistakenly believed the resident was only on Enhanced Barrier Precautions, not Contact Precautions. The facility's policy required staff and visitors to wear gloves and gowns when entering the room of a resident under Contact Precautions and to perform hand hygiene before leaving. The President of Clinical confirmed that the medical record did not document MRSA colonization and acknowledged the resident's refusal of treatment at times, preferring to perform wound care independently. This incident was identified during a complaint investigation, highlighting a lapse in following established infection control protocols.
Inadequate Temperature Control of Dairy Products
Penalty
Summary
The facility failed to ensure that dairy products were served at the appropriate temperature, potentially affecting 68 residents. During an observation in the dining area, it was noted that trays containing meals and milk cartons were lined up for delivery. The milk on one resident's tray was found to be at 46.6 degrees Fahrenheit, which is above the facility's policy requirement of 41 degrees or below. Dietary Aid #349 confirmed the temperature and admitted to not knowing the correct serving temperature for milk. Despite identifying the issue, the dietary staff did not replace the milk on four trays that were already on the cart, and these trays were subsequently delivered to residents. The Dietary Manager confirmed that milk should be maintained at 41 degrees Fahrenheit or less and stated that milk was placed in the freezer 30 minutes before being brought to the unit. A resident expressed that the milk received at breakfast could have been colder, indicating dissatisfaction with the temperature of the served milk.
Food Storage and Preparation Deficiencies
Penalty
Summary
The facility failed to ensure food was stored and prepared in a manner that prevents the potential spread of foodborne illness, affecting 68 residents. During an observation of the facility's walk-in cooler, gray and white speckled areas, identified as mold, were found throughout the shelves and milk crates. A puddle of brown liquid was observed on the floor beneath a box of potatoes, which was being contaminated by leaking cucumbers from the shelf above. Dietary Staff confirmed the presence of mold and the leaking cucumbers. The Dietary Manager stated the cooler had been recently cleaned, but the mold was attributed to a dirty fan, which had been cleaned by the Maintenance Director a month prior. Additionally, the walk-in freezer contained two open and unsealed boxes of vegetable protein loafs, exposing the food to air. The hood vents and sprinklers above the stove were coated in a dark gray fuzzy substance, indicating a lack of cleaning since May. The facility's policies on food storage and service, which require cleanliness and sanitary conditions, were not adhered to, as evidenced by the observations of spills, leaks, and unclean equipment.
Failure to Address Resident Grievances
Penalty
Summary
The facility failed to document and follow up on resident concerns raised during Resident Council meetings, affecting seven residents who participated in these meetings. The residents, most of whom were cognitively intact, expressed concerns about various issues, including dietary snacks, nursing call lights, showers, and housekeeping. Despite these concerns being consistently raised in meetings, the facility did not provide documented evidence of discussions or plans to address them. The review of Resident Council meeting minutes from August 2023 to August 2024 revealed a lack of documentation regarding the concerns brought up by residents and the facility's plans to address them. Specific issues such as snacks not being distributed at night, delayed call light responses, and incomplete showers were noted, but the action taken sections of the concern forms were often left blank. Additionally, there was no evidence of follow-up actions, such as staff education or audits, being completed as indicated in the meeting minutes. Interviews with residents and staff confirmed that the facility did not follow up timely on the concerns raised. Residents reported that the same issues were brought up repeatedly without resolution, and they were not provided with detailed meeting notes. The Activity Director acknowledged taking detailed notes during meetings but stated that management instructed her not to include them in the minutes. The facility's inability to locate additional concern forms and documented evidence of follow-ups further highlighted the deficiency in addressing resident grievances.
Inaccurate Code Status Documentation in Medical Records
Penalty
Summary
The facility failed to ensure the accuracy of code status in the medical records for three residents, which could potentially affect all 70 residents in the facility. For Resident #58, there was a discrepancy between the Do Not Resuscitate (DNR) order form in the paper chart, which indicated a DNR-Comfort Care-Arrest (CCA) status, and the electronic medical record (EMR), which showed a Full Code status. This inconsistency was confirmed by an LPN who stated that she would most likely refer to the EMR to check a resident's code status. Similarly, Resident #32's medical records showed a mismatch between the paper chart, which indicated a DNR-Comfort Care (CC) status, and the EMR, which listed a Full Code status. This discrepancy was verified by the same LPN. For Resident #29, the EMR indicated a DNR-CC status, while the paper chart had an undated DNR form showing DNR-CC-A. The Director of Nursing confirmed the mismatch in Resident #29's code status. The facility's policy on advance directives stated that residents' wishes should be communicated to direct care staff and physicians by placing the documents in a prominent, accessible location in the medical record.
Failure to Maintain a Safe and Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for a resident, as required by their policy. The deficiency was identified during an observation where a large hole was found in the drywall behind the resident's bariatric bed. The damage was approximately six inches by 18 inches in size. The Maintenance Director confirmed the damage and stated that he had not been informed of it. He also noted that the damage was significant enough that a simple patch would not suffice, and a larger section of drywall would need to be replaced. The resident involved had multiple diagnoses, including COPD, diabetes, dysphagia, heart failure, unspecified psychosis, respiratory failure, and morbid obesity.
Failure to Notify Residents of Hospital Transfer Reasons
Penalty
Summary
The facility failed to provide timely notification to residents and their representatives regarding the reason for transfer to the hospital, affecting three residents. Resident #43, with diagnoses including osteomyelitis of vertebra, heart failure, and kidney failure, was hospitalized multiple times without documented evidence of notification for the reason of transfer. Similarly, Resident #56, diagnosed with cerebral palsy, diabetes, and heart failure, was hospitalized without receiving a notification for the reason of transfer. Additionally, Resident #21, who had multiple complex diagnoses such as acute respiratory failure, severe sepsis, and multiple sclerosis, was transferred to the hospital without documented evidence of notification to the resident or their representative. Interviews with facility staff, including the Regional Director of Operations and the Business Office Manager, confirmed the absence of written notifications for these transfers. The facility's policy on transfer or discharge, dated 10/2022, requires that a notice of transfer be issued as soon as practicable before the transfer, which was not adhered to in these cases.
Failure to Provide Timely Bed Hold Notifications
Penalty
Summary
The facility failed to provide timely bed hold notifications to residents or their representatives upon transfer to a hospital, affecting three residents. Resident #43, with diagnoses including osteomyelitis of vertebra, heart failure, and kidney failure, was hospitalized twice, and in both instances, the bed hold notice was provided only upon discharge from the hospital, not at the time of admission. Similarly, Resident #56, diagnosed with cerebral palsy, diabetes, and heart failure, was hospitalized, and the bed hold notice was also given post-discharge. The Director of Nursing confirmed that the notices were issued after the hospital stays ended. Resident #21, with a complex medical history including acute respiratory failure, severe sepsis, and multiple sclerosis, was transferred to the hospital and readmitted to the facility. The bed hold notice for this resident was signed and dated after the hospital stay, indicating it was not provided at the time of transfer. The Business Office Manager verified that the facility's practice was to issue bed hold notices following hospital stays, contrary to the facility's policy requiring notification within 24 hours of emergency transfer.
Failure to Provide Adaptive Equipment as Ordered
Penalty
Summary
The facility failed to provide adaptive equipment as ordered for a resident with dementia and oropharyngeal dysphagia. The resident was admitted with a diagnosis that included severely impaired cognition and was assessed as independent with the use of a provale cup for safe intake of thin liquids. A physician order specified the use of a provale cup as part of the resident's dysphagia mechanical soft diet. The plan of care also included the provision of a provale cup due to the resident's physical functioning deficit related to impaired mobility and cognition. During an observation, the resident was found with a provale cup without a lid, despite the meal ticket indicating the need for a 10 CC provale cup with a lid. The resident confirmed the absence of the lid, and the Dietary Manager verified that the lid was not provided because the resident reportedly did not like using it. The Dietary Manager was unable to locate the lid in the dietary service area, acknowledging that adaptive equipment should be provided if listed on the meal ticket. The facility's policy stated that adaptive devices, including specialized cups, should be provided for residents who need them.
Failure to Maintain Resident Dignity
Penalty
Summary
The facility failed to treat all residents with dignity and respect, affecting two residents. Resident #28, who was severely cognitively impaired and required substantial assistance with eating, was observed in the dining room without being served lunch while other residents were eating. Despite being present in the dining room from 11:30 A.M. to 12:10 P.M., Resident #28 was not served until 12:25 P.M. after a State Tested Nursing Assistant (STNA) intervened. The resident expressed hunger and ate 75 percent of his meal once it was provided. Resident #29, who had multiple diagnoses including osteomyelitis and chronic pulmonary disease, was observed with a full foley catheter bag visible from the hallway without a dignity cover. The facility's policy required privacy covers for catheter bags, but this was not adhered to, as confirmed by interviews with an STNA and the facility's Administrator and Director of Nursing. This deficiency was investigated under Complaint Number OH00157658.
Facility Refusal to Re-admit Resident Post-Hospitalization
Penalty
Summary
The facility failed to allow a resident to return to the nursing home in a timely manner following a hospital stay, which affected one of four residents reviewed for hospitalization. The resident, who had been admitted with diagnoses including osteomyelitis of the vertebra, heart failure, cellulitis, kidney failure, and edema, was hospitalized due to critical laboratory findings. Upon stabilization and treatment at the hospital, the resident was deemed fit for discharge back to the facility by the ER physician. However, the facility's Director of Nursing (DON) refused to accept the resident back, citing the resident's condition as too critical for their care, despite the hospital's assessment of stability. The ER notes detail multiple attempts by hospital staff to communicate with the facility regarding the resident's condition and readiness for discharge. The ER physician and nurses repeatedly confirmed the resident's stability and appropriateness for nursing facility care, yet the facility's DON and staff refused to accept the resident, leading to the resident being sent back to the hospital shortly after initial discharge. The facility's refusal was based on elevated lab results, which the facility's physician and DON interpreted as indicating instability, despite the hospital's contrary assessment. Interviews with facility staff, including the LPN on duty and the Regional Director of Operations, revealed a lack of documentation and communication regarding the decision to refuse the resident's return. The facility's physician was not present during the incident and had limited communication with the DON. The facility's policy on transfer and discharge requires efforts to ascertain the resident's condition and needs through communication with hospital staff, which was not adequately followed in this case. The deficiency was investigated under a specific complaint number, highlighting non-compliance with regulatory requirements.
Failure to Communicate Resident Fall Incident
Penalty
Summary
The facility failed to ensure proper communication between nursing staff regarding a resident incident that was later determined to be a fall. A resident with a history of anxiety disorder, right femur fracture, atrial fibrillation, hypertension, and repeated falls, was found on the floor by a state-tested nursing assistant (STNA) in the early morning. The resident claimed to have intentionally sat on the floor to avoid falling due to forgetting her walker. The registered nurse (RN) on duty did not report this incident to the oncoming licensed practical nurse (LPN) and did not document the incident until his next shift. The RN did not consider the incident a fall because the resident stated she sat on the floor intentionally. Consequently, the RN did not communicate the incident to the oncoming LPN, who was unaware of the situation when she began her shift. Later, the resident reported pain in her hip, which led to an X-ray revealing a right hip fracture. The resident was subsequently sent to a local hospital for evaluation and required surgery to repair the fracture. The facility's policy on managing falls and fall risks requires staff to monitor and document each resident's response to interventions intended to reduce falling or the risk of falling. However, the RN's failure to report and document the incident promptly resulted in a lack of ongoing monitoring and potentially contributed to the resident's injury. This deficiency was identified during a survey and was part of a complaint investigation.
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Surveyors found that multiple hazardous storage areas, including a closet near medical records, a beauty salon used to store chemical cases, a supply room in one nursing station, a room leading to a smoking area, a housekeeping room near therapy, and a lobby storage room, lacked required self-closing or automatic-closing doors. These conditions did not comply with NFPA 101 requirements for hazardous area enclosure and had the potential to affect all residents and staff in an emergency.
Surveyors found that the facility did not conduct fire drills on every shift each quarter and did not vary drill conditions as required by NFPA 101. Record review showed that one shift lacked a documented drill for an entire quarter, and the pattern of drill times and dates did not demonstrate varied conditions. The Maintenance Director confirmed the incomplete and noncompliant fire drill schedule, which affected all residents and staff emergency preparedness.
Surveyors found that the facility did not maintain clear egress corridors as required by NFPA 101, with a TV/video cart plugged into a corridor outlet and multiple unsecured chairs placed in the hallway near resident rooms and the secured unit dining room, including directly in front of a fire extinguisher. These items projected about 29 inches into an approximately eight-foot-wide corridor and were located in front of the handrail, potentially affecting 28 residents and staff’s ability to assist in an emergency. The Maintenance Director confirmed these corridor obstructions during the survey.
A resident with intact cognition receiving Medicare Part A skilled services for metabolic encephalopathy had services discontinued while benefit days remained, but the facility did not issue the required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN). The Social Services Director later confirmed that no SNF ABN was provided and reported she believed only a Notice of Medicare Non-Coverage (NOMNC) was needed when all skilled services were stopped. This practice conflicted with the facility’s written policy, which required SNF ABNs to be issued when extended care items or services were initiated, reduced, or terminated due to expected non-coverage by Medicare.
Surveyors identified that the facility exceeded the acceptable medication error rate when two residents with type 2 DM received insulin doses that were not administered according to orders or manufacturer instructions. In two separate observations, an LPN administered Novolog and another LPN administered insulin glargine and insulin lispro without priming the insulin pens, and the insulin lispro and Novolog were given after the residents had already consumed a significant portion of their breakfast meals, despite orders for administration before meals. Manufacturer information for both insulin products required priming before each injection to ensure accurate dosing, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and specified time frames.
The facility failed to maintain accurate and complete crash cart audits for multiple full-code residents. Surveyors, accompanied by the DON, found that daily crash cart checks did not include verification of supply expiration dates, and that an extension cord documented as present on several audit dates was not actually in the cart. Audit logs also conflicted with the cart’s contents by indicating that required items such as eye protection, saline, and clear plastic were present when they were not. These findings were inconsistent with the facility’s policy requiring the crash cart to be checked every 24 hours and after each use, with prompt replacement of equipment and supplies.
A resident with chronic respiratory failure on supplemental O2, COPD, and cognitive risk factors was repeatedly documented as non-compliant with the smoking policy, including going out to smoke outside designated times and retaining cigarettes and lighters provided by family. Despite prior assessments identifying this resident as unsafe to smoke without supervision, a later assessment classified the resident as safe to smoke independently without documented rationale or care plan update. The resident subsequently went outside alone with an O2 nasal cannula in place, lit a cigarette, and sustained facial burns when the cannula ignited, as observed by staff and confirmed by EMS and ED records. In a separate case, another cognitively impaired resident with a history of falls had a care-planned intervention for non-skid strips in front of a recliner, but observation and staff confirmation showed the strips were not present, despite remaining on the active fall-risk care plan.
Multiple dependent residents did not receive scheduled showers, bed baths, or shaving as outlined in their care plans and the facility’s routine care policy. One resident recovering from spinal surgery missed numerous scheduled showers over several months. Another resident who relied on staff for self-care repeatedly requested shaving but was not shaved, and visible facial hair was observed after a recent shower. A resident with chronic respiratory failure and a tracheostomy, requiring substantial/maximal assist with personal hygiene, had no documented showers for an extended period and was observed with long facial hair, which staff acknowledged should be removed during bathing or as needed. A cognitively impaired resident with ESRD and CHF, scheduled for twice-weekly showers, had multiple undocumented or missed showers and reported not getting showers despite asking aides who said they lacked time. Another cognitively intact resident with hemiplegia and multiple comorbidities, also scheduled for twice-weekly showers, had several dates where documentation showed no shower/bath/bed bath provided or no entry at all, and she reported feeling unclean and unimportant when her showers were missed.
A resident with an indwelling urinary catheter for urinary retention, and care plan interventions requiring the drainage bag to be properly secured with a dignity cover, was observed seated in a chair with the catheter drainage bag uncovered and containing visible dark yellow urine that could be seen from the hallway. Later, an LPN confirmed the catheter bag was lying directly on the floor without a dignity cover. This situation occurred despite facility policy requiring care to be provided in a manner that respects and enhances each resident’s dignity and personal privacy.
A cognitively intact resident with chronic orthopedic pain had a PRN oxycodone order, but multiple doses were signed out on the narcotic log by an RN without corresponding entries on the MAR or documented pain assessments. A CNA/med tech reported frequent problems with this RN’s narcotic counts and documentation, describing erratic behavior when handling narcotic keys. The resident reported taking oxycodone only once or twice daily and otherwise using Tylenol, which conflicted with the number of oxycodone doses signed out. The facility’s investigation found it was inconclusive whether narcotics were misappropriated or whether there was a failure of documentation, but confirmed there was no evidence that all signed-out doses were administered.
Failure to Maintain Self-Closing Doors for Multiple Hazardous Storage Areas
Penalty
Summary
Surveyors identified a deficiency related to hazardous area protection and door requirements under NFPA 101, 2012 Edition. During facility tours, they observed that multiple hazardous storage areas did not have self-closing or automatic-closing doors as required for hazardous areas such as combustible storage and chemical storage. These areas included a closet next to medical records, a beauty salon being used to store cases of chemicals, a supply room in Station #2, and the room leading to the smoking area in Station #3. On a subsequent tour, surveyors observed additional hazardous areas without self-closing doors. The housekeeping room across from therapy and the lobby storage room were both noted to lack self-closing door mechanisms. The facility census at the time was 59 residents, and the surveyors stated that this deficient practice had the potential to affect all residents and staff's ability to assist in an emergency. The Maintenance Director verified these findings at the time they were observed.
Plan Of Correction
K 0321 This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be admissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as its allegation of substantial compliance as of 06/12/2026 K-0321 Doors with Self-Closing Devices Corrective action for resident/s: 1. The closet door next to medical records was lacking a self-closing door on 5/19/2026. Maintenance director to add self-closing device to closet door next to medical records on or before 06/12/2026 in accordance with applicable code. 2. The beauty salon had chemicals stored in it on 5/19/2026. Maintenance director moved chemicals from beauty salon on 05/20/2026 in accordance with applicable code. 3. The supply room on station 2 was lacking a self-closing door on 5/19/2026. Maintenance director to add self-closing door to supply room on station 2 on or before 06/12/2026 in accordance with applicable code. 4. The room to the smoking area on station 3 was lacking a self-closing door on 5/19/2026. Maintenance director to add a self-closing door to the smoking are on station 3 on or before 06/12/2026 in accordance with applicable code. 4. The housekeeping room across from therapy was lacking a self-closing door on 5/19/2026. Maintenance director to add a self-closing door to the housekeeping room across from therapy gym on or before 06/12/2026 in accordance with applicable code. 5. The lobby storage room was lacking a self-closing door on 5/19/2026. Maintenance director to add a self-closing door to the lobby storage room on or before 06/12/2026 in accordance with applicable code. Identification of other residents who may be affected: LNHA and Maintenance director/designee completed a full facility audit for doors with self-closing devices on 05/26/2026. Any corrective action, including, doors identified as needing self-closures will be added on or before 06/09/2026 in accordance with applicable code. Measures for systemic change: LNHA educated Maintenance Director on 05/26/2026 regarding NFPA 101-2012 sections 19.3.2.1 and 19.3.5.9 specifically regarding doors with self-closing devices. How Corrective Action will be monitored Ongoing "Doors with Self-Closing device audit" to be completed weekly x 2 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 06/12/2026
Failure to Conduct Required Quarterly Fire Drills on All Shifts
Penalty
Summary
The facility failed to conduct fire drills in accordance with NFPA 101, 2012 Edition, sections 19.7.1 through 19.7.1.8, specifically by not holding drills every shift each quarter and not varying drill conditions as required. Record review on 06/09/25 at approximately 10:32 A.M. showed there was no fire drill conducted for the first shift during the third quarter. The documented first-shift fire drills occurred on 01/30/26 at 2:42 P.M., 04/30/26 at 1:51 P.M., and 10/31/25 at 10:58 A.M., indicating a missed quarter. Second-shift fire drills were recorded on 02/26/26 at 5:20 P.M., 06/03/25 at 4:35 P.M., 08/29/25 at 3:46 P.M., and 11/25/25 at 5:09 P.M., and third-shift drills on 02/28/26 at 11:47 P.M., 05/30/25 at 12:18 A.M., 07/22/25 at 11:34 P.M., 09/26/25 at 11:40 P.M., and 12/15/25 at 5:17 A.M. The surveyor determined that drills were not conducted under varied conditions and that the required quarterly drill on each shift was not consistently performed. The Maintenance Director confirmed these findings at the time they were identified, and the deficiency had the potential to affect all 59 residents and staff response in an emergency. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency related to facility-wide emergency preparedness practices and documentation of fire drills.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 05/29/2026 K-0712 Fire Drills Corrective action for resident/s: There were no records of a fire drill for the first shift of the third quarter of 2025. First shift fire drill completed on 5/24/2026 by maintenance director/designee with no findings or corrective action necessary. Identification of other residents who may be affected: On 5/26/2026 Maintenance director/designee completed 100% audit of the scheduled fire drills to ensure a drill is scheduled quarterly each shift with no findings or corrective action necessary. Measures for systemic change: LNHA educated Maintenance Director on 05/26/2026 regarding NFPA 101-2012 section 19.7.1.4 through 19.7.1.7. specifically including fire drill frequency requirements. How Corrective Action will be monitored Ongoing "Fire Drill Audit" to be completed weekly x 2 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 05/29/2026
Obstructed Egress Corridors Due to Equipment and Chairs
Penalty
Summary
The facility failed to maintain required clear egress widths in corridors in accordance with NFPA 101, 2012 Edition, sections 19.2.3.4 through 19.2.3.5 and 7.3.2 through 7.3.2.3, creating projections into the egress corridor that exceeded allowable limits. Surveyors observed that on one day in Station #3, a cart with a television and video equipment was plugged into an outlet in the corridor by room 38, and five activity room chairs were placed in the corridor near the secured unit dining room directly in front of a fire extinguisher. On the following day, surveyors again observed chairs in the Station #3 corridor, with four by room 35 and four by the activities room, and the same television cart still in the corridor; the chairs were not secured. The corridor was approximately eight feet wide, and the projections extended approximately 29 inches into the corridor in front of the handrail. These conditions had the potential to affect 28 residents in the facility and the staff’s ability to assist in an emergency, and the Maintenance Director confirmed the observations at the time of discovery. No specific resident medical histories or conditions were described in the report, only that 28 residents were potentially affected and the facility census was 59.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be subsequent remedial measures and should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 05/29/2026 K-0232 Clear path of egress Corrective action for resident/s: 1. On 05/18/2026 station 3 had a cart with a television parked in the corridor by room 38 that exceeded allowable limits. Maintenance director/designee moved the TV cart into the activity room, out to the corridor on 05/18/2026 in accordance with applicable code. 2. On 5/18/2026 station 3 had 5 chairs in the corridor near the dining room directly in front of the fire extinguisher. Maintenance director/designee moved the chairs into the dining room, out of the corridor on 5/18/2026 in accordance with applicable code. 3. On 5/19/2026 station 3 had 4 chairs by the activity room and 4 by room 35. In addition, the TV cart was in the corridor. The maintenance director/designee moved the chairs and TV cart into the dining room, out of the corridor on 5/19/2026 in accordance with applicable code. Identification of other residents who may be affected: Maintenance director/designee completed a 100% facility audit for clear paths of egress on 5/26/26 with no findings or corrective action necessary. Measures for systemic change: Maintenance Director/designee educated staff on 5/26/2026 regarding NFPA 101-2012 section 19.2.3.4 and 19.2.3.5 specifically including maintaining a clear path of egress. How Corrective Action will be monitored Ongoing "Path of Egress Audit" to be completed weekly x 2 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 05/29/2026
Failure to Issue Required SNF ABN When Discontinuing Medicare Part A Services
Penalty
Summary
The deficiency involves the facility’s failure to issue a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) when Medicare Part A services were discontinued for a resident who still had available benefit days. The resident was admitted with a diagnosis of metabolic encephalopathy and had intact cognition per the Minimum Data Set assessment. The facility’s own SNF Beneficiary Notification Review documented that Medicare Part A skilled services began on 02/11/26 and the last covered day was 03/11/26, and that the facility initiated discharge from Medicare Part A services before the resident’s benefit days were exhausted. Despite this, no SNF ABN was provided to the resident or the resident’s representative. During interviews, the Social Services Director stated that the SNF ABN was issued hours prior to the last covered day but, upon reviewing her files, confirmed that no SNF ABN had actually been issued for this resident. She further explained that she believed an SNF ABN was only required if one skilled service remained and that if all skilled services were being discontinued, only the Notice of Medicare Non-Coverage (NOMNC) needed to be issued. The Administrator, however, stated that a resident should always receive both a SNF ABN and a NOMNC when Medicare Part A services are discontinued and benefit days remain. Review of the facility’s written policy dated 03/28/23 showed that the facility was required to issue SNF ABNs for initiation, reduction, or termination of extended care items or services when Medicare payment was not expected, which did not occur in this case.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as its allegation of substantial compliance as of 05/29/2026 F-0582 Corrective action for resident/s: On 5/14/26 Resident #34 was informed of rights and responsibilities related to Advanced Beneficiary Notice and voiced understanding of information for future reference by administrator. Identification of other residents who may be affected: Any resident receiving skilled services from nursing or therapy services. The Administrator audited all residents who were discharged from skilled services in the past 30 days to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary Notice on 5/29/26. No non-compliance was noted. Measures for systemic change: On 5/14/2026 Business Office Manager, Director of Rehab, Minimum Data Set nurse, Director of Nursing and Social Services Director were educated on proper procedure of issuing of Notice Of Medicare Non Coverage and Advanced Beneficiary Notice by administrator. All upcoming discharges from skilled services will be reviewed weekly at Utilization Review meeting to ensure notices will be delivered timely. How Corrective Action will be monitored: Administrator or designee to complete audits of all residents being discharged from skilled services to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 5/29/26
Insulin Administration Errors and Failure to Prime Insulin Pens
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5%, with surveyors identifying 3 errors out of 28 medication administration opportunities, resulting in a 10.71% error rate. For one resident with type 2 diabetes mellitus and moderate cognitive impairment, the physician’s order directed Novolog insulin 10 units via subcutaneous pen-injector to be given before meals. During an observed medication pass, the LPN administered 10 units of Novolog insulin without priming the pen and did so after the resident had already consumed approximately 50% of the breakfast meal. The LPN later confirmed she did not prime the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer instructions for the Novolog FlexPen specified that an air shot (priming) must be performed before each injection to ensure proper dosing. Another resident, also diagnosed with type 2 diabetes mellitus and with intact cognition, had orders for insulin glargine 35 units subcutaneously twice daily and insulin lispro 20 units subcutaneously before meals, plus 12 units subcutaneously if blood glucose was between 251 mg/dL and 300 mg/dL. During an observed medication administration, an LPN administered 35 units of insulin glargine and 32 units of insulin lispro without priming the insulin pens and after the resident had consumed approximately 90% of the breakfast meal, despite orders for insulin lispro to be given before meals. The LPN later stated she could not remember if she had primed the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer information for insulin lispro stated that the pen must be primed before each injection to confirm insulin delivery and remove air, and that failure to prime could result in too much or too little insulin. The DON confirmed the expectation that insulin be administered as ordered, including priming each pen with two units before dialing the prescribed dose, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and required time frames.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 5/29/2026. F-0759 Corrective action for resident/s: Residents #21 and #22 were assessed and evaluated by nurse and Director of Nursing 5/14/26. Resident #21 and #22 both denied any adverse effects and none were noted upon assessment by the Director of Nursing on 5/14/2026. Notification made to physician on 5/14/2026. LPN # 2 competency Eval on insulin administration with the Director of Nursing completed 5/14/2026. Identification of other residents who may be affected: Diabetic residents on assignment of LPN #2/station 2 have the potential to be affected and were assessed by the DON/Designee on 5/14/26 and found to be within normal limits. Measures for systemic change: All Nurses were educated by the Director of Nursing on the steps for Insulin administration per competency, diabetes clinical protocol policy, Medication and treatment orders policy, administering medications policy, and Obtaining fingerstick Glucose Level policy On 5/14/2026. How Corrective Action will be monitored: Director of Nursing and Assistant Director of Nursing will complete insulin administration audits on 5 nurses. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance: 5/29/2026
Inaccurate Crash Cart Audits and Missing Emergency Equipment
Penalty
Summary
The facility failed to ensure accurate and complete crash cart audits for residents requiring basic life support, affecting eighteen of thirty-five residents who were designated as full code. During an observation of the crash cart with the DON, surveyors found that the daily audit documentation for the month did not include verification of expiration dates for crash cart supplies. Review of the crash cart audit logs showed that an extension cord was documented as being in the cart on multiple dates, but the extension cord was not present in the cart at the time of inspection. Additionally, the audit documentation indicated that required items, including eye protection, saline, and clear plastic, were not present in the crash cart, yet they were documented as being in the cart. The facility’s undated “Emergency Crash Cart” policy stated that the crash cart is to be checked every 24 hours and after every use, and that equipment and supplies are to be noted and replaced promptly, but the observed documentation and contents of the cart did not match these requirements. This deficiency was verified with the DON at the time of the survey and was cited under the requirement that personnel provide basic life support, including CPR, to residents requiring emergency care, subject to physician orders and advance directives, and was investigated under Complaint Number 2687380.
Plan Of Correction
Cridersville Care Center Provider Number:366171 Survey Type: Complaint Survey Survey Date: 04/29/26 This Plan of Correction (PoC) outlines the actions completed by the facility with regards to the deficiency citation. This Plan of correction does not constitute any admission of guilt or liability by the facility and is submitted only in response to the regulatory requirements. Please accept the following as the facility's credible allegation of compliance as of 4/30/26. F678 CPR All Full Code residents #18 have the potential to be affected by the alleged deficiency. On 4/27/26 the DON/ADON re-stocked the crash cart per the inventory sheet for all missing items. Crash cart inventory sheet updated and new one will go into effect on 5/1/26. All licensed nursing staff provided with training related to crash cart inventory being a daily audit review using inventory sheet on 4/27/26 per DON/designee. The DON/designee will conduct clinical rounds and conduct a random audit of crash cart three times per week for 4 (four) weeks to ensure compliance. The results of the audit will be documented. The facility conducted an Ad-Hoc QAPI meeting on 4/27/26 and discussed the alleged deficiency and corrective actions. Date when corrective action will be completed: 4/30/26
Unsafe Smoking Practices with Oxygen and Missed Fall-Prevention Interventions
Penalty
Summary
The deficiency involves the facility’s failure to provide a safe smoking environment, adequate supervision, and appropriate implementation of its smoking policy for a resident who used oxygen and smoked, as well as failure to implement fall-prevention interventions as care planned for another resident. One resident had multiple relevant diagnoses, including chronic respiratory failure with hypoxia, COPD, end-stage renal disease, dependence on supplemental oxygen, diabetes, and necrotizing fasciitis. Her care plans identified impaired visual function, risk for respiratory complications related to a history of smoking, and risk for cognitive decline, with interventions including use of oxygen per order and observation for understanding. A smoking-related care plan created earlier documented that she wished to use smoking products, had been assessed as safe to smoke "with supervision," and was non-compliant with the smoking policy, with family continuing to provide smoking supplies despite education and a verbal warning for non-compliance. Smoking assessments and progress notes showed a pattern of non-compliance and inconsistent classification of this resident’s smoking safety. Multiple smoking observation/assessments completed earlier in March documented that she had no cognitive loss, visual deficits, or dexterity problems but was unsafe to smoke without supervision because she did not return smoking materials and did not follow designated smoke times. Progress notes described her going out to smoke multiple times by herself or with family, including sneaking out next door with a cigarette and going out multiple times in one evening, with staff documenting that she was "reeducated" and that family brought in cigarettes and lighters which she did not return to staff. Despite this history, a smoking assessment completed after a three-day hospital stay assessed her as safe to smoke without supervision, with no documentation explaining how this conclusion was reached or evidence that her care plan was updated accordingly. On the day of the incident, the resident reported she had cigarettes and a lighter on her person after returning from dialysis and stated she "could not find a nurse" and went outside to smoke, saying she "guessed" she forgot she had her oxygen on. A CNA observed her outside and saw a flame coming through the resident’s oxygen nasal cannula tubing, turned off the oxygen tank, removed the tubing, and patted out sparks on the resident’s shirt sleeve. The resident’s face and hands appeared black in color, and EMS documented first-degree burns to the head and face, with the resident stating she lit a cigarette with her nasal cannula on, causing the burn. The hospital record described her face as black from smoke and her lips and mouth as "burnt and charred," with a recommendation for intubation that she refused. The facility’s incident report recorded that she went outside with oxygen on to smoke without notifying staff, that staff witnessed the occurrence as she walked through the dining room door to the courtyard, and that she stated she thought she had turned her oxygen off. The facility’s smoking policy required interdisciplinary evaluation to determine safe versus unsafe smokers, staff maintenance of all smoking paraphernalia for both safe and unsafe smokers, and progressive consequences for policy violations. A separate deficiency involved another resident at risk for falls whose care plan included use of non-skid strips on the floor in front of her recliner as a fall-prevention intervention. This resident had severe cognitive impairment, used a walker and wheelchair, required supervision or touching assistance for transfers and ambulation, and had experienced two or more falls without injury since the prior assessment. The fall-risk care plan, initiated at admission, specified non-skid strips in front of the recliner beginning in November. However, nursing staff interviewed were not familiar with all of the resident’s fall-prevention interventions without checking the record, and observation of the room showed two recliners with no non-skid strips on the floor in front of them. An LPN confirmed that the non-skid strips were not present despite the intervention remaining active in the care plan, and moving the recliners did not reveal any strips. The facility’s fall management policy required identification of hazards and risk factors, implementation of interventions to minimize falls and injuries, and development and implementation of a care plan based on interdisciplinary evaluation, with interventions related to identified risk factors.
Plan Of Correction
Smoking: On 03/21/26 at 3:16 P.M. 911 response was activated for Resident #11 and Medical Director #601 was notified by Registered Nurse (RN) #322. On 03/21/26 at 3:18 P.M. on-call Nurse/Social Services #423 immediately notified the Administrator and Director of Nursing (DON) #304 of the incident involving Resident #11. On 03/21/26 at 3:22 P.M. Emergency Medical Services (EMS) arrived onsite. At 3:30 P.M. Resident #11 was transported to the emergency room. On 03/21/26 at 3:30 P.M. RN #322 completed a smoking re-assessment of Resident #11 assessing the resident to be an unsafe smoker requiring supervision due to failure to remove oxygen prior to entering designated smoking area. On 03/21/26 from 3:38 P.M. through 7:57 P.M. Licensed Practical Nurse (LPN) #337, #336, #335, #338; RN #334, and DON #304 re-assessed residents (who smoke). This included Resident #22, Resident #3, Resident #47, Resident #50, Resident #60, Resident #150, Resident #86, and Resident #10 to determine smoking safety (via smoking assessment). Each resident was re-educated regarding the facility smoking policy and staff verified there were no smoking materials on their person. The residents' smoking materials would be maintained by facility staff and distributed per policy. On 03/21/26 at 4:30 P.M. DON #304 responded to facility and an Ad Hoc (not scheduled) Quality Assurance (QA) meeting was held via telephone with the Administrator, DON #304 and Medical Director #601 to review investigative findings and plan of action. A root cause analysis was completed and determined Resident #11 had smoking materials on her person (believed to be obtained from family without staff knowledge) and failed to remove her oxygen. The QA team discussed a corrective action plan. On 03/21/26 from 5:00 P.M through 03/22/26 at 3:00 P.M. 26 RNs, 13 LPNs, one medical technician (MT), 54 Certified Nursing Assistants (CNA) four activities staff, one central supply staff, 11 dietary staff, 12 housekeeping staff, three laundry staff, one medical records staff, two social designees, two maintenance staff, nine administrative staff, and 19 therapy staff (158 staff at the time of the incident) were provided education regarding the facility smoking policy by DON #304 and the Administrator. This was completed via 1:1, small group in-services or via phone. Newly hired staff would receive education during general orientation regarding the facility's smoking policy. On 03/21/26 at 5:00 P.M. DON #304 completed an audit of all residents who smoke (Resident #22, Resident #3, Resident #47, Resident #50, Resident #60, Resident #150, Resident #86, and Resident #10) to verify smoking evaluations and plans of care accurately reflected the residents' smoking safety needs. The residents were educated on the facility smoking policy, and smoking materials were to be maintained at the nurses' station. An audit was completed which included verification of required safety measures present in designated smoking areas, including an ash can, fire extinguisher, fire blanket, ash trays and no oxygen signs. There were no identified concerns or changes made because of the audits. On 03/21/26 at 8:55 P.M. Resident #11 returned from the ED. LPN #332 verbally educated the resident regarding the facility smoking policy which included the need for supervision, a smoking apron (to be worn) and the facility smoke times. LPN #332 verified no smoking materials were on the resident's person or in her room at this time. On 03/23/26 at 11:00 A.M. the Interdisciplinary Team (IDT) (Administrator, DON #304, Medical Director #601, RN #302, Social Services #427, Social Services #423, DON #300, and Maintenance #436) met in-person to review the plan of action with DON #304/designee to complete weekly monitoring of residents who smoke and designated smoking areas weekly for four weeks with Housekeeping responsible to complete the cleaning. Housekeeping staff were responsible for cleaning ashtrays and the designated smoking area daily. Audits to be reviewed and any further actions required to be directed by the Quality Assurance and Performance Improvement (QAPI) Committee during scheduled meetings. The IDT also reviewed all current smoking assessments and care plans for residents who smoke. Resident #50 required a change in supervision levels with smoking due to cognition levels and her plan of care as well as Resident #11's plan of care was updated to reflect supervision/safety. On 03/23/26 from 3:45 P.M. to 8:55 P.M. Social Services #423 re-educated residents who smoke (Resident #22, Resident #3, Resident #47, Resident #50, Resident #60, Resident #150, Resident #86, Resident #10) and responsible parties, if applicable regarding the facility smoking policy and supervision levels. On 03/23/26 at12:13 P.M. Social Services #427 contacted Resident #11's family member (#602) to schedule a care conference. Family member #602 and Family Member #603 were not available to meet until 03/27/26. On 03/23/26 at 1:00 P.M. staff education related to smoking areas, removal of oxygen prior to entering smoking area and maintaining smoking materials at the nurses' station for residents who smoke was initiated by DON #304 and the Administrator via 1:1, small group in-services or via phone call. Education was completed for all 158 staff by 03/24/26 at 1:00 P.M. Newly hired staff would be educated during general orientation regarding the facility's smoking policy. The facility does not utilize agency staff. On 03/27/26 at 11:00 A.M. a care conference was held with Resident #11 and Family Members #602 and #603, the Administrator, Social Services #423 and Social Services #427. The facility smoking policy was reviewed. The resident and family were informed an involuntary discharge would be initiated should the resident exhibit non-compliance moving forward and supervision would be increased beyond the two-hour standard of care to monitor more closely for non-compliance with the facility smoking policy. Family Member #602 stated he educated his siblings as well. On 04/10/26 at 2:00 P.M. DON #304 initiated education with 26 RNs and 13 LPNs (100% of nurses educated) regarding completion of the smoking evaluation via 1:1, small group in-services, or phone. The education was completed by 6:00 P.M. on 04/10/26. A new resident who smokes must remain supervised until the interdisciplinary team (IDT) reviews and determines smoking safety, at which time the care plan is developed and resident and family education is provided. The communication through the staff would be the care plan. Newly hired staff receive education during general orientation regarding the facility's smoking policy and completion of smoking evaluation via Point Click Care (PCC). On 04/10/26 at 4:29 P.M. DON #304 initiated an order in PCC for the nurse to verify, each shift, that Resident #11's smoking materials were maintained at the nurses' station. On 04/13/26 at 5:30 P.M. DON #304 initiated orders in PCC for nurses to verify, each shift, that all residents who smoke would have smoking materials maintained at the nurses' station. An updated list of smokers included: Resident #60, Resident #50, Resident #11, Resident #86, Resident #113, and Resident #151. On 04/13/26 at 5:45 P.M. DON #304 initiated questionnaires for staff regarding the smoking policy with re-education provided as needed via 1:1 and small group in-services for staff currently in the facility with all staff to be questioned/educated prior to working their next scheduled shift. Falls: On 4/9/26, Maintenance Director placed non-skid strips on the floor in front of Resident #12's recliner. Like Residents are identified as residents who have had a fall within the facility. Utilizing the Fall Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, an audit of falls and appropriate interventions for the past 30 days will be completed by the Director of Nursing or designee to ensure fall interventions are in place per plan of care. This audit along with identified corrections will be completed on or F 0689 before 5/13/26. The Director of Nursing or designee will re-educate licensed nurses and STNA/CNAs on the Fall Management Policy to include fall interventions to be in place per the care plan. This education will be completed on or before 5/13/26. Utilizing the Fall Management Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, the Director of Nursing or designee will complete an audit of new admissions, new readmissions and residents who experience a fall within the last 7 days, weekly for four weeks, beginning 5/14/26 to ensure fall safety interventions are in place per plan of care. Current fall interventions found to not be in place will be corrected with all intervention in place per plan of care. Negative findings to be addressed immediately and negative trends or system wide issues will be reported to the QAPI committee, and the action plan will be adjusted as needed.
Removal Plan
- Activated 911 response for Resident #11 and notified the Medical Director.
- On-call Nurse/Social Services immediately notified the Administrator and DON of the incident.
- EMS arrived onsite and Resident #11 was transported to the emergency room.
- Completed a smoking re-assessment of Resident #11, determining the resident was an unsafe smoker requiring supervision due to failure to remove oxygen prior to entering the designated smoking area.
- Re-assessed all residents who smoke (Residents #22, #3, #47, #50, #60, #150, #86, and #10) to determine smoking safety via smoking assessment.
- Re-educated residents who smoke regarding the facility smoking policy and verified there were no smoking materials on their person.
- Implemented that smoking materials would be maintained by facility staff and distributed per policy.
- Held an ad hoc QA meeting to review investigative findings and plan of action.
- Completed a root cause analysis determining Resident #11 had smoking materials on her person and failed to remove oxygen.
- Developed a corrective action plan.
- Provided facility-wide education to staff on the facility smoking policy.
- Implemented that newly hired staff would receive smoking policy education during orientation.
- Completed an audit of all residents who smoke to verify smoking evaluations and plans of care accurately reflected smoking safety needs.
- Ensured smoking materials were maintained at the nurses’ station.
- Audited designated smoking areas for required safety measures (ash can, fire extinguisher, fire blanket, ash trays, and no-oxygen signs).
- Provided verbal education to Resident #11 on smoking policy (supervision, smoking apron, smoke times).
- Verified no smoking materials were on Resident #11’s person or in her room.
- Conducted an in-person IDT meeting to implement weekly monitoring of residents who smoke and designated smoking areas weekly for four weeks.
- Assigned housekeeping to clean ashtrays and the designated smoking area daily.
- Directed audits to be reviewed by QAPI.
- Reviewed all current smoking assessments and care plans for residents who smoke.
- Updated Resident #50’s supervision level.
- Updated Resident #11’s plan of care to reflect supervision/safety.
- Re-educated residents who smoke and responsible parties (as applicable) regarding the facility smoking policy and supervision levels.
- Contacted Resident #11’s family to schedule a care conference.
- Initiated additional staff education regarding smoking areas, removal of oxygen prior to entering smoking area, and maintaining smoking materials at the nurses’ station.
- Held a care conference with Resident #11 and family to review smoking policy.
- Informed resident/family that involuntary discharge would be initiated for future non-compliance.
- Increased supervision beyond the two-hour standard of care to monitor more closely for non-compliance.
- Provided education to all nurses regarding completion of the smoking evaluation.
- Implemented that new residents who smoke must remain supervised until IDT review determines smoking safety and care plan/education are completed.
- Entered an order in PCC for nursing to verify each shift that Resident #11’s smoking materials were maintained at the nurses’ station.
- Entered orders in PCC for nursing to verify each shift that all residents who smoke have smoking materials maintained at the nurses’ station.
- Initiated staff questionnaires regarding the smoking policy with re-education as needed.
- Required all staff to be questioned/educated prior to working their next scheduled shift.
Failure to Provide Scheduled Bathing and Shaving Assistance for Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide scheduled and needed bathing and shaving assistance to multiple dependent residents in accordance with their care plans, preferences, and the facility’s routine care policy. One resident with spinal stenosis and recent L2–L5 decompression fixation fusion was care planned for substantial/maximal assistance with shower/bath and toileting hygiene and was scheduled for showers on Tuesdays and Fridays. Electronic documentation from early January through early April showed this resident did not receive a shower or bed bath on 11 identified scheduled days, and the DON confirmed these missed bathing events. Another resident with dysphagia and developmental issues, who required assistance with self-care and mobility, reported that she asked staff to shave her but they did not, which bothered her. During an observation following a recent shower, she stated she had not been shaved and that the hair "itched"; small gray hairs were visible on her chin. A CNA confirmed the presence of gray chin hairs and acknowledged the resident needed shaving, stating it would be addressed with the next scheduled shower. A further resident with chronic respiratory failure, tracheostomy status, heart failure, moderate intellectual disabilities, anxiety, depression, and PTSD required substantial/maximal assistance with personal hygiene and had a care plan for assistance with self-care, including personal hygiene. Her shower schedule called for showers on Monday and Thursday nights, with complete shaves for men and women. Review of documentation showed her last recorded shower/bath was nearly a year earlier, with no indication of additional personal hygiene or facial hair removal on that date. Observations on two separate days showed long white hairs on her chin and jaw line, which a CNA later confirmed, stating facial hair removal should occur with baths/showers or as needed. A resident with end stage renal disease, respiratory failure, hyperlipidemia, and congestive heart failure, who had impaired cognition and required partial/moderate assistance with bathing and personal hygiene, was scheduled for showers on Wednesdays and Saturdays. Review of shower documentation from admission through early April revealed no showers provided or refusals documented on at least ten scheduled shower days. In interviews, this resident reported not receiving scheduled showers, was unsure of his shower days, and stated he could use a good scrub down, adding that he had asked aides who told him they did not have time. A CNA explained that shower days appear on shower sheets and in the computer and that CNAs are supposed to document daily, with nurses checking the documentation; the DON verified the resident had not received showers per schedule or preference. Another resident with a fracture of the lower end of the left humerus, hemiplegia and hemiparesis after cerebral infarction, rheumatoid arthritis, hypertensive heart disease, urinary retention, and osteoarthritis was care planned as non–weight bearing to the left upper extremity and requiring substantial/maximal assistance with showering/bathing. Her electronic record showed she was scheduled for showers on Wednesdays and Saturdays. The shower task question "did the resident receive a shower/bath/bed bath?" was documented as "no" on three dates, indicating no shower/bath/bed bath was completed, and left unanswered on three additional dates. The DON confirmed that one missed shower was due to an outside appointment, that on two dates the "no" response meant no bathing of any type occurred, and that on three dates there was no documentation at all. The resident, who was cognitively intact, reported that missing showers made her feel unimportant compared to others and that she did not feel clean when her shower was missed. Facility policy on routine resident care stated that showers, tub baths, and shampoos are to be scheduled according to person-centered care or state guidelines, with additional showers given upon request, but the documented and observed care did not reflect consistent provision of scheduled bathing and shaving for these residents.
Plan Of Correction
1. Resident #5 received a shower by the STNA on 4/13/26. Resident #8 received a shower by the STNA on 4/8/26. Resident #9 received a shower and had their chin shaved by the STNA on 4/14/26. Resident #70 received a shower by the STNA on 4/13/26. Resident #76 received a shower and had their chin shaved by the STNA on 4/15/26. 2. Like residents are identified as residents who need assistance with showering and shaving. Utilizing the Shower Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, an audit of like residents will be completed by the Director of Nursing or designee to ensure that showers and resident shaving are completed. This audit along with identified corrections will be completed on or before 5/13/26. 3. The Director of Nursing or designee will re-educate licensed nurses and STNA's on the Routine Resident Care Policy to include bathing and shaving residents. This education will be completed on or before 5/13/26. 4. Utilizing the Shower Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, the Director of Nursing or designee will complete an audit of 4-6 residents weekly for four weeks, beginning 5/14/26 to ensure that showers and resident shaving are completed. Noncompliance found during audits will be addressed and assistance with showers and/or shaving provided. Negative findings to be addressed immediately and negative trends or system wide issues will be reported to the QAPI committee, and the action plan will be adjusted as needed.
Uncovered Urinary Catheter Drainage Bag Compromises Resident Dignity
Penalty
Summary
The facility failed to maintain a resident’s right to privacy and dignity related to management of an indwelling urinary catheter. A resident admitted with malignant neoplasm of the esophagus and type II diabetes mellitus had a care plan identifying risk for urinary tract infection and catheter-related trauma due to an indwelling catheter for urinary retention. The care plan interventions included ensuring the catheter tubing was secured and the drainage bag was properly secured with a dignity cover in place. Physician orders directed that the resident’s 16 French indwelling urinary catheter be changed every 30 days and as needed, and the comprehensive MDS documented that the resident had an indwelling catheter and was cognitively intact. During observation, the resident was seen seated in a chair with the urinary catheter drainage bag hanging from the chair without a dignity cover, and dark yellow urine was visible in the bag from the hallway. In a later observation and interview, an LPN confirmed that the catheter bag was lying directly on the floor and did not have a dignity cover. Attempts to interview the resident to confirm cognitive status were unsuccessful, as the resident was unable to answer screening questions. Review of the facility’s “Resident Dignity & Personal Privacy” policy stated that the facility should provide care in a manner that respects and enhances each resident’s dignity, individuality, and right to personal property, which was not followed in this instance when the catheter drainage bag was left uncovered and visible.
Plan Of Correction
The Laurels of Athens wishes to have this plan of correction submitted as our written allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission to nor agreement with, either the existence of, or the scope and severity of, any of the cited deficiencies or conclusions set forth in the statement of deficiencies. This plan is prepared and/or executed to ensure continuing compliance with regulatory requirements. Our alleged date of compliance is 5/13/2026. 1. On 4/6/26, Resident #92's catheter bag was removed from the floor, the bag changed and covered for dignity by the licensed nurse. Resident #92 discharged from the facility on 4/11/26. 2. Like Residents are identified as residents who utilize urinary catheters. An audit will be completed by the Director of Nursing or designee for like residents utilizing the Urinary Catheter Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC to ensure catheter bags are covered for dignity and not laying directly on the floor. This audit along with identified corrections will be completed on or before 5/13/26. 3. The Director of Nursing or designee will re-educate licensed nurses on the Indwelling Urinary Catheter Policy as well as Resident Dignity & Personal Privacy Policy to include privacy covers are in place for urinary catheters and that the catheter is not laying on the floor. This education will be completed on or before 5/13/26. 4. Utilizing the Urinary Catheter Audit Tool which was created on 4/20/26 by the Director of Nursing for purpose of this POC, the Director of Nursing or designee will complete an audit of all residents with catheters weekly for four weeks, beginning 5/14/26 to ensure catheter bags are covered for dignity and not laying directly on the floor. Any catheters found to be touching the floor or uncovered will be removed from the floor, the bag changed and covered for dignity. Negative findings to be addressed immediately and negative trends or system wide issues will be reported to the QAPI committee, and the action plan will be adjusted as needed.
Failure to Prevent Possible Misappropriation and Poor Documentation of PRN Narcotics
Penalty
Summary
The deficiency involves failure to prevent potential misappropriation of a resident’s narcotic medication and failure to ensure accurate documentation of controlled substance administration. A cognitively intact resident with chronic pain related to an internal orthopedic device and left knee pain had an order for oxycodone 5 mg PO every four hours PRN for pain and a care plan directing staff to administer medications as ordered and observe for effectiveness and side effects. The resident’s MDS showed she rated her pain as 7/10 and received opioid medication. However, review of the February MAR and the narcotic log revealed multiple discrepancies between narcotic sign-outs and documented administration. On several occasions, oxycodone doses were signed out on the narcotic log by an RN without corresponding documentation on the MAR. Specifically, oxycodone was signed out on one evening at 9:30 p.m. with no MAR entry, and again on a subsequent night at 1:30 a.m. and 5:30 a.m. with no MAR entries for those times. Another dose was signed out at 9:00 p.m. while the MAR reflected administration at 10:16 p.m., and a later dose at 5:30 a.m. was documented on both the narcotic log and MAR. There was also no documentation of pain assessments before or after PRN opioid administration. These documentation gaps meant there was no evidence that all narcotic doses signed out were actually administered to the resident. Staff interviews further highlighted concerns about the handling of narcotics. A CNA/med tech reported frequently taking the narcotic keys from the RN and described the RN’s behavior as erratic, with repeated problems involving incorrect narcotic counts and missing documentation on both the MAR and narcotic log. The resident stated she did not receive oxycodone more than once or twice a day, preferring to take Tylenol the rest of the time, which conflicted with the number of oxycodone doses signed out. When questioned, the RN gave inconsistent explanations about how often she pulled and administered PRN narcotics and acknowledged struggling with the new system, while also suggesting the resident may have received PRN tizanidine instead of remembering oxycodone. The facility’s investigation concluded that evidence was inconclusive as to whether misappropriation occurred or whether the issue was solely lack of documentation, but confirmed there was no evidence the resident received all doses signed out on the narcotic log.
Plan Of Correction
1. Resident #99 had a Self-Reported Incident submitted and investigated via the EIDC on 3/2/26. The investigation was inconclusive as we could not prove that misappropriation occurred. On 2/24/26, Resident #99 was interviewed and pain assessed by Director of Nursing and resident had no ill effects related to the inconsistent documentation in the medical record as it relates to her controlled substance pain medication. 2. Like Residents are identified as residents who utilize controlled substance PRN pain medications. An audit will be completed by the Director of Nursing or designee for like residents utilizing the Controlled Substance Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC to ensure PRN controlled substance pain medications that are signed off the control sheet are documented in the resident medical record as well. This audit along with identified corrections will be completed on or before 5/13/26. 3. The Director of Nursing or designee will re-educate licensed nurses on the Controlled Substances Policy to include appropriate documentation of controlled substances. In addition, the licensed nurses will be re-educated by the Director of Nursing or designee on the Abuse Prohibition Policy to include misappropriation of resident property. This education will be completed on or before 5/13/26. 4. Utilizing the Controlled Substance Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, the Director of Nursing or designee will complete an audit three controlled substance sheets from each of the nine medication carts for a total of twenty-seven sheets weekly for four weeks, beginning 5/14/26 to ensure PRN controlled substance pain medications that are signed off the control sheet are documented in the resident medical record as well. Inconsistencies noted from the audit will be investigated for misappropriation. Negative findings to be addressed immediately and negative trends or system wide issues will be reported to the QAPI committee, and the action plan will be adjusted as needed.
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