Belmont Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in St Clairsville, Ohio.
- Location
- 51999 Guirino Drive, St Clairsville, Ohio 43950
- CMS Provider Number
- 366190
- Inspections on file
- 18
- Latest survey
- August 16, 2024
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Belmont Manor during CMS and state inspections, most recent first.
The facility's kitchen practices were found to be unsanitary, with staff unaware of dishwasher types and using expired chlorine strips for testing. The deep fryer oil was not changed as per policy, and the refrigerator contained expired food. The ice maker's scoop was stored on a soiled surface, indicating a lack of adherence to food safety protocols.
The facility failed to maintain resident dignity by leaving urinary catheter bags uncovered and visible, affecting several residents with various medical conditions. Additionally, STNAs placed clothing protectors on residents without consent and engaged in personal conversations during meal service, compromising the dignity of residents during dining.
The facility failed to update care plans for four residents, leading to deficiencies in addressing their current health needs. A resident with significant weight loss did not have their care plan revised to reflect nutritional interventions. Another resident receiving hospice care had an outdated activity care plan, and a third resident's care plan did not reflect a change in antibiotic medication. The DON confirmed these care plans were not updated.
The facility failed to ensure proper pureed food consistency for four residents on a pureed diet. During food preparation, a dietary staff member did not taste the pureed foods to check for texture. The chicken was fibrous, and the vegetables were lumpy, while only the rice met the correct consistency. The facility's policy requires pureed food to be smooth and lump-free to reduce choking risks.
The facility failed to meet professional standards for catheter care and did not identify infection patterns, affecting a resident with an indwelling catheter. The infection control log showed multiple UTIs with E. coli, all on the same unit. An STNA did not follow proper infection control procedures during catheter care, and the facility's policy lacked specific instructions on glove removal.
The facility failed to ensure call lights were accessible for a visually impaired resident and did not provide appropriate table heights for a resident during meals. A resident with macular degeneration could not reach her call light, and another resident with Alzheimer's was seated at a table that reached her chin, hindering her ability to eat. Staff did not intervene to correct these issues.
Two residents were found to be restrained in a facility, contrary to their care plans and facility policy. One resident was unable to self-propel due to a reclined wheelchair and chair alarm, while another could not release a seat belt independently, despite it being intended as self-releasing. Staff confirmed these conditions acted as restraints, violating the residents' rights to freedom of movement.
A facility failed to ensure accurate comprehensive assessments for a resident with dementia and other conditions. The MDS assessments inaccurately documented the resident's use of alarms and falls, failing to reflect the actual use of a bed alarm and self-releasing seat belt, and the number of falls sustained. Additionally, the assessments inaccurately recorded the resident's use of antipsychotic medications, as confirmed by medical record reviews and an interview with the DON.
A facility failed to provide a resident with a written summary of her baseline care plan within 48 hours of admission. The resident, who had multiple health conditions, did not recall receiving the summary. The baseline care plan included a section for a signature to confirm receipt, but it was noted that the plan was reviewed verbally instead. An RN confirmed the facility's failure to provide written summaries.
A facility failed to develop comprehensive care plans for a resident with multiple health conditions, including dementia, diabetes, and hypertension. The resident was at moderate risk for falls, yet no fall prevention plan was created, resulting in a fall. Additionally, the resident's known allergy to Exelon was not documented in a care plan. An LPN confirmed the absence of care plans for these issues, and a constipation care plan was discontinued despite ongoing PRN orders.
The facility failed to properly position residents during meals, affecting three individuals on the secured unit. Observations showed residents in tilt wheelchairs at inappropriate angles and one resident in a low wheelchair without leg rests, unable to reach their meal. Staff did not intervene to reposition the residents, and interviews confirmed the improper positioning. The facility's policy on dignity and respect was not followed.
The facility failed to provide adequate nail and oral care for two residents, leading to deficiencies in their personal hygiene. One resident, with multiple diagnoses including dementia and a Stage IV pressure ulcer, was observed with long, dirty fingernails despite orders for weekly inspection and trimming. Another resident, with cognitive deficits, was found with dirty fingernails and poor oral hygiene, as the STNA admitted to not providing the necessary care during the morning routine.
A facility failed to implement physician orders for a resident with edema, hypertension, and diabetes, who was supposed to wear tubigrips for compression. Observations showed the resident's feet were swollen, and she was not wearing the prescribed tubigrips. An STNA could not find the tubigrips in the resident's room and noted they were sometimes not returned from laundry. Documentation of the resident refusing the tubigrips was questioned as the STNA was not on duty that day.
A resident with visual impairments, including cataracts and Alzheimer's, was observed without eyeglasses multiple times, affecting their ability to engage in activities. The facility failed to replace the resident's broken glasses, and staff were unaware of the need for prescription glasses, despite a care plan encouraging their use.
A facility failed to properly implement and monitor restorative services for residents with mobility and range of motion issues. One resident was observed without required palm guards and lacked proper monitoring of restorative programs. Another resident's range of motion programs were not reassessed or adjusted, and a third resident did not receive recommended ambulation programs, leading to a decline in mobility. Staff interviews revealed a lack of consistent follow-through and evaluation of restorative needs.
A facility failed to implement fall prevention interventions and conduct accurate investigations for a resident with severe cognitive impairment and a history of falls. Despite being at moderate risk for falls, the resident had no fall care plan prior to their first fall and subsequent falls were not properly addressed. Investigations lacked immediate interventions and complete documentation, including neurological checks and medication administration records. The facility's policy requirements were not met, as confirmed by the DON.
A resident with significant weight loss did not receive necessary medications, supplements, or routine meals. Despite recommendations for nutritional supplements and Remeron to increase appetite, the facility did not administer the medication as ordered. The care plan was not updated, and staff failed to provide meals or supplements when the resident slept through meal times. Observations and interviews confirmed these deficiencies, contributing to the resident's continued weight loss.
A resident with dementia and diabetes was prescribed Rexulti, but the facility failed to conduct necessary baseline AIMS assessments and blood glucose monitoring. Interviews with the DON and an LPN confirmed these oversights, which are required by the facility's psychoactive medication policy.
The facility failed to comply with regulations for psychotropic medications, affecting two residents. One resident received an antianxiety medication without a 14-day stop date, while another was given an antipsychotic without behavior documentation or an AIMS assessment. The facility's policy on psychoactive medications was not followed, as confirmed by the DON.
The facility failed to maintain accurate medical records for two residents. One resident's pressure ulcer was incorrectly documented, and another resident's allergy to Exelon was not accurately recorded in their hard chart, despite known adverse effects. These inaccuracies were confirmed by staff interviews.
A resident's electronic medical record was left open and visible on a computer screen at the nurses station, exposing personal health information such as their picture, date of birth, physician name, and medications. No staff were present to monitor the exposed information, and a registered nurse later confirmed the breach of privacy.
A facility failed to implement pressure relieving measures for a resident with a history of pressure ulcers. Despite a care plan intervention to float heels while in bed, the resident's heel was observed resting on a pillow, causing discomfort. The resident had multiple diagnoses, including pressure-induced deep tissue damage, and required pressure-reducing measures, which were not adhered to, leading to the deficiency.
A resident with a history of UTIs and an indwelling catheter did not receive appropriate care as ordered. Despite recommendations for topical estrogen and a urology follow-up, these were not implemented. Catheter care was not performed every shift, and urine samples were not collected from a clean catheter. Observations showed the catheter bag was uncovered with sediment present. These actions led to the deficiency.
The facility failed to ensure proper review and consultation for antibiotic use in two residents. One resident was prescribed Cefdinir for a UTI without confirming the urine sample method, and culture results were delayed. Another resident was on a daily antibiotic regimen without specialist consultation. The DON acknowledged these issues.
Sanitation and Food Safety Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to maintain sanitary kitchen practices, which could potentially affect all residents except one who did not receive nutrition from the kitchen. During an observation, a dietary staff member was found to be unaware of whether the facility had a high or low temperature dishwasher and was using expired chlorine strips to test sanitation levels. The dishwasher's temperature gauge was clouded, making it difficult to read, and there were missing records of water temperature and sanitation levels for certain meals. The facility's dishwashing policy did not address chemical sanitation levels, and the staff member confirmed that the dishwasher's temperature and sanitation levels were not checked before starting breakfast dishes. Additionally, the deep fryer oil was observed to be covered with debris and appeared black, indicating it had not been changed or filtered according to the facility's policy. The oil had not been changed for over a month, and maintenance staff admitted to not adhering to the cleaning schedule. The walk-in refrigerator contained macaroni salad that was not discarded per policy, and the ice maker's scoop was stored on a soiled surface with visible debris and hairs. These observations highlight a lack of adherence to food safety and sanitation protocols within the facility's kitchen operations.
Failure to Maintain Resident Dignity with Catheter Use and Dining Practices
Penalty
Summary
The facility failed to maintain resident dignity in several instances involving the use of indwelling urinary catheters and during dining. For residents with urinary catheters, such as Resident #12, #22, and #6, the urinary drainage bags were observed to be uncovered and visible to other residents and visitors, compromising their dignity. These residents had various medical conditions, including Parkinson's disease, end-stage renal disease, dementia, and neuromuscular dysfunction of the bladder, which necessitated the use of catheters. The visibility of the urine in the bags and tubing was confirmed by interviews with Registered Nurses #522 and #528, who acknowledged that the bags were not in protective covers. During dining, State tested Nurse Aides (STNAs) #105, #108, and #244 were observed placing cloth clothing protectors on residents without asking for their consent, affecting residents such as #3, #19, #21, #44, and #46. Additionally, STNAs engaged in personal conversations unrelated to the residents during meal service, and STNA #244 was noted to stand while assisting residents with their meals, which is not conducive to maintaining dignity. The Director of Nursing confirmed that residents should be offered a choice regarding the use of clothing protectors. The facility's policy on Quality of Life-Dignity, revised in January 2024, prohibits practices that compromise resident dignity, including ensuring urinary catheter bags are covered.
Failure to Revise Care Plans for Residents
Penalty
Summary
The facility failed to revise comprehensive care plans for four residents, leading to deficiencies in addressing their current health needs. Resident #46, who was admitted with non-Alzheimer's type dementia, anxiety, breast cancer, and arthritis, experienced significant weight loss over several months. Despite the weight loss and the implementation of nutritional supplements, the care plan was not updated to reflect these changes. The Director of Nursing confirmed that the nutrition care plan had not been revised. Resident #21, with a history of Alzheimer's disease and other conditions, was receiving hospice services with a life expectancy of less than six months. The care plan, which had not been updated since 2020, did not reflect the resident's current status, including the loss of glasses and the admission to hospice care. The Director of Nursing verified that the activity care plan had not been revised to accommodate these changes. Resident #44, diagnosed with diabetes mellitus and other conditions, experienced a significant weight loss over several months. Despite the implementation of nutritional interventions, the care plan was not updated to reflect the resident's weight loss. Similarly, Resident #15, with a history of urinary tract infections and other health issues, had a care plan that inaccurately listed Macrobid as the long-term antibiotic, even though it had been changed to Trimethroprim in November 2023. The Director of Nursing confirmed that the care plan had not been updated to reflect this change.
Failure to Ensure Proper Pureed Food Consistency
Penalty
Summary
The facility failed to ensure that food was pureed to the correct consistency for four residents who were on a pureed diet. During an observation of the pureed food preparation process, it was noted that the dietary staff member, identified as Dietary #570, pureed barbeque chicken, rice pilaf, and mixed vegetables according to the recipe and under sanitary conditions. However, the staff member did not taste the pureed foods to check for texture consistency. Upon testing, the chicken was found to be fibrous and not pureed to a creamy consistency, while the vegetables contained visible bits and were lumpy, indicating they were not fully blended. The rice was the only item that met the correct consistency. Dietary #570 confirmed that the chicken and vegetables were not pureed to a smooth consistency. The facility's Pureed Diet policy, reviewed in 2017, states that individuals with swallowing difficulties require modified textures to reduce the risk of aspiration or choking, and that pureed food should be smooth and lump-free, served at a pudding or mashed potato consistency. This deficiency affected four residents in a facility with a census of 51.
Infection Control and Catheter Care Deficiencies
Penalty
Summary
The facility failed to ensure catheter care met professional standards and to identify patterns of infection, affecting one resident with an indwelling catheter. The infection control log for June 2024 showed four urinary tract infections (UTIs) acquired after admission, with three of these infections caused by E. coli. All three residents with E. coli resided on the same unit, with the onset of infections recorded on the same date. During an interview, the Infection Control Preventionist initially did not recognize any patterns in the infection surveillance but later acknowledged the pattern after discussion. An observation of catheter care revealed that a State Tested Nurse Aide (STNA) did not follow proper infection control procedures. The STNA performed catheter care on a resident in enhanced barrier precautions but failed to remove gloves before touching the resident's bed covers, bed control, and handing the resident a book. The facility's catheter care policy, reviewed in January 2024, did not include instructions to remove gloves before touching these items. This oversight in the policy and the STNA's actions contributed to the deficiency.
Deficiencies in Resident Accommodation and Meal Positioning
Penalty
Summary
The facility failed to accommodate the needs of residents by not ensuring that call lights were readily accessible. This deficiency was observed in the case of a resident with macular degeneration, who was unable to see and required assistance with personal care. During an observation, the resident was found in her room in a wheelchair, unable to reach her call light, which was looped over a bedside table across the room. The resident expressed her inability to see and requested assistance from the surveyor to locate her call light. A State tested Nurse Aide confirmed that the call light was not within the resident's reach, which was contrary to the care plan that required the call light to be accessible to ensure a safe environment. Additionally, the facility did not provide appropriate table heights for residents during meals on the secured unit. A resident with non-traumatic brain dysfunction and Alzheimer's disease was observed seated in a specialty tilt wheelchair at a table that reached her chin, making it difficult for her to eat. Despite the presence of State tested Nurse Aides, the resident was not repositioned to a more suitable height or position during meal times. An interview with the Director of Nursing confirmed that residents should be properly positioned and at an appropriate table height during meals, which was not adhered to in this case.
Failure to Ensure Residents are Free from Restraints
Penalty
Summary
The facility failed to ensure that residents were free from the use of physical restraints, affecting two residents. Resident #21, who was admitted with multiple diagnoses including Alzheimer's disease and unsteadiness on feet, was observed in a reclined specialty wheelchair with no leg rests, causing her legs to dangle without support. Despite the care plan indicating freedom of movement, the resident was unable to get out of the chair independently due to the reclined position and the use of a chair alarm. Interviews with staff confirmed that the wheelchair's configuration prevented the resident from self-propelling, effectively acting as a restraint. Resident #46, admitted with non-Alzheimer's dementia and other conditions, was also found to be restrained. The resident was observed in a specialized wheelchair with a seat belt and a chair pressure alarm. Despite being able to release the seat belt with cues, the resident was unable to do so upon command during the surveyor's observation, indicating that the seat belt acted as a restraint. The resident's care plan included a self-releasing seat belt, but the inability to release it independently was verified by staff, confirming the restraint. The facility's policy on restraints emphasized the right of residents to be free from restraints unless required for medical treatment. However, the observations and staff interviews revealed that the wheelchairs and alarms used for Residents #21 and #46 were not in compliance with this policy, as they restricted the residents' movement and ability to self-propel. The Director of Nursing confirmed that the wheelchairs and seat belt were considered restraints, highlighting a deficiency in the facility's adherence to its own policies and procedures.
Inaccurate Comprehensive Assessments for Resident
Penalty
Summary
The facility failed to ensure accurate comprehensive assessments for a resident with non-Alzheimer's dementia, anxiety, major depressive disorder, and diabetes mellitus type 2. The resident was ordered a self-releasing seat belt and a pressure-sensitive alarm, except while in a wheelchair, and received PRN Haldol for anxiety. However, the quarterly MDS assessments inaccurately documented the resident's use of alarms and falls. The assessments failed to reflect the resident's actual use of a bed alarm and self-releasing seat belt, and the number of falls sustained, which included five falls with two resulting in abrasions and a skin tear. Additionally, the MDS assessment inaccurately recorded the resident's use of antipsychotic medications. While the assessment indicated routine use only, the resident was administered PRN Haldol and began receiving Rexulti. These discrepancies were confirmed through medical record reviews, observations, and an interview with the Director of Nursing, highlighting errors in the MDS assessments related to alarms, falls, and psychotropic medications.
Failure to Provide Written Baseline Care Plan Summary
Penalty
Summary
The facility failed to provide a written summary of the baseline care plan to a resident within 48 hours of admission, as required. During an interview, the resident stated she did not recall receiving a summary of her baseline care plan. A review of the resident's medical record showed she was admitted with multiple diagnoses, including muscle wasting, hypokalemia, and depression, among others. The baseline care plan, dated shortly after admission, included a section for the resident or representative to sign, indicating receipt of the care plan and medication list. However, instead of a signature, there was a note stating the care plan was reviewed verbally with the resident. A registered nurse confirmed that the facility did not provide written summaries of the baseline care plans to residents or their responsible parties.
Failure to Develop Comprehensive Care Plans for Resident
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for a resident, affecting their highest practicable well-being. Resident #46, who was admitted with diagnoses including non-Alzheimer's type dementia, anxiety, breast cancer, and arthritis, was identified as being at moderate risk for falls. However, no care plan was developed to prevent falls between March and June 2024, and the resident sustained a fall on June 5, 2024. Additionally, the resident had multiple health conditions such as diabetes mellitus, pain, constipation, and hypertension, yet no comprehensive care plans were created to address these issues. Furthermore, the resident had a known allergy to Exelon, which was not included in a care plan. Despite the resident's daughter informing the nurse about the negative effects of Rivastigmine, a medication related to Exelon, and the nurse practitioner discontinuing it, the allergy was not documented in a care plan. An interview with an LPN confirmed the absence of care plans for falls, medication allergies, pain, hypertension, or diabetes mellitus. The LPN also mentioned that a care plan for constipation was discontinued based on pharmacy recommendations, despite ongoing PRN orders for constipation treatment.
Improper Positioning of Residents During Meals
Penalty
Summary
The facility failed to ensure proper positioning of residents during meals on the secured unit, affecting three residents. Observations revealed that two residents were seated in specialty tilt wheelchairs at angles between 60 to 75 degrees, with one resident's table height reaching their chin throughout the meal. The staff did not intervene or reposition the residents during the meal observation. Another resident was observed sitting in a low wheelchair without leg rests, with their feet dangling, and was not positioned properly at the table during breakfast. Despite staff presence, no intervention was made to reposition the resident to allow proper access to their meal. Interviews with staff confirmed the improper positioning of residents during meals. One staff member acknowledged that a resident was not positioned correctly at the table, citing concerns about the resident grabbing items off the table. The Director of Nursing verified that residents should be upright and properly positioned at an appropriate table height during meals. The facility's policy on Quality of Life - Dignity emphasizes care that promotes dignity, respect, and individuality, which was not adhered to in these instances.
Deficiency in Nail and Oral Care for Residents
Penalty
Summary
The facility failed to provide adequate nail and oral care for two residents, leading to deficiencies in their personal hygiene. Resident #22, who was admitted with multiple diagnoses including dementia and a Stage IV pressure ulcer, was observed with long fingernails and debris embedded under the nails, despite a physician's order to inspect and trim nails weekly. The facility's documentation indicated that aides were marking the task as completed, yet the resident's nails remained untrimmed and dirty. Additionally, the resident was under hospice care, receiving aide services five days a week, but the nail care was not adequately performed. Resident #49, admitted with diagnoses such as protein-calorie malnutrition and cognitive communication deficit, was also found with dirty fingernails and poor oral hygiene. Observations revealed debris under the nails and white buildup around the gums and between the teeth. Despite being moderately impaired for daily decision-making and requiring assistance with personal hygiene, the State Tested Nurse Aide (STNA) admitted to not providing nail or oral care during the morning routine. This lack of care was contrary to the physician's orders and the resident's care plan, which required regular inspection and maintenance of personal hygiene.
Failure to Implement Physician Orders for Compression Therapy
Penalty
Summary
The facility failed to implement physician orders for a resident diagnosed with edema, hypertension, and type two diabetes mellitus. The resident had a physician order to wear tubigrips on both legs at all times except during hygiene. However, observations and interviews revealed that the resident was not wearing tubigrips on multiple occasions, and her feet were swollen. The resident mentioned she used to wear compression stockings but was unaware of their current location. Documentation indicated that the resident wore tubigrips at one point but refused them later the same day. Further investigation showed that a State tested Nursing Assistant (STNA) was unable to locate the tubigrips in the resident's room and mentioned that sometimes they were not returned from laundry. The STNA also confirmed that she was not working on the resident's unit on the day the refusal was documented, raising questions about the accuracy of the documentation. The STNA stated she had a good relationship with the resident and could generally persuade her to comply with care requests.
Failure to Provide Necessary Visual Appliances
Penalty
Summary
The facility failed to ensure that a resident had access to necessary visual appliances, specifically eyeglasses, which affected their ability to engage in activities such as watching television and reading. The resident, who had diagnoses including cataracts, glaucoma, macular degeneration, and Alzheimer's disease, was observed multiple times without eyeglasses. Despite having a care plan that encouraged the use of glasses, the resident's eyeglasses were reportedly broken during a fall, and no replacement was provided. The facility's Missing Item Log showed no record of the glasses being broken or missing, and staff interviews revealed a lack of awareness regarding the resident's need for prescription glasses. The Director of Nursing confirmed that the resident had been seen by an eye doctor earlier in the year and was provided with a prescription, but was unaware of the missing glasses. The facility's policy on ancillary services indicated that ophthalmology visits were scheduled annually or as needed, but there was no evidence of follow-up to replace the broken glasses. The Activities Director and a Nurse Aide were both unaware of the resident's need for prescription glasses, and the resident was temporarily given non-prescription reader glasses found at the nursing station.
Failure to Implement and Monitor Restorative Services
Penalty
Summary
The facility failed to ensure that restorative services were properly initiated, assessed, reviewed, and revised for three residents with limited range of motion and mobility issues. Resident #12, who had multiple diagnoses including Parkinson's disease and rheumatoid arthritis, was observed without the required palm guards and had not been properly monitored for participation in restorative programs. The facility's documentation showed that restorative programs were signed off as completed, but there was no evidence of ongoing assessment or adjustment of these programs based on the resident's response or needs. Resident #21, with severe cognitive impairment and functional limitations, was enrolled in restorative programs for range of motion exercises. However, there was no documentation of cues provided, rest periods, or quarterly evaluations to assess the effectiveness of these programs. The care plan indicated a need for reassessment, but this was not carried out, leading to a lack of evidence that the programs were being effectively managed or adjusted. Resident #46, who had been discharged from physical therapy with recommendations for restorative programs, did not receive the recommended ambulation or transfer programs. Despite being initially independent, the resident experienced a decline in mobility, requiring further therapy. The facility failed to implement the recommended restorative programs, and there was no documentation explaining why these were not initiated. Interviews with staff revealed a lack of consistent follow-through and evaluation of the resident's restorative needs, contributing to the resident's decline in function.
Failure to Implement Fall Prevention Interventions and Accurate Investigations
Penalty
Summary
The facility failed to implement interventions and complete accurate investigations to prevent further falls for a resident with severe cognitive impairment and a history of falls. The resident, who was admitted with diagnoses including non-Alzheimer's type dementia, anxiety, and arthritis, was at moderate risk for falls according to the admission Fall Risk assessment. Despite this, there was no fall care plan in place prior to the resident's first fall on 06/05/24. Subsequent falls occurred on multiple occasions, with investigations revealing a lack of immediate interventions and incomplete documentation, such as missing neurological checks and failure to note medication administration prior to falls. The facility's policy required immediate intervention to prevent further falls and thorough documentation of assessments, including neurological checks for residents with head injuries or impaired cognition. However, the investigations into the resident's falls did not adhere to these requirements. For instance, after a fall on 07/06/24, no immediate intervention was implemented, and neurological checks were not completed. Similar deficiencies were noted in subsequent falls, where interventions were either not implemented or inaccurately documented, and neurological assessments were not conducted as per policy. The Director of Nursing confirmed these findings during an interview.
Failure to Provide Adequate Nutrition and Medication
Penalty
Summary
The facility failed to ensure that a resident with significant weight loss received the necessary medications, supplements, and routine meals. The resident, who was admitted with diagnoses including non-Alzheimer's dementia, anxiety, major depressive disorder, breast cancer, and diabetes mellitus type 2, experienced a notable weight loss over several months. Despite recommendations for nutritional supplements and a new medication, Remeron, to increase appetite, the facility did not administer the medication as ordered. The resident's care plan was not updated to reflect the weight loss, and the staff failed to provide meals or supplements when the resident slept through scheduled meal times. Observations revealed that the resident was not offered alternative meals or supplements after missing breakfast due to sleeping. Interviews with staff confirmed that the resident's nutritional needs were not met, and the documentation regarding the administration of Remeron was unclear. The Director of Nursing acknowledged the oversight in not revising the care plan and the failure to provide meals or supplements when the resident was awake. The facility's inaction contributed to the resident's continued weight loss and inadequate nutritional intake.
Failure to Monitor Side Effects of Psychoactive Medication
Penalty
Summary
The facility failed to monitor side effects associated with the use of a psychoactive medication for a resident diagnosed with dementia, anxiety, major depressive disorder, and diabetes mellitus type 2. The resident was prescribed Rexulti, an antipsychotic medication, but the facility did not conduct a baseline Abnormal Involuntary Movement Scale (AIMS) assessment or monitor blood glucose levels as required. The medication guide for Rexulti indicates that it can cause serious side effects, including tardive dyskinesia and hyperglycemia, necessitating regular monitoring of blood sugar levels. Interviews with the Director of Nursing (DON) and a Licensed Practical Nurse (LPN) confirmed that the necessary assessments and monitoring were not performed. The DON acknowledged that the resident, who has diabetes, was not receiving routine blood glucose monitoring as recommended. Additionally, the LPN admitted to not completing the required AIMS assessment before the resident began taking Rexulti. The facility's policy on psychoactive medications mandates that an AIMS assessment be conducted initially and every three months thereafter, which was not adhered to in this case.
Failure to Document and Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure compliance with regulations regarding the administration of psychotropic medications, specifically concerning the use of as-needed (PRN) antianxiety and antipsychotic medications. For Resident #22, the facility did not implement a 14-day stop date for an as-needed antianxiety medication, Ativan, which was ordered by hospice without a stop date. This oversight was confirmed by the Director of Nursing (DON), who acknowledged that more than 14 days had passed since the medication was ordered without a stop date being applied. For Resident #46, the facility did not document behaviors or provide an indication for the use of an antipsychotic medication, Haldol, which was administered as a one-time dose. The resident, who had diagnoses including dementia and anxiety, was given Haldol after being reported as extremely agitated. However, the Nurse Practitioner (NP) was not informed that a dose of Xanax, administered earlier in the day, had been effective. The NP stated that she would not have ordered the antipsychotic if she had known about the Xanax's effectiveness. Additionally, there was no behavior documentation for other PRN anxiolytics administered to the resident, and an AIMS assessment was not completed as required. The facility's policy on psychoactive medications, revised in January 2024, was not adhered to, as it requires documentation of specific behaviors and the use of a behavioral monitoring tool when PRN psychoactive medications are administered. The policy also mandates an AIMS assessment when such drugs are used, which was not completed for Resident #46. The DON confirmed the lack of behavior documentation and the absence of an AIMS assessment, indicating a failure to follow established protocols for the administration of psychoactive medications.
Inaccurate Medical Records for Residents
Penalty
Summary
The facility failed to maintain accurate medical records for two residents, leading to deficiencies in their care documentation. For one resident, the medical record inaccurately documented a pressure ulcer as a Stage 1 ulcer with a depth of 0.1 cm, which is inconsistent with the characteristics of a Stage 1 ulcer. Additionally, a Suspected Deep Tissue Injury (SDTI) was incorrectly recorded with a depth measurement, which should not have been present. These errors were confirmed by a registered nurse during an interview, indicating a lack of accuracy in the resident's medical documentation. For another resident, the facility failed to accurately document an allergy to Exelon, a medication that had previously caused adverse effects. Despite the resident's daughter informing the staff of the allergy and the medication being discontinued, the resident's hard chart inaccurately displayed a label indicating no known allergies. This discrepancy was verified by the Director of Nursing, highlighting a failure to update and maintain accurate allergy information in the resident's medical records.
Resident Information Privacy Breach
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of resident information, affecting one resident during a random observation. The resident, who was admitted with diagnoses including diabetes mellitus and depression, had their electronic medical record left open and visible on a computer screen at the main nurses station. This screen displayed personal health information, including the resident's picture, date of birth, physician name, and medications. At the time of the observation, no staff members were present at the nurses station to monitor the exposed information. A registered nurse later confirmed that the electronic medical record was indeed visible and open, exposing the resident's personal health information.
Failure to Implement Pressure Relieving Measures
Penalty
Summary
The facility failed to ensure pressure relieving measures were in place as ordered for a resident with a history of pressure ulcers. The resident, who was admitted with multiple diagnoses including pressure-induced deep tissue damage of the sacral region, had a care plan intervention to float heels while in bed. However, during an observation, it was noted that the resident's left heel was resting on a pillow instead of floating off it, as per the care plan. The resident expressed discomfort, and staff verified that the heel was not positioned correctly. The resident had a history of a fall resulting in a hip fracture and was readmitted with a suspected deep tissue injury to the sacrum. The resident's medical record indicated a risk of pressure ulcers and required pressure-reducing measures. Despite these documented needs, the facility did not adhere to the care plan, leading to the deficiency. This non-compliance was investigated under a specific complaint number.
Failure to Provide Adequate Catheter Care and Follow Medical Recommendations
Penalty
Summary
The facility failed to provide appropriate treatment and care for a resident with a history of urinary tract infections and an indwelling urinary catheter. The resident, who was admitted with multiple diagnoses including flaccid neuropathic bladder and urinary incontinence, experienced several urinary tract infections over a period of time. Despite recommendations from an infectious disease specialist for specific interventions such as the administration of topical estrogen and a follow-up with a urologist, there was no evidence that these were carried out. Additionally, the resident's catheter care was not performed every shift as ordered, with documentation showing it was only done once a day on several occasions. Further observations revealed that the resident's catheter bag was not covered, and there was white sediment in the tubing and bag, indicating potential issues with catheter maintenance. The facility's policy required catheter care every shift, but this was not adhered to, as confirmed by a registered nurse. Moreover, urine samples were not collected from a clean catheter as recommended, and there was no follow-up visit with a urologist to reassess the need for the indwelling catheter. These lapses in care and failure to follow medical recommendations contributed to the deficiency identified in the report.
Failure to Ensure Proper Antibiotic Review and Consultation
Penalty
Summary
The facility failed to ensure proper review and consultation regarding antibiotic use for two residents. Resident #9 was prescribed Cefdinir for a urinary tract infection (UTI) after returning from the emergency room, but the facility did not confirm whether the urine sample was obtained via catheterization, which is necessary to meet the McGeer criteria for a UTI. The culture results, which showed 50,000 cfu/ml of candida albicans, were not available until after the antibiotic course was completed, and there was no sensitivity panel to confirm the appropriateness of the antibiotic. The Director of Nursing (DON) acknowledged the lack of documentation and efforts to obtain timely lab results or consult with the physician. Resident #15 was admitted with a history of UTIs and was on a daily antibiotic regimen of Macrobid, which was later changed to Trimethoprim due to poor renal function. However, there was no evidence of consultation with a urologist or infectious disease specialist to assess the necessity of a daily preventative antibiotic. The DON confirmed that the resident was taking antibiotics daily without specialist consultation, and the facility physician had agreed to the long-term use of Macrobid for prevention.
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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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