Capital City Gardens Rehabilitation And Nursing Ce
Inspection history, citations, penalties and survey trends for this long-term care facility in Columbus, Ohio.
- Location
- 920 Thurber Drive West, Columbus, Ohio 43215
- CMS Provider Number
- 365315
- Inspections on file
- 56
- Latest survey
- February 4, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Capital City Gardens Rehabilitation And Nursing Ce during CMS and state inspections, most recent first.
The facility failed to maintain appropriate room temperatures, affecting three residents, with temperatures recorded below the acceptable range due to HVAC issues. Additionally, a resident's room had a leaking sink faucet due to scaling buildup, which was not addressed despite the resident's complaints. These deficiencies highlight the facility's failure to provide a comfortable and homelike environment as per their policy.
The facility failed to provide PPE in the laundry room for handling infectious materials, as confirmed by staff interviews. Additionally, a resident on Enhanced Barrier Precautions due to a hemodialysis catheter did not have the required signage on their room, as confirmed by the DON. These deficiencies indicate lapses in the facility's infection prevention and control program.
A resident with a complex medical history felt coerced into participating in a substance abuse program at a facility under the threat of discharge. Despite signing an agreement while hospitalized, the resident did not recall being informed about the program specifics. The facility required mandatory participation in the program, contradicting their agreement with an outpatient service provider, and threatened discharge for non-compliance.
The facility failed to ensure accurate PASARR documentation for three residents, as their current diagnoses were not reflected in the documents. This included omissions of conditions such as bipolar disorder, major depressive disorder, and insomnia, despite these being present in the residents' medical records. The deficiency was confirmed by the social services director, highlighting a lapse in the facility's coordination with the PASARR program.
The facility failed to notify the state mental health agency of significant mental health changes for three residents, affecting their PASARR documentation. One resident had multiple mental health diagnoses not updated, another had diagnoses like bipolar disorder and anxiety disorder missing from documentation, and a third had an inaccurate PASARR screening missing insomnia. Social Services confirmed the inaccuracies, and the facility's policy requiring coordination with the PASARR program was not followed.
The facility failed to obtain weekly weights for two residents as per physician orders, affecting nutritional monitoring. One resident, with complex medical conditions, had only one weight recorded despite orders for weekly checks. Another resident experienced significant weight fluctuations, but the facility did not continue weekly weights as recommended. The facility's policy required weekly weights, but this was not followed, as confirmed by staff interviews.
A resident with chronic respiratory conditions was readmitted to the facility without necessary BiPap orders, despite needing it nightly to prevent life-threatening risks. The omission of these orders was confirmed by the DON and a CNP, indicating a failure to meet the resident's respiratory care needs.
A facility failed to maintain ongoing communication with a dialysis vendor for a resident with chronic kidney disease and end-stage renal disease. The resident had regular dialysis appointments, but post-dialysis forms were incomplete, and staff did not consistently follow up with the dialysis center. Interviews revealed that communication needed improvement, and the facility's policy required ongoing communication about treatment details.
A facility failed to provide parameters for as-needed pain medication for a resident with a complex medical history. The resident's medication orders included acetaminophen, naproxen, and oxycodone, but lacked specific guidelines for administration based on pain levels. Interviews revealed that the facility allowed residents to choose their medication, leading to inconsistent administration practices.
A resident with a history of cerebral infarction and other conditions was found with a medicine cup containing tablets and capsules on the overbed table without a documented assessment for self-medication or a physician's order. The LPN confirmed the medications were left because the resident preferred to take them after breakfast, but did not realize they had not been taken. The DON confirmed that nurses are expected to observe medication administration according to professional standards.
The facility failed to conduct thorough investigations and documentations of allegations of abuse and misappropriation involving three residents. A resident reported a CNA pushed him, another resident reported inappropriate touching by a fellow resident, and a third resident reported a missing earring. In each case, the facility's investigation was incomplete, lacking detailed statements from the residents and relying on identical staff statements that did not recall specific events or interactions.
A facility failed to follow infection control procedures during a dressing change for a resident with multiple health conditions, as an LPN did not wear a gown or wash hands between glove changes. Additionally, improper handling of soiled laundry was observed, with staff throwing laundry down a stairwell and leaving it unbagged, contrary to infection control policies.
A plumbing failure in the B hallway shower room led to severe flooding and unsanitary conditions, affecting residents and staff. The issue persisted over several days, with brown, foul-smelling water reported in hallways and rooms. Despite attempts to manage the situation, structural issues remained unaddressed, violating the facility's maintenance policy.
A resident in a LTC facility sustained severe burns after staff failed to promptly implement fire procedures during a fire in her room. Despite the fire alarm and sprinkler activation, staff delayed in rescuing the resident and extinguishing the fire. The resident, who had a history of mental health issues and was a supervised smoker, intentionally started the fire. Staff inaction included walking past a fire extinguisher without using it and not evacuating other residents, leading to neglect and risk of serious harm.
A resident who required supervision while smoking was found with smoking materials in her room, leading to a fire that caused severe burns. Despite the facility's policy requiring smoking materials to be stored by staff, the resident accessed a lighter and cigarettes, igniting her mattress. The fire department concluded the fire was accidental, caused by smoking materials near high-concentration oxygen. Interviews revealed the facility did not consistently enforce its smoking policy, allowing residents to keep smoking materials in their rooms.
A resident suffered burns during a fire in her room due to the facility's failure to implement fire protocol. Staff did not use a fire extinguisher or evacuate residents promptly, as observed in video footage. The facility delayed reporting the incident to authorities.
A facility failed to manage resources effectively, resulting in a fire incident where a resident, who was supposed to have smoking materials stored by the facility, ignited her bed, causing severe burns. The facility did not report the incident timely, and the investigation was inadequate, revealing a delay in staff response and failure to follow fire safety procedures. The facility's smoking policy was not enforced, and emergency preparedness training was insufficient, placing multiple residents at risk.
A resident at high risk for falls did not have required interventions in place, such as a bed in the lowest position, non-skid footwear, and a reachable call light. An LPN confirmed these lapses, noting the resident's preferences and meal-related adjustments. The facility's fall prevention policy was not followed.
The facility failed to maintain proper infection control during medication administration for a resident with respiratory failure, as a nurse handled oral medications with bare hands. Additionally, the facility did not implement enhanced barrier precautions for a resident with an open coccyx wound, as nurses did not wear gowns during dressing changes, contrary to facility policy.
The facility was found to be in disrepair and unclean, affecting all 87 residents. Observations revealed missing transition strips, dirty and chipped door frames, peeling wallpaper, rusting vents, and splatter marks on walls. The therapy gym had a chipping door with a sharp edge, and the C and B hallways had dirty floors and walls. The downstairs counseling space had exposed brick, and the staff lounge was closed due to a water leak and mold-like substance. Employees faced slip, trip, and fall hazards from leaking pipes and potential health hazards from untreated mold. A policy for maintaining a safe and sanitary environment was not provided.
A resident, dependent on staff for personal hygiene due to medical conditions, was not assisted with shaving her face because of a lack of supplies. Despite having intact cognition and not refusing care, the resident had not been shaved since admission, leading to embarrassment. The DON confirmed the presence of facial hair but claimed the resident was not bothered. Facility policy required staff to assist with grooming, which was not followed.
A resident with a seizure disorder did not receive their prescribed valproic acid solution from 02/14/24 through 03/13/24 due to a transcription error by the admitting nurse. The resident was readmitted to the hospital with seizure activity, and the error was confirmed by the facility's Director of Nursing.
Facility Fails to Maintain Appropriate Room Temperatures and Address Maintenance Issues
Penalty
Summary
The facility failed to maintain appropriate air temperatures in resident rooms, affecting three residents. One resident, who was cognitively intact, was observed under multiple blankets due to cold temperatures in her room, which was recorded at 66 degrees Fahrenheit. The resident reported that the room was consistently cold, and maintenance staff confirmed the issue was due to air pockets in the HVAC system. Another resident also experienced cold room temperatures, recorded at 68 degrees Fahrenheit, and reported the issue had persisted for about a week. The maintenance director confirmed the temperature was outside the acceptable range and attributed it to the same HVAC issue. A third resident, who was also cognitively intact, reported that their room had been cold since admission, with temperatures fluctuating between 69 and 70 degrees Fahrenheit. The maintenance director confirmed the room temperature was below the acceptable range of 71 to 81 degrees Fahrenheit. The facility's policy on providing a homelike environment specifies maintaining comfortable and safe temperatures within this range. Additionally, the facility failed to address a maintenance issue in another resident's room, where a sink faucet was leaking due to a buildup of scaling. The resident, who was cognitively intact and had a diagnosis of anxiety, reported the issue and found the noise annoying. Despite notifying staff, the maintenance director was unaware of the problem and no request had been made to fix the sink. This oversight further contributed to the facility's failure to provide a comfortable and homelike environment as per their policy.
Infection Control Deficiencies in PPE and Isolation Procedures
Penalty
Summary
The facility was found to have deficiencies in its infection prevention and control program. During an observation of the laundry room, it was noted that there was no personal protective equipment (PPE) available for handling infectious materials. This was confirmed through interviews with the Housekeeping Supervisor and a Laundry Aide. Additionally, a Corporate Nurse revealed that there were residents on transmission-based precautions due to infections, yet the facility's policy from August 2014, which mandates the use of gloves for contact with potentially hazardous materials, was not being followed. Furthermore, the facility failed to implement proper isolation procedures for a resident with a hemodialysis catheter, who was on Enhanced Barrier Precautions. Observations showed that there was no signage on or outside the resident's room to indicate these precautions, which was confirmed by the Director of Nursing. The facility's policy from April 2024 requires signage to ensure staff awareness of hand hygiene and gown/glove use when Enhanced Barrier Precautions are in place, but this was not adhered to in the case of the resident.
Resident's Right to Refuse Treatment Violated
Penalty
Summary
The facility failed to honor a resident's right to refuse treatment without the threat of discharge, affecting one resident reviewed for dignity and rights. The resident, who was cognitively intact, had a complex medical history including osteomyelitis, asthma, and substance abuse. She signed a Substance Use Disorder Program agreement while hospitalized, agreeing to participate in the facility's Stepping Stones program. However, upon admission, she felt coerced into participating in the program under the threat of discharge, despite not recalling being informed about the program specifics during her hospital stay. Interviews with the resident revealed she felt forced to participate in the Stepping Stones program, which included counseling, drug testing, and supervised visits, under the threat of being discharged. She expressed that she did not want to participate in these activities and would not have chosen the facility had she known participation was mandatory. The facility's administrator and counselor confirmed that residents are required to sign a contract agreeing to the program before admission, and refusal to participate would lead to discharge planning. The facility's agreement with Stepping Stones Outpatient Services, LLC, stated that residents are not obligated to use the services offered by the provider. However, the facility's practice contradicted this agreement, as refusal to participate in the program led to discharge planning. The facility's policy required mandatory participation in the program, and refusal resulted in immediate discharge planning, which violated the resident's rights to refuse treatment without the threat of discharge.
Inaccurate PASARR Documentation for Residents
Penalty
Summary
The facility failed to ensure that the Pre-Admission Screening and Resident Review (PASARR) documents were accurate and reflective of the current conditions and diagnoses of the residents. This deficiency affected three residents out of the four reviewed for PASARR documents. For Resident #3, the PASARR document did not include diagnoses such as bipolar disorder, major depressive disorder, and post-traumatic stress disorder, despite these being present in the resident's medical record. Similarly, Resident #15's PASARR document omitted diagnoses like bipolar disorder, anxiety disorder, and adult failure to thrive, which were documented in her medical record. Resident #59's PASARR document was also found to be inaccurate as it did not include the diagnosis of insomnia, despite the resident being treated for it with Melatonin and other medications. The facility's policy requires coordination with the PASARR program to ensure residents with mental disorders or related conditions receive appropriate care. However, the social services director confirmed that the PASARR documents for these residents were not updated to reflect their current diagnoses, leading to the identified deficiency.
Failure to Update PASARR Documentation for Residents
Penalty
Summary
The facility failed to notify the state mental health agency of significant mental health changes for residents requiring Pre-Admission Screening and Resident Review (PASARR) updates. This deficiency affected three residents who had changes in their mental health diagnoses that were not communicated as required. Resident #3 had multiple mental health diagnoses, including bipolar disorder and major depressive disorder, which were not updated on her PASARR document. Similarly, Resident #15 had diagnoses such as bipolar disorder and anxiety disorder that were not reflected in her PASARR documentation. In both cases, there was no evidence in the progress notes to indicate that the state mental health agency had been informed of these significant changes. Resident #59 also experienced a deficiency in PASARR documentation. The resident's PASARR screening did not include the diagnosis of insomnia, despite it being a part of the resident's medical record and treatment plan. An interview with Social Services confirmed that the PASARR screening was inaccurate and had been sent to the Department of Aging without the necessary updates. The facility's policy requires coordination with the PASARR program to ensure residents with mental disorders receive appropriate care, but this was not adhered to, leading to the deficiencies noted.
Failure to Obtain Weekly Weights for Nutritional Monitoring
Penalty
Summary
The facility failed to ensure weekly weights were obtained per physician orders for two residents, leading to deficiencies in nutritional monitoring. Resident #92, who was admitted with multiple complex medical conditions including infective endocarditis, hepatitis, and a history of weight loss, had a physician order for weekly weight checks to monitor and maintain a stable weight. However, the facility only recorded one weight measurement on 11/12/24, despite the care plan and physician orders indicating the need for weekly monitoring. Interviews with facility staff confirmed the oversight in obtaining the required weekly weights. Resident #77, admitted with conditions such as end-stage renal disease and congestive heart failure, also had physician orders for weekly weight checks to establish a baseline due to significant weight fluctuations. The resident's weights showed a notable decrease from 200 pounds to 180.2 pounds over a short period, triggering dietary recommendations for continued weekly monitoring. Despite these orders and recommendations, the facility failed to record any weights after 02/10/25, which was necessary to verify the initial weight and monitor ongoing changes. The facility's policy on weight assessment and intervention, dated September 2012, outlines the requirement for weights to be measured on admission, the next day, and weekly for two weeks thereafter. However, the facility did not adhere to this policy, resulting in a lack of consistent weight monitoring for the residents involved. Interviews with the dietitian and corporate nurse confirmed the failure to obtain the necessary weekly weights, highlighting a gap in the facility's adherence to its own policies and physician orders.
Failure to Ensure Resident's Respiratory Needs with BiPap
Penalty
Summary
The facility failed to meet the respiratory needs of a resident who required a BiPap machine. The resident, admitted with chronic obstructive pulmonary disease, asthma, pulmonary embolism, and heart failure, was hospitalized and upon readmission to the facility, her BiPap orders were omitted. The resident was supposed to have BiPap orders for use at bedtime, as per physician orders, to prevent life-threatening risks. However, there was a gap in the orders from the time of her readmission until several days later, during which the necessary BiPap orders were not entered. This omission was confirmed by both the Director of Nursing and the Certified Nurse Practitioner, highlighting a lapse in ensuring the resident's critical respiratory care needs were met.
Deficiency in Dialysis Communication for Resident
Penalty
Summary
The facility failed to ensure ongoing communication between the facility and the dialysis vendor for a resident requiring dialysis services. This deficiency affected a resident with chronic kidney disease, end-stage renal disease, chronic viral hepatitis C, hypertension, and dependence on renal dialysis. The resident had a standing appointment for dialysis at an outside clinic three times a week, with orders for nursing staff to complete pre- and post-dialysis communication forms on specific days. However, observations revealed that some post-dialysis forms were incomplete in the resident's hard chart. Interviews with staff, including an LPN and the Director of Nursing (DON), highlighted lapses in communication. The LPN admitted that when the resident returned from dialysis without a communication sheet, there was no follow-up with the dialysis center to inquire about the services performed. Additionally, the DON confirmed that communication with the dialysis center needed to be more defined and expected nurses to read communications from the dialysis center. A review of the facility's undated Hemodialysis policy indicated that there should be ongoing communication between the dialysis center staff and the facility, including details on weight changes, medication administration, and treatment complications.
Lack of Parameters for As-Needed Pain Medication
Penalty
Summary
The facility failed to provide parameters for as-needed pain medication for a resident, which was identified during a medical record review and staff interview. The resident, who was admitted in March 2019, had a complex medical history including conditions such as acute bronchitis, epileptic seizures, PTSD, and pain, among others. The physician orders from December 2024 to March 2025 included acetaminophen, naproxen, and oxycodone for pain management, but lacked specific parameters indicating which medication should be administered based on the resident's pain level. The medication administration record showed that the resident received these medications at varying pain levels, with oxycodone being administered even at pain levels as low as 0. Interviews with the LPN and DON revealed that the facility did not have a standard practice for setting parameters for as-needed pain medications. Instead, the decision was left to the residents, with nurses asking about their pain levels and allowing them to choose their preferred medication. This lack of structured guidance led to the deficiency noted by the surveyors.
Failure to Secure and Administer Medications Properly
Penalty
Summary
The facility failed to secure and store medications appropriately, affecting one resident during the annual survey. The resident, who was cognitively intact and had a history of cerebral infarction, dysphagia, major depressive disorder, psychoactive substance abuse, disorientation, anxiety disorder, and pain, was observed with a medicine cup containing several tablets and capsules on the overbed table. There was no documented assessment or screening for self-medication, nor was there a physician's order for the resident to self-administer medications. An interview with the resident revealed that the medications might be his morning doses, which he needed to confirm with his nurse. The LPN confirmed that the medication cup with morning medications was left on the overbed table because the resident preferred to take medications after breakfast. The LPN did not realize the resident had not taken the medication yet. The Director of Nursing confirmed that the expectation is for nurses to follow professional standards of medication administration, which includes observing the patient take the medication at the time it is brought into the room. The facility's policy on administering medications, dated December 2012, aligns with these expectations.
Incomplete Investigations of Abuse and Misappropriation Allegations
Penalty
Summary
The facility failed to conduct thorough investigations and documentations of allegations of abuse and misappropriation involving three residents. Resident #94, who was cognitively intact, reported an incident where a CNA allegedly pushed him after being woken up for assistance. The facility initiated an investigation, but the documentation was incomplete, lacking a written or signed statement from the resident. The investigation relied on identical staff statements that did not recall specific events or interactions, and the facility's summary did not constitute actual evidence. Resident #86, also cognitively intact, reported inappropriate touching by another resident. The police were notified, and an investigation was initiated. However, the investigation documentation was insufficient, with no detailed statement from the resident and only a brief questionnaire with yes or no answers. The facility's investigation summary did not include a direct account from the resident, and the staff statements were identical and lacked specific details about the incident. Resident #95 reported a missing diamond earring, but there was no specific allegation of theft. The facility conducted interviews with like residents, but failed to provide evidence of interviews or statements from the resident or staff. The investigation documentation was incomplete, and the facility's summary did not include a direct account from the resident. The facility's policy required thorough investigations with documented evidence, but the investigations in these cases were incomplete and lacked necessary documentation.
Infection Control Deficiencies in Wound Care and Laundry Handling
Penalty
Summary
The facility failed to implement proper infection control procedures during a dressing change for a resident with multiple health conditions, including type 2 diabetes mellitus, HIV, pneumonia, and a staphylococcus infection. The resident required enhanced barrier precautions due to an indwelling medical device and a wound. During an observation, an LPN did not wear a gown as required and failed to wash hands between glove changes while performing wound care on the resident. The facility's policy on wound care and enhanced barrier precautions clearly outlined the need for gown and glove use during such procedures, which was not adhered to by the LPN. Additionally, the facility did not follow proper infection control procedures in handling soiled laundry. Due to an out-of-order elevator, laundry staff were observed throwing soiled laundry down a stairwell to a landing, where it was left until it could be collected and taken to the laundry room. Observations revealed unbagged and visibly soiled laundry on the stairwell, contrary to the facility's expectations for handling soiled laundry. Interviews with staff confirmed these practices, which did not align with the infection control procedures required to prevent contamination.
Plumbing Failure and Unsanitary Conditions in Shower Room
Penalty
Summary
The facility failed to maintain a safe, functional, and sanitary environment in the shower room located in the B hallway, which had the potential to affect all residents residing in the facility. The issue began with a plumbing failure that resulted in a shower drain backup, leading to emergency flooding over the course of three days. The plumbing company was called to address the issue, and although they initially removed a blockage, the problem persisted, causing severe flooding in the B hallway and affecting several resident rooms. Observations revealed that the shower room had multiple ceramic tiles on the floor, exposing wet wall material, and a three-inch hole behind the toilet. A brown substance with dried particles was noted in the shower stall, indicating unsanitary conditions. Interviews with residents and staff confirmed the presence of brown, foul-smelling water in the hallway and rooms, and the shower room was unusable for a period. The facility attempted to manage the situation by offering to relocate affected residents and providing emergency water sources and hygiene wipes during the water shut-off. The plumbing company returned to the facility to further investigate and repair the issue, discovering that the blockage was caused by washcloths and fabric debris. Despite the restoration of water flow and the shower room being placed back into service, the structural issues, such as the hole in the wall and loose tiles, remained unaddressed. The facility's maintenance policy requires maintaining the building in a safe and operable manner at all times, which was not upheld in this instance.
Neglect in Fire Response
Penalty
Summary
The facility failed to ensure a resident was free from neglect when staff did not timely implement fire procedures during a fire incident in a resident's room. The fire occurred in the resident's room, igniting the mattress and bedding, which activated the fire alarm and sprinkler system. Despite the alarm, staff did not immediately implement fire protocols to rescue, contain, or extinguish the fire. The delay in response resulted in the resident sustaining burns to her legs, torso, and arm, and she was transferred to the hospital for treatment of extensive burns and acute respiratory failure. The resident involved had a history of chronic obstructive pulmonary disease, peripheral vascular disease, depression, anxiety, and suicidal ideation. She was cognitively intact but required assistance with personal hygiene, dressing, and transfers. The resident was a supervised smoker, and her smoking materials were supposed to be stored by the facility for safety. However, the resident intentionally started the fire to get staff's attention, using a lighter to ignite the fire on her bed. The facility's investigation could not determine how the resident obtained the lighter. Video footage and staff interviews revealed that multiple staff members walked past a fire extinguisher without attempting to use it, and they did not evacuate other residents or close room doors to contain the fire. The staff's inaction and failure to follow fire safety protocols placed the resident and others in the smoke compartment at risk of serious harm. The facility's response to the fire was inadequate, as staff did not promptly rescue the resident or effectively manage the fire situation.
Removal Plan
- The fire alarm sounded which transmits an alarm to the fire department of the fire.
- The facility's incident investigation indicated Licensed Practical Nurse (LPN) #251 called 911 to report the incident of fire.
- Residents are seen via facility video camera footage to be directed out of their rooms and attempting to make their way off the hallway.
- LPN #251 was observed via video footage to take a fire extinguisher into the resident's room B05, identified as Room B05.
- The facility had completed a head count of residents, and all 90 residents were accounted for.
- The Columbus Fire Department exited the facility, and a Fire Watch was initiated and completed by the Administrator and DON.
- Respiratory Assessments were initiated by Unit Manager/ LPN #225, and LPN #203 on Residents #17, #20, #18, #15, #21, #23, #22, #16, and #11, who resided in the same smoke compartment where the fire was located, with no adverse reactions noted.
- Cleaning of the fire debris in Room B05 and the adjacent hall area began by Maintenance Director #390 and Regional Environmental Services #805.
- All residents who lived in the smoke compartment where the fire occurred were temporarily moved to open rooms in the B and C halls.
- Four sprinkler heads were replaced in Room B05 by Fire Safety Company #800 to maintain safety in the building and restore water to the facility.
- All 88 residents were interviewed for post incident safety, conducted by Admissions, Licensed Social Worker (LSW) #270 and Human Resource Director #259.
- The Fire Department inspected the facility and cleared the facility from Fire Watch.
- The two fire extinguishers that were used and deployed during the fire were replaced by Maintenance Director #390.
- All department managers were educated by the Regional Director of Clinical Services (RDCS) #810 on the Smoking Policy, Change in Condition Policy, Fire safety (RACE & PASS), and Abuse and Neglect Policy.
- An all-staff education was initiated by Department Managers and the DON for the facility's employees.
- All 88 resident rooms were searched by the Department Managers for smoking contraband.
- All 88 residents were assessed by Unit Manager LPN#225, Unit Manager LPN #579, and Registered Nurse (RN) #820 for a change in condition.
- A Fire Drill was conducted by Maintenance Director #390 without incident.
- The Fire Marshall was notified by the Administrator of the incident of fire via the Fire Marshall's electronic portal.
- A second Respiratory Assessment was initiated on Residents #17, #20, #18, #15, #21, #23, #22, #16, and #11.
- A Quality Assurance and Performance Improvement (QAPI) meeting was held with the Administrator, RDCS #810, LSW #270, Maintenance Director #390, Unit Manager LPN #225, Human Resources #259, Therapy Director #825, Business Office Manager #830, Activity Director #268, Dietary Manager #835, Medical Records/Central Supply #840, Assistant Director of Dietary #845, Housekeeping Manager #850, and Medical Director #900.
- Resident Smoke Breaks- five times a week for four weeks, then one time a week for four weeks, completed by the DON.
- Room Sweeps for Smoking Materials- three times per week for four weeks and one time a week for four weeks, completed by the Departmental Managers.
- Fire Drills on Each Shift - weekly for eight weeks (7a-7p and 7p-7a), completed by Maintenance Director #390.
- Assess/Re-educate as needed - staff knowledge of Fire Safety RACE/PASS - weekly/per shift times eight weeks, completed by Maintenance Director #390.
Failure to Enforce Smoking Policy Leads to Resident Fire Incident
Penalty
Summary
The facility failed to ensure a safe environment for a resident who utilized oxygen therapy and smoked cigarettes, leading to a fire in the resident's room. The resident, who was cognitively intact but required supervision with smoking, was found to have smoking materials, including cigarettes and a lighter, in her room. This was against the facility's smoking policy, which required smoking materials to be stored by the facility. The fire, which occurred in the resident's room, resulted in severe burns to the resident and posed a risk to other residents in the same smoke compartment. The resident had a history of chronic obstructive pulmonary disease and required oxygen therapy. Despite being assessed as needing supervision while smoking, the resident was able to access smoking materials and a lighter, which led to the ignition of her mattress and bedding. The fire department's investigation concluded that the fire was accidental, caused by smoking materials in close proximity to high-concentration oxygen. The resident was transferred to the hospital with extensive burns and acute respiratory failure. Interviews with staff and residents revealed that the facility did not consistently enforce its smoking policy, allowing residents to keep smoking materials in their rooms. Several residents confirmed that they were not required to hand in their smoking materials, and staff interviews indicated a lack of adherence to the policy. The facility's failure to monitor and control the possession of smoking materials by residents who required supervision directly contributed to the incident.
Removal Plan
- The fire alarm sounded which transmits an alarm to the fire department of the fire.
- The facility's incident investigation indicated Licensed Practical Nurse (LPN) #251 called 911 to report the incident of fire.
- Residents are seen via facility video camera footage to be directed out of their rooms and attempting to make their way off the hallway.
- LPN #251 was observed via video footage to take a fire extinguisher into the resident's room, identified as Room B05.
- Resident #19 was observed on the video footage being brought out of Room B05 in the bed and was pushed down the hallway by LPNs #251 and #444, and STNA #248 with Police Officers following.
- The facility had completed a head count of residents, and all 90 residents were accounted for.
- The Columbus Fire Department exited the facility, and a Fire Watch was initiated and completed by the Administrator and DON.
- Respiratory Assessments were initiated by Unit Manager/LPN #225, and LPN #203 on Residents #17, #20, #18, #15, #21, #23, #22, #16, and #11, who resided in the same smoke compartment where the fire was located, with no adverse reactions noted.
- Cleaning of the fire debris in Room B05 and the adjacent hall area began by Maintenance Director #390 and Regional Environmental Services #805.
- All residents who lived in the smoke compartment where the fire occurred were temporarily moved to open rooms in the B and C halls.
- Four sprinkler heads were replaced in Room B05 by Fire Safety Company #800 to maintain safety in the building and restore water to the facility.
- All 88 residents were interviewed for post incident safety, conducted by Admissions, Licensed Social Worker (LSW) #270 and Human Resource Director #259.
- The facility smoking policy was reviewed and revised by [NAME] President of Clinical services #340 to make all smoking supervised and all smokers have to submit smoking articles to staff.
- The Fire Department inspected the facility and cleared the facility from Fire Watch.
- The two fire extinguishers that were used and deployed during the fire were replaced by Maintenance Director #390.
- All department managers were educated by the Regional Director of Clinical Services (RDCS) #810 on the Smoking Policy, Change in Condition Policy, and Fire Safety (RACE & PASS) Policy.
- An all-staff education was initiated by Department Managers and the DON for the facility's employees.
- The Administrator held a meeting with the 50 residents who smoke to review and sign the revised Smoking Policy and smoking process.
- Smoking assessments began on all residents that currently smoke by Unit Manager LPN #579 and Unit Manager LPN #225.
- All 88 resident rooms were searched by the Department Managers for smoking contraband.
- All 88 residents were assessed by Unit Manager LPN #225, Unit Manager LPN #579, and Registered Nurse (RN) #820 for a change in condition.
- A Fire Drill was conducted by Maintenance Director #390 without incident.
- The Fire Marshall was notified by the Administrator of the incident of fire via the Fire Marshall's electronic portal.
- A second Respiratory Assessment was initiated on Residents #17, #20, #18, #15, #21, #23, #22, #16, and #11.
- The care plans of residents who were previously unsupervised smokers were revised to now being supervised smokers by Minimum Data Set (MDS) LPN #855.
- A Quality Assurance and Performance Improvement (QAPI) meeting was held with the Administrator and other key staff.
- Resident Smoke Breaks - five times a week for four weeks, then one time a week for four weeks, completed by the DON.
- Room Sweeps for Smoking Materials - three times per week for four weeks and one time a week for four weeks, completed by the Departmental Managers.
- Fire Drills on Each Shift - weekly for eight weeks (7a-7p and 7p-7a), completed by Maintenance Director #390.
- Assess/Re-educate as needed - staff knowledge of Fire Safety RACE/PASS - weekly/per shift times eight weeks, completed by Maintenance Director #390.
Failure to Implement Fire Protocol and Report Incident
Penalty
Summary
The facility failed to report an incident of potential neglect when it did not timely implement fire protocol during a fire in a resident's room. The incident involved Resident #19, who had a fire in her room, and it had the potential to affect nine other residents living in the same smoke compartment. The facility's staff did not follow the fire safety procedures, which included rescuing residents, containing the fire, and evacuating residents. Resident #19, who was cognitively intact and dependent on staff for various daily activities, suffered third-degree burns to her legs during the incident. The fire alarm was activated, and staff members were observed on video footage failing to take immediate action to extinguish the fire or evacuate residents. Staff walked past a fire extinguisher multiple times without using it and did not assist residents in evacuating the hallway filled with smoke. The facility's Regional Director of Operations confirmed that the staff did not follow the fire safety policy and procedures. The facility did not submit a self-reported incident regarding the fire until after a review of the video footage, which showed that the staff's response was inadequate. The facility's policy required immediate reporting of such incidents to the Administrator and the Ohio Department of Health, which was not done in a timely manner.
Facility's Ineffective Resource Management Leads to Fire Incident
Penalty
Summary
The facility failed to administer its resources effectively and efficiently, leading to a significant incident involving a fire in a resident's room. The fire occurred when a resident, who was supposed to have her smoking materials stored by the facility, was found with a lighter and cigarettes, which she used to ignite her bed. This resulted in the resident sustaining severe burns and requiring hospitalization. The facility did not report the incident as an injury of unknown origin or potential neglect to the State Survey Agency in a timely manner. The investigation into the fire incident was inadequate, as the facility did not thoroughly review all available camera footage, which later revealed a delay in staff response to the fire. The staff failed to follow established fire safety procedures, such as using fire extinguishers and closing doors to contain the fire. Interviews with staff and residents indicated that the facility's smoking policy was not enforced prior to the incident, allowing residents to keep smoking materials in their possession unsupervised. Additionally, the facility's emergency preparedness training was insufficient, with only a portion of the staff receiving education on fire safety procedures. Some staff members were unable to recall the training or the meaning of fire safety acronyms. The facility's failure to implement its smoking policy and emergency procedures contributed to the severity of the incident, placing multiple residents at risk.
Failure to Implement Fall Interventions for High-Risk Resident
Penalty
Summary
The facility failed to ensure that fall interventions were in place for a resident identified as high risk for falls. Resident #22, who was admitted with diagnoses including seizures, delirium, hemiplegia, and mild cognitive impairment, was assessed using the Morse Fall Scale and determined to be at high risk for falling. The care plan for this resident included specific fall interventions such as bright colored tape on the call light, a defined perimeter mattress, non-skid footwear, a fall mat on the right side of the bed, and keeping the bed in the lowest position with the call light within reach. During an observation, it was noted that several of these interventions were not in place. The resident's bed was not in the lowest position, non-skid footwear was not worn, and the call light was not within reach nor marked with bright colored tape. An LPN confirmed these observations, noting that the resident did not like to wear socks to bed and that the bed was elevated for lunch. The facility's policy on falls, dated 09/2012, requires staff to implement and monitor interventions to prevent falls, which was not adhered to in this instance.
Infection Control Deficiencies in Medication Administration and Wound Care
Penalty
Summary
The facility failed to maintain proper infection control measures during medication administration for Resident #22. The resident, who was admitted with diagnoses of respiratory failure and muscle weakness, was dependent on staff for activities of daily living, including medication administration. During an observation, a registered nurse dispensed Gabapentin capsules into her bare hand before placing them into a medication cup for administration to the resident. This action was confirmed by the nurse during an interview, acknowledging that she should not have touched the resident's oral medications with her bare hands. The facility's policy on administering medications requires staff to follow established infection control procedures, which were not adhered to in this instance. Additionally, the facility failed to implement enhanced barrier precautions (EBP) for Resident #28, who had an open coccyx wound. The resident, admitted with diagnoses including protein calorie malnutrition and muscle weakness, required assistance with activities of daily living and had intact cognition. During a wound care observation, nurses did not don gowns prior to completing the dressing change, despite the presence of personal protective equipment in the resident's room. Interviews with nursing staff and the Director of Nursing confirmed that there was no order for EBP related to the resident's open wound, and that gowns should have been worn during dressing changes. The facility's policy on EBP indicates that such precautions are necessary for residents with open wounds, regardless of their multi-drug resistant organism status.
Facility Maintenance and Cleanliness Deficiencies
Penalty
Summary
The facility was found to be in a state of disrepair and uncleanliness, affecting all 87 residents. During a survey, it was observed that various areas of the facility were not maintained in a clean, homelike environment. Specific issues included a missing transition strip to the dining room, dirty and chipped door frames, peeling wallpaper, rusting ceiling vents, and splatter marks on walls. Additionally, the therapy gym had a chipping door with a sharp edge and stained wallpaper. The C hallway had dirty floors with mud and tire marks, and the B hallway had a bathroom door splattered with a brown substance and rusted vents. The downstairs counseling space had exposed dirty brick due to missing drywall, and the staff lounge was closed due to renovations after a water leak and mold-like substance were identified. The facility's maintenance issues extended to safety hazards, as employees were exposed to slip, trip, and fall hazards from leaking pipes, and potential health hazards from untreated mold accumulation. The facility failed to provide a policy for maintaining a safe and sanitary environment. The report also noted that a sink in room B27 had been broken for three months before being repaired. These deficiencies were investigated under Complaint Number OH00154570, highlighting the facility's failure to maintain a safe, clean, and comfortable environment for residents, staff, and the public.
Failure to Assist Resident with Personal Hygiene
Penalty
Summary
The facility failed to assist a female resident with shaving her face, which was necessary for her personal hygiene. The resident, who was admitted with diagnoses including cerebral infarction, hemiplegia, hemiparesis, depression, chronic obstructive pulmonary disease, and type II diabetes, was dependent on staff for personal hygiene tasks. Despite having intact cognition and not refusing care, the resident had not been shaved since her admission due to a lack of supplies. This was confirmed during an observation and interview, where the resident expressed embarrassment over her facial hair. The Director of Nursing acknowledged the resident's facial hair but stated that the resident was not bothered by it. The facility's policy indicated that staff should assist with grooming as needed, but this was not adhered to in this case.
Failure to Administer Seizure Medication
Penalty
Summary
The facility failed to ensure that medications were administered without significant errors, affecting a resident with a seizure disorder, COPD, and dependence on a respirator. The resident was readmitted to the facility on 02/14/24 with an order for valproic acid solution to be administered three times daily via a gastrostomy tube. However, due to a transcription error by the admitting nurse, the medication order was not entered into the electronic medical record (EMR), resulting in the resident not receiving the prescribed medication from 02/14/24 through 03/13/24. The resident was subsequently readmitted to the hospital on 03/14/24 with seizure activity. The hospital staff noticed that valproic acid solution was missing from the resident's medication list. The facility's Director of Nursing confirmed the medication error and the failure to administer the medication as ordered. The facility's policy requires that medications be administered as ordered by the physician, which was not followed in this case. This deficiency was investigated under Complaint Number OH00152209.
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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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