Carecore At Margaret Hall
Inspection history, citations, penalties and survey trends for this long-term care facility in Cincinnati, Ohio.
- Location
- 1960 Madison Road, Cincinnati, Ohio 45206
- CMS Provider Number
- 365733
- Inspections on file
- 22
- Latest survey
- February 23, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Carecore At Margaret Hall during CMS and state inspections, most recent first.
A resident with cognitive deficits, total dependence for ADLs, and incontinence was care planned as being at risk for constipation and had PRN bowel medications ordered, along with an intervention to record daily bowel patterns. For approximately two months, staff failed to document any bowel movements despite a policy requiring shift-by-shift bowel documentation, and the NP was not made aware of the lack of bowel records. During a change in condition, staff focused on respiratory symptoms and did not perform or document an abdominal assessment, even though it was reported the resident had not had a recent bowel movement. The resident was subsequently hospitalized with respiratory failure and was found to have a fecal impaction with concern for stercoral colitis, requiring manual disimpaction, enema, and initiation of a bowel regimen.
Surveyors found that breakfast service did not follow the approved menu or dietary spreadsheets, including required portion sizes and planned items. Instead of the scheduled sausage egg bake, staff routinely served scrambled eggs, toast, and sausage patties, and hot cereal was dished out with a slotted spoon without measuring, resulting in inconsistent portions. The dietary manager acknowledged that casseroles and similar items on the menu were regularly replaced with scrambled eggs and the corresponding breakfast meat due to some residents not eating pork, and that these substitutions were not reviewed with the RD. The RD stated that menus and spreadsheets were expected to be followed and that she should be consulted for any menu changes. The facility identified two residents who did not receive food from the kitchen, and the practice had the potential to affect most residents in the building.
Surveyors found that hot foods and cold beverages were not served at appropriate temperatures during a meal service, with eggs and sausage measured in the 90°F range and milk and juice above 48°F. The Dietary Manager confirmed these temperatures and acknowledged expectations that hot foods be at least 120°F and cold beverages at or below 40°F. Several residents reported receiving cold eggs and sausage, and facility policy identified the temperature range between 41°F and 135°F as a danger zone for potentially hazardous foods such as meats, poultry, eggs, and milk.
Surveyors identified multiple food safety and hygiene failures, including staff with facial hair preparing and handling food without beard restraints, staff entering the kitchen and handling prepared trays without prior handwashing, and improper cleaning of a food thermometer between checking different foods. Inspectors also found improperly labeled and outdated refrigerated items, such as thickened water and cottage cheese, and observed a dropped breakfast tray being reassembled after contact with the floor and then placed on a cart containing clean trays, glasses, condiments, and milk. These issues affected nearly all residents receiving meals from the kitchen.
Surveyors found that kitchen staff did not have access to adequate handwashing facilities while food was being prepared for most residents. One dietary staff member was observed cooking while the front kitchen handwashing sink had no running water, and the back sink lacked soap. The staff member suggested using a pot-filling spigot for handwashing and obtained paper towels from a food preparation area because none were stocked at the front sink. The dietary manager later reported he was unaware the front sink was not working, despite facility policy requiring accessible sinks, soap, and towels.
Surveyors found that the facility failed to provide and document required ADL care for two residents. One resident with Parkinson’s disease, DM2, and spinal stenosis, who was cognitively intact but dependent on staff for bathing, had scheduled showers twice weekly, yet there was no documentation of showers or refusals on multiple scheduled days, confirmed by the DON. Another cognitively intact resident with DM2, Raynaud’s syndrome, osteoarthritis, and significant self-care deficits required substantial/maximal assistance with bathing and personal hygiene; observations showed excessively long and jagged fingernails on two consecutive days. The resident reported requesting nail trimming and not wanting long nails, and a CNA confirmed the condition of the nails and that nail care, typically done with showers or daily care, had not been completed despite notifying the assigned aide and nurse. Facility policy required appropriate hygiene, bathing, and grooming support for residents unable to perform ADLs independently.
The facility failed to maintain accurate and complete medical records and ADL documentation for three residents. One resident with diabetes, Parkinson’s disease, and spinal stenosis had extensive missing documentation over two months for ADLs, continence, behaviors, and meal/fluid intake, despite requiring staff assistance. Another resident with COPD and CHF who died in the facility had no progress note documenting the death, which the DON later confirmed was absent. A third resident with cerebral infarction, anemia, depression, and mood disorder, identified as at risk for constipation and always incontinent per MDS, had no bowel movement documentation for two months, contrary to the care plan requirement for daily bowel movement recording.
Staff failed to follow the facility’s Enhanced Barrier Precautions (EBP) policy when an LPN administered medication via gastrostomy tube to a resident with an enteral tube and wounds, who had been placed on EBP by physician order, without wearing a gown or gloves. The LPN acknowledged awareness that the resident was on EBP and that appropriate PPE should have been used, despite a facility policy stating EBP would be implemented to prevent transmission of multidrug-resistant organisms.
The facility failed to answer phones during nighttime hours, affecting a resident who fell and required assistance. The resident's family had to enter the facility with EMTs due to the inability to reach staff by phone. The night shift supervisor did not report to work, and the phone was left on the reception desk, leading to calls going to voicemail instead of being answered.
A resident with chronic respiratory failure and dementia did not receive timely incontinence care, as required by their care plan. The CNA responsible did not change the resident's incontinence brief for several hours, despite the care plan's directive for changes every two hours. This lapse in care was confirmed during a complaint investigation.
A resident with chronic respiratory failure and dementia, at risk for falls, was transferred using a sit to stand lift by a single CNA, contrary to facility policy requiring two staff members. The resident slid to the floor without injury. The CNA was terminated for violating the policy.
A resident experienced discomfort due to inadequate room temperature, with the heater blowing cold air despite complaints since October. The room temperature was recorded at 68°F, below the facility's policy of 71-81°F. Maintenance attempts were made, but the issue remained unresolved, and a space heater provided by the resident's brother was removed by staff.
A resident with cognitive deficits and a history of cerebral infarction was injured due to improper use of a stand-up lift instead of the recommended Hoyer lift. The resident, on blood-thinning medication, sustained bruising, which was confirmed to be caused by the incorrect transfer method, contrary to the care plan and therapy recommendations.
A resident, dependent on staff for transfers and severely cognitively impaired, was not assisted out of bed despite requesting to do so after breakfast. The resident remained in bed for several hours, and the STNA did not return to assist her, failing to provide timely ADL assistance.
The facility failed to provide adequate pressure ulcer care and prevention for three residents. A resident with a right heel wound did not receive necessary wound treatment as per hospital orders, with no documentation of dressing changes. Two other residents, both at risk for pressure ulcers, were not turned and repositioned as required by their care plans. Observations and staff interviews confirmed these deficiencies.
A facility failed to conduct timely bladder scans and notify the physician for a resident after catheter removal, as per hospital discharge orders. The resident required substantial assistance and had orders for scans every six hours, with catheterization if retaining over 300 ml. No scans were documented for two days, and attempts to catheterize were unsuccessful without physician notification, violating facility policy.
A resident with severe cognitive impairment and multiple diagnoses did not receive medications via the physician-ordered gastrostomy (g-tube) route. The error was observed by the family through a live video camera and reported to the DON. The resident did not experience any negative effects from the incident.
The facility failed to securely store medications, affecting two residents. One resident was left with unsupervised tablets in applesauce, and another had Miralax left at her bedside after refusing to take it immediately. Both instances were against facility policy, which requires physician and care team approval for self-administration.
The facility failed to disinfect a glucose monitoring device after usage and ensure staff completed hand hygiene after removing a wound dressing on a resident in enhanced barrier precautions. These lapses affected multiple residents and were confirmed by staff interviews and observations.
Failure to Monitor and Document Bowel Function Resulting in Fecal Impaction
Penalty
Summary
The deficiency involves the facility’s failure to monitor and document bowel function for a resident who was care planned as being at risk for constipation. The resident, admitted with diagnoses including cerebral infarction, dysphagia, depression, and mood disorder, had physician orders for PRN milk of magnesia and senna for constipation and a care plan intervention to record bowel movement patterns each day and monitor for complications of constipation. The MDS indicated the resident had moderate cognitive deficits, was dependent for ADLs, and was always incontinent of bowel and bladder. Review of bowel records for December 2025 and January 2026 showed no documented bowel movements, and the DON verified there was no documentation of a bowel movement after 11/19/25, despite a facility policy requiring nursing staff to document bowel movements each shift. On the date of the change in condition, the resident was evaluated with documented signs of fever and shortness of breath, along with other vital signs, but there was no documentation of an abdominal assessment. An LPN reported that when she came on duty, the ADON told her the resident had not had a recent bowel movement and was having respiratory issues; however, the LPN focused on the respiratory concerns when sending the resident to the hospital and did not assess the abdomen. At the hospital, the resident was admitted with acute hypoxic respiratory failure with pneumonia, encephalopathy, hypernatremia, and hyperglycemia, and was found to have a fecal impaction with concern for stercoral colitis. Imaging showed a large ball of stool in the rectum, and the resident required manual removal of the impaction, an enema, and initiation of a bowel regimen. The NP later stated she was unsure if staff had alerted her to the absence of bowel movements and was unaware that bowel movements had not been documented for the resident for two months, despite her expectation that staff document the presence or absence of bowel movements every shift.
Failure to Follow Approved Menus and Portion Sizes for Breakfast Service
Penalty
Summary
The deficiency involves the facility’s failure to follow the planned menu and dietary spreadsheets, including required portion sizes, for multiple residents. On the specified breakfast date, the approved menu called for cereal, toast, and sausage egg bake for residents on regular textured diets, and the dietary spreadsheet specified that all diets were to receive six ounces of cereal, with some diets requiring specific hot cereals. Another spreadsheet for a different date indicated that all diets were to receive a #16 scoop (two ounces) of scrambled eggs when scrambled eggs were on the menu. During observation of breakfast service, surveyors noted that the steam table contained pureed eggs, pureed toast, scrambled eggs, sausage patties, and toast, but no sausage egg bake. For residents on regular diets, the dietary staff member used a four-ounce scoop of scrambled eggs, served one sausage patty, and one slice of toast per plate, and for residents on pureed diets, served a three-ounce scoop of pureed eggs, a two-ounce scoop of pureed toast, and an insulated bowl of hot cereal. Further observation showed that hot cereal was served directly from a pan on the stove using a slotted spoon, with two scoops placed into an insulated bowl, filling it only about halfway, and later a single scoop was served onto a divided plate along with pureed eggs and pureed toast. The dietary staff member confirmed he was using a four-ounce scoop for scrambled eggs and a three-ounce scoop for pureed eggs, and acknowledged that the portion sizes did not match the dietary spreadsheets. He also stated he had always substituted scrambled eggs and the corresponding breakfast meat when casseroles or similar items were on the menu, citing that several residents did not eat pork. The dietary manager confirmed that the egg bake was not prepared because about half of the residents did not eat pork, acknowledged that casseroles and similar items on the menu were routinely replaced with scrambled eggs and the associated breakfast meat, and verified that the hot cereal was not measured and that substitutions had not been discussed with the registered dietitian. The registered dietitian stated her expectation that menus and spreadsheets be followed as planned and that she should be consulted for menu changes, and indicated that the egg bake should have been provided as planned with alternate selections for residents who do not eat pork. The facility identified two residents who did not receive food from the kitchen, and the deficient practice had the potential to affect 76 residents in the facility.
Improper Food and Beverage Temperatures During Meal Service
Penalty
Summary
The facility failed to ensure that food and beverages were served at appropriate, palatable temperatures, affecting the majority of residents who received meals from the kitchen. During observation of a test tray after breakfast trays had been passed, the eggs and sausage were found to be lukewarm and not palatable, with temperatures of 93°F and 93.4°F respectively. The milk, poured from a carton that had been placed on top of the tray cart, measured 48.8°F, and the orange juice measured 51°F. The Dietary Manager confirmed these temperatures and stated his expectation that hot foods should be at least 120°F and that milk and juice should be 40°F or less when served. Interviews with several residents confirmed that their eggs and sausage were cold when they received their trays. The facility’s “Food Preparation and Service” policy, dated April 2019, defined the temperature “danger zone” for food as between 41°F and 135°F, noting that this range promotes rapid growth of pathogenic microorganisms that cause foodborne illness. The policy identified potentially hazardous foods as including meats, poultry, eggs, and milk, and stated that these foods must be maintained below 41°F or above 135°F. The deficiency was identified through observation, staff and resident interviews, and policy review, and was associated with multiple complaint investigations.
Food Safety and Hygiene Failures in Kitchen and Meal Service
Penalty
Summary
The deficiency involves multiple failures in food safety and hygiene practices in the facility’s kitchen and meal service areas, affecting food served to nearly all residents. Surveyors observed several dietary staff and another employee with beards of varying lengths preparing and handling food without wearing required beard restraints, despite facility policy requiring hair restraints to prevent hair from contacting food. One staff member confirmed that beard restraints were not available in the kitchen, and the Dietary Manager acknowledged that employees with facial hair should wear restraints. Additionally, a floor tech entered the kitchen, immediately donned gloves, and began handling prepared breakfast plates without first washing his hands, contrary to facility policies and staff statements that all employees should wash their hands upon entering the kitchen and before handling food. Further observations showed improper handling and storage of food and food-contact equipment. A dietary cook retrieved a food thermometer from a pan containing other utensils, used it to check the temperature of scrambled eggs, then immediately inserted the same uncleaned thermometer into a sausage patty, despite policy requiring food-contact equipment, including thermometers, to be cleaned and sanitized between uses. In the tray line cooling area, surveyors found an open carton of nectar-thickened water past its “best by” date with no opening date, and an opened container of cottage cheese dated well beyond the stated 10-day use period; the Dietitian confirmed all foods should be labeled with open and discard dates, and the Dietary Manager acknowledged these items should have been discarded or used within 10 days. During breakfast tray distribution, staff dropped a tray onto the floor, picked up the items, placed them back on the tray, and then set the soiled tray on top of a cart containing clean meal trays, clean glasses, condiments, and a gallon of milk, which the Dietary Manager confirmed involved placing a dirty tray on a cart with clean items.
Inadequate Handwashing Facilities in Kitchen
Penalty
Summary
The deficiency involves the facility’s failure to ensure kitchen staff had access to adequate, functioning handwashing facilities in the kitchen. Upon entering the kitchen at 8:00 A.M., a surveyor observed a dietary staff member cooking scrambled eggs at the stove. When the surveyor attempted to use the handwashing sink at the front of the kitchen, the water did not flow. The dietary staff member confirmed the sink was not working and directed the surveyor to use the handwashing sink at the back of the kitchen, stating this was where he normally washed his hands. At the back handwashing sink, the surveyor found there was no soap available, which the dietary staff member confirmed, suggesting the surveyor obtain soap from the non-functioning front sink. The dietary staff member then turned on water from a pot-filling spigot that had been pulled over the sink and suggested it could be used for handwashing. There were no paper towels at the front handwashing sink, and the dietary staff member retrieved a roll of paper towels from the food preparation area and handed it to the surveyor. Later, the dietary manager stated he was not aware that the front handwashing sink was not working and verified that hand soap should be available at all kitchen handwashing sinks. The facility census was 78 residents, with 76 receiving food from the kitchen, and the facility’s handwashing policy required that sinks, soap, and towels be readily accessible and convenient for staff use.
Failure to Provide Scheduled Bathing and Needed Nail Care for Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide and document adequate ADL care, specifically bathing, for a resident who was dependent on staff for showers. One resident with Parkinson’s disease, type 2 diabetes mellitus, and spinal stenosis had an MDS showing intact cognition and dependence on staff for bathing, with a care schedule indicating showers on day shift on Wednesdays and Saturdays. Shower documentation for a specified month showed that the resident received showers on several listed dates, but there was no documentation of the resident receiving or refusing showers on three scheduled shower days. The DON confirmed there was no documented evidence that the resident received showers on those dates. The deficiency also includes failure to provide needed grooming care, specifically fingernail trimming, to another cognitively intact resident with type 2 diabetes mellitus, Raynaud’s syndrome, osteoarthritis, and self-care and mobility deficits requiring substantial/maximal assistance with toileting, personal hygiene, and bathing. A progress note documented that the resident refused a bath/shower on one date but allowed nail trimming at that time, with no further documentation of nail care. On observation, the resident’s fingernails were of varying lengths, with several extending about one and one-half inches beyond the nail tip and others jagged and shorter. The resident stated she did not like her nails that long, had asked staff to trim them, and was considering breaking them herself. A CNA confirmed the nails were long and jagged and stated nails are usually trimmed with showers and daily care. On a subsequent observation the next day, the resident’s nails remained untrimmed, and both the resident and the CNA confirmed that nail trimming still had not been done, despite the CNA having informed the assigned aide and nurse the previous day. Facility policy required appropriate support and assistance with hygiene, bathing, and grooming for residents unable to carry out ADLs independently.
Failure to Maintain Accurate and Complete Medical Records and ADL Documentation
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate and up-to-date medical records and documentation for multiple residents. For one resident with type 2 diabetes mellitus, Parkinson’s disease, and spinal stenosis, the MDS showed intact cognition and a need for assistance with ADLs, including eating, bed mobility, transfers, toileting, and bathing. However, documentation survey reports for two consecutive months showed extensive gaps, with no recorded information on bed mobility, bladder and bowel continence and movements, eating, dressing, hygiene, ambulation, transfers, wheelchair/scooter use, toileting, and behaviors. Meal and fluid intake records were blank for numerous specified dates and meals across November and December. The DON confirmed the missing ADL and meal intake documentation for this resident. Another resident, admitted with COPD and congestive heart failure and later discharged due to death, had an MDS indicating intact cognition and a need for substantial/maximal assistance with ADLs. The progress notes for the date of death contained no documentation of the resident’s death, and the DON verified that no note describing the death could be found, despite stating she had been present when the resident died. A third resident, admitted with cerebral infarction, anemia, depression, and mood disorder, had a care plan identifying risk for constipation with interventions requiring daily recording of bowel movement patterns and monitoring for complications. The MDS indicated this resident had moderate cognitive deficits, was dependent for ADLs, and was always incontinent of bowel and bladder. Review of bowel movement records for two months revealed no documentation of bowel movements, and the DON confirmed this lack of documentation.
Failure to Use Required PPE for Resident on Enhanced Barrier Precautions
Penalty
Summary
Facility staff failed to follow the infection prevention and control program by not using required personal protective equipment (PPE) for a resident on Enhanced Barrier Precautions (EBP). The resident was admitted on 01/04/26 with diagnoses including encephalopathy, sleep apnea, heart failure, and severe sepsis, and had no cognitive deficits but required staff assistance with ADLs. A physician’s order dated 01/07/26 placed the resident on EBP due to the presence of an enteral tube and wounds. On 02/09/26 at 9:23 A.M., during observation of medication administration via gastrostomy tube, an LPN provided care without wearing a gown or gloves. In a subsequent interview, the LPN confirmed she was not wearing a gown or gloves, acknowledged the resident was on EBP, and stated she should have donned a gown and gloves prior to administering the medication. Review of the facility’s Enhanced Barrier Precautions policy dated 07/30/25 showed the facility would implement EBP as appropriate for prevention of transmission of multidrug-resistant organisms. These findings demonstrate that, despite an active EBP order and a facility policy requiring implementation of EBP, staff did not consistently wear appropriate PPE while providing care involving an enteral tube to a resident under EBP.
Failure to Answer Phones During Nighttime Hours
Penalty
Summary
The facility failed to ensure that phones were answered during nighttime hours, affecting a resident who required assistance after a fall. The resident, who was cognitively intact and required staff assistance with activities of daily living, was unable to reach the facility staff via telephone. Consequently, the resident's family had to enter the facility with emergency medical technicians because they could not get in touch with the facility. This incident was confirmed by a Licensed Practical Nurse who noted the family's arrival and the lack of phone response. Further investigation revealed that the night shift nursing supervisor did not report to work, and the phone was left on the reception desk instead of being picked up by the night shift nurse supervisor. Observations by the surveyor showed that calls to the facility went directly to voicemail, indicating that calls were not properly forwarded by the front desk staff. The Registered Nurse in charge confirmed that the phone should have been answered directly, especially in emergencies, but the calls were not forwarded correctly, leading to the deficiency.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care for a resident, identified as Resident #36, who was at risk for urinary incontinence and potential impaired skin integrity. The resident, who was cognitively intact and required substantial assistance with toileting, was observed sitting in her room with a noticeable odor of feces. Despite the care plan's directive to check and change the resident frequently, the resident's incontinence brief was not changed for several hours. Observations revealed that the Certified Nursing Assistant (CNA) responsible for the resident did not provide incontinence care between 8:30 A.M. and 1:35 P.M., despite the care plan's requirement for changes every two hours. The CNA confirmed the lapse in care, acknowledging that the resident's brief was not changed as frequently as required. This deficiency was identified during a complaint investigation and affected the quality of care provided to the resident.
Inadequate Supervision During Resident Transfer
Penalty
Summary
The facility failed to ensure the appropriate level of supervision during resident transfers using a sit to stand lift, affecting one resident. The resident, who was admitted with chronic respiratory failure with hypoxia and non-Alzheimer's dementia, was at risk for falls due to impaired mobility. The care plan for the resident was not updated to reflect the use of a sit to stand lift for transfers, despite therapy recommendations. During a transfer from a chair to a bed, the resident slid to the floor, although no injuries were reported. The incident occurred when a Certified Nursing Assistant (CNA) attempted the transfer alone, contrary to the facility's policy requiring two staff members for such procedures. The Director of Nursing confirmed the violation of the policy, which mandates that staff be trained and demonstrate competency in using mechanical lifts. The CNA involved was terminated for not adhering to the facility's policy, which was established to ensure safe resident transfers.
Failure to Maintain Adequate Room Temperature
Penalty
Summary
The facility failed to maintain a satisfactory temperature in the room of Resident #43, who was affected by this deficiency. Resident #43, who was admitted with conditions including [NAME] Syndrome, malnutrition, depression, respiratory disorder, and biliary cirrhosis, was cognitively intact and required assistance with activities of daily living. On observation, the resident was found wearing an oversized house coat and gloves, indicating discomfort due to the cold temperature in her room. The heater in her room was blowing out cold air, and despite her complaints since October 2024, the issue remained unresolved. Maintenance Man #100 had attempted to adjust the heater several times, but the room temperature was recorded at 68 degrees Fahrenheit, which was below the facility's policy of maintaining temperatures between 71 and 81 degrees Fahrenheit. The resident confirmed that a space heater provided by her brother was removed by staff, leaving her without adequate heating. The facility's policy titled Safe and Homelike Environment, updated on the day of the observation, was not adhered to, resulting in an uncomfortable and potentially unsafe environment for the resident.
Improper Use of Lift Leads to Resident Injury
Penalty
Summary
The facility failed to use the proper lift for resident transfers, affecting one resident who required a Hoyer lift for safe transfers. The resident, who had a history of cerebral infarction, hemiplegia, and other medical conditions, was documented in the care plan to need a Hoyer lift with the assistance of two staff members. Despite this, staff used a stand-up lift, which was not recommended by therapy or the care plan, leading to bruising on the resident's rib cage, underarms, and wrist. The resident was on Eliquis, a blood-thinning medication, which increased the risk of bruising. The facility's investigation confirmed that the bruising resulted from the improper use of a stand-up lift instead of the Hoyer lift. Interviews with the Director of Nursing and the Physical Therapy Manager corroborated that the Hoyer lift was the safer option as recommended by therapy, but staff had been using the incorrect equipment, leading to the resident's injuries.
Failure to Assist Resident with ADLs
Penalty
Summary
The facility failed to provide timely assistance with activities of daily living (ADL) for a resident who was dependent on staff for transferring out of bed. The resident, who was severely cognitively impaired and had medical diagnoses including coronary artery disease, heart failure, and cerebrovascular attack, was observed on multiple occasions remaining in bed despite expressing a desire to get up after breakfast. On the morning of the incident, a State tested Nursing Aide (STNA) asked the resident if she wanted to get out of bed after breakfast, to which the resident agreed. However, subsequent observations revealed that the resident remained in bed for several hours, and the STNA did not return to assist her as requested. The STNA later confirmed that she did not get the resident out of bed but did not provide an explanation for her inaction.
Failure to Provide Adequate Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevention for three residents, leading to deficiencies in their care. Resident #18, who was cognitively intact and had a right heel wound, did not receive the necessary wound treatment as per hospital orders after admission. The hospital had instructed to relieve pressure from the heel and maintain a dressing for three days, followed by daily cleansing. However, there were no physician orders or documentation of dressing changes for the right heel from admission through 09/15/24. The Director of Nursing confirmed the lack of treatment and orders for the wound care during this period. Residents #72 and #10, both at risk for developing pressure ulcers, were not turned and repositioned as required by their care plans. Resident #72, who was severely cognitively impaired and dependent on staff for mobility, was observed lying in the same position for several hours without being repositioned. Similarly, Resident #10, who was rarely understood and dependent on staff for mobility, was also observed in the same position for an extended period. Interviews with staff confirmed that these residents were not turned or repositioned as needed, and Resident #10's family reported that staff did not regularly turn her.
Failure to Conduct Bladder Scans and Notify Physician
Penalty
Summary
The facility failed to ensure that bladder scans were completed for a resident following the removal of an indwelling catheter as per hospital discharge orders. The resident, who was cognitively intact and required substantial assistance for toileting and bed mobility, was admitted with orders to have bladder scans every six hours and to be straight catheterized if retaining more than 300 ml of urine. However, the medical record showed no documentation of bladder scans on the first two days following admission, and only two scans were completed on the third day, both indicating significant urine retention. Additionally, the charge nurse was unable to successfully catheterize the resident, and there was no documentation that the physician was notified about the delay in bladder scanning or the unsuccessful catheterization attempt. The Director of Nursing confirmed that the physician was not informed of these issues, which was a violation of the facility's policy requiring prompt notification of changes in a resident's condition to obtain appropriate treatment orders.
Failure to Administer Medications via Ordered Route
Penalty
Summary
The facility failed to ensure medications were administered via the physician-ordered route for one resident. Medical record review for the resident revealed an admission with diagnoses including cerebral infarction, hypertensive cerebral ischemic attack, chronic pain, and hemiplegia and hemiparesis. The resident had severely impaired cognition and was dependent on assistance for daily activities. Physician orders specified that several medications were to be administered via gastrostomy (g-tube). However, on a specific date, the morning medications were given whole instead of via the g-tube, as observed by the resident's family through a live video camera. The incident was reported to the Director of Nursing (DON) by the family, and the physician was notified. The resident did not experience any negative effects from the incident. The facility's policy on administering medication states that medications should be administered in accordance with prescribers' orders. The medication/treatment error report confirmed that the medications were not administered via the ordered route. The DON acknowledged the error and confirmed that the family had notified her of the incident. The documentation was signed by the physician, the nurse who made the error, and the DON. This deficiency was investigated under Complaint Number OH00153089.
Failure to Securely Store Medications
Penalty
Summary
The facility failed to ensure medications were securely stored, affecting two residents. Resident #22, who has diagnoses including cerebral infarction and vascular dementia, was observed with two tablets in applesauce left unsupervised on his bedside table. There was no order or assessment permitting Resident #22 to self-administer medications. Staff interviews confirmed that the medication was left by a nurse who was not present at the time of observation, and the Director of Nursing verified that no medication should be left at the bedside unsupervised. Similarly, Resident #19, who has diagnoses including cerebrovascular disease and dementia, was observed with Miralax left at her bedside after she refused to take it immediately. The LPN left the medication for the resident to take after breakfast, which was confirmed as acceptable by the LPN but later verified as non-compliant by the Director of Nursing. The facility policy states that residents may only self-administer medications if deemed safe by the attending physician and interdisciplinary care planning team, which was not the case for either resident.
Infection Control Deficiencies
Penalty
Summary
The facility failed to disinfect a glucose monitoring device after usage with an appropriate disinfectant, which had the potential to affect two residents residing on the B unit of the second floor who share the glucose monitoring device. Medical record reviews revealed that both residents had diagnoses including type two diabetes mellitus and required blood sugar monitoring multiple times a day. Observations showed that an LPN did not cleanse or disinfect the glucose monitoring device after using it on one resident and before using it on another. The LPN admitted to being unaware of the cleaning requirements related to the glucose monitoring unit, despite the availability of Sani Wipes on the medication cart. The Director of Nursing confirmed that the glucose monitoring device should be cleaned with germicidal wipes between each resident use, as per CDC guidelines and the manufacturer's recommendations. The facility's policy also stated that blood glucose meters intended for reuse should be cleaned and disinfected between resident uses. However, these protocols were not followed, leading to the deficiency. Additionally, the facility failed to ensure staff completed hand hygiene after removing a wound dressing on a resident in enhanced barrier precautions. The resident had a pressure ulcer and required wound care, which included cleansing the wound and applying medi honey ointment and a foam border. During an observation, an RN and an NP donned personal protective equipment but did not follow proper hand hygiene protocols. The RN's gown came into contact with bed linen multiple times, and she exited the room without removing the gown to collect additional dressing supplies. The RN also failed to complete hand hygiene before reapplying gloves and did not change her gown after it brushed against a black uniform jacket hanging on the treatment cart. The RN admitted to not following proper protocols and was unaware that her gown had touched the jacket. The facility's policies for infection control and wound care were not adhered to, leading to potential risks for the residents. The CDC's guidance and the manufacturer's recommendations for cleaning and disinfecting glucose monitoring devices were not followed, and the facility's own policies for hand hygiene and wound care were also neglected. These lapses in protocol contributed to the deficiencies identified during the survey.
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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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