Carecore At Mentor
Inspection history, citations, penalties and survey trends for this long-term care facility in Mentor, Ohio.
- Location
- 8881 Schaefer St, Mentor, Ohio 44060
- CMS Provider Number
- 366015
- Inspections on file
- 30
- Latest survey
- February 5, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Carecore At Mentor during CMS and state inspections, most recent first.
Surveyors found that the facility did not maintain its heating units and thermostats in good repair, leading to a smoking blower motor belt in a conference room heater that generated excessive heat and activated the fire alarm. A subsequent inspection identified numerous malfunctioning thermostats in multiple resident rooms, affecting many residents’ room temperatures. This was inconsistent with the facility’s own policy requiring a safe, clean, comfortable environment with safe and comfortable temperatures.
A resident with multiple risk factors, including impaired cognition, mobility issues, and a history of infection, did not receive timely monitoring or interventions for bowel and bladder elimination as required by physician orders and facility protocol. Despite several days without a bowel movement, staff did not follow the bowel protocol or promptly notify the physician, resulting in the resident developing severe symptoms and requiring hospital transfer, where the resident was diagnosed with aspiration pneumonia and possible small bowel obstruction, and later died from sepsis.
A resident with quadriplegia and multiple comorbidities was admitted with two Stage IV pressure ulcers that deteriorated due to the facility's failure to implement a comprehensive pressure ulcer prevention program and delays in obtaining and processing wound cultures. Despite care plans and physician orders, inconsistent documentation, lack of timely interventions, and absence of a wound culture policy led to wound infection, osteomyelitis, and hospitalization.
A resident with multiple chronic conditions was transferred to the hospital after calling 911 due to feeling scared. Although the spouse was notified of the transfer, the POA, who was the primary emergency contact, was not informed, and no change of condition form was completed. The DON confirmed these omissions during the investigation.
A resident with multiple health conditions experienced increased confusion, leading to a family request for a urinalysis to check for a UTI. Staff did not promptly collect the urine sample or initiate antibiotic treatment, resulting in an eight-day delay from the initial request to the start of therapy. The DON confirmed the delays in both sample collection and treatment initiation.
The facility failed to ensure proper kitchen sanitation and staff hair covering practices. An unclean ice machine filter was observed, and a dietary staff member was seen preparing food with unsecured braids, contrary to facility expectations. This affected all residents receiving food, except two with orders for nothing by mouth.
The facility failed to maintain the walk-in freezer in proper working condition, affecting all residents receiving food from the kitchen, except for two with orders for nothing by mouth. Ice buildup was observed due to a malfunctioning door seal, known to maintenance since May. A repair quote was delayed in approval until July, attributed to the Administrator's absence and indecision on repair options.
The facility failed to change nasal cannula oxygen tubing in a timely manner for four residents using oxygen therapy. Observations revealed outdated or undated nasal cannulas, with no documentation of changes in the MAR and TAR for June and July 2024. Interviews with staff confirmed these findings, and the facility's policy requiring weekly changes and dating of tubing was not followed.
A facility failed to accurately document a resident's dialysis treatment in the MDS assessments. Despite having clear documentation and physician orders for dialysis three times a week, the MDS assessments did not reflect this treatment. The DON confirmed the oversight, acknowledging that the resident was an established dialysis patient and the assessments should have captured this information.
A facility failed to develop and implement a care plan for a resident's use of psychotropic medications. The resident, diagnosed with schizophrenia, insomnia, and anxiety, received an antipsychotic and antidepressant, but the care plan did not address these medications. The DON confirmed the absence of a care plan, despite facility policy requiring comprehensive person-centered care plans.
A facility failed to securely administer medications to a resident with multiple diagnoses, including COPD and depression. The resident was observed self-administering a Fluticasone inhaler and had several medication bottles at her bedside without proper orders or a self-administration assessment. She reported ordering her own medications due to stock issues and self-medicating with an additional dose of Desvenlafaxine. An LPN confirmed these findings.
A resident was observed self-administering medication without an order, contributing to a medication error rate of 14.8%. The resident, with multiple diagnoses, reported ordering her own medications due to facility errors. An LPN failed to administer all prescribed medications, and the facility's policy on medication administration was not followed.
A resident with chronic kidney disease was administered a diuretic medication despite orders to hold it, leading to severe dehydration and hospitalization. The facility failed to communicate effectively with the primary care physician and nephrologist, resulting in a significant medication error.
The facility failed to ensure a resident's medical record was complete and accurate, lacking documentation on the resident's assessment, condition, and reason for hospital transfer. The nurse on duty could not recall the details, and the Director of Nursing confirmed the record was incomplete, violating the facility's documentation policy.
The facility failed to provide adequate wound care for two residents, resulting in one resident developing a severe infection and requiring hospitalization. The facility did not follow its policies on skin breakdown and pain management, leading to significant harm.
A resident with multiple medical conditions experienced a severe weight loss of 14.5% over 56 days due to the facility's failure to provide prescribed nutritional supplements and to monitor the resident's weight as required. Interviews confirmed that the resident often did not receive the supplements, and the facility did not promptly address the weight loss.
The facility failed to provide sufficient tracheostomy care for two residents, leading to significant health issues, including multiple hospital admissions and severe health complications. The lack of care included failing to administer oxygen, monitor oxygenation levels, perform suctioning, change the cannula, and clean the tracheostomy site as ordered. Interviews with the family and staff confirmed the inadequate care and visibility issues of the care orders for the nursing staff.
The facility failed to implement required enhanced barrier precautions for two residents with tracheostomies, improperly handled soiled linen and paper towels during tracheostomy care for another resident, and did not perform proper hand hygiene during wound care for a resident with multiple medical conditions.
The facility failed to maintain a clean and homelike environment, with observations of unused incontinence briefs, soiled socks, and dirty meal trays in resident hallways, as well as an overfilled trash can in the shower room. These issues were confirmed by an STNA and an LPN.
The facility failed to conduct thorough and accurate fall investigations for three residents, leading to deficiencies in accident prevention and supervision. One resident was found on the floor but was later revealed to have been placed in a sitting position by STNAs. Another resident's fall intervention was not implemented, and a third resident's fall was not thoroughly documented or investigated.
The facility failed to obtain orders for and provide sufficient urinary catheter-related care for a resident with multiple diagnoses, including diabetes and chronic kidney disease. Despite having a urinary catheter in place from January to April 2024, there were no physician orders or documented care for the catheter. The DON confirmed the lack of orders and care, which was against the facility's policy on urinary incontinence.
Failure to Maintain Heating Units and Thermostats in Good Repair
Penalty
Summary
The deficiency involves the facility’s failure to maintain heating units in good repair, resulting in malfunctioning thermostats and an overheating incident. A fire department incident report documented that a blower motor belt in the conference room heating unit began smoking and generating excessive heat, which triggered the facility’s fire alarm system. The Administrator reported that the motor on this heating unit had frozen, causing the belt to smoke and produce excessive heat. Subsequent review of facility documentation titled "Monitoring of Heaters" showed that 18 thermostats were not functioning correctly in identified resident rooms, affecting 20 residents. A service quote confirmed that 21 thermostats in the building required replacement, including two in non-resident areas. The Administrator confirmed that the rooms listed on the monitoring document were resident rooms identified during a heating unit inspection. The facility’s own "Quality of Life – Homelike Environment" policy stated that residents are to be provided a safe, clean, comfortable environment with comfortable and safe temperatures, which was not met due to the malfunctioning heating equipment.
Failure to Monitor and Timely Treat Constipation and Infection
Penalty
Summary
A deficiency occurred when the facility failed to adequately monitor a resident's condition, specifically regarding bowel and bladder elimination, which resulted in a delay in identifying and treating infection and constipation. The resident had multiple risk factors, including diabetes, impaired cognition and mobility, cystitis, a history of sepsis, and was at high risk for both constipation and infection. The care plan included interventions for constipation and infection, but did not comprehensively address all infection risks related to the resident's diagnoses. After returning from a hospital stay for sepsis, there was no evidence of comprehensive infection monitoring as outlined in the care plan. The resident had physician orders and a bowel protocol in place, which required administration of specific medications if no bowel movement occurred after three days, escalating to physician notification if interventions were unsuccessful. Despite documentation showing no bowel movement for four consecutive days, the required interventions were not administered in a timely manner according to the protocol. Staff interviews confirmed that the bowel protocol was not followed as ordered, and there was a lack of timely physician notification and assessment when the resident's condition changed. On the day of the incident, the resident exhibited progressive symptoms including stomach upset, diaphoresis, vomiting fecal matter, a firm and distended abdomen, hypoxemia, change in mental status, elevated heart rate, and pallor. Although some interventions were eventually initiated, there was a delay in both the administration of bowel protocol steps and in notifying the physician. The resident was ultimately transferred to the hospital with diagnoses of aspiration pneumonia and possible small bowel obstruction, and subsequently passed away with sepsis listed as the cause of death.
Failure to Implement Comprehensive Pressure Ulcer Prevention and Timely Infection Management
Penalty
Summary
The facility failed to develop and implement a comprehensive and individualized pressure ulcer prevention program for a resident admitted with two Stage IV pressure ulcers. Despite being identified as at high risk for impaired skin integrity due to multiple diagnoses including quadriplegia, malnutrition, and prior osteomyelitis, the resident experienced a deterioration in wound status, including increased wound size and signs of infection such as green drainage. Although wound cultures were ordered when infection was suspected, there were significant delays in obtaining and processing these cultures, with a two-week gap between the initial failed culture and the subsequent successful collection. During this period, the wounds continued to worsen, and appropriate interventions were delayed. The resident's care plan included interventions such as use of barrier creams, pressure reduction devices, repositioning, and wound care per physician orders. However, documentation and interviews revealed inconsistent implementation and monitoring of these interventions. Staff interviews indicated that the resident was sometimes non-compliant with off-loading and repositioning, but there was insufficient documentation of educational efforts or follow-up regarding non-compliance. Additionally, the facility lacked a policy on wound cultures, contributing to the delay in obtaining necessary diagnostic information and initiating timely treatment for infection. As a result of these failures, the resident's wounds became infected, with cultures eventually revealing multiple bacteria including MRSA and carbapenem-resistant organisms. The resident developed osteomyelitis and required hospitalization after experiencing confusion, lethargy, and overall decline. The deficiency was substantiated by medical record review, staff interviews, and the absence of timely and effective wound management practices.
Failure to Notify POA of Resident Hospitalization
Penalty
Summary
The facility failed to timely notify the appropriate family member, specifically the resident's Power of Attorney (POA), regarding a resident's hospitalization. The resident, who had diagnoses including COPD, a displaced fracture of the left femur, an open wound to the left hip, diabetes, a left artificial hip, and peripheral vascular disease, was admitted to the facility and later transferred to the hospital after calling 911 due to feeling scared. Emergency Medical Services (EMS) responded and, at the resident's request, transported her to the hospital for evaluation. Documentation showed that the resident's spouse was notified of the transfer, but there was no evidence that the POA, listed as the primary emergency contact, was informed. Additionally, the medical record review revealed that no change of condition form was completed for this event. The Director of Nursing (DON) confirmed during an interview that the required notification to the POA was not made and that the change of condition form was not filled out. This deficiency affected one resident out of three reviewed for change in condition, in a facility with a census of 80.
Delay in Urine Sample Collection and UTI Treatment
Penalty
Summary
A deficiency occurred when staff failed to timely collect a urine sample and initiate antibiotic treatment for a resident who exhibited signs of a possible urinary tract infection (UTI). The resident, who had multiple diagnoses including COPD, diabetes, and a recent hip fracture, was noted to have increased confusion, prompting a request from the resident's daughter for a urinalysis with culture and sensitivity (UA C&S). Although the need for a urine sample was communicated between nursing shifts, the sample was not collected promptly, as the resident had just used the restroom when the nurse attempted collection, and the task was passed to the oncoming nurse. Despite documentation of the UA C&S order and ongoing family inquiries about the results, there was a significant delay in both obtaining the urine sample and starting antibiotic therapy. The positive urinalysis was noted several days after the initial request, and the antibiotic order was not placed until eight days after the family first raised concerns. The DON confirmed that both the urine sample collection and the initiation of antibiotic treatment were not completed in a timely manner.
Kitchen Sanitation and Hair Covering Deficiencies
Penalty
Summary
The facility failed to maintain cleanliness and sanitation standards in the kitchen, specifically regarding the ice machine filter and staff hair covering practices. During an initial tour of the kitchen, it was observed that the ice machine filter was not clean and had accumulated a layer of dust. This was confirmed by a dietary staff member who acknowledged that the filter was supposed to be cleaned monthly. Additionally, a dietary staff member was observed preparing food with long braids that were not secured or covered by a hairnet, contrary to the facility's expectations for hair covering. The facility's policy on kitchen sanitation, dated 2010, indicated that the ice machine should be cleaned regularly to ensure sanitary conditions. The deficiency had the potential to affect all residents receiving food from the kitchen, except for two residents who had orders for nothing by mouth. The facility census at the time was 84.
Delayed Repair of Walk-In Freezer Door
Penalty
Summary
The facility failed to maintain the walk-in freezer in proper working condition, which had the potential to affect all residents receiving food from the kitchen, except for two residents who were identified as having orders for nothing by mouth. The issue was identified through observations of ice buildup inside the freezer, including ice on the floor and on boxes of food items. Interviews with dietary staff confirmed that the freezer door did not seal properly, causing the ice buildup, and that maintenance was aware of the issue but had not yet repaired it. The facility received a repair quote on 05/13/24, but the repair was not approved until 07/10/24. The delay in addressing the malfunction was attributed to the Administrator being out of the office for three weeks and the facility's indecision on whether to replace the broken part or the entire door. Despite the freezer maintaining an appropriate temperature, the lack of timely action to repair the door resulted in continued ice accumulation, as confirmed by multiple observations and interviews with facility staff.
Failure to Timely Change Nasal Cannula Oxygen Tubing
Penalty
Summary
The facility failed to change nasal cannula oxygen tubing in a timely manner for four residents who were utilizing oxygen therapy. Resident #32, diagnosed with chronic obstructive pulmonary disease, had no documentation of nasal cannula changes in their Medication Administration Records (MAR) and Treatment Administration Records (TAR) for June and July 2024. An observation on July 8, 2024, revealed no date on the nasal cannula, and the resident was unsure when it was last changed. Similarly, Resident #64, with chronic respiratory failure, had a nasal cannula dated May 23, 2024, with no subsequent changes documented in the MAR and TAR for the same period. An interview confirmed the outdated nasal cannula. Resident #69, with atherosclerotic heart disease and impaired cognition, also had no documentation of nasal cannula changes in their records for June and July 2024. An observation on July 8, 2024, showed no date on the nasal cannula. Resident #22, with chronic obstructive pulmonary disease and mild cognitive impairment, similarly lacked documentation of nasal cannula changes, and an observation confirmed the absence of a date on the nasal cannula. Interviews with staff verified these findings, and a review of the facility's policy indicated that oxygen tubing and nasal cannulas should be changed weekly and dated, which was not adhered to in these cases.
Failure to Accurately Capture Dialysis in MDS Assessments
Penalty
Summary
The facility failed to accurately capture the health status of a resident undergoing dialysis during the Minimum Data Set (MDS) assessments. The resident, who was admitted with diagnoses including intraductal carcinoma of the left breast and end-stage renal disease, was dependent on renal dialysis. Despite having physician orders for dialysis three times a week and documentation from the admitting hospital and facility indicating the resident's dialysis schedule, the MDS assessments did not reflect dialysis as a treatment. This oversight was identified during a review of the admission and 5-Day MDS assessments, as well as the quarterly and modified quarterly MDS assessments. The Director of Nursing (DON) confirmed that the resident was an established dialysis patient and acknowledged that the MDS assessments should have accurately captured this treatment. The facility's policy on comprehensive assessments, revised in October 2023, stated that MDS assessments should be conducted to develop person-centered care plans through direct observations and communication with residents and staff. However, the facility failed to communicate effectively to complete the MDS assessments accurately, leading to the deficiency.
Failure to Implement Care Plan for Psychotropic Medications
Penalty
Summary
The facility failed to develop and implement a care plan for the use of psychotropic medications for Resident #72. The resident was admitted with diagnoses including schizophrenia, insomnia, and anxiety. A review of the quarterly Minimum Data Set (MDS) Assessment indicated that the resident received an antipsychotic and antidepressant during the seven-day lookback period. However, the comprehensive care plan, last reviewed on 04/19/24, did not include a plan for the use of these medications. Physician's orders for July 2024 included Invega Sustenna, an antipsychotic, and Trazodone Hydrochloride, an antidepressant, but there was no corresponding care plan. The Director of Nursing confirmed the absence of a care plan for the psychotropic medications. The facility's policy required a comprehensive person-centered care plan with measurable objectives and timetables to meet the resident's needs, which was not developed or implemented in this case.
Medication Administration Deficiency
Penalty
Summary
The facility failed to securely administer medications according to the needs of a resident, affecting one of five residents reviewed for medications. The resident, who had diagnoses including COPD, diabetes, visual hallucinations, major depressive disorder, and bipolar disorder, was observed self-administering a Fluticasone inhaler without a self-administration assessment. The resident had multiple medication bottles at her bedside, including acetaminophen, Turmeric, Alrex, Desvenlafaxine, and Fluticasone, despite not having orders to keep these medications at her bedside, except for nasal spray. The resident reported that the facility often did not have her medications in stock, prompting her to order her own and self-medicate with an additional dose of Desvenlafaxine beyond the facility-administered dosage. An LPN confirmed these findings during an interview.
Medication Error Rate Exceeds Acceptable Limit
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5%, resulting in a rate of 14.8% during a medication administration observation. This deficiency affected one resident, who was observed self-administering a Fluticasone inhaler without an order to do so. The resident had multiple pill containers at her bedside, including Desvenlafaxine, which she took in a dosage not prescribed by the facility. The Licensed Practical Nurse (LPN) responsible for administering medications did not provide the resident with all her prescribed medications, as the artificial tears and FiberCon were not found or administered. The resident, who had diagnoses including COPD, diabetes, and major depressive disorder, reported frequently ordering her own medications due to the facility's failure to provide the correct ones. The LPN confirmed that the resident had no orders to self-administer medications and acknowledged the missing medications. The facility's medication administration policy requires medications to be given according to prescriber orders and only allows self-administration if deemed safe by the attending physician and care team, which was not the case here.
Failure to Hold Diuretic Medication Leads to Resident Harm
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, leading to actual harm. Resident #91, who had a history of chronic kidney disease, diabetes, and other conditions, was ordered by her primary care physician (PCP) to hold her diuretic medication, Torsemide, due to worsening kidney function. Despite this order, the facility administered the medication without a physician's order, resulting in a significant change in the resident's condition and an unplanned hospitalization. The resident's creatinine levels, which indicate kidney function, continued to rise, and she showed signs of severe dehydration and renal failure. On 03/29/24, the PCP ordered to hold the Torsemide due to abnormal lab results, but the facility restarted the medication on 04/01/24 without a physician's order. The facility was unable to contact the nephrologist regarding the increased creatinine levels until 04/03/24. During this period, the resident continued to receive the diuretic, which exacerbated her condition. The resident was eventually sent to the hospital, where she was found to be severely dehydrated and at risk of requiring dialysis. Interviews with facility staff and the resident's husband revealed that there was a lack of communication and documentation regarding the resident's medication and lab results. The Director of Nursing confirmed that the Torsemide should not have been restarted and that the facility failed to contact the PCP when they were unable to reach the nephrologist. The facility's policy on administering medications was not followed, leading to the resident's deterioration and hospitalization.
Incomplete Medical Record Documentation
Penalty
Summary
The facility failed to ensure that Resident #91's medical record was complete and accurate. Resident #91, who had diagnoses including partial amputation of her right foot, diabetes, chronic kidney disease, lymphedema, and osteomyelitis, was transferred to the hospital on 04/03/24. However, the medical record lacked documentation regarding the resident's assessment, condition, who ordered the hospital transfer, and the reason for the transfer. This deficiency was identified during a review of the medical records, facility policy, and interviews with staff members, including RN #601 and the Director of Nursing. RN #601, who was on duty at the time of the transfer, could not recall the details of why Resident #91 was sent to the hospital and admitted that she did not document the necessary information. The Director of Nursing confirmed that the medical record was incomplete and that RN #601 should have documented the resident's assessment, condition, and the reason for the hospital transfer. The facility's policy on charting and documentation, dated July 2017, requires that all services provided to the resident and any changes in the resident's condition be documented in the medical record. This deficiency was investigated under Complaint Number OH00152934.
Failure to Provide Adequate Wound Care
Penalty
Summary
The facility failed to provide comprehensive, individualized, and sufficient wound care for two residents, resulting in actual harm to one of them. Resident #28, who was admitted for wound care, experienced a significant decline in their condition due to inadequate monitoring and treatment. Despite being admitted with a wound that required specific care, the facility did not initiate the necessary treatment until several days after admission. This delay led to the resident developing a foul-smelling, pus-draining, and painful wound, which was later diagnosed as cellulitis/infection, necessitating hospital admission. The resident reported that the dressing was supposed to be changed twice daily but was only changed four times in ten days, contributing to the infection and increased pain. The Director of Nursing (DON) confirmed that the wound was not treated promptly and that the resident had to contact emergency services due to the lack of care and increased pain. Additionally, the facility's records showed discrepancies, with treatments being signed off as completed even when the resident was not in the facility. The facility's policies on skin breakdown and pain management were not followed, leading to the resident's condition worsening and requiring hospitalization. Resident #95 also did not receive the ordered wound care on multiple occasions, as confirmed by the DON. The resident's treatment administration record showed that wound care was not completed as ordered on several dates, indicating a pattern of neglect in providing necessary wound care. This deficiency represents non-compliance investigated under Complaint Number OH00152133 and Complaint Number OH00152075.
Failure to Provide Nutritional Supplements and Monitor Weight
Penalty
Summary
The facility failed to ensure that a resident received nutritional supplements as ordered, did not develop and implement a comprehensive and effective nutrition program, and failed to obtain re-weights and/or weekly weights when a severe weight loss was noted. This deficiency affected a resident who experienced a severe weight loss of 14.5% over 56 days. The resident's weight loss was not addressed until 23 days after it was first documented, and the resident did not receive the prescribed nutritional supplements consistently during this period. The resident, who had multiple medical conditions including rheumatoid arthritis, diabetes, lupus, emphysema, Bell's palsy, hypertension, hyperlipidemia, schizophrenia, hypothyroidism, and anxiety, was on a consistent carbohydrate diet with mechanical soft texture and thin consistency. Despite the physician's orders for various nutritional supplements, the resident's medical record and Medication Administration Record (MAR) revealed numerous instances where the supplements were not provided. The resident's weight dropped from 111 pounds to 95.4 pounds over the course of two months, indicating a severe weight loss that was not promptly addressed. Interviews with the resident, dietary manager, registered dietitian (RD), and director of nursing (DON) confirmed that the resident often did not receive the prescribed supplements. The facility's policy required immediate notification of the dietitian in case of significant weight loss, but this was not followed. The RD tracked weight loss but did not document a nutrition note until 23 days after the initial weight loss was noted. The facility's failure to provide the necessary nutritional supplements and to monitor the resident's weight as required led to the resident's severe weight loss and the deficiency noted in the report.
Failure to Provide Adequate Tracheostomy Care
Penalty
Summary
The facility failed to provide sufficient tracheostomy care for two residents, leading to significant health issues. Resident #19, who was cognitively impaired and dependent on staff for tracheostomy care, was admitted to the hospital multiple times with acute on chronic respiratory failure, hypoxia, recurrent infection, and the need for mechanical ventilation. Despite having specific physician orders for tracheostomy care, there was no documented evidence that the required care was provided consistently, especially when the respiratory therapist was not present in the facility. This lack of care included failing to administer oxygen, monitor oxygenation levels, perform suctioning, change the cannula, and clean the tracheostomy site as ordered. The resident's condition deteriorated, leading to multiple hospital admissions and severe health complications, including cardiac arrest and respiratory failure due to mucus plugging and infection. Interviews with the family and staff confirmed the inadequate tracheostomy care and the visibility issues of the care orders for the nursing staff. The Director of Nursing (DON) verified these findings, indicating a systemic issue in ensuring the visibility and execution of tracheostomy care orders by the nursing staff when the respiratory therapist was not available. Resident #29, who had no cognitive impairment and was dependent on a respiratory ventilator, also did not receive the required tracheostomy care after re-entering the facility. The resident's medical records showed no evidence of completed tracheostomy care orders, and interviews with the resident and staff revealed a reliance on the respiratory therapist for tracheostomy care. The DON confirmed that the tracheostomy care orders were not visible to the nursing staff, leading to a lack of routine care when the respiratory therapist was not present. This deficiency represents non-compliance investigated under Complaint Number OH00152226.
Infection Control Deficiencies
Penalty
Summary
The facility failed to ensure staff used appropriate infection control practices by not implementing required enhanced barrier precautions (EBP) for three residents. Resident #19, who had a tracheostomy and a positive MRSA diagnosis, and Resident #61, who had a tracheostomy and gastrostomy tube, did not have EBP posted or PPE available at their room entrances. Staff members, including an LPN, STNA, and RT, performed various care activities for these residents without wearing the required PPE, such as gowns. The Director of Nursing acknowledged the lack of EBP and PPE, attributing it to recent training that had not yet been disseminated to the staff. Facility policy and CMS guidelines required EBP for residents with wounds or indwelling medical devices, effective from 04/01/24, but these were not followed for Residents #19 and #61. Additionally, RT #281 failed to appropriately handle soiled linen and paper hand towels during tracheostomy care for Resident #61, using a visibly soiled roll of paper towels for hand drying multiple times during the procedure, which was against the facility's policy for handling soiled linen and maintaining hygiene standards. The soiled towel and paper roll were not removed promptly, and the RT continued to use them, compromising infection control practices. For Resident #22, who had multiple medical conditions including a tracheostomy and an abdominal wound, LPN #238 did not perform hand hygiene between glove changes during wound care. The LPN also placed clean dressing supplies on an inadequate barrier, contaminating them with the resident's pillow. This was in violation of the facility's hand hygiene policy, which required handwashing after removing gloves, and the use of a clean barrier for wound care supplies. These deficiencies were identified during observations and interviews with staff, and were confirmed by a review of the facility's policies and CMS guidelines.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean and homelike environment within resident hallways and a shower room, affecting eight residents and potentially all 90 residents in the facility. Observations revealed unused incontinence briefs stuffed into handrails, a soiled sock on the floor, and dirty meal trays placed on heating units and wheelchairs. Additionally, a large Starbucks beverage and food package were found within the handrail alongside soiled linen and trash containers. These items were confirmed by a State tested Nursing Assistant (STNA), who indicated uncertainty about the procedure for returning dirty meal trays and admitted to placing her breakfast items in the resident care area due to being from an agency and not knowing where to keep them. Further observations revealed that the 300-hall shower room had an overfilled trash can with no bag, resulting in trash items spilling onto the floor, including paper towels, wadded-up toilet paper, and a candy wrapper. These findings were verified by a Licensed Practical Nurse (LPN). The deficiency was investigated under Complaint Numbers OH00152036 and OH00152394.
Deficient Fall Investigations and Supervision
Penalty
Summary
The facility failed to ensure thorough and accurate fall investigations for three residents, leading to deficiencies in accident prevention and supervision. Resident #97, who had moderately impaired cognition and multiple diagnoses including acute kidney failure and diabetes, was found on the floor by a nurse. The fall investigation lacked witness statements and contained inaccuracies, as later interviews revealed the resident had not fallen but was placed in a sitting position by STNAs. The DON confirmed the investigation was not thorough or accurate. Resident #5, with impaired cognition and diagnoses including COPD and congestive heart failure, was found on the floor near his bed. The fall investigation did not include witness statements, and the intervention of a perimeter mattress was not implemented. The DON confirmed that the resident refused the mattress, but there was no documentation of this refusal. Resident #94, with intact cognition and diagnoses including a femur fracture and dementia, experienced a fall that was not thoroughly documented. The fall investigation lacked detail, did not include neurological checks, and did not address predisposing factors such as poor lighting and incontinence. The DON verified the fall concerns and the lack of thorough investigation.
Failure to Provide Sufficient Urinary Catheter Care
Penalty
Summary
The facility failed to obtain orders for and provide sufficient urinary catheter-related care for Resident #19. The resident, who had multiple diagnoses including diabetes mellitus type II, acute respiratory failure, hemiplegia, and chronic kidney disease, had a urinary catheter in place during various periods from January to April 2024. Despite the presence of the catheter, there were no physician orders to monitor, maintain, or care for it, and the medication and treatment administration records showed no evidence of catheter care being provided. Progress notes indicated the presence of the catheter on specific dates, but there was no consistent documentation of its maintenance or care. An observation on April 3, 2024, revealed that the resident did not have a urinary catheter in place. The Director of Nursing confirmed that the resident had a urinary catheter for urinary retention, which was believed to have been placed on February 5, 2024, and removed after returning from the hospital on April 1, 2024. However, there were no urinary catheter-related orders during the time the catheter was in place, and no evidence of sufficient care being provided. The facility's policy on urinary incontinence required staff to monitor for complications with long-term indwelling catheters, but this was not followed in the case of Resident #19.
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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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