Circle Of Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Salem, Ohio.
- Location
- 1985 East Pershing Street, Salem, Ohio 44460
- CMS Provider Number
- 365977
- Inspections on file
- 20
- Latest survey
- June 12, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Circle Of Care during CMS and state inspections, most recent first.
The facility did not ensure timely notification of significant changes in condition and hospital transfers to resident representatives for two residents with complex medical needs. In both cases, documentation and interviews confirmed that family members or legal guardians were not informed as required, despite facility policy and staff acknowledgment of this responsibility.
The facility did not update or follow its water management plan after repeated positive tests for legionella, failed to restrict resident access to potentially contaminated water sources, and did not assess or monitor residents for symptoms of Legionnaires' Disease, including those with high-risk conditions. Staff were unaware of the severity of the water test results, and infection surveillance and control practices were inadequate, affecting all residents.
The facility did not renew its food service operation license on time, resulting in a period where the kitchen operated without a valid license. This affected all residents receiving food from the kitchen, except those with orders for nothing by mouth. The lapse was confirmed through observation, record review, and staff interviews, which showed the renewal application and payment were submitted late.
The facility did not ensure its QAPI committee included all required members, with the Medical Director's attendance undocumented and the Infection Preventionist absent or uncertified for several meetings. Meeting minutes and sign-in sheets lacked evidence of proper participation, and facility policies did not specify committee requirements.
The facility did not ensure that the staff member overseeing the infection prevention and control program had completed the required specialized training before assuming the role. After the previous IP left, the new IP had to self-train and did not obtain the necessary certification until several months later, leaving the facility without a qualified IP during that period. The job description for the position also lacked a requirement for specialized training.
The facility did not ensure that required in-person physician examinations were conducted for new admissions. Instead, a CNP performed all documented assessments, with the physician participating remotely via telemedicine or not at all, as confirmed by staff interviews and progress notes. The absence of in-person physician visits and proper documentation resulted in a deficiency.
The facility did not provide documentation that a physician personally completed or participated in required admission examinations for several residents with complex medical conditions. Instead, a CNP conducted these assessments via telemedicine, and staff interviews confirmed that the physician's involvement was not documented, with most communication occurring virtually or by phone.
Two residents with facility-managed funds had account balances above the Medicaid asset limit, but did not receive required spend-down notices. Staff interviews confirmed that no such notices were provided to any residents, despite awareness of the Medicaid requirements.
A resident with a history of multiple medical issues and recent hospitalizations was given new antipsychotic medications and diagnosed with Schizoaffective disorder, but the facility did not complete a required PASRR level two evaluation following this significant change in mental health status.
A resident with multiple complex diagnoses, including end stage renal disease and pressure ulcers, was admitted without timely development or documentation of a baseline care plan. The care plan lacked a completion date, signature, and evidence of communication to the resident or representative. Comprehensive care plans for key clinical areas were not initiated within 48 hours of admission, and the DON confirmed these deficiencies in documentation and process.
Two residents did not have comprehensive care plans addressing their specific needs, including catheter care and fall prevention, despite ongoing clinical indications and staff confirmation that such interventions were required. The care plans failed to reflect current assessments and did not include necessary interventions as outlined in facility policy.
A resident with a history of neurocognitive disorder, dementia, and high fall risk experienced multiple falls over several months. Despite repeated incidents and new interventions being implemented after each fall, the care plan was not updated to reflect these changes. The DON confirmed the care plan contained duplicate interventions and was not revised as required by facility policy.
Two residents identified as independent smokers were found to keep their smoking materials, including cigarettes, lighters, and a vape cartridge, in their rooms rather than in the designated locked storage as required by facility policy. Staff interviews revealed confusion and inconsistency regarding the enforcement of the smoking materials policy, and observations confirmed that the required interventions outlined in care plans and signed agreements were not implemented.
A resident with multiple complex conditions did not receive appropriate and timely IV midline catheter care. After completion of IV antibiotics, there were no orders for continued flushing or dressing changes, and documentation showed the last flush and dressing change occurred several days prior. Observation confirmed the IV dressing was outdated and had not been changed as required by facility policy, and an LPN was unable to find related orders.
A pharmacist's recommendation to increase the dosage of Metformin for a resident with multiple complex conditions was not reviewed or addressed by the physician, as evidenced by a lack of documentation in the medical record and no changes to the medication order. The facility also could not provide a policy for monthly medication regimen reviews.
A resident with multiple chronic conditions was documented as having a Legionella assessment and vital signs recorded by an LPN, despite not having returned from the hospital. Staff interviews and record reviews confirmed the resident was still hospitalized at the time, resulting in incomplete and inaccurate medical record documentation.
The facility failed to ensure non-pharmacological interventions were attempted before administering PRN lorazepam to a resident and did not include a stop date for the medication order. This was confirmed through medical record reviews and an interview with the DON.
Failure to Notify Resident Representatives of Significant Changes and Hospital Transfers
Penalty
Summary
The facility failed to ensure that resident representatives were notified of significant changes in condition, as required by both facility policy and the Nursing Home Residents' Rights. In the case of one resident with multiple complex medical diagnoses, including sepsis, paraplegia, and end stage renal disease, there were two separate hospital transfers due to acute changes in condition. Documentation showed that the resident's mother, who was the designated representative, was not notified of either transfer. This was confirmed by both the resident and the mother, who expressed distress at not being informed. Nursing staff interviews confirmed that it was their responsibility to notify family or representatives, but there was no documentation of such notifications for these events. Another resident, with diagnoses including diabetes insipidus, traumatic brain injury, neurocognitive disorder, and cancer, was transferred to the hospital after removing sutures from a surgical site, resulting in bleeding. This resident had a legal guardian, as documented in the medical record. However, there was no evidence that the guardian was notified of the incident or the subsequent hospital transfer. The guardian reported only learning of the transfer when contacted by the hospital for necessary paperwork. Nursing staff again confirmed their responsibility to notify representatives, but no documentation of notification was found. Review of facility policy and residents' rights documents indicated that representatives should be informed of significant changes in health status, including hospital transfers, as soon as possible or within 12 hours. Despite these requirements, the facility did not document or provide evidence of timely notification to the appropriate representatives in these cases, resulting in a deficiency related to communication and notification of significant changes.
Failure to Implement Effective Water Management and Infection Control for Legionella
Penalty
Summary
The facility failed to develop, implement, and follow a comprehensive and effective infection prevention and control program, specifically regarding its water management plan to prevent the growth and spread of legionella bacteria in the water supply. Despite receiving water test results indicating elevated and increasing levels of legionella, the facility did not re-evaluate or update its water management risk assessment or plan, nor did it provide effective interventions to mitigate the risk. The facility also did not ensure that residents were prevented from accessing or using water from areas where legionella could be present, as evidenced by residents continuing to use sinks and showers in affected areas without appropriate filters or signage restricting use. The facility's water management risk assessment was outdated and lacked critical components such as summaries, acceptable control levels, and response procedures for positive legionella findings. Maintenance activities were inconsistently documented, with no evidence of routine maintenance or cleaning of showers, whirlpools, or flushing of water in unoccupied rooms as required. Water testing was limited to a single location, and when results showed a significant increase in legionella levels, there was no documented investigation or intervention. Staff interviews confirmed a lack of awareness of the severity of the test results, and there was no evidence that residents were assessed for symptoms of Legionnaires' Disease during the period of elevated risk, including those with respiratory symptoms or hospitalizations. Residents, including those with high-risk conditions such as tracheostomies, ventilator dependence, and those receiving dialysis, continued to use water sources that were potentially contaminated. Interviews with residents confirmed ongoing use of sinks and showers in areas where legionella was present, and staff confirmed that there were no effective restrictions or visual cues to prevent such use. The facility's infection surveillance system was also found to be ineffective, as it failed to track infections and monitor trends, and appropriate infection control techniques were not followed during wound care for at least one resident.
Removal Plan
- An all-staff in-service was completed on risks, signs and symptoms and interventions for legionella by the DON and IP Nurse #302.
- Water to each sink in all facility rooms was shut off to prevent accidental use by residents and staff. Gallon jugs of purified water were put in place to wash hands with dates and names on each.
- The DON/designee would audit employee call-offs weekly, monitoring for any symptoms related to legionella illness. Any concerns would be immediately reported to the Administrator and addressed by the Quality Assessment Performance Improvement (QAPI) committee as necessary.
- The facility contracted with PT enterprises to assist with the water management plan. PT enterprises took twelve water samples (four swabs and eight additional 250 ml potable water samples).
- Point of use filters for all water sources in the facility were ordered.
- The DON brought in hot and cold-water dispensers for use on the second and third floors. This water was provided for residents' use for any residents who did not want to drink bottled water and staff were responsible for bringing the water to residents. Additional bottled water was supplied to the fourth floor.
- The DON educated the weekend staff and agency staff working on-site on not using the room sinks or shower on the second floor, as well as signs and symptoms of legionella.
- A Legionella assessment data collection form was created in point click care (PCC), which included a set of vital signs, a review of potential symptoms of legionella, a place for a narrative, and a yes or no question as to whether or not the resident experienced more than three symptoms beyond their baseline.
- All nurses would be educated on this form. Any nurse not educated would not be allowed to work the floor until the education was completed. Nurses would complete this assessment on resident admission and with resident change of respiratory condition.
- New legionella filters were received and placed on the main floor bathroom sink, therapy room sink, room [ROOM NUMBER] sink faucet, shower heads on the second, third and forth floors, at the nursing station sinks on the second, third and forth floors and on the dialysis center sinks by Maintenance Manager #322.
- Legionella tests for six residents who were transferred from the facility for signs and symptoms of respiratory distress were completed.
- A contracted plumbing company ([NAME] Plumbing) came to the facility to evaluate appropriate adapters to fit on the sink filters. They also evaluated sanitation. The water remained off to the room sinks at this time.
- The DON/designee completed resident assessments (legionella assessment data collection form) for all facility residents. The resident assessments would continue to be conducted weekly by the DON/designee and/or Infection Preventionist. Any concerns would be immediately reported to the Administrator and Medical Director for follow-up.
- The facility Water Management Committee, including the Administrator, DON, IP #302, Maintenance Manager #322, Housekeeping/Laundry Supervisor, RT Director and Dietary Manager met to further discuss the facility's Water management -Legionella plan.
- The facility QAPI committee met to review any updates to the water management plan and complete audits.
- The facility new water management protocols included: a.) Each faucet and shower head aerator would be cleaned with an approved scale and lime build-up cleaner semi-annually to ensure proper water flow quarterly. b.) The hot water boilers would be set at 140 or greater. Facility staff would record the temperature of each hot water device weekly and adjust immediately if less than 140. To ensure compliance to policy, staff would retest the following day to confirm appropriate temperature. c.) Hot water holding tanks would be set at a minimum of 140 to inhibit the growth of Legionella and other opportunistic pathogens. Facility staff would record the temperature weekly and adjust immediately if less than 140 to ensure compliance. d.) Regular cleaning and changing of filters would be done per manufacturers' recommendations. The facility would remove scale and clean using approved cleaning agents semi-annually and changing the filters every six months or per manufacturer recommendations. Maintenance Manager #322 would audit monthly to ensure compliance and audits will be reviewed in QAPI meetings. e.) Weekly flushing of water would be added to housekeepers assignments which would consist of flushing for three minutes each faucet and showers also flush all toilets at least once every week. The supervisor would review documentation weekly to ensure compliance. Audits would be reviewed, and the facility would determine where the failure occurs during QAPI meetings. f.) If the facility experiences one or more positive cases of legionellosis, the facility would conduct semi-annual testing to determine if the water management plan (WMP) was effective in controlling legionella and the Maintenance Manager #322 will follow up with the vendor to determine failure to conduct and correct this. g.) For any positive legionella in the water, the facility would contact PT enterprises, to conduct testing on water samples, provide alternate water sources for bathing and patient care, inspect all faucets for built-up scaling and cleaning with appropriate cleaner and replace all filters on incoming water sources. h.) Legionella filters would be changed per manufacturers' recommendations.
- The facility received ordered parts which were being installed with a plan to have all installation of parts/filters completed.
Failure to Timely Renew Food Service Operation License
Penalty
Summary
The facility failed to renew its food service operation license in a timely manner, resulting in a period during which there was no valid license for the kitchen. This deficiency was identified through observation of the expired license posted in the kitchen, review of records showing the license expiration and late renewal application, and interviews with the Dietary Manager and Administrator. The Administrator confirmed that the renewal application was submitted late and the corporate office delayed issuing the payment for the renewal. As a result, all 35 residents who received food from the kitchen were affected during the lapse in licensure, except for five residents who had orders for nothing by mouth. The facility census at the time was 40 residents. The deficiency was substantiated by documentation showing the required application was not completed and submitted by the due date, and the check for the license fee was also issued late. There was a documented gap between the expiration of the previous license and the issuance of the updated license, during which the facility operated its food service without a valid license.
QAPI Committee Lacked Required Members and Documentation
Penalty
Summary
The facility failed to ensure that its Quality Assurance and Performance Improvement (QAPI) committee included the minimum required members and met the participation requirements. Review of QAPI meeting sign-in sheets from July 2024 through February 2025 showed no evidence of attendance by the Medical Director, and the Infection Preventionist (IP) was not present at all required meetings, with gaps in attendance and certification. The sign-in sheets did not document the Medical Director's virtual attendance, and there was no written evidence of his participation in the meeting minutes. Additionally, the previous IP left in August 2024, and the new IP did not obtain the required certification until January 2025, leaving a period without a qualified IP present at meetings. Interviews with the DON confirmed that the Medical Director typically attended QAPI meetings by phone due to personal circumstances, but this was not documented. The Medical Director himself could not recall his last attendance and stated his participation was usually virtual, with updates provided by the facility. The facility's QAPI policy, last revised in October 2017, did not specify committee member requirements, and no other relevant policies were provided. These findings indicate the facility did not maintain the required composition and documentation for its QAPI committee, potentially affecting all residents.
Infection Preventionist Lacked Required Training for IPCP Oversight
Penalty
Summary
The facility failed to ensure that the staff member responsible for overseeing the infection prevention and control program (IPCP) had completed the required specialized training in infection prevention and control. The designated Infection Preventionist (IP) began her training in August 2024, but her predecessor left after only eight hours of training, leaving her to learn the role independently. She did not complete the necessary training and obtain her certificate until January 2025. Review of her personnel file confirmed there was no evidence of completed specialized training prior to this date. Interviews with the Director of Nursing (DON) and other staff confirmed that, during the period between the previous IP's departure and the new IP's completion of training, there was no qualified staff member overseeing the IPCP. Additionally, the job description for the Infection Preventionist Director position did not require completion of specialized training before or after assuming the role. This lapse had the potential to affect all 40 residents in the facility.
Failure to Provide In-Person Physician Examinations for New Admissions
Penalty
Summary
The facility failed to provide evidence that the physician conducted required in-person examinations for all new admissions, as mandated. Record reviews for four residents admitted from short-term general hospitals revealed that there were no progress notes written by the physician in the electronic health records for any of these residents. Instead, all documented examinations and follow-up visits were completed by a Certified Nurse Practitioner (CNP), with the physician either participating via telemedicine or not mentioned as participating at all. The CNP's notes consistently indicated that evaluations were completed via telehealth or telemedicine, and there was no documentation of the physician being physically present for any of the required visits. Interviews with facility staff, including the Director of Nursing (DON), an LPN, and the CNP, confirmed that the physician typically attended meetings and resident visits virtually due to personal circumstances, specifically his inability to leave his wife. The DON and LPN both stated that the CNP usually conducted resident visits, with the physician participating remotely via telemedicine. The LPN described a process where nurses would initiate a video call with the physician and move the device from room to room, while most communication with the physician was conducted by phone. The CNP verified that visits were conducted virtually if indicated in the progress notes and acknowledged that the physician's participation was not always documented. The CNP also stated that the progress note would specify if the physician or CNP conducted any portion of the visit in-person, but in these cases, there was no such documentation. The lack of in-person physician examinations and insufficient documentation of physician involvement led to the deficiency cited by surveyors.
Lack of Physician Documentation and Delegation in Admission Examinations
Penalty
Summary
The facility failed to provide evidence that the physician did not delegate tasks to non-physician providers that were required to be completed personally by the physician. For four residents admitted from short-term general hospitals, medical record reviews showed that there were no progress notes written by the physician, who also served as the facility's Medical Director, documenting participation in the admission examinations. Instead, admission evaluations were completed by a Certified Nurse Practitioner (CNP) via telehealth or telemedicine, with no documentation of the physician's involvement in these assessments. Interviews with facility staff, including the Director of Nursing (DON), an LPN, and the CNP, confirmed that the physician often participated in meetings and resident visits via telephone or telemedicine due to personal circumstances. However, there was no documentation in the residents' records to verify the physician's participation in the admission process. The CNP also stated she was unaware of any law prohibiting her from completing initial visits via telemedicine, and verified that visits were conducted virtually if indicated in the progress notes.
Failure to Provide Spend-Down Notices for Resident Funds Exceeding Medicaid Limits
Penalty
Summary
The facility failed to provide required spend-down notices to two residents whose funds were managed by the facility and whose account balances exceeded the Medicaid asset limit. For one resident with moderate cognitive impairment and multiple diagnoses including vascular dementia and major depressive disorder, quarterly account statements showed balances above the $2,000 Medicaid limit, but no spend-down notices were issued. Similarly, another resident with no cognitive impairment and a history of neurocognitive disorder and traumatic brain injury also had account balances above the allowable Medicaid limit, and did not receive any spend-down notices. Interviews with the Business Office Manager confirmed that the facility was aware of the Medicaid asset limit and that no spend-down notices were provided to any residents, including those whose balances exceeded the limit. The Director of Nursing confirmed that one resident was losing Medicaid coverage due to being over the asset limit, and would only regain coverage after spending down the excess funds. The deficiency was identified through record review and staff interviews, affecting two of five residents reviewed for resident funds.
Failure to Complete PASRR Level Two After New Schizoaffective Disorder Diagnosis
Penalty
Summary
The facility failed to complete a new Pre-Admission Screening and Resident Review (PASRR) level two evaluation for a resident after a new diagnosis of Schizoaffective disorder was added. The resident was initially admitted with multiple medical conditions, including muscle weakness, hypothyroidism, protein-calorie malnutrition, encephalopathy, cellulitis, hypokalemia, hypertension, and cognitive communication deficit. The initial PASRR level one screening indicated no serious mental illness and no recent use of psychotropic medications. However, subsequent hospital records documented unspecified psychosis, adjustment disorder, refusal of medical treatment, and a determination of incompetence to make informed healthcare decisions. Following admission, the resident received several new orders for antipsychotic medications, and a new diagnosis of Schizoaffective disorder was formally added. Despite these significant changes in the resident's mental health status and treatment, the facility did not complete a new PASRR evaluation as required. This was confirmed during an interview with the Admissions Coordinator, who acknowledged that a significant change PASRR should have been completed for the resident.
Failure to Timely Develop and Document Baseline Care Plan for New Admission
Penalty
Summary
The facility failed to provide evidence that a baseline care plan was developed in a timely manner for a resident admitted with multiple complex medical conditions, including hypertension, iron deficiency anemia, bronchiectasis, atrial fibrillation, dementia, severe malnutrition, diabetes, pressure ulcers, enterocolitis due to clostridium difficile, open wound, and end stage renal disease. The resident's medical record review showed that the handwritten baseline care plan document lacked a date of completion, signature, or identification of the person who completed it. Additionally, there was no indication that the resident or their representative received a copy of the baseline care plan. Further review revealed that comprehensive care plans for several critical focus areas, such as nutrition and hydration risk, end-stage renal disease and hemodialysis, hypertension, fall risk, activities of daily living self-care deficit, incontinence, renal failure, clostridium difficile, pain, polypharmacy, discharge planning, and others, were not initiated within 48 hours of admission as required. The DON confirmed that baseline care plans were always completed on paper, not in the electronic health record, and verified the lack of documentation and communication regarding the baseline care plan for this resident.
Failure to Develop and Implement Comprehensive Care Plans for Identified Resident Needs
Penalty
Summary
The facility failed to develop and implement person-centered, comprehensive care plans that addressed the identified needs of two residents. For one resident with diagnoses including end stage renal disease, diabetes, heart failure, and bladder dysfunction, the care plan did not include interventions for elimination status, specifically omitting catheter care and bowel incontinence management, despite the resident having an indwelling catheter and frequent bowel incontinence. Interviews with facility staff confirmed that such interventions should have been present in the care plan and linked to aide documentation tasks, but were not. For another resident with a history of encephalopathy, weakness, dementia, and a previous fall resulting in a fractured ankle, the care plan lacked interventions for fall risk, even though fall risk assessments consistently indicated a moderate risk. The only fall-related care plan was marked as resolved after the previous fall, and no new interventions were documented despite ongoing risk. Staff interviews confirmed that care plan interventions for fall prevention should have been included, and facility policy required identification and documentation of fall risk factors and implementation of preventive interventions.
Failure to Update Care Plan After Multiple Falls
Penalty
Summary
The facility failed to re-evaluate and update the care plan with new interventions for a resident who experienced multiple falls over several months. Despite repeated incidents, the care plan was not revised to reflect new or different interventions after each fall, as required by facility policy and regulatory standards. The care plan contained duplicate interventions with different dates, and new interventions implemented after falls were not consistently added to the resident's care plan. The resident involved had a complex medical history, including neurocognitive disorder with Lewy bodies, major depressive disorder, dementia, and a history of traumatic brain injury. The resident was identified as being at high risk for falls, with multiple documented falls occurring both from bed and wheelchair, often while attempting self-transfers or sitting on the edge of the bed. After each fall, interventions such as education on call light use, neurological checks, and environmental adjustments were documented in progress notes and fall investigations, but these were not systematically incorporated into the formal care plan. Interviews with the Director of Nursing confirmed that the care plan was not updated after each fall and that there were duplicate interventions listed. The DON acknowledged ongoing challenges with the resident's memory and behavior due to Lewy Body Dementia but could not identify additional measures to prevent further falls. Facility policy required care plans to be revised when the desired outcome was not met or when the resident's condition changed, but this was not followed in the case of this resident.
Failure to Secure Smoking Materials in Accordance with Facility Policy
Penalty
Summary
The facility failed to ensure that smoking materials were stored in a safe and secure location, as required by facility policy, affecting two residents identified as independent smokers. Both residents were permitted to smoke independently and were observed to keep their smoking materials, including cigarettes, lighters, and a vape cartridge, in their rooms rather than in the designated locked storage as outlined in the facility's smoking policy. Multiple staff interviews revealed uncertainty and inconsistency regarding the enforcement of the policy, with some staff unsure whether independent smokers were allowed to keep their smoking supplies in their rooms. For one resident, who had diagnoses including encephalopathy, alcohol dependence with persisting dementia, and tobacco use, observations revealed a strong odor of smoke in the resident's room, a vape cartridge found on the floor near an oxygen concentrator, and confirmation from the resident that she kept her smoking materials in her room or coat pocket. Staff interviews confirmed that smoking materials were supposed to be locked in the medication cart, but this was not being followed for this resident. The resident's care plan and signed smoking agreement both required that smoking materials be locked up, but these interventions were not implemented. Similarly, another resident with a history of alcohol and nicotine dependence and a cognitive communication deficit was also found to keep smoking materials in his room, contrary to facility policy. Staff interviews and observations confirmed that this resident, too, was not following the policy requiring smoking materials to be locked up. Both residents' care plans and signed agreements specified that smoking materials should be secured, and any infraction would result in loss of smoking privileges, but these measures were not enforced. The facility's own policy and procedure documents reiterated the requirement for locked storage of smoking materials, which was not adhered to in these cases.
Failure to Ensure Timely IV Midline Maintenance and Dressing Changes
Penalty
Summary
The facility failed to ensure the appropriate and timely administration and maintenance of an intravenous (IV) midline catheter for a resident with multiple complex medical conditions, including diabetes, acute kidney failure, necrotizing fasciitis, osteomyelitis, sepsis, and chronic ulcers. The resident was ordered to receive IV antibiotics and saline flushes through a midline catheter, but after the completion of the antibiotic course, there were no physician orders for continued flushing to maintain line patency or for regular IV dressing changes. Documentation showed that the last antibiotic dose and saline flush were administered several days prior, and there was no record of any IV dressing changes during the period reviewed. Observation revealed that the resident's IV dressing had not been changed since insertion, and the IV tubing and bag remained hanging on the pole days after the last use. The resident confirmed not receiving any IV medications or flushes in several days, and the dressing had never been changed. An LPN interviewed was unable to locate any orders for dressing changes and confirmed the dressing was outdated. Facility policy required midline catheters to be flushed at least every 24 hours and dressings to be changed within 24 hours of insertion and then every five to seven days, but these protocols were not followed.
Pharmacist Medication Recommendation Not Reviewed by Physician
Penalty
Summary
The facility failed to ensure that pharmacist recommendations regarding a resident's medication regimen were reviewed and addressed by the physician. Specifically, a pharmacist recommended increasing the dosage of Metformin for a resident with multiple complex diagnoses, including end stage renal disease, heart failure, hypertension, anxiety, major depressive disorder, necrotizing fasciitis, overactive bladder, neuromuscular dysfunction of the bladder, and type 2 diabetes mellitus. The recommendation was documented in the pharmacist consultation report, but there was no evidence in the medical record, medication administration records, or progress notes that the physician or other prescribing provider reviewed or acted upon this recommendation. The resident in question had intact cognition and was receiving several medications, including hypoglycemics, antidepressants, diuretics, opioids, and anticonvulsants. Despite the pharmacist's recommendation to adjust the Metformin dosage, the medication order remained unchanged for several months, and no documentation was found indicating that the recommendation was considered by the medical staff. Additionally, the facility was unable to provide a policy related to monthly medication regimen reviews when requested.
Incomplete and Inaccurate Medical Record Documentation
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for Resident #34. Resident #34, who had diagnoses including end stage renal disease, chronic obstructive pulmonary disease, pleural effusion, and type one diabetes mellitus, was admitted to the facility and later discharged to the hospital. Despite the resident not having returned from the hospital, a Legionella signs and symptoms assessment was documented for Resident #34, including vital signs recorded on a date when the resident was still hospitalized. The assessment was completed by an LPN, who could not recall the specifics of completing the assessment for this resident or the source of the information documented. Further review of the resident's census information, progress notes, and MDS assessments confirmed there was no evidence that Resident #34 had returned to the facility at the time the assessment was completed. Observations and interviews with facility staff, including a CNA and the DON, verified that the resident remained in the hospital and that the room was empty. The DON confirmed the assessment's date and content, and the LPN acknowledged completing multiple assessments but could not explain the documentation for this particular resident.
Failure to Implement Non-Pharmacological Interventions and Stop Date for PRN Lorazepam
Penalty
Summary
The facility failed to ensure that non-pharmacological interventions were attempted prior to the administration of an as-needed antianxiety medication for Resident #22. The resident, who had a complex medical history including encephalopathy, end stage renal disease, and anxiety disorders, received lorazepam multiple times without any documented attempts of non-pharmacological interventions. This was confirmed through a review of the medical records and an interview with the Director of Nursing, who verified that non-pharmacological interventions were not attempted prior to the administration of lorazepam on several occasions in March and April 2024. Additionally, the facility did not ensure that the as-needed lorazepam order for Resident #22 included a stop date, as required by regulations. The resident's physician's order for lorazepam one milligram IM every four hours as needed for anxiety and agitation, dated 03/15/24, lacked a stop date. This was also confirmed by the Director of Nursing during an interview. The facility's policy on psychotropic drugs was reviewed and found to be in place to promote the utilization of such drugs in accordance with accepted principles of geriatric medicine and long-term care practice, but it was not followed in this instance.
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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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