Columbus Alzheimer's Care Ctr
Inspection history, citations, penalties and survey trends for this long-term care facility in Columbus, Ohio.
- Location
- 700 Jasonway Avenue, Columbus, Ohio 43214
- CMS Provider Number
- 365839
- Inspections on file
- 20
- Latest survey
- March 10, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Columbus Alzheimer's Care Ctr during CMS and state inspections, most recent first.
A resident with severe cognitive impairment was injured after being pushed by another resident, leading to a fall and a right femur fracture. The incident occurred when the injured resident wandered into the other resident's room, despite existing care plans to prevent such interactions. The facility's investigation concluded there was no intent to harm, but the incident highlights a failure to protect residents from physical abuse.
The facility failed to investigate and document allegations of abuse, neglect, and misappropriation for several residents. Incidents included injuries of unknown origin and resident-to-resident altercations, with missing or incomplete documentation of required 15-minute checks. The Director of Nursing acknowledged these deficiencies, which were not in line with the facility's policy for handling such allegations.
A resident's wedding ring was reported missing by family to a Unit Manager, who failed to report the incident to management or initiate an investigation promptly. The delay led to non-compliance with the facility's policy requiring timely reporting of misappropriation to the state health department.
The facility failed to ensure call lights were accessible for two residents, affecting their ability to summon assistance. One resident's call light was hung behind the headboard, while another's was on the floor under the bed. A nurse confirmed the call lights should have been within reach. The Administrator and DON were unsure if a policy on call light accessibility existed.
The facility failed to ensure a qualified Activity Director was in place, as the current AD lacked the necessary certification, degree, and experience. Despite being promoted to Activities Manager, the AD had only six months of full-time experience and no supervisory experience, relying on online resources for planning activities. This deficiency potentially affected all 99 residents.
The facility failed to properly label and store medications and secure medication carts. Two RNs left their carts unlocked while administering medications, violating facility policy. A resident's eye drops lacked an opening date, contrary to guidelines. Additionally, improper storage of a tuberculin solution and influenza vaccine was observed, risking medication errors.
The facility failed to prevent contamination of clean utensils, maintain kitchen equipment, and follow datemarking procedures. Observations revealed chipped paint above clean pots, a leaking garbage disposal, and expired or undated food items. Additionally, a noncommercial microwave with peeling metal and a reach-in cooler with pooling water were noted, with no work orders submitted for these issues.
The facility's assessment was incomplete, missing critical information on ethnic, cultural, or religious factors, third-party agreements, health IT resources, and risk assessments. Interviews confirmed the presence of residents with language needs not documented in the assessment, and the QAPI meeting did not address these deficiencies.
The facility failed to maintain a clean and homelike environment for several residents, as observed during a survey. Rooms were found to be filthy, with sticky floors, soiled bedspreads, and stained walls. Other rooms lacked personal items or decorations, making them appear bare and uninviting. These conditions were confirmed by facility staff, indicating a failure to adhere to the facility's policies on cleanliness and homeliness.
A LTC facility reported a 12.9% medication error rate, affecting four residents. A resident missed a Namenda dose due to unavailability, another received a partial Zoloft dose, a third was given the wrong laxative, and a fourth had insulin administered without priming the pen. These errors were against facility policies.
The facility failed to ensure proper infection control practices, including the absence of signage and PPE for residents on enhanced barrier precautions, improper wound care procedures by an LPN, and inadequate glove use and hand hygiene by staff. These deficiencies affected multiple residents with specific medical needs.
A facility failed to manage a resident's financial affairs by missing a scheduled life insurance payment, leading to the policy's cancellation. The resident, with dementia and Alzheimer's, was unable to manage their own finances, and the facility's business office was responsible for making quarterly payments. Despite previous payments being made, the April payment was missed, and efforts to reinstate the policy were ongoing.
A resident with an open wound and cognitive intactness had a wound culture showing heavy growth of streptococcus pyogenes. The results were available, but the physician was not notified until two days later, contrary to the facility's policy requiring immediate notification. An LPN confirmed the delay in notification.
A resident with dementia and aphasia, who spoke French Creole, was not provided with necessary communication aids like an interpreter or communication board, despite these being part of her care plan. Staff admitted to guessing her needs due to the language barrier. Another resident with multiple health issues was observed with unkempt hair over several days, indicating a failure to provide necessary personal hygiene care. The facility's policy on supporting ADLs was not followed, as staff did not implement the required interventions for these residents.
The facility failed to provide activities that met the needs and preferences of several residents, including one with dementia and another with Alzheimer's disease. Residents expressed dissatisfaction with the lack of activities and opportunities to go outside, and activity logs showed minimal engagement. Staff interviews revealed a lack of awareness of residents' preferences and a failure to invite them to activities, contributing to feelings of unhappiness and isolation.
A facility failed to follow physician orders for daily weight monitoring of a resident with CHF, Alzheimer's, and other conditions. The resident's care plan required daily weights at 6:00 A.M., with significant weight changes reported. However, weights were not documented on three occasions, as confirmed by the Unit Manager.
A resident with dementia and visual impairments was not consistently assisted with wearing his corrective lenses, despite needing them for clear vision. Observations showed the resident without glasses on multiple occasions, and staff were often unaware of his need for them. The glasses were frequently found out of reach, and staff had to assist the resident in wearing them, which improved his vision.
The facility failed to maintain pressure ulcer interventions for three residents. One resident was observed without a pressure-reducing cushion, another without heel elevators, and a third with an incorrectly set mattress. Staff were unaware of the correct settings and equipment, leading to non-compliance with physician orders.
A facility failed to administer tube feedings at the physician-ordered rate for a resident with severe protein calorie malnutrition and other medical conditions. The resident was supposed to receive Isosource 1.5 at 55 cc per hour, but was observed receiving Jevity 1.5 at 50 cc per hour, as confirmed by the UM.
A resident with type two diabetes received insulin injections outside the physician's specified parameters, as confirmed by the DON. The facility's policy required verification of medication administration, but insulin was administered incorrectly on multiple occasions.
The facility did not have transfer agreements with hospitals certified by Medicare or Medicaid, potentially affecting all 99 residents. The facility only had agreements to transfer residents to sister facilities in emergencies. Interviews confirmed that a written transfer agreement was not executed until late August, indicating a failure to ensure timely hospital transfers for residents.
Resident-to-Resident Altercation Results in Injury
Penalty
Summary
The facility failed to protect Resident #100 from physical abuse by another resident, Resident #57, resulting in actual harm. On 02/03/25, Resident #57, who had a history of resident altercations and impaired cognition, pushed Resident #100, causing a fall and a right femur fracture. This incident occurred when Resident #100 wandered into Resident #57's room, leading to the altercation. Both residents were assessed for injuries, and Resident #100 was immobilized on the floor due to an obvious range of motion deficit to the right hip and was subsequently transferred to the hospital. Resident #100 had severe cognitive impairment and was independent for mobility, with a history of Alzheimer's disease, vascular dementia, and other conditions. The care plan for Resident #100 included interventions to monitor his safety and redirect him away from areas where he might encounter Resident #57. Despite these measures, Resident #100 was found lying on the floor near Resident #57's room, in pain, and was given pain medication before being taken to the hospital, where he was diagnosed with a right hip fracture. Resident #57, who also had severe cognitive impairment, was known to be resistive to care and had a history of aggression towards male residents entering his room. His care plan included interventions to manage his behavior, such as psychiatric evaluations and maintaining consistency in his routine. After the incident, Resident #57 was placed on 15-minute checks, and the facility's investigation concluded that the incident was not abuse, as both residents were reacting impulsively without intent to harm. However, the facility's policy on abuse requires protection of residents from such incidents, indicating a failure to ensure a safe environment for Resident #100.
Failure to Investigate and Document Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to thoroughly investigate and implement interventions for allegations of abuse, neglect, misappropriation, and injuries of unknown origin affecting eight residents. For Resident #54, an injury of unknown origin was reported, but no resident interviews or statements were completed, and the intervention of 15-minute checks was not documented as completed. The Director of Nursing acknowledged the lack of evidence for these checks, which were not typical for such an injury. For Resident #89, investigations into misappropriation involving a missing wedding ring and clothes were incomplete, lacking resident interviews and specific questions asked of staff. The investigation mixed information from a previous incident and did not document interactions with the Ohio Department of Health. The facility also failed to consider staff working prior to the allegation date. The Director of Nursing admitted these oversights during the interview. Other residents, including #52, #100, #33, #48, #20, and #21, were involved in incidents of resident-to-resident altercations. The facility did not complete resident interviews or statements, and 15-minute checks were either missing or inconsistently documented. The Director of Nursing confirmed the missing documentation and acknowledged the discrepancies in the records. The facility's policy required immediate reporting and thorough investigation of such allegations, which was not adhered to in these cases.
Failure to Timely Report Misappropriation of Resident Property
Penalty
Summary
The facility failed to report an allegation of misappropriation of a resident's property to the state agency in a timely manner. This incident involved a resident with cognitive impairments, including dementia and aphasia, who required extensive assistance with daily activities. The resident's family reported a missing wedding ring to the Unit Manager before Christmas, but the Unit Manager did not inform facility management or initiate an investigation promptly. The Unit Manager attempted to locate the ring but did not escalate the issue to management, as the usual staff were unavailable, and then went on vacation. The delay in reporting the incident to the Director of Nursing and subsequently to the Ohio Department of Health resulted in non-compliance with the facility's policy. The policy mandates that any allegations of misappropriation must be reported to the Administrator and the state health department within 24 hours of being known to a staff member. The Director of Nursing confirmed that the Unit Manager should have reported the missing ring immediately, which would have allowed the facility to comply with the reporting requirements.
Inaccessible Call Lights for Residents
Penalty
Summary
The facility failed to ensure that call lights were accessible to residents, affecting two residents who were observed in their rooms. Resident #35, who was admitted with diagnoses including dementia, osteoarthritis, aphasia, and anxiety, was found with a call light that was not within reach. The call light was hung behind the headboard over a wall clock, approximately six feet from the ground. A Registered Nurse confirmed that the call light was out of reach and should have been accessible to the resident while in bed. Similarly, Resident #54, who had multiple diagnoses including Alzheimer's disease, dementia, and diabetes, was also found with an inaccessible call light. The call light was located on the floor under the footboard side of the bed, requiring staff to climb around the bed to retrieve it. The Registered Nurse confirmed that the call light should always be within reach of the resident while in bed. Interviews with the Administrator and Director of Nursing revealed uncertainty about the existence of a facility policy regarding call light accessibility, and no policy was provided.
Unqualified Activity Director in Place
Penalty
Summary
The facility failed to ensure that a qualified Activity Director (AD) was in place to oversee the activity services for all 99 residents. The personnel file review revealed that the current AD, who was initially hired as a part-time activities aide, did not meet the qualifications required for the position. The AD had a high school diploma and some college experience but did not graduate. She was promoted to Activities Manager despite lacking the necessary certification, an associate degree in recreation, or two years of full-time experience as an activities aide, as stipulated in the facility's job description for the position. Interviews with the AD and the Human Resources Director (HRD) confirmed that the AD had only six months of full-time experience and no supervisory experience. The HRD acknowledged that the AD did not meet the criteria for the role, as she lacked the required educational background and certification. The AD relied on online resources for planning activities and confirmed that there was no regional or corporate oversight for the activities program. This deficiency had the potential to affect all residents in the facility.
Medication Management and Storage Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling and storage of medications, as well as securing medication carts when not in use. During observations, two registered nurses were found leaving their medication carts unlocked and unattended while administering medications to residents. This was against the facility's policy, which mandates that medication carts must be locked when out of sight or unattended. Additionally, the facility did not adhere to proper labeling practices for medications, as evidenced by the lack of an opening date on a vial of Cosopt ophthalmic solution for a resident with Alzheimer's disease, glaucoma, and osteoarthritis. The medication had been administered without knowing when it should be discarded, contrary to the manufacturer's guidelines that specify a 28-day usage period after opening. Further deficiencies were noted in the medication storage practices within the facility. An open, undated vial of tuberculin testing solution and a vial of influenza vaccine were improperly stored in a medication room refrigerator. The influenza vaccine was found inside a tuberculin testing solution box, which could lead to medication errors. The manufacturer's guidelines for the tuberculin testing solution require that vials be discarded after 30 days of opening to prevent degradation, a practice not followed by the facility. These lapses in medication management had the potential to affect all residents in the facility, which had a census of 99 residents.
Deficiencies in Kitchen Equipment Maintenance and Food Safety Practices
Penalty
Summary
The facility failed to prevent contamination of clean equipment and utensils, maintain kitchen equipment in proper working condition, and adhere to datemarking procedures. Observations revealed chipped paint on a ceiling door above a storage rack for clean pots and pans, posing a risk of contamination. The Dietary Director confirmed the potential for paint chips to fall onto the clean items. Additionally, a leak from the garbage disposal was noted, with pooling liquid on the dish room floor, which had been an issue for approximately two months without a work order being filed for repair. Further deficiencies were observed in the facility's datemarking practices. Bags of cheese and a log of bologna in the walk-in cooler were found to be past their hold time or undated, contrary to the facility's policy of marking food for disposal within seven days. The Dietary Director confirmed these items should have been discarded. Similarly, mushrooms in the cooler were out of date, indicating a failure to follow the datemarking policy. The facility also failed to maintain kitchen equipment, as evidenced by a noncommercial microwave with peeling metal and a reach-in cooler with pooling water. Despite daily monitoring by kitchen staff, no work orders were submitted for these issues. The local health department had advised the facility to replace the microwave with a commercial-grade unit, but this had not been done. The pooling water in the reach-in cooler was a recurring problem, yet no maintenance requests were documented.
Incomplete Facility Assessment Documentation
Penalty
Summary
The facility failed to ensure that their facility-wide assessment contained all required information, which had the potential to affect all residents residing in the facility. The assessment, updated on 08/19/24, was incomplete in several critical areas. Specifically, the sections regarding ethnic, cultural, or religious factors that could affect resident care, contracts and agreements with third parties for services or equipment, health information technology resources, and facility-based and community-based risk assessments were left blank. This lack of comprehensive assessment documentation was confirmed during a review of the facility's records. Interviews conducted on 08/26/24 with the Administrator and the Director of Nursing (DON) further confirmed the deficiencies in the facility assessment. The DON acknowledged that the facility had residents whose primary language was not English, including two who spoke French Creole, one who spoke another language, and one who spoke Vietnamese. Despite these language needs, the relevant section in the assessment was not completed. Additionally, the DON noted that the facility's Quality Assurance/Performance Improvement (QAPI) meeting was held on the same day, but the members did not have time to review the assessment thoroughly, leaving the deficiencies unaddressed.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean and homelike environment for several residents, as observed during an annual survey. Resident #44's room was found to be filthy, with a sticky floor and soiled bedspread, and stained walls. These conditions were confirmed by the Maintenance Director and Housekeeping Supervisor. Similarly, Resident #78's room had a sticky floor, dried residue on the bathroom floor, and shredded rubber pellets scattered on the floor, which were also verified by the facility staff. Other residents, including #26, #90, #35, #92, and #18, were found to have rooms that were not in a homelike condition. These rooms had scuffed walls, drywall patches, and lacked personal items or decorations, making them appear bare and uninviting. The Maintenance Director, Housekeeping Supervisor, and Activity Supervisor confirmed these observations, noting the absence of items that would contribute to a homelike environment, such as clocks and dressers. The facility's Routine Cleaning and Disinfection Policy and Quality of Life-Homelike Environment policy were reviewed, indicating a commitment to providing a safe, clean, and comfortable environment. However, the observations and interviews during the survey revealed a failure to adhere to these policies, resulting in an environment that did not meet the standards of cleanliness and homeliness expected in a long-term care setting.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a 12.9% error rate. This deficiency affected four residents, each with specific medication administration issues. Resident #64 did not receive their prescribed dose of Namenda due to its unavailability, despite the presence of an emergency supply. The LPN responsible did not notify the Director of Nursing and failed to utilize the emergency supply, leading to a missed dose. Resident #27 was prescribed Zoloft 150 mg but only received 100 mg due to a shortage of the required dosage in the medication cart. The RN administering the medication was unable to find the correct dosage in the emergency supply and proceeded to give a partial dose. This was confirmed by the Unit Manager, who noted that the missing medication had been ordered but would not arrive until later. Resident #08 received the wrong laxative, Senna 8.6 mg instead of the prescribed Senna-S, due to the RN's assumption that the available medication was close enough to the ordered one. Additionally, Resident #49's insulin administration was compromised as the RN failed to prime the insulin pen, contrary to the manufacturer's instructions. These errors were not in line with the facility's policies on medication administration and error reporting.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure that residents with physician's orders for enhanced barrier precautions (EBP) had appropriate signage and personal protective equipment (PPE) available outside their rooms. This deficiency affected three residents who were identified to be on EBP due to open wounds. Observations revealed that there were no signs indicating EBP on the doors of these residents, nor were there containers of PPE available outside their rooms. Interviews with staff confirmed the absence of necessary signage and PPE, which was against the facility's policy requiring such precautions. Additionally, the facility did not adhere to proper infection control practices during wound care for a resident. An LPN was observed using the same scissors to cut both the soiled dressing and the new dressing without cleaning them in between. The LPN also touched the tip of a cream container directly to the resident's open wound and failed to perform hand hygiene between glove changes. This was in violation of the facility's policy, which mandates hand hygiene before and after contact with residents and between glove changes. The facility also failed to ensure proper glove use and hand hygiene in other instances. A nursing assistant was observed exiting a resident's room wearing gloves, touching her hair and face, and using her phone before entering another resident's room and the nurses' station without changing gloves. Furthermore, an RN administered insulin to a resident without wearing gloves, contrary to the facility's policy that requires gloves to be worn during such procedures. Interviews with staff confirmed these lapses in infection control practices.
Failure to Manage Resident's Financial Affairs
Penalty
Summary
The facility failed to manage a resident's financial affairs properly, specifically regarding the payment of a life insurance policy. The resident, who was admitted with diagnoses including dementia and Alzheimer's disease, was unable to make daily care decisions due to poor cognition and memory. The resident's life insurance policy, which had been managed by the family since 2002, was transferred to the facility's business office manager in May 2023. The facility was responsible for making quarterly payments starting in July 2023. However, the facility did not make the scheduled payment in April 2024, resulting in the cancellation of the life insurance policy by the insurance company. The business office manager confirmed the oversight and acknowledged that a double payment was made in June 2024 in an attempt to reinstate the policy, but it had not been reinstated at the time of the report. The facility's policy on abuse, mistreatment, neglect, exploitation, and misappropriation of resident property emphasizes the importance of preventing such issues, yet the failure to make the insurance payment led to a deficiency in managing the resident's financial affairs.
Failure to Timely Notify Physician of Abnormal Lab Results
Penalty
Summary
The facility failed to ensure timely notification of a resident's physician regarding abnormal lab results. Resident #72, who was cognitively intact and had diagnoses including Alzheimer's disease, venous insufficiency, and an open wound on the left lower leg, was affected by this deficiency. A physician's order was placed to obtain a culture of the wound, which was done on 08/21/24. The results, received on 08/24/24, indicated a heavy growth of streptococcus pyogenes, which required antibiotic treatment. Despite the availability of these results, the nurse progress notes from 08/24/24 to 08/26/24 did not document any notification to the physician. It was confirmed through an interview with LPN #215 that the physician was only notified on 08/26/24, two days after the results were received. This delay was not in accordance with the facility's policy, which mandates immediate notification of significant changes in a resident's condition to the physician and family members.
Communication and Personal Hygiene Deficiencies in LTC Facility
Penalty
Summary
The facility failed to effectively communicate with a resident who primarily spoke French Creole and had medical conditions including dementia, depression, aphasia, and a history of stroke. Despite the resident's care plan indicating the need for an interpreter and alternative communication methods such as a communication board, staff interviews and observations revealed that these interventions were not utilized. Staff members, including registered nurses and licensed practical nurses, admitted to guessing the resident's needs due to the language barrier and lack of communication tools. The facility's assessment did not address ethnic, cultural, or personal preferences that could affect care, and there was no evidence of attempts to use alternative communication means in the resident's progress notes. Another resident, who had medical conditions such as dementia, COPD, rheumatoid arthritis, and congestive heart failure, was observed with unkempt hair over several days. Despite the resident's care plan indicating the need for assistance with activities of daily living, including personal hygiene, staff failed to provide necessary hair care. An RN confirmed the resident's hair was unkempt and noted that the resident complied when asked to have her hair fixed, indicating a lack of proactive care from the staff. The facility's policy on supporting activities of daily living, which includes providing appropriate care and services for residents unable to carry out ADLs independently, was not adhered to in these cases. The policy emphasized interventions in accordance with assessed needs and preferences, yet the facility did not implement the necessary support for communication and personal hygiene as outlined in the residents' care plans.
Failure to Meet Residents' Activity Needs
Penalty
Summary
The facility failed to provide activities that met the needs and preferences of several residents, as evidenced by the experiences of three residents. Resident #27, who has dementia and moderately impaired cognition, expressed dissatisfaction with the lack of activities and opportunities to go outside. Despite having interests in music, outdoor activities, and religious services, the resident's activity participation logs showed minimal engagement in these areas. Interviews with staff revealed a lack of awareness of the resident's preferences and a failure to invite the resident to activities, contributing to the resident's feelings of unhappiness and isolation. Resident #72, with intact cognition and a history of Alzheimer's disease, also reported insufficient activities and restrictions on movement within the facility. The resident expressed a desire for exercise and outdoor activities but was often told to return to his room when attempting to engage in such activities independently. The activity participation logs for this resident showed limited involvement in preferred activities, and staff interviews indicated a lack of knowledge about the resident's interests and a failure to invite him to participate in activities. Resident #45, who is severely cognitively impaired and dependent on staff for activities, experienced gaps in activity participation, particularly at the end of each month. Despite having preferences for music and outdoor activities, the resident was not consistently engaged in these activities. Staff interviews revealed staffing shortages and a lack of structured activity offerings, particularly in the afternoons and evenings. The resident's activity sheets showed blank weeks, indicating a lack of engagement during those periods, and the resident was not invited to participate in a scheduled nature walk, further highlighting the deficiency in meeting the resident's activity needs.
Failure to Follow Physician Orders for Daily Weights
Penalty
Summary
The facility failed to adhere to physician orders regarding the daily weighing of a resident, which was crucial for monitoring her congestive heart failure. The resident, who had Alzheimer's disease with agitation, congestive heart failure, psychotic disorder with delusions, and paranoid schizophrenia, was admitted to the facility with a care plan that included daily weight monitoring. The physician's order specified that the resident should be weighed daily at 6:00 A.M., with any significant weight gain reported immediately. However, the medical record review revealed that weights were not documented on three specific dates. An interview with the Unit Manager confirmed that the weights were not obtained and documented as ordered.
Failure to Assist Resident with Corrective Lenses
Penalty
Summary
The facility failed to assist Resident #78 with applying his corrective lenses, which was necessary for his visual acuity. Resident #78, who has a medical history of dementia, polyneuropathy, and hemiplegia following a stroke, was assessed to have myopic astigmatism and presbyopia, requiring new bifocals for full-time use. Despite receiving new glasses, observations revealed that Resident #78 was frequently not wearing them, and they were often found on top of a tall wardrobe, out of his reach. Multiple observations over several days showed Resident #78 without his glasses, both in his room and in common areas like the dining room. Interviews with staff, including a State Tested Nurse Aide (STNA) and the Activity Director, indicated a lack of awareness or action regarding the resident's need for glasses. On several occasions, staff had to retrieve the glasses from the wardrobe and assist Resident #78 in wearing them, after which he expressed improved vision. The facility's policy on Supporting Activities of Daily Living (ADLs) states that residents should be provided with appropriate care and assistance in accordance with their care plan. However, the repeated failure to ensure Resident #78 wore his glasses as needed suggests a deficiency in adhering to this policy, impacting his ability to see clearly and navigate the facility safely.
Failure to Maintain Pressure Ulcer Interventions
Penalty
Summary
The facility failed to maintain interventions to promote healing of pressure ulcers for three residents. Resident #18, who had a Stage II pressure ulcer and was supposed to have a pressure-reducing cushion in her chair, was observed multiple times without the cushion. This was confirmed by Unit Manager #227, indicating a failure to follow the physician's orders and care plan. Resident #90, who was at risk for impaired skin integrity, had physician's orders for heel elevators to be used while in bed. However, observations revealed that the heel elevators were not in place during multiple checks. Unit Manager #227 confirmed the absence of the heel elevators, showing a lack of adherence to the prescribed preventive measures. Resident #01, who had an unstageable pressure ulcer and was receiving hospice services, was supposed to have an alternating pressure mattress as per physician's orders. However, observations and interviews revealed that the mattress was set on static or pulsate settings instead of the required alternate setting. Both RN #190 and LPN UM #215 were unaware of the correct settings, indicating a lack of knowledge and training regarding the equipment used for pressure ulcer prevention and treatment.
Failure to Administer Tube Feeding as Ordered
Penalty
Summary
The facility failed to administer tube feedings at the rate ordered by the physician for a resident with multiple medical conditions, including dementia with agitation, dysphagia, severe protein calorie malnutrition, and diabetes. The resident was cognitively impaired and had a physician's order for Isosource 1.5 to be administered via gastrostomy tube at 55 cc per hour continuously. However, observations on two separate occasions revealed that the resident was receiving Jevity 1.5 at 50 cc per hour instead. This discrepancy was confirmed by the Unit Manager, indicating a failure to follow the physician's specific orders for the resident's nutritional needs.
Insulin Administration Error
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors related to insulin administration. Specifically, Resident #49, who was cognitively impaired and had a diagnosis of type two diabetes, received insulin injections outside the parameters specified in the physician's order. The physician's order for Resident #49 required Humalog insulin to be administered only if the blood glucose level was 140 mg/dl or higher. However, the Medication Administration Record (MAR) indicated that the resident received insulin on multiple occasions when the blood glucose level was below the specified threshold. The Director of Nursing (DON) confirmed that the insulin was administered outside the parameters on several dates in August 2024. The facility's policy on medication administration required nurses to verify each medication to ensure it was the right drug, dose, route, rate, time, and for the right customer, and to ensure the MAR reflected the most recent medication order. Despite this policy, the insulin was administered incorrectly, indicating a failure to adhere to the established guidelines.
Lack of Transfer Agreements with Hospitals
Penalty
Summary
The facility failed to ensure that transfer agreements with hospitals certified by Medicare or Medicaid were in place, which had the potential to affect all 99 residents residing in the facility. A review of the facility's 2024 Tabletop Disaster Drill document revealed that the facility had agreements to transfer residents to two sister facilities in the event of an emergency. However, it was confirmed through interviews with the Director of Nursing and the Administrator that a written transfer agreement was not executed until August 26, 2024. Prior to this date, the facility did not have a transfer agreement in place, which was a requirement to ensure residents could be moved quickly to a hospital when they needed medical care.
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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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