Country Club Center I
Inspection history, citations, penalties and survey trends for this long-term care facility in Dover, Ohio.
- Location
- 860 Iron Avenue, Dover, Ohio 44622
- CMS Provider Number
- 365417
- Inspections on file
- 36
- Latest survey
- February 2, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Country Club Center I during CMS and state inspections, most recent first.
A resident with diabetes, impaired cognition, decreased mobility, and incontinence, identified as at risk for skin breakdown, developed a new buttock pressure area that was documented as a small, painful open area but not followed by timely treatment orders or accurate documentation of wound location. For three days after the wound was first identified, no physician orders or specific interventions were implemented, and later NP wound care orders were delayed and in some cases incorrectly transcribed, while a wound culture result was never obtained or followed up. The wound progressed to an unstageable and then Stage III pressure ulcer with undermining, and the resident reported that dressings frequently fell off and were not consistently replaced. An RN was observed performing a dressing change without cleaning a visibly soiled overbed table, placing clean supplies and scissors on the dirty surface, and then using the contaminated scissors to cut and apply the dressing, contrary to facility wound care policy.
A resident with multiple complex conditions, including ESRD on dialysis, COPD, traumatic brain injury, and depression, requested help from CNAs to return to her room after dinner. One CNA stated she was busy passing trays, and another CNA used an expletive in connection with the request in front of the resident and others, which the resident reported as being directed at her and causing embarrassment and emotional distress. Witness accounts and the CNA’s own statement confirmed that the expletive was used within earshot of the resident. The resident reported crying herself to sleep afterward, yet nursing notes contained no documentation of the incident or of emotional support or counseling, despite a facility abuse policy that guarantees residents freedom from abuse, including verbal and emotional abuse.
A resident with intact cognition and multiple chronic conditions, including respiratory failure, COPD, PVD, DM, CKD, bipolar disorder, GAD, lymphedema, and gout, was observed to have their room door opened by maintenance staff without a prior knock while the staff member was performing fire watch rounds. The staff member acknowledged not knocking before entering. Facility policy on resident rights states that residents have the right, upon reasonable request, to have room doors closed and not opened without knocking, except in emergencies or when medically inadvisable as documented by the attending physician. No such exception was documented for this resident, resulting in a violation of the resident’s privacy rights.
Residents reported and records confirmed significant delays in call light response times, with some waiting over an hour for assistance. Despite staff education on timely response, there was no evidence of follow-up or monitoring, and grievances about the issue remained unresolved, affecting multiple residents.
Staff failed to follow infection control protocols during care for two residents, including not performing hand hygiene after glove removal and after contact with contaminated surfaces. These lapses occurred during wound care and incontinence care, despite facility policy requiring hand washing after glove removal and handling contaminated objects.
Multiple residents reported that their food was sometimes or always cold, and direct observation of meal service confirmed that hot foods dropped below required holding temperatures before being served. A test tray measured significantly below the facility's policy standard, and the food was confirmed to be cold by both thermometer and taste test, in violation of USDA guidelines and facility policy.
A resident with multiple chronic conditions and impaired cognition was not provided with a timely orthopedic referral as ordered, despite experiencing significant knee pain and awaiting further assessment. The facility administrator confirmed the appointment was not scheduled during the resident's stay.
A resident's room was found to be unclean and disorganized, with an empty medication cup on the floor, a basin containing a dried dark substance, clothes on the floor, brown discoloration and stool splatter on the toilet, and a suction machine container with a dried yellow substance. These conditions were confirmed by the Regional Maintenance Director during a facility tour.
A registered nurse failed to wear a gown, as required by Enhanced Barrier Precautions, while changing the dressing of a resident with a jejunostomy tube and recent tracheostomy removal. The resident's room had an EBP sign posted, and the facility's policy mandated both gown and glove use for high-contact care activities. The nurse acknowledged not following the policy during the observed dressing change.
The facility failed to serve meals at palatable temperatures, affecting all 55 residents. Multiple residents reported their meals were consistently cold. Observations confirmed that food temperatures dropped significantly by the time they were delivered. The Dietary Supervisor acknowledged the issue, and previous complaints about cold meals were noted in the facility's concern log.
The facility failed to maintain sanitary conditions in food storage and preparation, affecting all residents receiving meals. Observations revealed unlabeled and undated food items, inadequate sanitation practices, and a dish machine not meeting temperature requirements. Sanitation audits consistently scored below the desired goal, indicating ongoing issues with cleanliness and food storage practices.
The facility failed to maintain a clean and sanitary dumpster area, with debris including a Styrofoam plate, surgical gloves, and plastic utensils observed around the dumpsters. The Dietary Supervisor confirmed the debris, and a previous sanitation audit noted the area as unacceptable. The facility's policy prohibits trash on the ground.
The facility failed to provide appropriate diet consistency for residents on mechanically altered diets. A resident on a pureed diet received non-pureed potatoes, while another on a mechanical soft diet was served an intact hotdog. Two other residents received meals not consistent with their dietary needs. The dietary staff lacked guidance on diet consistencies, leading to these errors.
The facility failed to maintain proper infection control practices, including hand hygiene during meal distribution, handling of soiled linens, and storage of a nasal cannula. Additionally, Enhanced Barrier Precautions were not followed during IV medication administration, and proper disinfection and hand hygiene were not observed during wound care. These deficiencies affected multiple residents and were against the facility's policies.
The facility failed to maintain a safe environment, affecting three residents. A resident experienced water leakage from the bathroom into his room due to a short shower curtain and lack of a lip on the shower floor. The DON acknowledged this issue during an observation. Additionally, the DON verified gouges and missing pieces in the walls of two residents' rooms, with uncertainty about whether maintenance was informed.
The facility failed to ensure call lights were within reach for two residents, leading to a deficiency. One resident with severe cognitive impairment and multiple medical conditions had her call light out of reach on two occasions, confirmed by staff. Another resident with moderately impaired cognition and left side hemiparesis was unable to reach his call light while in a recliner, requiring him to yell for assistance. The facility's policy did not address the need for call lights to be within reach.
A facility failed to include a signed DNR form in a resident's medical record, despite the resident's documented wish to be a DNR-CCA. The resident's care plan and physician orders indicated their preference for no CPR, but both physical and electronic records lacked the necessary signed documentation. A nurse confirmed the absence of the form and could not explain why it was missing.
A resident's preference to wear undersized nightgowns, which exposed her abdomen and brief, was not documented in her care plan despite being known to the staff. The resident, who was cognitively intact and had multiple diagnoses, preferred her own nightgowns despite suggestions to cover herself. The facility's policy requires care plans to include all necessary instructions for person-centered care, which was not followed in this instance.
The facility failed to complete discharge summaries for two residents, one with schizoaffective disorder and another with metabolic encephalopathy, upon their discharge home. Despite the facility's policy requiring comprehensive discharge documentation, including a summary of stay and post-discharge plan of care, these were not completed. The absence of these documents was confirmed by the Social Service Designee and the Director of Nursing.
A resident at risk for falls due to Alzheimer's and other conditions did not have the ordered Dycem on their wheelchair, as observed by surveyors. The facility's policy requires fall interventions based on individual assessments, but this was not followed, leading to a deficiency.
The facility failed to ensure timely reweights and adequate monitoring of meal intakes for two residents, leading to deficiencies in nutritional care. One resident experienced a significant weight fluctuation that was not promptly reweighed, while another had inconsistent meal intake documentation and untimely reweights. The facility's policy required more frequent reviews based on changes in condition, but these were not adhered to, impacting the nutritional care provided.
A resident with chronic obstructive pulmonary disease and dementia was not receiving oxygen at the prescribed rate of 2 LPM, as it was set to 3.5 LPM. The nasal cannula tubing was undated and lying on the floor, and there was no signage indicating oxygen use. The DON and ADON confirmed these deficiencies.
A resident with chronic kidney disease and dependence on dialysis was not properly monitored for dialysis site complications, despite undergoing dialysis three times a week. The facility's policy required ongoing assessment, but no evidence of such monitoring was found in the medical records, a deficiency confirmed by the ADON.
A facility failed to address pharmacy recommendations for a resident with multiple diagnoses, including bipolar disorder and schizophrenia. The pharmacist suggested dose reductions for Restoril and Olanzapine and compliance with CMS regulations for Ativan. However, the physician's responses lacked the required rationale for not implementing these changes. An RN confirmed the recommendations were not fully addressed.
A facility failed to consistently monitor the blood glucose levels of a resident with diabetes mellitus, despite having orders to do so daily. The resident was on medications including Metformin, Trulicity, Tresiba insulin, and Humalog insulin. A review of records showed only one blood glucose level was recorded over a ten-day period, which was confirmed by an LPN.
A facility failed to manage psychotropic medications for a resident with psychiatric diagnoses, including bipolar disorder and schizophrenia. The resident was prescribed Restoril, Ativan, and Olanzapine without implementing gradual dose reductions (GDR) or providing documented rationale for contraindications. The pharmacist's recommendations for dosage adjustments were not addressed, and the physician's responses lacked necessary documentation, affecting the resident's medication management.
A facility failed to administer medications according to physician orders, resulting in a 10% error rate. A resident received an incorrect dosage of Mucinex, another was given unprimed Humalog Insulin, and a third received a lower dose of Mucus Relief due to stock issues. These errors were confirmed by the staff involved.
The facility failed to properly label, store, and dispose of medications for two residents. An insulin pen was stored at room temperature instead of refrigerated, and another insulin pen lacked a complete open date label. Additionally, a vial of flonase was found without an open date and no physician order. These issues indicate non-compliance with medication storage policies.
The facility's arbitration agreement failed to allow for a mutually agreeable arbitrator and venue, affecting all residents. The agreement specified the National Arbitration Forum as the arbitrator but did not provide a venue or allow residents a choice in the arbitration process. Interviews revealed that facility representatives were unaware of the need for mutual agreement and lacked a policy on arbitration agreements.
The facility failed to ensure pneumonia vaccinations were up-to-date for two residents. One resident received the PPSV23 vaccine but did not receive the recommended PCV15, PCV20, or PCV21 vaccines. Another resident also received the PPSV23 vaccine without the subsequent recommended doses. The facility's policy required assessment and administration of pneumococcal vaccines per CDC guidelines, but these were not followed.
The facility did not submit required Payroll Based Journal (PBJ) data for the administrator for the third quarter of fiscal year 2024, resulting in a 1 Star Rating. The Administrator confirmed that the corporate office handles PBJ submissions and acknowledged the oversight.
A facility failed to follow infection control standards during pericare for a resident. Two STNAs did not separate the labia while cleaning and improperly wiped from the rectal area toward the vagina. They also failed to remove soiled gloves and wash hands before touching the bedding and bed controls. The DON confirmed these actions were against facility policy.
A resident with a history of epilepsy, alcohol abuse, diabetes, chronic kidney disease, and muscle weakness reported an incident where an STNA used profanity and made inappropriate comments, instructing him not to use his call light. The resident, who was cognitively intact, felt safe despite the incident, which was corroborated by his roommate.
A resident with intact cognition did not receive prescribed hydrocodone-acetaminophen for pain management from April to June 2024. A nurse was the only staff member to sign out the medication, but it was not administered as recorded. The facility identified a discrepancy when six tablets were missing, leading to an investigation. The suspected nurse did not cooperate and refused a drug test, resulting in termination. The incident was reported to authorities.
The facility failed to perform routine respiratory assessments for two residents on continuous supplemental oxygen and nebulizer treatments. Despite physician orders for regular oxygen saturation monitoring, the residents' medical records showed infrequent assessments. Interviews with the DON, ADON, and an RT confirmed the lack of routine evaluations, highlighting a deficiency in the facility's respiratory care practices.
Failure to Timely Assess and Treat New Pressure Ulcer and Maintain Aseptic Wound Care Technique
Penalty
Summary
The deficiency involves the facility’s failure to comprehensively assess and promptly obtain treatment orders for a newly developed, in-house acquired pressure ulcer, resulting in further decline of the wound. The resident involved had multiple diagnoses including diabetes, diabetic neuropathy, hypertension, atherosclerotic heart disease, repeated falls, altered mental status, and a history of a left buttock Stage III pressure ulcer. The care plan identified the resident as needing assistance with ADLs due to decreased mobility and as being at risk for skin breakdown related to decreased mobility, diabetes, and incontinence, with interventions such as turning and repositioning, staff skin checks, toileting assistance, and appropriate diet. A Braden Scale assessment documented the resident as at risk for pressure injuries, and a quarterly MDS showed moderately impaired cognition and the need for assistance with mobility, but no pressure injuries at that time. On 12/12/25, a Weekly Skin Observation note documented a new reddened, hard area on the buttock measuring 0.5 cm, and a progress note the same day described a small open area on the buttock that was hard and painful to touch. The area was cleaned and covered with a bordered foam dressing, and it was reported to the NP and wound team, but no treatment order was written at that time. There was no further documentation of a buttock pressure ulcer or any ordered or completed treatments until 12/15/25, when a physician order was finally obtained for cleansing, topical antibiotic, dressing changes, and systemic antibiotics, and the location was documented as the left gluteal fold rather than the right buttock. The DON and the former wound nurse later acknowledged that the original documentation of the wound as being on the right buttock was incorrect and that the wound had always been on the left buttock, and the DON verified that no treatment orders or interventions were put in place for three days after the wound was first identified. Subsequent wound care NP notes documented that the buttock wound progressed to an unstageable ulcer and then a Stage III pressure ulcer, with measurements showing a significantly larger wound than initially described, the presence of slough, and later undermining. Orders for specific wound treatments, including Anasept gel, calcium alginate, silicone bordered foam dressings, Mesalt, and antibiotics, were written over time, but there were transcription errors and delays in initiating some NP orders. The DON confirmed that the NP’s 12/18/25 order for Anasept gel and moist gauze was not initiated until 12/23/25 and that the order for a silicone bordered foam dressing was incorrectly transcribed as a dry sterile dressing. A wound culture was obtained, but the facility never received or followed up on the results. During a later observation, the resident’s buttock wound was found without a dressing in place after the resident reported that dressings frequently fell off and were not always replaced when she requested. During the observed dressing change, the RN failed to prepare a clean, dry work area as required by policy, placed clean supplies and scissors on a visibly soiled overbed table, and used scissors that had been placed directly on the dirty surface to cut the dressing before applying it to the wound, contrary to the facility’s wound and skin care procedures.
Failure to Protect Resident From Verbal Abuse by CNA
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from verbal abuse by a CNA. The resident had multiple complex medical conditions, including traumatic subdural hemorrhage, COPD, asthma, respiratory failure, diabetes, blindness, heart failure, end-stage renal disease on dialysis, major depressive disorder, generalized anxiety disorder, cannabis use, hypertension, hypothyroidism, and traumatic brain injury. A recent MDS assessment documented intact cognition and no behaviors. On an evening in the dining room, the resident requested assistance from staff to return to her room. One CNA stated she would help when finished passing trays, while another CNA was reported to have responded with an expletive directed at or in front of the resident, in the presence of others, causing the resident to feel embarrassed and humiliated and to be tearful throughout the night. Multiple accounts described the same core event: the resident asked to be taken back to her room after dinner, one CNA indicated she was busy, and the other CNA used the word “[expletive]” in connection with the request. The resident reported that the CNA yelled “[expletive] you” at the dinner table and that she did not like this CNA because she was not nice and seemed to hate her. A social services designee documented that the resident said the CNA said “[expletive] you,” threw her arms down, and that another aide eventually pushed the resident back to her room, where the resident cried herself to sleep in her wheelchair. A witness CNA reported that the CNA in question said, “[expletive] I do not wanna do this,” in a manner that the resident heard, and the resident stated she would report the CNA to the DON. The CNA involved acknowledged in a written statement that she used the expletive in front of the resident after the resident requested to be put to bed, stating she was talking to another CNA and did not realize the resident heard her, and that she later went to the resident’s room to apologize. The facility’s abuse policy states that residents have the right to be free from abuse, including emotional or verbal abuse. Despite the resident’s report of crying herself to sleep and feeling embarrassed and humiliated, review of nursing progress notes for the period around the incident showed no documentation of the incident, emotional distress, or provision of emotional support or counseling. The social services designee stated she followed up with the resident the next day but confirmed there was no documentation in the chart of this follow-up for emotional support.
Failure to Knock Before Entering Resident Room Violates Privacy Policy
Penalty
Summary
The deficiency involves a failure to maintain resident privacy and confidentiality when staff did not knock before entering a resident’s room, contrary to facility policy and resident rights. Resident #16, who had intact cognition and multiple medical diagnoses including respiratory failure, COPD, peripheral vascular disease, diabetes, chronic kidney disease, bipolar disorder, generalized anxiety disorder, lymphedema, and gout, had been admitted to the facility prior to the survey. During an observation and interview on 01/17/26 at 10:12 A.M., Maintenance #106 opened Resident #16’s room door without knocking while conducting fire watch rounds and confirmed at that time that she had not knocked before entering. Review of the facility’s “Ohio Resident Rights and Facility Responsibilities” policy showed that residents have the right, upon reasonable request, to have room doors closed and not opened without knocking, except in emergencies or when not medically advisable as documented by the attending physician, conditions which were not documented for this resident. This failure to knock prior to entering the resident’s room constituted a breach of the facility’s own policy and the resident’s right to privacy, affecting one resident reviewed for privacy out of three sampled.
Failure to Resolve Resident Grievances Regarding Call Light Response
Penalty
Summary
The facility failed to ensure that resident grievances regarding the timely answering of call lights were resolved appropriately and within a reasonable timeframe. Multiple records, including in-service documentation, grievance logs, and resident council minutes, indicated ongoing concerns about delayed call light responses. Specific incidents were documented where residents waited extended periods, ranging from over 26 minutes to more than two hours, for their call lights to be answered. Residents consistently reported long wait times during interviews, and the issue was also raised during resident council meetings. Despite staff being in-serviced on the importance of timely call light response, there was no evidence of follow-up audits or monitoring to ensure compliance. The facility's grievance policy required immediate action to prevent further violations of resident rights, but the lack of timely resolution and monitoring led to repeated and unresolved complaints from residents. This deficiency affected nine residents and was substantiated through multiple sources, including direct resident interviews and review of facility records.
Failure to Follow Infection Control Protocols During Resident Care
Penalty
Summary
The facility failed to implement infection control standards during resident care, as evidenced by observations involving two residents. For one resident with chronic kidney disease, necrotizing fasciitis, and Fournier gangrene, a wound nurse was observed touching a trash can with gloved hands and then proceeding to perform wound care without changing gloves or sanitizing hands. Additionally, after handling a soiled colostomy bag, the nurse changed from soiled to clean gloves without performing hand hygiene in between, contrary to the facility's hand washing policy which requires hand washing after handling contaminated objects and after removing gloves. In a separate incident, a certified nurse assistant provided incontinence care to another resident with metabolic encephalopathy, COPD, diabetes, and vascular dementia. During care, the CNA changed contaminated gloves but did not perform hand hygiene before immediately donning new gloves to continue care. This action was also inconsistent with the facility's hand washing policy, which specifies that hands should be washed after removing gloves. Both staff members confirmed these practices during interviews.
Failure to Maintain Safe and Palatable Food Temperatures
Penalty
Summary
The facility failed to maintain palatable and appetizing food temperatures for residents, as evidenced by multiple complaints and direct observations. Resident council minutes documented a complaint about cold biscuits and gravy, and several residents reported that their food was sometimes or always cold. During a meal service observation, food items were initially prepared at appropriate temperatures, but a test tray placed on a food cart and distributed last was found to have significantly dropped in temperature. The BBQ chicken measured 122°F, the vegetable blend 107.5°F, and the mashed potatoes and gravy 112°F, all below the facility's policy requirement of holding hot foods at 135°F or above. The facility's policy, consistent with USDA guidelines, requires hot foods to be held at or above 135°F to prevent bacterial growth. However, the observed meal service process allowed food temperatures to fall into the 'danger zone' as defined by the USDA, with the test tray food confirmed to be cold by both thermometer and taste test. The deficiency was identified through resident interviews, review of council minutes, direct observation of meal service, and review of facility policy and USDA guidelines.
Failure to Arrange Ordered Orthopedic Consultation
Penalty
Summary
A deficiency occurred when the facility failed to arrange an orthopedic consultation as ordered for a resident who was admitted with multiple diagnoses, including congestive heart failure, hypertension, atherosclerotic heart disease, atrial fibrillation, venous insufficiency, diabetes, spinal stenosis, hypothyroidism, and anemia. The resident was transferred from assisted living to the skilled nursing facility due to increased difficulty with ambulation, and a new order was received for an orthopedic referral and pain management with Tramadol. Documentation in the medical record and occupational therapy evaluation indicated the resident was experiencing significant right knee pain and was awaiting an orthopedic appointment. Despite the physician's order for an orthopedic referral due to worsening knee pain, there was no evidence in the medical record that the referral was set up during the resident's stay. The resident, who had moderately impaired cognition, continued to report pain and was awaiting further assessment. The facility administrator confirmed that the orthopedic appointment was never scheduled, citing the short duration of the resident's stay as the reason.
Resident Room Not Maintained in Clean and Sanitary Condition
Penalty
Summary
The facility failed to maintain a resident's room in a clean, organized, and sanitary condition. During a facility tour with the Regional Maintenance Director, it was observed that the resident's room contained an empty medication cup on the floor, a basin on the sofa with a dried dark brownish red substance, clothes scattered on the floor, brown discoloration in the toilet with a splattered spot of stool on the toilet tank, and a dried yellow substance in the bottom of the suction machine container at the bedside. The Regional Maintenance Director confirmed these observations, verifying that the room was not clean, organized, or sanitary at the time of inspection. This deficiency was identified during an investigation under a specific complaint number and affected one resident in a facility with a census of 62.
Failure to Use Required PPE During Dressing Change Under Enhanced Barrier Precautions
Penalty
Summary
A deficiency occurred when a registered nurse failed to use appropriate personal protective equipment (PPE) during a dressing change for a resident with multiple medical conditions, including a malignant neoplasm of the esophagus, dysphagia, tracheostomy status, and a jejunostomy feeding tube. The resident had an order for the J-tube site to be cleaned and dressed three times daily, and a recent tracheostomy removal required daily bandage changes. During observation, the nurse donned gloves but did not wear a gown while changing the dressing, despite the presence of green drainage on the dressing and the resident's clothing. The resident's room had an Enhanced Barrier Precaution (EBP) sign posted, and the facility's EBP policy required both gown and glove use during high-contact care activities, such as device and wound care, for residents at risk of multi drug-resistant organism (MDRO) acquisition. The nurse acknowledged not wearing a gown during the procedure, which was inconsistent with facility policy and the posted precautions. This event was identified during a survey and affected one resident out of a facility census of 62.
Facility Fails to Serve Meals at Palatable Temperatures
Penalty
Summary
The facility failed to ensure that meals were served at a palatable temperature, affecting all 55 residents who received meals from the kitchen. Multiple residents, including those with various medical conditions such as atrial fibrillation, diabetes, and chronic kidney disease, reported that their meals were consistently served cold. Observations and interviews confirmed that residents found the food to be cold and unappetizing, with specific complaints about the temperature of the meals. During a tray line observation, it was noted that while food items were initially at a safe serving temperature, by the time they were delivered to residents, the temperatures had dropped significantly. For instance, the brussel sprouts were at 115 degrees Fahrenheit, and the ham was at 120 degrees Fahrenheit, both of which were not considered warm. The Dietary Supervisor confirmed these findings, noting that the food items were not warm enough. Additionally, the facility's concern log indicated previous complaints about cold room trays, and the facility's policy did not address the palatability of meals.
Sanitation and Food Storage Deficiencies in Kitchen
Penalty
Summary
The facility failed to ensure that food was stored, prepared, and served under sanitary conditions, potentially affecting all 55 residents who received meals from the kitchen. During an observation of the kitchen, several issues were noted, including unlabeled and undated food items in the walk-in cooler and freezer, such as hamburger patties, mashed potatoes, spaghetti sauce, taco meat, and carrots. The dry stock area had an opened bag of gravy mix not dated when opened, and the sandwich cooler had a buildup of shredded cheese. Additionally, the refrigerator/freezer combination unit contained several undated and open-to-air food items, including pickles, parmesan cheese, fish patties, potato wedges, tater tots, and breakfast sausage patties. The Dietary Supervisor confirmed that items should be dated when opened, not open to air, and discarded after seven days. The facility's sanitation audits consistently scored below the desired goal of 90%, indicating ongoing issues with kitchen cleanliness and food storage practices. Multiple audits revealed that a significant number of pieces of equipment in the cook's work area were not acceptable in terms of cleanliness. Additionally, there were repeated findings of undated, uncovered, or unlabeled food items, including moldy hotdogs and pasta. Despite the facility's policy requiring an action plan and follow-up review for scores below 90%, the sanitation scores remained low, with the most recent audit scoring 80%. The dish machine in the facility was also found to be non-compliant with temperature requirements for sanitization. The machine's rinse temperature did not meet the minimum requirement of 180 degrees Fahrenheit, as observed during a facility tour. Despite attempts to rerun the machine, the temperature did not exceed 150 degrees Fahrenheit for the rinse cycle. The facility's policy required manual washing or the use of disposable products if the dishwasher did not meet the proper temperatures. Additionally, the puree process was observed to be inadequate, as the dietary staff did not properly sanitize equipment by submerging it in a sanitizer solution, as required by the facility's procedure.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to maintain the dumpster area in a clean and sanitary manner, which had the potential to affect all residents residing in the facility. During an observation of the dumpster area, a buildup of debris was noted around the base of two dumpsters. The debris included a Styrofoam plate, an empty box of oatmeal cream pies, multiple blue surgical gloves, two large clear fast food plastic cups, a white carafe lid, a plastic shopping bag, several plastic drinking straws, numerous plastic utensils, two small plastic drinking cups, and a medicine cup. The Dietary Supervisor confirmed the presence of the debris during the observation. A review of the facility's Nutrition Services Quality Validation-Kitchen Sanitation document, dated two months prior, indicated that the area was previously noted as unacceptable due to trash around and behind the dumpster. An interview with the Dietitian confirmed that she conducted monthly sanitation audits in the facility kitchen and identified numerous cleanliness concerns. The facility's policy, dated five years prior, stated that trash should not be deposited on the ground for any reason.
Inadequate Diet Consistency for Mechanically Altered Diets
Penalty
Summary
The facility failed to ensure that residents requiring mechanically altered diets were served the appropriate diet consistency, affecting four residents. Resident #12, who had severe cognitive impairment and was on a pureed diet, was served non-pureed au gratin potatoes. The dietary staff did not have a spreadsheet to indicate what each diet was allowed, leading to the error. Similarly, Resident #42, with moderately impaired cognition and on a mechanical soft diet, was served an intact hotdog instead of a ground one, which was corrected after the surveyor's intervention. Resident #153, on a mechanical soft diet, was served tacos with lettuce cut into small square pieces instead of shredded, which was not appropriate for their diet. The dietary staff again lacked a spreadsheet to guide them on diet consistencies, resulting in the improper meal preparation. Resident #202, on a mechanical soft diet, was served ham that was cut up with a knife instead of being ground, which was corrected after the surveyor's intervention. The dietary staff were unsure of the requirements for a mechanical soft diet, contributing to the error. Additionally, the puree process for ham was observed to be inadequate, as the final product was not smooth and had bits sticking to the tongue. The dietary staff did not routinely test the puree consistency, leading to the initial improper preparation. The facility's policy on therapeutic diets, which should match resident orders, was not effectively implemented, resulting in these deficiencies.
Infection Control Deficiencies in Hand Hygiene and Barrier Precautions
Penalty
Summary
The facility failed to maintain proper hand hygiene during meal tray distribution, as observed with a State tested Nursing Assistant (STNA) who did not wash her hands between handling meal trays and interacting with residents. This was noted during a dining observation where the STNA moved personal items and assisted residents without performing hand hygiene, contrary to the facility's handwashing policy. This affected multiple residents who received meals in their rooms. In the laundry room, the facility did not ensure proper handling of soiled linens, as observed with a pile of bed pads and linens lying directly on the floor. The Housekeeping Supervisor confirmed the lack of a protective barrier and the absence of a policy for handling linens. Additionally, a resident's nasal cannula was not stored in a protective barrier when not in use, as confirmed by a Registered Nurse, which was against the facility's oxygen therapy policy. The facility also failed to utilize Enhanced Barrier Precautions (EBP) during intravenous medication administration for a resident with a peripherally inserted central catheter. The Licensed Practical Nurse did not wear a gown as required by EBP protocol. Furthermore, during wound care for another resident, the staff did not disinfect the over-the-bed table before placing supplies and failed to perform hand hygiene after cleansing the wound, which was against the facility's handwashing policy.
Facility Fails to Maintain Safe Environment
Penalty
Summary
The facility failed to maintain a safe environment in good repair, affecting three residents. Resident #160 experienced water leakage from the bathroom into his room due to a shower curtain that was too short, lacking a lip on the shower floor to contain the water. This issue was acknowledged by the Director of Nursing (DON) during an environmental observation. Additionally, the DON verified the presence of gouges and missing pieces in the walls of Residents #7 and #48's rooms, although it was unclear if maintenance had been informed about these issues.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that call lights were within reach for two residents, leading to a deficiency in accommodating the needs and preferences of these residents. Resident #7, who had severe cognitive impairment and multiple medical conditions including chronic obstructive pulmonary disease and vascular dementia, was observed on two occasions with her call light out of reach. On November 25, 2024, she was in her wheelchair with the call light attached to her bed's grab bar, and on November 27, 2024, the call light was hanging on her ventilator machine, both times confirmed by staff to be out of reach. Similarly, Resident #8, who had moderately impaired cognition and left side hemiparesis, was observed with his call light out of reach while sitting in a recliner. The call light was placed on the right grab bar, which was inaccessible due to his left side paralysis. Resident #8 reported that he had to yell for assistance as he could not reach the call light. This was confirmed by RN #320, who acknowledged that the call light was too short to reach the recliner. The facility's policy on call lights did not address the requirement for them to be within reach of residents.
Missing DNR Form in Resident's Medical Record
Penalty
Summary
The facility failed to ensure that a signed Do Not Resuscitate (DNR) form was present in the medical record of a resident, affecting their right to have their end-of-life wishes respected. The resident, who had diagnoses including intellectual disability, fatty liver, chronic obstructive pulmonary disease, and essential hypertension, had an order for DNR-CCA (do not resuscitate comfort care arrest) documented in their electronic medical record. Additionally, the resident's care plan indicated their wish to be a DNR-CCA, with interventions stating that no CPR should be performed and that advance directives would be reviewed quarterly and as needed. However, upon review, both the physical and electronic medical records lacked a signed DNR form to support the resident's expressed wishes. This deficiency was confirmed during an interview with a registered nurse, who acknowledged the absence of the signed code status form and was unable to provide an explanation for its omission.
Resident's Clothing Preference Not Documented in Care Plan
Penalty
Summary
The facility failed to ensure that a resident's preference to wear undersized clothing was documented in her care plan. The resident, who was cognitively intact and had diagnoses including panic disorder, bipolar disorder, anxiety disorder, intellectual disability, and morbid obesity, preferred to wear an undersized nightgown that exposed her abdomen and brief. Despite this preference being known to the staff, it was not included in her care plan, which is a requirement for providing effective and person-centered care. Observations and interviews with staff confirmed that the resident's preference for wearing undersized nightgowns was known but not documented in her care plan. The Director of Nursing and other staff members acknowledged the oversight, noting that the resident was finicky and preferred her own nightgowns despite suggestions to cover herself for modesty. The facility's policy mandates that care plans include all necessary instructions for care, including respecting residents' rights and preferences, which was not adhered to in this case.
Failure to Complete Discharge Summaries for Residents
Penalty
Summary
The facility failed to ensure that discharge summaries were completed for two residents, Resident #47 and Resident #51, as required by their policy. Resident #51 was admitted with multiple diagnoses including schizoaffective disorder and anxiety disorder, and was discharged home with her husband after completing rehabilitation services. However, there was no evidence of a discharge summary, post-discharge plan of care, or discharge instructions in her medical record. The Social Service Designee confirmed the absence of these documents, attributing it to her inexperience in the position. Similarly, Resident #47, who had diagnoses such as metabolic encephalopathy and type two diabetes, was discharged home after short-term rehabilitation. Despite the care plan indicating a need for a discharge summary, none was found in the resident's medical record. The Director of Nursing confirmed the lack of a discharge summary after reviewing the records. The facility's policy required a comprehensive discharge summary, including a summary of stay, medication reconciliation, and a post-discharge plan of care, none of which were completed for these residents.
Failure to Implement Fall Interventions for Resident
Penalty
Summary
The facility failed to implement fall interventions as ordered for a resident, identified as Resident #31, who was at risk for falls due to conditions such as Alzheimer's disease, dementia, and muscle weakness. The resident's care plan included specific interventions to mitigate fall risks, such as the use of Dycem on the wheelchair, medication reviews, and maintaining a clutter-free environment. However, during an observation, it was noted that the Dycem was not present on the resident's wheelchair, contrary to the physician's order dated 09/30/24. The deficiency was confirmed during an interview with a Certified Nursing Assistant (CNA) who acknowledged the absence of Dycem on the wheelchair. The facility's policy on falls, dated 01/27/20, mandates that residents at risk for falls be monitored and assessed, with interventions developed and implemented based on individual needs. Despite these guidelines, the necessary intervention for Resident #31 was not in place, contributing to the deficiency identified by the surveyors.
Deficiencies in Nutritional Monitoring and Documentation
Penalty
Summary
The facility failed to ensure timely reweights and adequate monitoring of meal intakes for two residents, leading to deficiencies in nutritional care. Resident #15, who had multiple diagnoses including anemia and osteoporosis, experienced a significant weight fluctuation that was not promptly reweighed to verify accuracy. Despite a dietary note indicating gradual weight loss and a recommendation for weekly weights, a 28.1-pound weight increase was recorded without immediate reweighting, which was later found to be inaccurate. The Registered Dietitian and Registered Nurse acknowledged the oversight in not obtaining a timely reweight. Resident #31, diagnosed with Alzheimer's disease and other conditions, also experienced issues with weight monitoring. The resident had a significant weight gain followed by a weight loss without timely reweights. Meal intakes were inconsistently documented, with numerous instances of missing intake records over two months. The Registered Dietitian confirmed the lack of documentation and acknowledged the ongoing problem with meal intake records at the facility. The facility's policy on nutrition and hydration required quarterly reviews by the dietitian and more frequent reviews based on changes in condition or weight concerns. However, the facility did not adhere to this policy, as evidenced by the delayed reweights and incomplete meal intake documentation for the residents. These deficiencies highlight lapses in the facility's monitoring and documentation processes, impacting the nutritional care provided to the residents.
Failure to Administer Prescribed Oxygen and Maintain Safety Protocols
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident by not administering oxygen at the prescribed dose, not ensuring oxygen in use signage was posted, and not dating the oxygen tubing or keeping it off the floor. This deficiency affected one resident who was admitted with diagnoses including chronic obstructive pulmonary disease, anxiety disorder, and unspecified dementia. A physician's order required continuous oxygen at two liters per minute via nasal cannula. However, an observation revealed that the resident's portable oxygen concentrator was set to deliver oxygen at 3.5 liters per minute, and the nasal cannula tubing was undated and lying on the floor. Additionally, there was no sign outside the resident's room indicating that oxygen was in use. Interviews with the Director of Nursing and Assistant Director of Nursing confirmed these findings.
Failure to Monitor Dialysis Site in Resident
Penalty
Summary
The facility failed to ensure proper assessment and monitoring of a resident undergoing dialysis, which was identified during a review of medical records, facility policy, and staff interviews. The resident, who had been admitted with conditions including diabetes mellitus, acute kidney failure, stage four chronic kidney disease, and dependence on renal dialysis, was not monitored for dialysis site complications as required. Despite having a dialysis port and undergoing dialysis three times a week, there was no evidence in the medical records of ongoing assessment or monitoring of the dialysis site. This lack of monitoring was confirmed by the Assistant Director of Nursing during an interview. The facility's policy stated that orders for central line care and other dialysis needs should be implemented and maintained, but this was not adhered to in the case of the resident.
Failure to Address Pharmacy Recommendations
Penalty
Summary
The facility failed to ensure that pharmacy recommendations were fully addressed for a resident with multiple diagnoses, including bipolar disorder, dementia with behavioral disturbance, manic episodes, and schizophrenia. The resident was prescribed Restoril for insomnia, Ativan for anxiety, and Olanzapine for psychotic symptoms. The pharmacist recommended a gradual dose reduction (GDR) for Restoril and Olanzapine, and compliance with CMS regulations for the Ativan prescription. However, the physician's responses to these recommendations lacked the required rationale for not implementing the suggested changes or dose reductions. Specifically, the pharmacist suggested reducing the Restoril dosage to achieve the minimum effective dose, but the physician's response only noted a pending psychiatric evaluation without providing a rationale for maintaining the current dose. Similarly, the Ativan prescription did not comply with CMS regulations, as it lacked a documented rationale and specific time frame for continuation. The Olanzapine prescription also did not include a rationale for not reducing the dose. An interview with a registered nurse confirmed that the pharmacy recommendations were not fully addressed, as there was no documented rationale for contraindicating the GDRs for Restoril and Olanzapine, nor was the Ativan recommendation fully addressed.
Failure to Monitor Blood Glucose Levels for Diabetic Resident
Penalty
Summary
The facility failed to ensure proper monitoring of blood glucose levels for a resident with diabetes mellitus, morbid obesity, and intellectual disabilities. The resident was prescribed Metformin, Trulicity, Tresiba insulin, and Humalog insulin, with orders to check blood glucose levels every morning. However, a review of the November 2024 Medication Administration Record (MAR) and blood glucose recordings revealed that between November 14 and November 23, only one blood glucose level was recorded on November 20. This lack of consistent monitoring was confirmed during an interview with an LPN, who acknowledged the order to check the resident's blood glucose level daily but noted the failure to do so consistently during the specified period.
Failure to Implement GDR and Document Rationale for Psychotropic Medications
Penalty
Summary
The facility failed to ensure proper management of psychotropic medications for a resident with multiple psychiatric diagnoses, including bipolar disorder, dementia with behavioral disturbance, manic episodes, and schizophrenia. The resident was prescribed Restoril for insomnia, Ativan for anxiety, and Olanzapine for psychotic symptoms. The facility did not implement gradual dose reductions (GDR) for these medications, nor did they provide documented rationale for why GDRs were contraindicated, as required by regulations. Specifically, the pharmacist recommended a reduction in Restoril dosage, but the physician's response lacked a rationale for maintaining the current dose. Similarly, the Ativan order did not include a time limit or rationale for its continued as-needed use, and the Olanzapine dosage was not reduced or justified. Interviews with facility staff confirmed the absence of documented rationale for not implementing GDRs and the lack of compliance with regulations regarding the as-needed use of anti-anxiety medications. The pharmacist's recommendations were not fully addressed, and the physician's responses did not provide the necessary documentation to justify the continued use of the prescribed dosages. This oversight affected the resident's medication management and demonstrated a failure to adhere to regulatory requirements for psychotropic medication use in the facility.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to ensure medications were administered in accordance with physician orders, resulting in a 10% medication error rate. Three errors were identified out of 30 opportunities for error, affecting three residents. Resident #10 was administered an incorrect dosage of Mucinex, receiving 400 mg instead of the prescribed 600 mg. This error was confirmed by the LPN responsible for the administration. Resident #152 received Humalog Insulin without the pen being primed, as required by the manufacturer's instructions. The RN administering the insulin confirmed the oversight. Additionally, Resident #20 was given 400 mg of Mucus Relief instead of the ordered 600 mg due to a lack of stock, as verified by the RN involved. These errors highlight a failure in adhering to prescribed medication dosages and administration protocols.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling, storage, and disposal of multi-dose medication vials and pens, as observed during a survey. Specifically, one of the two medication carts observed had issues affecting two residents. For Resident #33, an insulin glargine pen was improperly stored at room temperature instead of being refrigerated as per manufacturer instructions. Additionally, an admelog insulin pen was found with an incomplete open date label, and it was discovered that there was no physician order for this medication, leading to its disposal. The manufacturer's guidelines for admelog require disposal after 28 days, but the lack of a complete date made it impossible to verify compliance. For Resident #252, a vial of flonase was found in the medication cart without an open date on the label, and there was no current physician order for flonase. The facility's policy mandates that expired medications be removed and destroyed, and that containers or vials be dated when initially opened. These observations indicate a failure to adhere to the facility's medication storage policy and manufacturer guidelines, potentially affecting the safety and efficacy of the medications administered to residents.
Arbitration Agreement Lacks Mutual Agreement on Arbitrator and Venue
Penalty
Summary
The facility failed to ensure that its arbitration agreement allowed for a mutually agreeable arbitrator and venue, affecting all 55 residents residing in the facility. The arbitration agreement specified that disputes would be resolved by binding arbitration administered by the National Arbitration Forum (NAF) under their rules and procedures. However, the agreement did not specify a venue for the arbitration, and if the NAF was no longer available, the parties were to mutually agree on an alternative organization. Interviews with the Vice President of Operations and Corporate Marketing revealed that during the admission process, residents were presented with the arbitration agreement by trained staff, but the agreement did not provide residents or their representatives with a choice in selecting the arbitrator or venue. Further interviews confirmed that the facility's arbitration agreement clearly stated the facility's choice of arbitrator without ensuring the venue would be convenient for both parties. The facility's representatives were unaware that the venue and arbitrators must be mutually agreed upon by both the resident or resident representative and the facility. Additionally, it was revealed that the facility did not have a policy on arbitration agreements, indicating a lack of awareness and compliance with the requirement for mutual agreement on arbitration terms.
Failure to Ensure Up-to-Date Pneumonia Vaccinations
Penalty
Summary
The facility failed to ensure that pneumonia vaccinations were up-to-date for two residents, Resident #7 and Resident #30, out of five reviewed for vaccination status. Resident #7 had received the PPSV23 vaccine on 12/17/21, but there was no documentation of receiving the PCV15, PCV20, or PCV21 vaccines as recommended by the Pneumonia Recommendations Vaccinations Advisor application. The application advised that Resident #7 should have received one dose of PCV15, PCV20, or PCV21 at least one year after the last dose of PPSV23, which was not administered. Infection Preventionist #356 confirmed that Resident #7 was not up-to-date on her vaccine and was unaware of the need for another dose. Similarly, Resident #30 had received the PPSV23 vaccine on 06/03/19, but there was no documentation of receiving the PCV15, PCV20, or PCV21 vaccines. The Pneumonia Recommendations Vaccinations Advisor application recommended that Resident #30 should have received one dose of PCV15, PCV20, or PCV21 at least one year after the last dose of PPSV23, which was not given. Infection Preventionist #356 also verified that Resident #30 was not up-to-date on her vaccine. The facility's policy, dated 01/20/20, stated that all newly admitted residents should be assessed for their pneumococcal vaccine status and receive the vaccine per CDC guidelines if consent and physician orders are obtained.
Failure to Submit Required PBJ Data
Penalty
Summary
The facility failed to ensure the submission of Payroll Based Journal (PBJ) data as required, which had the potential to affect all 53 residents residing in the facility. A review of the facility's PBJ submission data report revealed no evidence of administrator data submitted for the fiscal year 2024 for the third quarter, covering April 1 to June 30. This resulted in the facility receiving a 1 Star Rating for the same period. During an interview, the facility Administrator confirmed that the corporate office is responsible for submitting the PBJ data and acknowledged the absence of administrator data, which was not identified during their review.
Infection Control Deficiency in Pericare Technique
Penalty
Summary
The facility failed to adhere to infection control standards during pericare for a resident, as observed by surveyors. Two State Tested Nurse Aides (STNAs) were involved in the incident. After washing their hands and donning gloves, one STNA used a moist washcloth to clean the resident's groin area but did not separate the labia, which is against the facility's policy. The STNA then improperly cleaned a bowel movement by wiping from the rectal area toward the vagina, which is contrary to the recommended front-to-back cleaning method. This improper technique resulted in the resident not being adequately cleaned before a clean brief was applied. Additionally, the STNAs failed to follow proper glove removal and hand hygiene protocols. After cleaning the resident, they adjusted the resident's bedding and used the bed control without removing their soiled gloves. They also left the room with soiled linen before washing their hands. The Director of Nursing confirmed that the facility's policy requires gloves to be removed and hands washed before touching bedding or other surfaces. This deficiency was identified during a complaint investigation.
Failure to Ensure Resident Dignity and Respect
Penalty
Summary
The facility failed to ensure that residents were treated with dignity and respect, specifically affecting one resident. The incident involved a State-tested Nursing Assistant (STNA) who used profanity and made inappropriate comments to a resident, instructing him not to use his call light. The resident, who was cognitively intact and required assistance with activities of daily living, reported the incident, which was corroborated by his roommate. The resident involved had a medical history that included epilepsy, alcohol abuse, diabetes mellitus, chronic kidney disease, and muscle weakness. Despite the inappropriate behavior from the STNA, the resident reported feeling safe and denied any negative effects from the incident. The facility's census at the time was 55, and the deficiency was investigated under a specific complaint number.
Medication Misappropriation by Staff Member
Penalty
Summary
The facility failed to prevent the misappropriation of medication for a resident by a staff member. The resident, who had intact cognition, was admitted with multiple diagnoses including chronic respiratory failure, morbid obesity, and diabetes. The resident had a physician's order for hydrocodone-acetaminophen (Norco) for pain management, but the medication was not administered as prescribed from April to June 2024. A review of the narcotic sign-out sheet revealed that a registered nurse was the only staff member to sign out the medication during this period, yet the medication was not recorded as administered in the resident's Medication Administration Records (MAR) for May and June 2024. The facility identified a discrepancy when a supply of six tablets was found missing, and the suspected staff member was suspended pending investigation. The resident reported not receiving the medication for several months and was unaware of its availability. The facility's investigation included interviews with the resident, the suspected staff member, and other residents and staff. The suspected staff member did not cooperate with the investigation and refused a drug test. The facility concluded that misappropriation had occurred, leading to the termination of the staff member's employment. The incident was reported to local law enforcement, the Board of Pharmacy, and the Board of Nursing.
Failure to Conduct Routine Respiratory Assessments
Penalty
Summary
The facility failed to conduct routine respiratory assessments for residents requiring continuous supplemental oxygen and aerosolized respiratory medications. This deficiency affected two residents, one with chronic obstructive pulmonary disease and diabetes mellitus, and another with pulmonary fibrosis and hypertension. Both residents were prescribed supplemental oxygen and bronchodilator medications via nebulizer. However, their medical records showed a lack of routine monitoring of oxygen saturation levels, which is crucial for assessing the effectiveness of the oxygen therapy and ensuring the residents' respiratory needs are met. The medical records of the affected residents revealed sporadic monitoring of oxygen saturation levels, with significant gaps between assessments. The facility's policies for oxygen therapy and respiratory assessments did not address the need for routine evaluations. Interviews with the Director of Nursing, Assistant Director of Nursing, and a Respiratory Therapist confirmed the absence of regular respiratory assessments, including oxygen saturation monitoring, during continuous supplemental oxygen use and before and after nebulizer treatments. This deficiency was identified during an investigation under Complaint Number OH00153845.
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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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