Daughters Of Miriam Center For Nursing & Rehabilit
Inspection history, citations, penalties and survey trends for this long-term care facility in Beachwood, Ohio.
- Location
- One David N Myers Parkway, Beachwood, Ohio 44122
- CMS Provider Number
- 365046
- Inspections on file
- 36
- Latest survey
- March 12, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Daughters Of Miriam Center For Nursing & Rehabilit during CMS and state inspections, most recent first.
A resident experienced a delay in receiving his medical records due to the absence of the newly hired medical records staff, who went on vacation shortly after starting. The request, made on February 4, was not processed until February 24, when the resident paid the fee and received the records. The facility's policy to comply with HIPAA was not followed, resulting in the delay.
A resident with multiple medical conditions, including bladder and bowel incontinence, did not receive proper perineal care as per facility policy. During an observation, a nurse failed to cleanse the resident's front genital area, which was confirmed by the nurse and the DON. The facility's policy requires cleaning the front perineal area first, followed by the buttocks, to ensure cleanliness and comfort.
A facility failed to secure and store medications appropriately, affecting a resident who was left with a medicine cup containing 6 1/2 pills on their overbed tray. The resident confirmed these were their morning medications, which a nurse had left for them to take. A supervisor LPN and the DON verified that medications should not be left unattended in a resident's room, and the responsible LPN admitted to leaving the medications at the bedside.
A facility failed to document the confirmation of a resident's death by an RN, as required by policy. The resident, with a complex medical history, was found deceased by an LPN who informed the Nursing Supervisor. However, the medical record lacked the RN's confirmation of death, which was a requirement according to the facility's documentation policy.
A resident with Alzheimer's and other medical conditions did not receive proper assistance with activities of daily living. Observations showed the resident was improperly dressed, had a full incontinence brief, and received inadequate incontinence care. The CNA used the same washcloth for different areas, and the wheelchair was not disinfected. The resident's hands were not washed until prompted, and their fingernails were excessively long. The DON confirmed the issues, and the care plan was revised to require a stand-up lift for transfers.
A resident with multiple health conditions did not receive necessary interventions for constipation due to staff's failure to follow the facility's bowel protocol. Despite being on the protocol, the resident did not have a bowel movement for five days, and staff were unaware or did not act on the protocol alerts. The facility's policy required specific interventions, which were not administered, leading to a deficiency finding.
A resident with a history of falls and fractures experienced an unwitnessed fall, resulting in a right femur fracture. Despite complaints of pain and visible swelling, the facility delayed obtaining and acting on x-ray results, leading to a lack of timely medical intervention. The resident expired shortly after, unrelated to the fracture, following unsuccessful CPR and EMS intervention.
A resident's pressure ulcer worsened significantly due to the facility's failure to assess and treat the wound promptly upon re-admission from the hospital. Despite being at high risk for pressure ulcer breakdown, wound care orders were delayed, and multiple treatments were missed. Interviews with staff confirmed the lack of timely wound care, and the facility's policy lacked specifics on intervention initiation and tracking.
The facility failed to implement a comprehensive fall prevention program, resulting in harm to a resident who sustained fractures after an unwitnessed fall. Despite a care plan intervention, there was no evidence of monitoring. Additionally, another resident was unsafely transferred using a Hoyer lift by a single CNA, contrary to policy requiring two staff members.
The facility failed to prepare and serve menu items as planned, affecting meal service for residents. During lunch, vegetables and pureed grilled cheese were not served as required, and during breakfast, a resident did not receive the expected eggs, yogurt, and banana. A CNA confirmed discrepancies, and residents reported frequent mismatches between their meals and the menu or meal tickets.
The facility failed to provide palatable and properly temperature-controlled meals, as identified by the Dietary Director and confirmed through resident interviews and observations. Residents reported issues with meal quality, including overcooked and unappetizing food, leading to dissatisfaction and reliance on outside food.
The facility failed to serve meals in a timely manner, affecting all residents. Observations and interviews revealed significant delays, with breakfast and lunch often served later than scheduled. Increased census and changes in serving processes contributed to the issue, and residents expressed a preference for dining room service. Staffing issues also hindered timely meal delivery.
The facility failed to ensure kitchen staff followed proper food safety protocols, affecting meal safety for 159 residents. A Mashgiach refused to wear a hair net, and a staff member improperly handled food and equipment, violating policies on handwashing, glove use, and equipment sanitation. These actions were confirmed by the Dietary Manager.
The facility failed to provide a dignified dining experience for several residents, including one with severe dementia who was left unattended with her meal. Loud music, not preferred by the residents, played during meals, and some residents experienced significant delays in receiving their meals. Staff interviews confirmed these issues, highlighting a lack of coordination and consideration for resident preferences.
The facility failed to follow proper puree preparation techniques for 17 residents requiring a puree diet. A staff member prepared food without consulting recipes, using excessive water and thickener, and added inappropriate chunky seasoning. Interviews confirmed these practices, and recipe reviews showed deviations from the correct preparation methods.
The facility failed to notify physicians in a timely manner about changes in condition for two residents. One resident, with a history of falls, experienced a fall and subsequent fracture, but the physician was not promptly informed due to incorrect contact information and delayed fax checks. Another resident missed a dialysis appointment due to transportation issues, and the medical provider was not notified, preventing necessary medical assessments. These deficiencies highlight lapses in communication protocols.
A resident's family raised concerns about missing dentures and requested medical records, but the facility failed to address these grievances in a timely manner. Despite a meeting with the family and consent for dental care, the facility did not resolve the issues, and the Administrator did not follow up on multiple communications from the family. The facility did not reimburse for the dentures and lost contact with the family after the resident's discharge.
Three residents in an LTC facility did not receive necessary assistance with meals, despite their care plans indicating they required help. A resident with severe dementia and dysphagia was left with minimal feeding assistance, consuming only 10% of her meal. Another resident, needing meal setup and supervision, was left unsupervised. A third resident, with multiple health issues, often did not receive full feeding assistance due to staff being unaware of her needs. Staff interviews confirmed these deficiencies.
A resident with multiple health conditions, including hemiplegia, did not receive prescribed treatments to maintain range of motion, such as a hand splint and PRAFO boot. Observations and interviews revealed the resident was not wearing these appliances, and staff were unaware of the orders. The facility's documentation errors led to the omission of these treatments from care tasks, resulting in a decline in the resident's condition.
A resident with multiple medical conditions, including dysphagia, did not receive appropriate care for their PEG tube. The facility lacked active physician orders for PEG tube site care, leading to inconsistent dressing changes and prolonged beeping of the feeding pump without timely staff intervention. Staff interviews revealed a lack of knowledge and adherence to the facility's PEG tube care policy.
The facility failed to provide adequate dialysis care for residents, with incomplete and inaccurate pre and post-dialysis assessments. A resident's records showed missing assessments and incorrect data, while another resident's documentation lacked vital signs and weights. Staff interviews revealed a lack of understanding of responsibilities, contributing to the deficiencies.
A resident with diabetes did not receive their prescribed insulin due to an LPN's incorrect decision to withhold it based on a blood sugar reading, despite no parameters for withholding being in the physician's order. The facility's policy requires medications to be administered as prescribed, which was not followed in this case.
The facility failed to maintain accurate medical records for three residents, including incorrect timestamps and missing documentation for falls and dialysis assessments. A resident's fall was inaccurately documented, leading to a hospital visit without a physician's order. Another resident's dialysis assessments were incomplete, with missing vital signs and weights. Additionally, discrepancies were found in the documentation of falls for a third resident.
A facility failed to maintain infection control standards during medication administration for a resident, where an LPN did not sanitize hands or use gloves, and her hair contacted the resident. In another case, an LPN did not wear a gown during PEG tube care for a resident, contrary to enhanced barrier precautions policy. These deficiencies were identified during a survey and involved non-compliance with the facility's infection control policies.
A medication cart was left unattended and unlocked in a hallway, with a resident and a family member nearby. An LPN confirmed the cart should have been locked, as per the facility's policy. This oversight had the potential to impact 40 residents on the unit.
The facility failed to adhere to menu production sheets, serving fewer food items and incorrect portion sizes, affecting residents' meals. Observations revealed discrepancies in the lunch tray line, with residents receiving fewer tacos and no cornbread, contrary to the menu. The Registered Dietitian justified the portion size based on protein content, but the menu was not updated to reflect these changes. Residents and their families expressed dissatisfaction with the food quality and service.
A facility failed to follow infection control protocols during medication administration. An LPN was observed placing medications into her bare hand instead of using a medication cup, contrary to the facility's policy. This affected a resident with multiple health conditions, including acute kidney failure and impaired cognition. The LPN admitted that medications should be placed into a medication cup.
The facility failed to provide timely employment verification for STNAs, resulting in their registry status being changed to expired. This was confirmed through a review of staff schedules, the nurse aide registry, and interviews. The Administrator acknowledged the delay in submitting employment verifications, potentially affecting all 150 residents.
The facility did not have daily nurse staffing information posted in a prominent place, affecting all 150 residents. An observation revealed the absence of staffing information, and the Administrator confirmed it should have been available at the front desk but was being printed.
Delay in Providing Medical Records to Resident
Penalty
Summary
The facility failed to ensure timely access to medical records for a resident, which affected one out of three residents reviewed for medical record access. The resident, identified as Resident #75, requested his medical records on February 4, 2025. However, due to a series of delays, he did not receive them until February 24, 2025. The delay was primarily caused by the absence of the newly hired medical records staff member, who went on vacation the day after starting her position and did not return until February 20, 2025. During this period, the request was not processed, and the resident was left waiting for his records. Interviews with the designated social worker and the administrator revealed that the request was not submitted for approval until February 24, 2025, the same day the resident paid the fee and received his records. The facility's policy on medical record requests, which aims to comply with HIPAA requirements, was not followed in this instance, leading to the delay. The administrator confirmed the timeline of events and acknowledged the oversight in processing the request promptly.
Improper Incontinence Care for a Resident
Penalty
Summary
The facility failed to provide proper incontinence care for Resident #129, who was diagnosed with several conditions including COVID-19, dysphagia, cirrhosis of the liver, nontraumatic intracerebral hemorrhage, hemiplegia affecting the right dominant side, and sickle-cell disease. The resident was admitted with bladder and bowel incontinence, as noted in the care plan dated 12/10/24, which included interventions such as offering to toilet the resident at specific times and providing perineal care after each episode of incontinence. However, during an observation on 03/05/25, Wound Nurse #581 failed to cleanse the resident's front genital area during perineal care, which was confirmed by the nurse during an interview. The Director of Nursing (DON) confirmed that the procedure for perineal care was not followed correctly, as the facility's policy requires cleaning the front perineal area first, followed by the buttocks. The facility's policy, dated August 2009, emphasizes the importance of providing cleanliness and comfort through proper perineal care. This deficiency was identified during a complaint investigation under Complaint Number OH00161455, affecting one resident out of three reviewed for incontinence care, with a facility census of 152.
Failure to Secure and Store Medications Appropriately
Penalty
Summary
The facility failed to secure and store medications appropriately, affecting one resident out of three reviewed for secured medications. On the morning of March 4, 2025, Resident #136 was due to receive several medications, including Amiodarone HCI, Jardiance, Metoprolol Succinate ER, Potassium Chloride ER, sodium chloride, Vitamin C, and Acyclovir. During an observation and interview at 11:52 A.M., it was found that a medicine cup containing 6 1/2 pills was left on Resident #136's overbed tray. The resident confirmed that these were his morning medications, which the nurse had left for him to take. Further interviews and observations confirmed the deficiency. At 12:03 P.M., a supervisor LPN verified that medications should not be left in a resident's room and confirmed the presence of 6 1/2 pills in the medicine cup, which were then removed. The Director of Nursing also verified that medications should not be left unattended in a resident's room. LPN #322 admitted to leaving the medications at the resident's bedside and confirmed that they were the resident's morning medications. The facility's policy on Medication Administration, dated September 14, 2020, states that medications should be administered as ordered and that staff should stay with the resident until the medications are consumed or refused.
Failure to Document Resident's Death Confirmation
Penalty
Summary
The facility failed to ensure that the medical record of a resident accurately reflected the confirmation of the resident's death. The resident, who had a complex medical history including malignant neoplasm of the nasopharynx, respiratory failure, and other serious conditions, was found deceased in the facility. A Licensed Practical Nurse (LPN) checked on the resident and was unable to obtain vital signs, indicating the resident had passed away. The LPN informed the Nursing Supervisor, a Registered Nurse (RN), who verified the absence of vital signs. However, the medical record did not contain documentation from the RN confirming the resident's death. The facility's policy on documenting the death of a resident requires that all pertinent information, such as the date and time of death and the name and title of the individual pronouncing the death, be recorded in the nurse's notes. Despite this policy, the Director of Nursing confirmed that the medical record lacked the necessary documentation from the RN. This oversight in documentation was identified during a review of the resident's medical record, interviews with the involved staff, and a review of the facility's policies.
Inadequate ADL Assistance for Resident
Penalty
Summary
The facility failed to provide adequate and proper assistance for activities of daily living (ADL) to Resident #146, who was dependent on staff assistance. Resident #146 had a medical history that included bradycardia, type two diabetes mellitus, vascular dementia, and Alzheimer's disease. The resident's care plan indicated a need for staff assistance for transfers and incontinence care due to a self-care performance deficit. Observations revealed that Resident #146 was not properly dressed, with one shoe missing, untied shoelaces, and a full incontinence brief. The resident's clothing was also stained, and the incontinence brief was visibly full of urine. During an observation, a Certified Nursing Assistant (CNA) attempted to transfer Resident #146 to the toilet but required additional assistance from a Licensed Practical Nurse (LPN). The transfer was difficult, and the resident's incontinence care was not performed according to the facility's policy. The CNA used the same washcloth for different areas, which was against the proper procedure. Additionally, the wheelchair seat cushion was not disinfected after the incontinence care, and the resident's hands were not washed until prompted. The resident's fingernails were also noted to be excessively long, indicating a lack of proper grooming. The Director of Nursing (DON) confirmed the improper incontinence care and the difficulty in transferring Resident #146. The care plan was subsequently revised to require the use of a stand-up lift with two staff members for transfers. The facility's policies on perineal care and activities of daily living were not followed, leading to the deficiency identified in the report.
Failure to Implement Bowel Protocol for Resident
Penalty
Summary
The facility failed to implement adequate interventions for a resident's constipation as per the facility's bowel protocol. The resident, who had multiple diagnoses including bradycardia, type two diabetes mellitus, vascular dementia, and Alzheimer's disease, was admitted and reentered the facility on specified dates. The resident's care plan indicated a need for assistance with activities of daily living due to various health conditions, and the resident was noted to be always incontinent of urine and bowel. Despite this, the resident did not have a bowel movement for five days, and there was no evidence of assessment for bowel sounds, pain, tenderness, or firmness of the abdomen during this period. The facility's electronic medical record showed that the resident was on a bowel protocol, which was not effectively communicated or acted upon by the staff. Certified Nursing Assistant (CNA) #402 and Licensed Practical Nurse (LPN) #403 were unaware of the resident's status on the bowel protocol, despite it being displayed on their computer screens. The Unit Manager (UM) #404 also failed to check the bowel protocol list due to being busy, and did not ensure that the nurses were aware of the residents on the protocol. This lack of communication and follow-through resulted in the resident not receiving the necessary interventions for constipation. The facility's bowel protocol policy required nursing staff to maintain a record of bowel movements and initiate a bowel protocol if there was no bowel movement for three days or six shifts. The protocol included administering Milk of Magnesia, Dulcolax suppository, and potentially a Fleets enema if necessary. However, these steps were not followed for the resident, and there was no documentation of bowel movements or related assessments in the medical record. This deficiency was part of a complaint investigation and represented continued non-compliance from a previous survey.
Delayed Response to Fall and Fracture
Penalty
Summary
The facility failed to ensure timely injury identification and physician notification and treatment following a fall with fracture for Resident #162. After an unwitnessed fall, the resident complained of pain, had swelling, and an abrasion to the knee, and was unable to stand. An x-ray was ordered, but the results indicating a right femur fracture were not located by the facility staff until several hours later, delaying medical intervention. The resident expired shortly after, unrelated to the fracture, following unsuccessful CPR and EMS intervention. Resident #162 had a history of chronic respiratory failure, COPD, malignant neoplasm of the bronchus or lung, atherosclerotic heart disease, essential hypertension, and a history of fractures. The care plan indicated the resident was at risk for falls and required staff to follow the facility fall protocol. Despite these precautions, the resident experienced a fall, and the facility's response was inadequate, as evidenced by the delay in obtaining and acting upon the x-ray results. Interviews with facility staff revealed communication breakdowns and procedural lapses. The x-ray results were received but not identified until hours later, and the physician was not contacted promptly. The facility's investigation confirmed these failures, and the Director of Nursing acknowledged the delay in identifying the x-ray results and the incorrect contact information for the physician, which contributed to the lack of timely care for the resident's fracture.
Failure to Provide Timely Pressure Ulcer Care
Penalty
Summary
The facility failed to properly assess and treat a pressure ulcer for a resident upon re-admission from the hospital, leading to a significant decline in the resident's condition. The resident, who had diagnoses including end-stage renal disease, diabetes, and moderate malnutrition, was readmitted to the facility with a new wound on the buttocks. Despite being identified as having a very high risk for pressure ulcer breakdown, the facility did not initiate wound care orders until four days after re-admission. The resident's pressure ulcer progressed from a Stage III to an unstageable ulcer with suspected osteomyelitis due to the lack of timely assessment and implementation of wound care orders. The facility's records revealed multiple instances where wound care was not completed as ordered, with no documented evidence of care on specific dates. The resident's treatment administration record showed missed wound care on several occasions, and there was no documentation of wound care on the afternoon of certain days. Additionally, the facility's pressure ulcer prevention policy lacked specifics on how interventions should be initiated or tracked, contributing to the deficiency. Interviews with facility staff, including the Unit Manager, Wound Nurse Practitioner, and Director of Nursing, confirmed the resident's wound care was not completed as ordered, and there were multiple missed treatments. The Wound Nurse Practitioner expressed concerns about the resident's wound care not being completed and noted that orders sometimes had to be made twice daily to ensure care was provided. The Director of Nursing verified the decline in the resident's wound and acknowledged the lack of documentation indicating the decline was unavoidable.
Deficiencies in Fall Prevention and Transfer Safety
Penalty
Summary
The facility failed to develop and implement a comprehensive and individualized fall prevention program, resulting in actual harm to a resident. Resident #19, who was cognitively impaired and at high risk for falls, sustained an unwitnessed fall that resulted in displaced fractures of the right seventh through 12th ribs and a non-displaced sternal fracture. Despite having a care plan intervention to check on the resident between 10:00 P.M. and 12:00 A.M., there was no evidence that this intervention was monitored or completed. The resident was transferred to the hospital due to pain and admitted to the ICU. The facility's investigation into the fall revealed several deficiencies. There was no documentation indicating when Resident #19 was last checked by staff before the fall. The fall investigation and witness statements were incomplete, and there was a discrepancy in the medication administration records. Interviews with staff revealed confusion about the documentation process and the timing of interventions. The Director of Nursing confirmed that the intervention to check on the resident was not documented, as it was considered a routine check. Additionally, the facility failed to ensure safe transfer practices for another resident, Resident #68. The resident required assistance from two staff members for transfers, but a CNA completed a transfer using a Hoyer lift without a second staff member present. This was confirmed by both the CNA and the resident, and it was not the first time such an incident occurred. The facility's policy required two staff members for mechanical lift transfers, highlighting a failure to adhere to established safety protocols.
Failure to Follow Menu and Substitution Protocols
Penalty
Summary
The facility failed to ensure that all menu items were prepared in advance and that menus and substitutions were followed during resident meal service. On 10/30/24, during lunch, the facility did not serve oven-roasted vegetables to residents on regular and mechanical soft textured diets, nor did they serve pureed grilled cheese to residents on puree textured diets. It was only halfway through the tray line that vegetables were brought out, and pureed grilled cheese was not available until later. This oversight was confirmed by the Dietary Director and Dietary Manager, and there was no evidence that the missing items were provided to residents who had already been served. Additionally, during breakfast on the same day, the facility did not follow the menu or substitution log. A resident expected eggs as per the menu but received a Danish, applesauce, and farina instead, without the yogurt and banana listed on her meal ticket. A CNA confirmed the discrepancy and noted that several residents received applesauce instead of yogurt and banana. A group interview with several residents revealed that food often did not match the menu or meal tickets, and they were not informed of substitutions. The facility's policy on menu substitutions requires recording changes and notifying residents, which was not adhered to.
Deficiency in Meal Quality and Temperature Control
Penalty
Summary
The facility failed to ensure that meals served to residents were palatable, attractive, and at a safe and appetizing temperature. The Dietary Director identified issues with meal timeliness and temperature control, noting that the new facility ownership had changed the process from serving meals from the pantry on each unit to serving from the main kitchen. During an observation, a test tray revealed that the grilled cheese sandwich was soggy and lacked sufficient cheese, and the tomato soup was lukewarm and not palatable. These findings were confirmed by the Dietary Director and Dietary Manager. The Food Committee Meeting Minutes from August indicated that proper food temperatures and meal delivery were already a focus of concern. Multiple residents expressed dissatisfaction with the quality of food served. One resident described the food as horrible, citing examples of burnt cabbage rolls, undercooked baked potatoes, and dry, hard chicken breasts. This resident relied on food brought in by her son to have enough to eat. Another observation revealed a meal tray with hard, dry toast and no condiments, which the resident refused to eat. A group interview with several residents highlighted concerns about overcooked breaded items, unappealing breakfast options, and food presentation that made meals look unappetizing. These issues were investigated under a specific complaint number, indicating non-compliance with dietary service standards.
Delayed Meal Service in LTC Facility
Penalty
Summary
The facility failed to ensure meals were served in a timely manner, affecting all residents receiving meals from the kitchen. The facility's meal times were scheduled with a 15-minute deviation allowance, but observations and interviews revealed significant delays. Residents reported receiving meals late, with breakfast trays being delivered well past the scheduled time. Staff interviews confirmed that meal trays were routinely delivered late, particularly on the secured dementia unit, and lunch was often served later than scheduled. The facility's increased census contributed to the delays, as noted in interviews with dietary staff. The Dietary Director acknowledged issues with meal timeliness and temperature, attributing some delays to a change in the serving process initiated by new facility ownership. The Registered Dietitian reported that concerns about meal times had been raised multiple times, and residents expressed a preference for returning to dining room service, which had previously resulted in higher customer satisfaction. Observations further highlighted the inconsistency in meal delivery, with some residents waiting extended periods for their meals. On one occasion, two residents did not receive their lunch trays until 30 minutes after others had been served. Staff interviews indicated that the process of passing trays was hindered by staffing issues, including the use of agency aides who interrupted tray pass to provide morning care. The facility had experienced turnover in dietary management, which may have contributed to the ongoing issues with meal service.
Non-compliance with Food Safety Protocols in Kitchen
Penalty
Summary
The facility failed to ensure that kitchen staff adhered to proper food safety and handling protocols, which could potentially affect all 159 residents receiving meals from the kitchen. Observations revealed that a Mashgiach in the kitchen area was not wearing a hair net, despite being asked to do so by the Dietary Director. The Mashgiach refused, citing that wearing a wig negated the need for a hair net. Additionally, a staff member preparing pureed foods was observed adjusting his beard net with gloved hands without changing gloves or washing hands, improperly cleaning and sanitizing equipment, and not allowing equipment to dry before reuse. This staff member also failed to wash hands after handling soiled gloves and continued to use wet gloves during food preparation. The facility's policies on hair restraints, hand washing, general safe food handling, and disposable gloves were not followed. The staff member was seen rinsing food processor parts and utensils in a preparation sink, allowing water to splash into food, and using utensils without proper drying. The Dietary Manager confirmed these observations and acknowledged the failure to adhere to the facility's policies. The report highlights the lack of compliance with established food safety protocols, which are critical to maintaining a safe and sanitary environment for food preparation and service.
Deficiency in Dignified Dining Experience
Penalty
Summary
The facility failed to ensure a dignified dining experience for several residents, including Resident #62, Resident #13, Resident #52, and Resident #24. Observations revealed that Resident #62, who has severe dementia and requires assistance with feeding, was left unattended with her meal tray, resulting in her consuming only 10% of her meal. The dining environment was further compromised by loud rock-n-roll music, which was not to the residents' liking, and they were not given a choice in the music selection. This lack of consideration for resident preferences contributed to an undignified dining experience. Additionally, Resident #13 and Resident #24 experienced delays in receiving their meals, which were not served simultaneously with other residents seated at the same table. Both residents expressed concerns about the extended wait times and lack of communication regarding the delay. The meal cart arrived late, and these residents did not receive their meals until much later than others, causing them distress and uncertainty about whether they would be served. Interviews with staff, including CNA #900 and LPN #763, confirmed the issues observed. CNA #900, who was from a contracted staffing agency, was unaware of Resident #62's need for feeding assistance and acknowledged the staggered meal service. LPN #763 confirmed that Resident #62 required feeding assistance and that the responsibility lay with the CNA supervising the dining room. The facility's failure to coordinate meal service and respect resident preferences for dining conditions led to a deficiency in providing a dignified dining experience.
Improper Puree Preparation Techniques
Penalty
Summary
The facility failed to ensure proper puree preparation techniques were followed, affecting 17 residents who required a puree textured diet. During an observation, a staff member was seen preparing puree cake, Brussels sprouts, sweet potatoes, and tomato soup without referring to any recipes or diet manual. The staff member added large amounts of water and thickener to the food items and used a chunky seasoning that contained large pieces of dried garlic, onion, and other spices. There was no additional check to ensure the appropriate consistency of the pureed food. Interviews with the staff member, the Dietary Director, and the Dietary Manager confirmed the excessive use of water and thickener, as well as the use of inappropriate seasoning. The staff member admitted to not consulting the puree recipes or diet manual, relying instead on his own judgment of the desired texture. A review of the recipes revealed that the sweet potatoes should have been prepared with milk, margarine, ground cinnamon, and ground nutmeg, while the Brussels sprouts should have been prepared with broth or gravy, and the tomato soup did not require any thickening or seasoning.
Failure to Notify Physician of Changes in Resident Condition
Penalty
Summary
The facility failed to notify the physician in a timely manner regarding a change in condition for two residents, leading to significant deficiencies. Resident #162, who had a history of falls and fractures, experienced an unwitnessed fall and was found on the floor complaining of pain. Despite the X-ray results indicating a fracture, there was a delay in notifying the physician due to incorrect contact information and failure to check the fax machine promptly. This delay in communication contributed to the resident being found unresponsive and subsequently pronounced deceased without timely medical intervention. Resident #126, who required regular dialysis due to end-stage renal disease, missed a scheduled dialysis appointment because the transportation company failed to show up. The facility did not notify the medical provider of the missed appointment, which was against the protocol. The resident confirmed missing the dialysis session, and the unit secretary and RN acknowledged the lapse in communication. The failure to inform the medical provider prevented necessary medical assessments and interventions from being conducted. The facility's policies on notifying medical providers of significant changes in residents' conditions were not adhered to in both cases. The lack of timely communication and incorrect contact information for the physician were critical factors in the deficiencies observed. These lapses in protocol highlight the need for accurate and prompt communication channels to ensure residents receive appropriate and timely medical care.
Failure to Address Grievances Timely for a Resident
Penalty
Summary
The facility failed to follow up on grievances involving a resident in a timely manner, affecting one of the three residents reviewed for grievances. The resident, who had diagnoses including heart failure, dysphagia, and dementia without behavioral disturbance, was admitted and later discharged from the facility. The family of the resident raised concerns about missing dentures and requested medical records. Despite a meeting with the family and a consent given for the resident to be seen by a dentist, the facility did not resolve the issues promptly. The resident's son sent multiple voicemails and an email to the Administrator regarding the medical records, but the Administrator only forwarded the request and did not follow up further. Additionally, the resident's daughter sent an email marked as important regarding reimbursement for dentures, which the Administrator claimed not to have received, despite it being sent to the correct email address. The facility did not pay for the dentures and lost contact with the family after the resident was discharged. This deficiency was investigated under several complaint numbers.
Failure to Assist Residents with Meals
Penalty
Summary
The facility failed to ensure that three residents, identified as Resident #62, Resident #108, and Resident #79, received the necessary assistance with eating their meals, which is a critical activity of daily living (ADL). Resident #62, who had severe dementia, hemiplegia, and dysphagia, was observed during a meal service where she was not adequately assisted with her meal. Despite her care plan indicating she required one-person assistance for feeding, she was left with her meal tray and only received minimal assistance, resulting in her consuming only 10% of her meal. The staff involved, including a CNA and an LPN, confirmed the lack of proper feeding assistance. Resident #108, diagnosed with osteoporosis and vitamin D deficiency, required assistance with meal setup and supervision during meals. However, observations revealed that she was not encouraged to get out of bed for meals and was left unsupervised while eating. Interviews with the CNA responsible for her care confirmed that Resident #108 was not consistently assisted out of bed and was not supervised during meals, contrary to her care plan requirements. Resident #79, who had multiple diagnoses including epilepsy, diabetes, and dysphagia, required full feeding assistance as per her care plan. However, documentation and observations indicated that she frequently did not receive the necessary assistance, with staff often unaware of her feeding needs. Interviews with various staff members, including CNAs and a dietitian, confirmed inconsistencies in providing feeding assistance, with some staff unaware of her need for assistance due to inadequate communication and documentation on assignment sheets.
Failure to Provide Prescribed ROM Treatments
Penalty
Summary
The facility failed to ensure that a resident received prescribed treatments to maintain or prevent a decline in range of motion (ROM). Resident #27, who had diagnoses including chronic obstructive pulmonary disease, depression, primary hypertension, osteoarthritis, muscle weakness, pain in the left shoulder, and hemiplegia following a cerebral infarction, was affected by this deficiency. The resident was supposed to wear a left hand splint throughout the day and a PRAFO boot on the left foot when in bed, as per physician orders. However, there was no documentation in the medical record indicating that these appliances were applied, and the resident reported not having worn the hand splint for several months. Observations and interviews revealed that the resident was not wearing the prescribed hand splint or PRAFO boot during multiple checks. The resident expressed concerns about her hand becoming tighter and more closed, indicating a decline in her condition. Staff interviews confirmed a lack of awareness and documentation regarding the application of the splint and boot. The resident's care plan included these interventions, but they were not reflected in the point-of-care task documentation or the medication and treatment administration records. Further investigation revealed that the facility did not provide restorative nursing services, and the orders for the splint and boot were incorrectly entered on the care plan, leading to their omission from the Kardex for nursing staff. This oversight resulted in the resident not receiving the necessary support to maintain her ROM, as recommended by occupational therapy. The deficiency was identified during a complaint investigation, highlighting a significant lapse in the facility's care processes.
Deficiency in PEG Tube Care for a Resident
Penalty
Summary
The facility failed to ensure appropriate care and services for a resident with an enteral feeding tube, specifically a PEG tube. The resident, who had multiple medical conditions including dysphagia, relied on the PEG tube for primary nutrition and hydration. Despite the care plan indicating the need for PEG tube site care, there were no active physician orders for such care. Observations revealed that the resident's feeding pump was beeping for an extended period without staff intervention, and the PEG tube dressing was stained and dated several days prior. Interviews with staff confirmed a lack of consistent care and knowledge regarding the PEG tube site care, with one LPN unable to specify the strength of the antiseptic solution used or the orders for the care performed. Further interviews revealed that the resident experienced discomfort around the PEG tube site, and there was inconsistency in the dressing changes. The facility's policy on PEG tube care and maintenance was not followed, as no orders were in place for the application of dressings or cleaning solutions. The LPN Unit Manager confirmed that PEG tube site care should be done daily, yet there were no orders for such care, only for checking placement and residuals. This lack of adherence to policy and absence of specific care orders contributed to the deficiency in the resident's care.
Inadequate Dialysis Monitoring and Documentation
Penalty
Summary
The facility failed to provide appropriate assessments and monitoring for residents requiring dialysis, affecting three residents. For Resident #126, the facility did not complete pre-dialysis or post-dialysis assessments on multiple occasions, and the assessments that were completed often contained inaccurate or duplicated data. The facility's electronic medical record system showed assessments with statuses of 'Errors' or 'In Progress,' indicating incomplete documentation. Interviews with staff confirmed that the pre-dialysis and post-dialysis assessments did not reflect actual times and were not completed as required. Resident #50 also experienced deficiencies in dialysis care. The facility's records showed missing pre-dialysis and post-dialysis vital signs on several dates. Additionally, the assessments often used outdated or incorrect vital signs and weights, failing to provide accurate monitoring of the resident's condition before and after dialysis sessions. The facility's documentation practices were inconsistent, with vital signs and weights not being recorded accurately or timely. The facility's policy required pre and post-dialysis assessments, but these were not consistently performed or documented. Interviews with staff revealed a lack of understanding of the facility's responsibilities regarding dialysis care, particularly concerning the recording of weights and vital signs. The facility's failure to adhere to its policy and ensure accurate and timely assessments contributed to the deficiencies identified in the care of residents receiving dialysis.
Failure to Administer Insulin as Ordered
Penalty
Summary
The facility failed to ensure that Resident #107 received their prescribed insulin medication as ordered by the physician. Resident #107, who was readmitted with a diagnosis of diabetes mellitus and required long-term use of insulin, had a physician's order to receive 21 units of Insulin Glargine Solution subcutaneously once a day. However, during an observation of medication administration, the insulin was not given as scheduled. The Medication Administration Record (MAR) indicated that the insulin was not administered because it was either unavailable or deemed outside the parameters for pulse, blood pressure, or blood sugar, despite no such parameters being specified in the physician's order. An interview with the LPN responsible for administering the medication confirmed that the insulin was withheld due to a blood sugar reading of 98 mg/dL. The LPN acknowledged that there were no parameters in the physician's order to hold the insulin and that it was a long-acting insulin scheduled for daily administration. The facility's policy on administering medications, which was revised in December 2012, mandates that medications be administered safely, timely, and as prescribed. This incident was investigated under Complaint Number OH00159071, highlighting a significant medication error affecting Resident #107.
Deficiencies in Medical Record Documentation
Penalty
Summary
The facility failed to ensure complete and accurate documentation for three residents, leading to deficiencies in maintaining medical records. For Resident #19, the documentation of a fall incident was inaccurately recorded with incorrect timestamps, and there was no witness statement from the LPN who documented the progress note. The resident experienced an unwitnessed fall, was in significant pain, and was sent to the hospital without a physician's order. Interviews with staff confirmed the inaccuracies in the documentation and the lack of a witness statement. Resident #50's medical records revealed inconsistencies in documenting pre- and post-dialysis assessments. The MARs for several dates lacked vital signs, and some assessments were time-stamped while the resident was out of the facility. The DON confirmed that dialysis assessments were not completed every dialysis day, and the RN Supervisor verified missing weights and assessments. The Unit Manager acknowledged that the time stamps did not necessarily reflect when the assessments were completed. For Resident #15, the facility's fall investigations showed discrepancies between the documented times of falls and the nursing progress notes. Several falls were recorded without timely progress notes, and there was no indication of late entries to correct the timing. An LPN verified these findings, highlighting the facility's failure to maintain accurate and timely documentation of fall incidents.
Infection Control Deficiencies in Medication Administration and PEG Tube Care
Penalty
Summary
The facility failed to maintain infection control standards during medication administration for Resident #107. The LPN involved did not sanitize or wash her hands before handling medications and touched the medications with her bare hands. Additionally, her long hair came into contact with the resident during the process, and she placed her finger inside the cup of water given to the resident. These actions were in violation of the facility's hand hygiene policy, which requires handwashing or the use of an alcohol-based hand rub before handling medications and after direct contact with residents. In another incident, the facility did not adhere to enhanced barrier precautions during PEG tube site care for Resident #111. The LPN performing the procedure wore gloves but failed to don a gown, which was required by the facility's policy for high-contact resident care activities. The absence of gowns in or near the resident's room contributed to this oversight. The LPN and the unit manager confirmed that a gown should have been worn during the procedure, as per the facility's policy. These deficiencies were identified during a survey and were part of a complaint investigation. The facility's policies on hand hygiene and enhanced barrier precautions were not followed, leading to potential cross-contamination risks during care for the residents involved. The report highlights specific instances where infection control standards were not maintained, affecting the quality of care provided to the residents.
Unattended and Unlocked Medication Cart
Penalty
Summary
The facility failed to ensure medications were stored securely at all times, as observed on the [NAME] three unit. A medication cart was found unattended and unlocked in the hallway between two residents' rooms, with one resident and a family member present in the vicinity. This incident was confirmed by an LPN, who acknowledged that the cart should have been locked. The facility's policy on Medication Administration/Treatment, dated 10/18, requires that medication carts be locked when unattended. This deficiency had the potential to affect 40 residents residing on the unit.
Deficiency in Meal Portion Sizes and Menu Adherence
Penalty
Summary
The facility failed to provide all food items and portion sizes as indicated on the menu production sheets, potentially affecting all residents except those with orders for nothing by mouth. During an observation of the lunch tray line, it was noted that residents received one soft beef taco, half a cup of rice, half a cup of corn, and half a cup of fruit, whereas the tray tickets indicated that two tacos and a piece of cornbread should have been served. The absence of cornbread was attributed to a vendor issue, and fruit was substituted without updating the menu production sheet or tray tickets. The Registered Dietitian confirmed that only one taco was served because it contained four ounces of meat, which was deemed sufficient to meet protein requirements, despite the menu indicating two tacos per serving. Interviews with residents and their families revealed dissatisfaction with the food quality and discrepancies between what was served and what was supposed to be served. A resident's family member described the food as awful, and a resident confirmed not receiving the planned lunch meal. The facility's Administrator and Registered Dietitian insisted that the protein portion was adequate, despite the menu production sheet not specifying the size or protein content of the tacos. This deficiency was investigated under Complaint Number OH00157273.
Infection Control Breach in Medication Administration
Penalty
Summary
The facility failed to maintain standard infection control protocols during medication administration, affecting one resident. During a random observation, an LPN was seen administering medications to a resident with acute kidney failure, spastic quadriplegic cerebral palsy, and neuromuscular dysfunction of the bladder. The resident also had impaired cognition. The LPN placed three out of thirteen medications from medication cards into her bare hand, which is against the facility's policy. The facility's policy, dated 2010, clearly directs staff not to touch medications with their hands and to use a medication cup instead. During an interview, the LPN acknowledged that medications should be placed into a medication cup, not a bare hand.
Failure to Provide Timely Employment Verification for STNAs
Penalty
Summary
The facility failed to provide timely employment verification for State tested Nurse Aides (STNAs) #400 and #403, which resulted in their status on the nurse aide registry being changed to expired. This deficiency was identified through a review of staff schedules, the nurse aide registry, employment verification letters, and staff interviews. The review revealed that no evidence of employment had been provided for these STNAs within a 24-month period. An interview with the Administrator confirmed that the facility had not submitted the necessary employment verifications until after the expiration of their registry status. This deficiency had the potential to affect all 150 residents in the facility and was investigated under Complaint Number OH00156057.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post daily nurse staffing information in a prominent place on 09/05/24, which had the potential to affect all 150 residents. During an observation at 10:45 A.M., it was noted that the staffing information for that day was not available. An interview with the Administrator at 10:53 A.M. confirmed that the staffing information should have been in a binder at the front desk, but it was not present and was in the process of being printed.
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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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