Divine Rehabilitation And Nursing At Canal Pointe
Inspection history, citations, penalties and survey trends for this long-term care facility in Akron, Ohio.
- Location
- 145 Olive St, Akron, Ohio 44310
- CMS Provider Number
- 365259
- Inspections on file
- 40
- Latest survey
- September 12, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Divine Rehabilitation And Nursing At Canal Pointe during CMS and state inspections, most recent first.
During meal service, hot foods were not kept at appropriate temperatures due to lack of heat conservation methods, resulting in food being served below the required 135°F. Staff and residents reported ongoing complaints about cold meals, and observations confirmed that food temperatures dropped significantly before reaching residents, contrary to facility policy.
Surveyors identified unsanitary conditions in the kitchen and a second floor kitchenette, including the presence of flying insects, rodent droppings, chipped paint, food debris, standing water, and heavy grime on multiple surfaces. These issues were confirmed by dietary and nursing staff and were not in compliance with facility policy, potentially affecting over 100 residents receiving meals.
Surveyors found that foods in unit refrigerators were not consistently labeled, dated, or discarded when expired, and that refrigerators were not maintained in a clean condition. Multiple expired and undated food items, as well as visible spills and stains, were observed across several floors. Staff interviews confirmed these practices were not in line with facility policy, potentially affecting over 100 residents, including several who were NPO.
The facility did not ensure that employees received and completed required annual training, as staff were provided with in-service packets to sign in advance of the actual due date, and some only briefly reviewed the materials or were unsure of their location. The Human Resource Director lacked a system to track training completion after discontinuing the online program, and the Administrator confirmed that other education provided was insufficient. This affected all employees reviewed and had the potential to impact all residents.
The facility did not ensure that CNAs received the required 12 hours of annual in-service training. Instead of regular training, staff were given a packet of materials to review on their own, with no system to track completion or understanding. This affected all residents in the facility.
A resident was found with unsecured inhalers at the bedside without documentation permitting self-administration, and expired medications were observed in medication storage rooms. Staff confirmed that medications should have been secured and expired items discarded, in accordance with facility policy.
Surveyors found that the facility did not consistently develop or implement comprehensive care plans for several residents, including those using oxygen, receiving high-risk anticoagulant medications, self-managing colostomy and catheter care, requiring enhanced barrier precautions, and experiencing PTSD. Care plans were missing, incomplete, or not individualized to reflect residents' needs and interventions, as confirmed by staff interviews and record reviews.
The facility did not complete timely or accurate smoking safety assessments for several residents, including those with severe cognitive impairment and behavioral issues. Some residents were allowed to smoke without supervision based on outdated or incorrect assessments, and required evaluations were not performed as per facility policy. Staff interviews confirmed lapses in assessment practices and documentation.
Two residents with cognitive impairments were found living in rooms with broken furniture, soiled surfaces, dirty bathrooms, and unclean air conditioning units. Staff confirmed these conditions, and housekeeping practices were found lacking, with no routine cleaning of certain areas and inadequate attention to cleanliness in shared spaces such as the shower room and resident lounge. These deficiencies had the potential to affect many other residents in the facility.
The facility did not thoroughly investigate multiple abuse allegations involving residents with behavioral and cognitive issues. Incidents included a physical altercation between two residents, repeated aggressive behaviors by a resident toward staff and peers, and an unreported allegation of inappropriate touching. Required investigations were not completed, and documentation was lacking or incomplete.
Multiple residents experienced significant medication errors, including late administration of critical medications such as insulin, anticoagulants, and cardiac drugs, as well as improper insulin administration techniques. LPNs failed to check blood sugar before meals and did not prime insulin pens as required. The DON confirmed that medications were often administered outside the facility's policy window, and residents reported receiving medications late or combined with other scheduled doses.
The facility did not serve food portions as specified in the menu, resulting in residents receiving less food than required. Incorrect serving utensils were used, leading to under-serving of items such as onions, peppers, and ground sausage. A resident reported insufficient food, and the Dietary Manager confirmed the portion discrepancies during meal service.
A resident with severe cognitive impairment and multiple vascular diagnoses did not have ordered labs completed due to refusal and lack of available staff. The missed labs were not documented, and neither the physician nor the responsible party was notified, contrary to facility policy.
Two residents, both with complex medical and behavioral histories, were involved in a physical altercation after one attempted to remove a female resident in a wheelchair from an elevator. Despite a documented pattern of aggression and daily behavioral issues, the facility did not implement additional safety measures such as secured unit placement, citing the resident's refusal. The incident was not substantiated as abuse by the facility, and no witnesses or perpetrator were identified in the records.
A resident with severe cognitive impairment and urinary retention requiring an indwelling catheter did not have daily fluid intake and urine output monitored or documented as required by their care plan. This deficiency was confirmed by the DON, who acknowledged that intake and output should have been tracked both while the catheter was in place and after it was discontinued.
A resident with severe cognitive impairment and multiple diagnoses, including diabetes and dysphagia, experienced significant weight loss after not receiving soup with lunch and dinner as ordered by the RD and physician. Staff failed to provide the prescribed nutritional intervention, did not encourage the resident to eat, and were unaware of the dietary orders, despite clear documentation and care plan instructions.
A resident receiving hospice care and oxygen therapy was found to be using oxygen without a physician's order, and the oxygen tubing in use was not dated as required by facility policy. Staff confirmed the absence of orders and the missing date on the tubing during interviews and observations.
A resident with end stage renal disease requiring dialysis did not have communication from the dialysis provider sent to the facility after each treatment. Staff confirmed that updates were not consistently received, and the resident reported never receiving paperwork to give to the facility. Only monthly summaries were available, and the facility's dialysis policy was not provided during the survey.
A resident with a history of suicidal ideation and multiple mental health diagnoses was not provided with adequate behavioral health care or a safe environment. Staff failed to implement or communicate suicide precautions, allowing the resident access to razors, inhalers, and a full sharps container in her room. Interviews and observations confirmed that staff were unaware of necessary interventions and did not secure potentially dangerous items, contrary to facility policy.
A resident with a history of stroke and on anticoagulant therapy did not receive timely physician-ordered lab tests to assess renal function and medication appropriateness. The lab draw was delayed, and when the resident refused, the lab tech did not inform the floor nurse, resulting in no follow-up, physician notification, or documentation of the missed labs.
Two residents requiring enhanced barrier precautions did not have PPE readily available in their rooms, and staff were observed not using required PPE during high-contact care activities. Soiled dressings were found on the floor, and staff demonstrated confusion about EBP protocols, with no trash cans available for PPE disposal as required by facility policy.
A resident with severe cognitive impairment and behavioral issues reported to a psychiatric NP that she lifted her shirt and a peer touched her breast. The incident was not communicated to the administrator, resulting in a failure to promptly report the abuse allegation to the State agency, initiate an investigation, or notify the resident's guardian as required by facility policy.
Two residents with diabetes had their blood sugar checked and insulin administered after eating breakfast, rather than before the meal as required. In both cases, LPNs did not follow facility policy to prime the insulin pen before each use, with one LPN stating she only primed new pens. The DON confirmed that blood sugar assessments should occur before meals. These failures had the potential to affect additional residents who require pre-meal blood sugar checks and insulin via pen.
The facility failed to ensure safe and secure disposal of medications. A sharps disposal container in the third-floor medication room was found without a lid and partially filled with various medications. Staff confirmed this was the method used for destroying medications due to a lack of proper disposal fluid. The DON acknowledged the issue but did not provide the facility's medication destruction policy.
Failure to Maintain Safe and Appetizing Food Temperatures
Penalty
Summary
The facility failed to provide food at appetizing and safe temperatures, as observed during a lunch meal service. Initial food temperatures at the start of tray line service were within appropriate ranges, but there were no plate warmers or hot pellets used to maintain food temperature after plating. Chicken enchiladas were left uncovered on a cart next to the steam table, rather than being kept on the steam table, resulting in a significant drop in temperature. The last chicken enchilada served from the uncovered baking sheet measured 130°F, below the facility's policy requirement of holding hot foods at 135°F. Additional observations showed that by the time food reached residents, temperatures had dropped further, with one meal measuring 115°F for both the chicken enchilada and mashed potatoes, and 95°F for green beans. Multiple interviews with dietary staff, CNAs, and residents confirmed ongoing complaints about hot foods being served cold. Residents expressed dissatisfaction with the temperature of their meals, specifically noting a preference for warmer food. Review of facility policies indicated that hot foods should be served at appetizing temperatures and held at or above 135°F, but these standards were not met during the observed meal service.
Unsanitary Food Storage and Preparation Conditions Identified
Penalty
Summary
The facility failed to ensure that food was stored, prepared, and served under sanitary conditions, as evidenced by multiple observations and interviews. Surveyors observed a pervasive problem with small, flying insects throughout the kitchen, including above the handwash sink, around the dishwasher, near a hanging dish cabinet, and near the oven. There were also multiple areas of chipped or bubbled paint and damaged drywall in food preparation areas, a moderate collection of food debris on storage racks and walls, and standing water near the dishwasher. Additionally, several surfaces, such as oven doors, range tops, pipes, kitchen floors, range hood fire suppression nozzles, and sprinkler pipes, were found to have moderate to heavy black grime. These findings were confirmed by the Dietary Supervisor during the inspection. Further inspection of the second floor kitchenette revealed a rodent bait box with multiple rodent droppings on the floor and on the microwave stand behind the microwave. The Assistant Director of Nursing verified these findings. Review of pest control invoices indicated ongoing issues with kitchen insects and rodents, with extra service provided for rodents. Facility policy required all food service areas to be kept clean and protected from pests, with weekly inspections to ensure compliance, but these standards were not met. The deficiency had the potential to affect 108 residents receiving meals from the kitchen, with three residents identified as receiving nothing by mouth (NPO).
Improper Food Labeling, Storage, and Sanitation in Unit Refrigerators
Penalty
Summary
Surveyors observed that the facility failed to ensure that foods stored in unit refrigerators were properly labeled, dated, and discarded when expired, and that the refrigerators were maintained in a clean condition. During an inspection with the Dietary Manager, multiple expired and undated food items were found in nourishment refrigerators on the second, third, and fourth floors, including expired milk, soy sauce, hot sauce, potato salad, apples, yogurt, and a frozen entrée. Additionally, several food items lacked labels or dates, and there were visible spills and stains inside the refrigerators. The base of one refrigerator was stained with an unidentifiable pink substance, and another contained a red sticky substance and crumbs. Interviews with the Dietary Manager confirmed that foods should be labeled, dated, and discarded when expired, in accordance with facility policy. The Administrator and Quality Assurance RN acknowledged that housekeeping staff were responsible for cleaning the unit refrigerators every three days, but were made aware of the unsanitary conditions and expired foods during the survey. Facility policies reviewed indicated that all food items brought in by families or visitors must be labeled and dated, and prepared foods should be consumed within three days or discarded. The deficiency had the potential to affect 108 residents receiving meals from the kitchen, with three residents identified as NPO at the time of the survey.
Failure to Ensure Required Annual Staff Training
Penalty
Summary
The facility failed to ensure that employees received the required annual training as mandated by applicable laws and regulations. Review of personnel files for 13 employees revealed that staff were provided with two types of in-service packets, which they signed to acknowledge receipt and review. However, some employees signed these packets upon hire or in advance of the actual annual due date, indicating that the training may not have been completed at the appropriate time. Additionally, the packets were distributed for the upcoming year, and signatures were obtained before the information was reviewed. Interviews with staff confirmed that some employees only briefly reviewed the materials or were unsure of the location of their packets, suggesting that the training was not effectively delivered or tracked. The Human Resource Director stated that the facility had discontinued its online training program and replaced it with the packet system, but did not have a method to track completion of education otherwise. The Administrator acknowledged that other training provided by the DON throughout the year was insufficient, as it was not conducted monthly. This deficiency affected all 13 employees reviewed and had the potential to impact all 111 residents in the facility.
Failure to Provide Required Annual CNA In-Service Training
Penalty
Summary
The facility failed to provide regular annual training for certified nursing assistants (CNAs), as required for their 12 hours of in-services each year. Review of personnel files for three CNAs showed no evidence of ongoing training throughout the year. Instead, the facility discontinued its online training program over a year ago and began giving staff a packet of in-service materials for the entire year at orientation and annually, with only the first page signed by the employee. There was no system in place to track or verify that staff actually read or completed the training materials, as confirmed by the Human Resource Director. This lack of regular and verifiable training had the potential to affect all 111 residents in the facility.
Failure to Securely Store Medications and Remove Expired Drugs
Penalty
Summary
The facility failed to ensure that medications were securely stored and that expired medications were discarded, as required by policy and professional standards. In one instance, a resident with diagnoses including anxiety disorder, depression, post-traumatic stress disorder, and borderline personality disorder was found to have an albuterol inhaler and a Trelegy inhaler unsecured at the bedside. The resident was cognitively intact and independent with mobility, but there was no physician's order or documentation indicating the resident was permitted to self-administer medications. Nursing staff confirmed that all medications for this resident should have been stored and administered by staff, and that the inhalers should not have been left at the bedside. Additionally, observations of medication storage rooms revealed multiple expired items, including a COVID-19 test, glucose test strips, magnesium, bisacodyl tablets, guaifenesin, and omeprazole. The DON confirmed the presence of these expired house stock items, which should have been discarded according to facility policy. The policy also stated that all drugs and biologicals must be stored in locked compartments and that the pharmacy and medication rooms are routinely inspected for outdated medications.
Failure to Develop and Implement Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans that addressed the full scope of residents' medical, psychosocial, and mental health needs, as identified through record review, observation, and staff interviews. For one resident with diagnoses including malignant neoplasm of the prostate and COPD, who was receiving hospice services and using oxygen, there was no care plan in place for oxygen use, despite observations confirming its use and facility policy requiring such a plan. Another resident receiving high-risk anticoagulant medication did not have a care plan addressing the monitoring and management of side effects, even though physician orders specified monitoring requirements. A resident with a colostomy and suprapubic catheter, who was cognitively intact and self-managed his care, had care plans that did not reflect his self-management, instead listing only standard nursing interventions. For a resident with severe cognitive impairment and chronic wounds requiring enhanced barrier precautions (EBP), there was no care plan addressing EBP, despite physician orders and staff confirmation that such a plan was required. Additionally, a resident with PTSD and other mental health diagnoses had an incomplete care plan that did not identify specific triggers or interventions to alleviate symptoms, with only a single generic intervention documented and no measurable goals. These deficiencies were confirmed through interviews with nursing and social work staff, who acknowledged the absence or incompleteness of required care plans. Facility policies reviewed indicated that comprehensive, person-centered care plans with measurable objectives and time frames were required for all identified needs, but these were not consistently developed or implemented for the affected residents.
Failure to Timely and Accurately Assess Residents for Smoking Safety
Penalty
Summary
The facility failed to timely and accurately assess residents for smoking safety, as evidenced by record reviews, interviews, and policy review. Four residents with varying degrees of cognitive impairment and complex medical histories were affected. For two residents with severe cognitive impairment, the smoking safety screens incorrectly indicated no cognitive loss, despite their low BIMS scores and care plans noting significant cognitive deficits. Orders allowed these residents to smoke without supervision, and the assessments did not reflect their true cognitive status. Another resident, also severely cognitively impaired with behavioral issues, had not received a smoking assessment in the previous 12 months, contrary to facility policy. The resident was listed as a supervised smoker, but documentation and assessment practices were inconsistent. Additionally, a cognitively intact resident had not received a smoking safety screen for nearly two years, despite being an active smoker. Staff interviews revealed a lack of adherence to the facility's policy, which required smoking assessments at admission and with each quarterly or comprehensive MDS assessment. Nursing staff acknowledged that assessments were not being completed as required, and there was confusion regarding the use of cognitive assessments. The facility's failure to conduct timely and accurate smoking assessments resulted in residents being permitted to smoke without appropriate supervision or updated evaluations of their safety needs.
Failure to Maintain Safe, Clean, and Homelike Environment for Residents
Penalty
Summary
Surveyors identified that the facility failed to provide a safe, clean, and homelike environment for its residents, as evidenced by multiple observations and interviews. Two residents were found living in rooms with significant cleanliness and maintenance issues, including broken furniture, soiled and dusty surfaces, stained and dirty curtains, and unclean bathrooms with foul odors and visible stool. One resident, moderately cognitively impaired with Alzheimer's disease, was observed in a room with a broken closet door, food crumbs, dirt, soiled clothing, and a bathroom with dried stool and grime. Another resident, severely cognitively impaired with dementia and ADHD, was found in a room with broken furniture, stained recliner, soiled curtains, and a broken bed footboard. Both residents' rooms had air conditioning units and dressers with dried spills and dust buildup, and staff confirmed these conditions during the survey. Further observations revealed that the facility's cleaning practices were inadequate. Housekeeping staff reported that deep cleaning was only performed for major messes, and that certain areas, such as the edges of floors and privacy curtains, were not routinely cleaned. The second-floor shower room, used by all residents on that floor, had a dirty floor with scum buildup, a rusted bedside commode, and a ceiling with mold and peeling paint. Additionally, the third-floor resident lounge contained worn and ripped chairs. Facility policy required staff to report furniture in disarray and maintain a sanitary environment, but these standards were not met, affecting not only the two residents observed but also potentially impacting 78 additional residents on the second and third floors.
Failure to Investigate Allegations of Abuse
Penalty
Summary
The facility failed to thoroughly investigate multiple allegations of abuse involving four residents. In one incident, two cognitively intact residents with significant behavioral histories were involved in a physical altercation in the lobby after a dispute over elevator access. The facility's self-reported incident (SRI) did not identify witnesses or a perpetrator, and the allegation of abuse was unsubstantiated. Documentation showed that one resident had a history of physical aggression and behavioral issues, yet was not placed on a secured unit due to his refusal, despite ongoing threats and aggressive behavior toward others. Another resident with moderate cognitive impairment and behavioral disturbances was involved in several incidents, including making sexually explicit comments to staff, attempting to hit another resident, and becoming physically aggressive during a dispute. On one occasion, after a resident believed another had spit on him, he attempted to punch the other resident. The facility did not file an SRI for this incident, and documentation was limited to separating the residents and providing emotional support, without a thorough investigation as required by policy. A third resident, who was severely cognitively impaired and had a history of delusions and disruptive behaviors, reported to the psychiatric nurse practitioner that a peer had touched her breast after she lifted her shirt. The administrator was unaware of this allegation, and no investigation was initiated because staff did not report the incident. The facility's policy requires all allegations of abuse to be investigated and residents to be protected during investigations, but this was not followed in these cases.
Significant Medication Administration Errors Due to Late and Improper Dosing
Penalty
Summary
Multiple residents experienced significant medication administration errors, including late administration of critical medications and improper insulin administration techniques. For example, one resident with diabetes mellitus and diabetic nephropathy received insulin after consuming breakfast, and the LPN failed to check blood sugar prior to the meal and did not prime the insulin pen before administration. Another resident with type two diabetes mellitus received insulin after breakfast, but the blood sugar was checked only after the meal, contrary to care plan interventions requiring blood sugar monitoring before meals. Several residents with complex medical conditions, such as congestive heart failure, COPD, hypertension, and diabetes, had their scheduled medications administered several hours late on multiple occasions. Medications affected included metoprolol, Entresto, Lasix, Ativan, gabapentin, spironolactone, Macrobid, Colchicine, Eliquis, trazodone, insulin Lispro, insulin Glargine, Depakote, Tamsulosin, and others. These late administrations were confirmed by both medical record review and interviews with the DON, who acknowledged that medications were given outside the facility's policy window of 60 minutes before or after the scheduled time. Residents also reported receiving medications late, sometimes receiving multiple scheduled doses together, such as morning and noon medications at the same time. The facility's own policy required medications to be administered within a specific time frame, but this was not consistently followed. The DON confirmed that these late administrations constituted medication errors, and the deficiency affected multiple residents reviewed for medication administration.
Failure to Serve Menu-Specified Food Portions
Penalty
Summary
The facility failed to provide food items at the designated portions as written on the menu for residents receiving meals from the kitchen. Observations and interviews revealed that the portions served did not match the amounts specified in the menu spreadsheet. Specifically, for a lunch meal, the portions of onions and peppers and ground Polish sausage were under-served by one ounce and one third of a cup, respectively. The dietary staff used incorrect serving utensils, resulting in residents not receiving the full portions as planned. The Dietary Manager confirmed that the portions served were less than required and verified the use of incorrect utensils during the meal service. Additionally, a resident reported that the portions were insufficient and that residents did not always get enough food to eat. The facility census was 111, with three residents identified as NPO and seven residents observed to receive alternate meals. The deficiency was identified through observation, interview, and review of menu documentation, affecting 101 residents who received food from the kitchen.
Failure to Notify Physician and Responsible Party of Missed Lab Orders
Penalty
Summary
The facility failed to notify the physician and the resident's responsible party when laboratory tests ordered for a resident were not completed as directed. The resident, who had diagnoses including vascular dementia, cerebral infarction, and a history of TIA, was severely cognitively impaired and receiving Eliquis, a blood thinner. A pharmacy review noted that the resident's renal function might require a dosage adjustment, prompting the physician to order a complete metabolic panel, complete blood count, and renal function panel. However, these labs were not completed, and there was no documentation in the medical record explaining the missed tests or indicating that the physician or responsible party had been informed. Further investigation revealed that the lab technician attempted to collect the blood sample, but the resident was combative and refused, and no qualified personnel were available to assist. The lab requisition was left incomplete, and the floor nurse was not made aware that the labs were not obtained, resulting in a lack of follow-up or documentation. The facility's policy required notification of the physician and responsible party in such circumstances, but this was not done, constituting a failure to follow established procedures for notification of changes affecting the resident.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to prevent resident-to-resident physical abuse involving two residents. One resident, with a history of chronic medical and psychiatric conditions including PTSD and major depressive disorder, was involved in an altercation with another resident who had paraplegia and a documented pattern of physical and verbal aggression. The incident occurred when several residents attempted to use the elevator at the same time, leading to one resident attempting to forcibly remove a female resident in a wheelchair to gain access. The other resident intervened, resulting in both residents physically striking each other and falling to the floor before being separated by staff. Documentation and interviews revealed that the aggressive resident had a history of daily physical and verbal aggression, including attacking staff, using foul language, and rejecting care. Despite these ongoing behaviors, the facility did not implement additional safety measures such as placement in a secured unit, citing the resident's refusal and status as his own responsible party. The facility had planned to present a behavior contract at a care plan conference, but the resident was discharged to a psychiatric unit before this could occur. The facility's abuse policy required protection of residents and review of risk factors, but the incident was not substantiated as abuse by the facility due to uncertainty about who initiated the altercation. The facility's records did not list witnesses or identify a perpetrator for the incident, and the administrator confirmed that the allegation of abuse was unsubstantiated. The aggressive resident was eventually given an immediate discharge notice and escorted from the property by police after returning from the hospital against medical advice. The facility's failure to implement effective interventions to address the known aggressive behaviors contributed to the occurrence of resident-to-resident physical abuse.
Failure to Monitor Intake and Output for Resident with Urinary Retention
Penalty
Summary
A deficiency was identified regarding the facility's failure to monitor and document daily fluid intake and urine output for a resident diagnosed with urinary retention and requiring an indwelling urinary catheter. The resident, who was severely cognitively impaired and had diagnoses including vascular dementia, cerebral infarction, neuromuscular dysfunction of the bladder, and retention of urine, was admitted with an indwelling urinary catheter. The care plan specified that intake and output should be monitored and documented per facility policy. Despite these requirements, review of the medical record revealed that from the time the resident had the indwelling catheter and after its discontinuation, there was no documentation of daily fluid intake or urine output. This lack of monitoring occurred even after the resident experienced a change in condition, was sent to the emergency room, and returned with a Foley catheter in place. The deficiency was confirmed by the Director of Nursing, who acknowledged that intake and output should have been documented and monitored for this resident due to the diagnosis of urinary retention.
Failure to Provide Ordered Nutritional Interventions for Resident with Weight Loss
Penalty
Summary
A resident with diagnoses including Alzheimer's disease, type one diabetes mellitus, and dysphagia experienced a significant weight loss of 6.72% over a three-month period. The resident was assessed as severely cognitively impaired and required set up or clean up assistance with meals. The care plan and physician orders specified that the resident should receive a regular diet with thin liquids and soup provided with lunch and dinner as a nutritional intervention to address weight loss. Despite these orders, observations revealed that the resident was not served soup with either lunch or dinner, and staff confirmed that soup was not routinely provided. Additionally, staff did not encourage the resident to eat or offer alternatives when the resident did not consume the meal provided. Interviews with staff indicated a lack of awareness regarding the resident's dietary orders, with one CNA stating she did not read the meal tickets and an LPN expressing uncertainty about the resident's dietary requirements. The registered dietitian confirmed that soup was added to the resident's meals as an intervention for weight loss and expected staff to encourage meal consumption and offer alternatives as needed. The facility's policy required individualized nutritional interventions and monitoring, but these were not consistently implemented for this resident.
Failure to Ensure Physician Orders and Proper Dating of Oxygen Tubing
Penalty
Summary
A deficiency was identified when a resident with diagnoses including malignant neoplasm of the prostate, chronic obstructive pulmonary disease, anxiety, and hypertension was observed receiving oxygen therapy without a corresponding physician's order in place. The resident was cognitively intact, receiving hospice services, and was noted to be using oxygen during multiple observations. Review of the medical record and interviews with staff confirmed that there were no orders for oxygen administration documented in either the paper or electronic records, despite facility policy requiring physician orders for oxygen except in emergencies. Additionally, the oxygen tubing in use for the resident was not dated as required by facility policy, which mandates that oxygen tubing and cannulas be dated and changed weekly or as needed. Staff interviews verified that the tubing should have been dated and that this requirement was not met. The lack of proper orders and failure to date the oxygen tubing were observed and confirmed by both direct observation and staff interviews.
Failure to Obtain Post-Dialysis Communication from Provider
Penalty
Summary
The facility failed to obtain communication from the dialysis provider after each dialysis treatment for a resident who required such services. The resident was admitted with multiple diagnoses, including end stage renal disease dependent on dialysis, and had physician's orders to attend dialysis three times a week with a fluid restriction. While the facility completed pre and post dialysis assessments on the days the resident attended dialysis, there was no evidence that the facility received or documented communication from the dialysis center after each treatment. Interviews with facility staff confirmed that communication from the dialysis center was not consistently received after each visit, and the resident reported never being given paperwork to provide to the facility following dialysis sessions. When requested, the facility was only able to provide a monthly summary of lab work and weights, with no documentation of updates from the dialysis center after each treatment. Additionally, the facility's dialysis policy was requested but not provided during the survey.
Failure to Ensure Safe Environment and Behavioral Health Services for Resident with Suicidal Ideation
Penalty
Summary
The facility failed to ensure a safe environment and provide necessary behavioral health care and services for a resident with a history of suicidal ideation and multiple mental health diagnoses, including anxiety disorder, depression, PTSD, gender identity disorder, and borderline personality disorder. The resident had previously expressed suicidal thoughts, including specific plans and intent, which led to a hospital transfer. Upon return, the resident continued to express thoughts of self-harm and disclosed access to a razor in her room. Staff interviews revealed a lack of awareness and implementation of suicide precautions for the resident. Several CNAs and an LPN who worked with the resident were either unaware of any interventions in place or did not know of any specific precautions being used. The resident was able to access potentially dangerous items, such as disposable razors, inhalers, and a full sharps container in her room. The DON and other staff confirmed that these items should not have been unsecured and accessible to a resident with suicidal tendencies. Observations confirmed the presence of unsecured inhalers and a full sharps container in the resident's room, and staff acknowledged these were not appropriate. The facility's behavioral health policy emphasized person-centered care and safety, but staff actions and interviews demonstrated a failure to follow through with necessary interventions and environmental safety measures for a resident at risk for self-harm.
Failure to Complete and Communicate Physician-Ordered Labs
Penalty
Summary
The facility failed to ensure that physician-ordered laboratory tests were completed in a timely manner for a resident with multiple diagnoses, including vascular dementia, cerebral infarction, and a history of transient ischemic attack. The resident was prescribed Eliquis, an anticoagulant, and a pharmacy review raised concerns about the appropriateness of the dosage based on the resident's renal function. As a result, a physician ordered a complete metabolic panel, complete blood count, and renal function panel to assess the resident's suitability for the prescribed medication. Despite the order, the laboratory tests were not completed as required. The blood draw was scheduled several days after the order and was not performed because the resident was combative and refused, and no qualified personnel were available to assist. The lab technician did not notify the floor nurse of the unsuccessful attempt, and the nurse did not follow up, notify the physician, or document the missed lab or any reattempts. This sequence of inactions resulted in the ordered labs not being completed or communicated appropriately.
Failure to Maintain Enhanced Barrier Precautions and PPE Availability
Penalty
Summary
The facility failed to maintain proper infection control practices and ensure that personal protective equipment (PPE) was readily available for two residents who required enhanced barrier precautions (EBP). For one resident with a history of attention deficit hyperactivity disorder, dementia, and a chronic wound, observations revealed a soiled dressing on the floor next to the bed and no PPE available inside or outside the room. Staff interviews confirmed that the resident frequently removed dressings and that there was confusion among staff regarding the purpose of the EBP signage. Additionally, there was no trash can near the exit for disposing of used PPE, and staff confirmed that PPE was not readily accessible for use. For another resident with severe protein calorie malnutrition, an indwelling catheter, and a feeding tube, staff were observed administering medications and handling the feeding tube without donning an isolation gown, as required under EBP. The LPN involved stated that she did not believe a gown was necessary for medication administration via tube feeding and confirmed that she worked across multiple floors. Facility policy required gowns and gloves to be available near or outside the resident's room and a trash can positioned for discarding PPE, but these measures were not observed to be in place.
Failure to Timely Report Resident-to-Resident Sexual Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of resident-to-resident sexual abuse to the State agency as required by policy. A resident with severe cognitive impairment, delusions, and disruptive behaviors reported to the psychiatric nurse practitioner that she lifted her shirt and a peer touched her breast. The resident denied being assaulted, but the incident was not communicated to the facility administrator by either the nurse or the nurse practitioner. As a result, the allegation was not reported to the State agency, was not investigated, and the resident's guardian was not notified in a timely manner. The facility's policy requires all allegations of abuse to be reported and investigated, but this process was not followed until several days later when a self-reported incident was filed.
Failure to Perform Pre-Meal Blood Sugar Checks and Proper Insulin Pen Priming
Penalty
Summary
The facility failed to ensure that blood sugar assessments were performed prior to breakfast and that insulin pens were properly primed before administration for two residents with diabetes. In both observed cases, residents had already consumed their entire breakfast before LPNs assessed their blood sugar levels and administered insulin. For one resident, the LPN administered a total of nine units of Humalog insulin (six units routine and three units per sliding scale) after breakfast, without priming the insulin pen. The LPN stated she only primed new pens and had not been priming the pen for ongoing use, despite working with all residents on all floors. The resident's care plan and physician orders required blood sugar checks and insulin administration in relation to meals, and the facility policy specified that insulin pens should be primed prior to each use. A second resident, also with diabetes, had their blood sugar checked and received both Humalog and glargine insulin after finishing breakfast. The LPN confirmed the timing of the blood sugar assessment and insulin administration occurred post-meal. The Director of Nursing confirmed that blood sugar assessments were to be completed prior to meals. Facility policy required insulin pens to be primed before each use, but this was not followed. These failures affected two observed residents and had the potential to impact an additional 24 residents identified as requiring pre-meal blood sugar assessments and/or insulin via pen.
Improper Medication Disposal
Penalty
Summary
The facility failed to ensure all medications were disposed of in a safe and secure manner. During an observation of the third-floor medication room, a large sharps disposal container was found on the counter, approximately one quarter full of various medications, without a lid. Interviews with a Registered Nurse (RN) and a Licensed Practical Nurse (LPN) confirmed that the container was not secure and that this was the method used to destroy medications for discharged residents or discontinued medications. Both nurses stated that there was no fluid available for the destruction of the medications, so they continued to place them in the sharps container. The Director of Nursing (DON) acknowledged that the facility was out of the liquid used for medication destruction and mentioned that more would be ordered from the pharmacy. However, the facility's policy for the destruction of medications was not provided when requested. A review of the Medication Administration policy revealed no information regarding the destruction of expired or discontinued medications. This deficiency was investigated under Complaint Number OH00153460.
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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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