Divine Rehabilitation And Nursing At Sylvania
Inspection history, citations, penalties and survey trends for this long-term care facility in Sylvania, Ohio.
- Location
- 5757 Whiteford Rd, Sylvania, Ohio 43560
- CMS Provider Number
- 365898
- Inspections on file
- 34
- Latest survey
- June 23, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Divine Rehabilitation And Nursing At Sylvania during CMS and state inspections, most recent first.
A resident with significant cognitive and physical impairments, identified as a fall risk, did not have care-planned safety interventions in place, including enabler bars, a body pillow, and an accessible call light. Staff interviews confirmed these items were not provided or available, and the facility's fall prevention policy was not followed.
A resident with dementia, heart failure, and diabetes developed an unstageable pressure ulcer due to the facility's failure to provide timely wound assessment and treatment. The resident's high risk for skin breakdown was not addressed in a care plan, and a low air loss mattress was delayed. Staff interviews revealed inadequate communication and coordination in wound care management.
The facility failed to conduct quarterly care plan conferences for residents, affecting six out of seven reviewed. Despite various medical conditions, residents had fewer than required conferences, with some having none. This deficiency indicates a lack of adherence to the facility's policy of involving residents and their representatives in care planning.
The facility failed to monitor the effectiveness of psychotropic medications for several residents, including those with anxiety, depression, and schizoaffective disorder. Despite care plans requiring monitoring, there was no documentation of behavior tracking or non-pharmacological interventions. Interviews confirmed the lack of monitoring, leading to deficiencies in care.
An LPN failed to sanitize hands between serving meals to residents, affecting four residents. The LPN was observed delivering meal trays and touching surfaces without hand sanitizing between each resident. This was confirmed in an interview with the LPN.
The facility failed to maintain a clean and functional environment, affecting several residents with broken window blinds and other maintenance issues. Residents expressed dissatisfaction, and observations confirmed dirt buildup and loose wiring. Maintenance and housekeeping responsibilities were not fulfilled according to facility standards.
A facility failed to maintain a resident's dignity during meal assistance. The resident, with severe cognitive impairment and requiring meal supervision, was observed being fed by a CNA who stood over them while providing food. This practice was confirmed by the CNA, contradicting the facility's policy on promoting resident dignity.
The facility failed to ensure call lights were accessible to two residents, leading to discomfort and inability to call for assistance. One resident with Parkinson's and dementia was found with the call light and bed remote out of reach, while another resident with brain damage and epilepsy had the call light placed on the wrong side, contrary to the care plan. LPNs were unaware of the care plan requirements, and the facility policy on call light accessibility was not followed.
A resident with anxiety disorder, borderline personality disorder, and insomnia requested access to dental information in his medical record due to dental pain. Despite having intact cognition and making a verbal request to the DON two weeks prior, the resident had not received the requested records. The facility's policy requires records to be accessible within 24 hours of a request.
The facility failed to provide adequate assistance with ADLs for residents dependent on staff for grooming and hygiene. A resident with multiple health issues did not receive scheduled showers, resulting in matted hair and untrimmed facial hair. Another resident with paraplegia reported not receiving showers as scheduled, with no documentation of refusals. A third resident, dependent due to hemiplegia, did not receive showers for over a month due to alleged equipment issues, despite alternative options being available.
The facility failed to follow physician orders for wound care and edema management for two residents. One resident's wound dressing was not changed as scheduled, and another resident did not receive lymphedema pump treatments as ordered, with incorrect settings causing discomfort. These deficiencies were confirmed by staff and medical records.
A facility failed to provide ordered range of motion (ROM) exercises for a resident with bilateral lower extremity contractures. Despite a physician's order for twice-daily ROM exercises, observations and interviews revealed that the exercises were not performed. The resident reported not receiving the exercises, and CNAs confirmed they did not provide them, nor did they observe nurses doing so.
The facility failed to report and monitor falls for two residents at risk. One resident was not documented as having fallen despite expressing pain and later being diagnosed with a fracture. Another resident, who was supposed to be monitored in common areas, was left alone in a dining room, positioned unsafely. These actions were contrary to the facility's fall prevention policy.
A resident with severe cognitive impairment and multiple health conditions was frequently found without access to water, both in his room and in common areas. Despite the facility's policy to offer fluids between meals, staff interviews and observations confirmed inconsistencies in providing water, leading to the resident expressing thirst and being without water on several occasions.
A facility failed to maintain and apply oxygen equipment as ordered for a resident with COPD and chronic respiratory failure. The resident's CPAP machine was not used as prescribed due to a lack of distilled water, and there was no documentation of oxygen saturation levels being monitored every shift. Additionally, the resident's oxygen nasal cannula was heavily soiled, and the Unit Manager LPN confirmed the equipment was not maintained as required.
A resident with end-stage chronic kidney disease did not receive adequate dialysis care at the facility. The facility failed to document monitoring of the dialysis port and fluid intake/output, and communication with the dialysis center was inconsistent. Staff interviews revealed a lack of confirmation on medication administration during dialysis and no documentation of fluid intake during meals. The facility also lacked a dialysis policy.
A resident did not receive prescribed tramadol for pain management on four occasions due to the facility's failure to ensure the medication was available. Despite the resident's awareness and notification to the nurse practitioner, the medication was not administered as a controlled medication form was required. The facility's pain management policy was not followed.
The facility failed to ensure timely physician responses to pharmacy recommendations for three residents, leading to deficiencies in medication management. A resident with chronic conditions did not receive a recommended calcium supplement, another with diabetes had delayed medication adjustments, and a third did not have their medication dosage increased or necessary lab tests conducted. The facility's policy to encourage physician action on pharmacy recommendations was not followed.
The facility experienced a medication error rate of 20%, exceeding the acceptable 5% threshold. Errors included an LPN failing to administer spilled medications to a resident and another LPN not adhering to the required interval between inhaler administrations and lacking a prescribed nasal spray.
The facility failed to ensure proper medication management, as observed during medication administration sessions. An LPN improperly disposed of medications in a trash can attached to the medication cart, and several medications were found opened without being dated. Another LPN left a medication card unattended on a cart. The facility's policy lacked guidelines for dating opened medications, affecting two cognitively impaired residents.
A resident with multiple diagnoses, including anxiety and bipolar disorder, did not receive his requested double portions of meals, despite a physician's order. Observations and interviews confirmed that during dinner and breakfast, the resident received only single portions, leading to reports of hunger.
A facility failed to ensure staff adhered to Enhanced Barrier Precautions (EBP) for a resident with a gastrostomy tube. An LPN was observed administering medication without wearing a gown, despite signage indicating the requirement for gloves and a gown during feeding tube care. The LPN acknowledged the oversight, citing nervousness, although PPE was available.
A resident with cognitive impairment and multiple health conditions was found to have a mattress that did not fit the bed, creating a large gap. The facility lacked a program for regular inspections of bed frames, mattresses, and bedrails. The Maintenance Supervisor noted a nine-inch gap, and the DON confirmed the bed was a rental, acknowledging the need for an extender or longer mattress.
The facility failed to provide required transfer/discharge notices to residents and their representatives, affecting four residents who were sent to the hospital without proper notification. The facility's policy requires such notices to be given in an understandable manner, but this was not followed, as confirmed by the administrator.
The facility failed to provide bed hold notices to residents or their representatives at the time of hospital transfer, affecting four residents. The facility's policy requires written notice specifying the bed-hold duration and return information, but this was not documented for residents transferred for medical reasons such as shortness of breath and abnormal lab values. The Administrator confirmed the oversight.
A resident with multiple sclerosis and other conditions was not notified before a new roommate moved in, violating facility policy. The new roommate, who has intellectual disabilities and other mental health conditions, was informed of the change, but the resident was not, leading to a deficiency finding during a complaint investigation.
A facility failed to provide adequate wound care for a resident on hospice, resulting in a significant decline in a wound on the left lower extremity. The wound became infected and necrotic, necessitating emergency services, hospital admission, surgical debridement, and prolonged antibiotic therapy. This situation was classified as Immediate Jeopardy due to the potential for serious life-threatening harm. Additionally, another resident with a surgical incision did not receive proper wound monitoring and documentation, leading to a classification of Severity Level 2 for potential more than minimal harm.
The facility failed to provide appropriate care and ongoing monitoring of a stage IV pressure ulcer for a resident with multiple diagnoses, including paraplegia. The facility did not complete required weekly skin assessments, and there were inconsistencies in the documentation of wound care treatments and assessments. The Director of Nursing confirmed the lack of completed assessments, and an LPN verified that wound appearance was not documented with each dressing change.
Failure to Implement Fall Prevention Interventions as Care Planned
Penalty
Summary
A deficiency was identified when a resident with multiple complex diagnoses, including multiple sclerosis, chronic pain syndrome, anxiety, muscle spasm, tremor, altered mental status, weakness, seizures, and schizophrenia, was not provided with the safety interventions outlined in their care plan. The resident was assessed as being at risk for falls and was dependent on staff for activities of daily living. The care plan specified the use of enabler bars attached to the bed, a body pillow for positioning, and ensuring the call light was within reach. However, during multiple observations, the resident was found in bed without enabler bars or a body pillow, and the call light was not within reach but instead placed on the resident's wheelchair, which was not accessible to the resident. Interviews with CNAs regularly assigned to the resident confirmed that the required interventions, such as the body pillow and enabler bars, were not in place and that staff were unaware of the need for a body pillow. The facility's fall prevention policy required that interventions be provided as needed, but these were not implemented for this resident. The lack of these safety measures constituted a failure to follow the care plan for a resident identified as being at risk for falls.
Failure to Provide Timely Pressure Ulcer Care
Penalty
Summary
The facility failed to provide timely and appropriate care for a resident's skin impairment, resulting in the development of an unstageable pressure ulcer. Upon readmission, the resident, who had a history of dementia, heart failure, and type two diabetes mellitus, was noted to have skin impairment to the coccyx and buttocks. However, there was no wound assessment completed, and no physician orders for wound treatment were obtained until two days later. This delay in care led to the resident developing an unstageable pressure ulcer requiring debridement. The facility's documentation and care planning were inadequate. There was no baseline care plan addressing the resident's high risk for skin breakdown, and a care plan was not initiated until five days after the unstageable pressure ulcer was identified. Additionally, the facility failed to implement a low air loss mattress until several days after it was ordered, and there were lapses in completing wound treatments as prescribed. The facility's policies on wound documentation and pressure injury prevention were not followed, contributing to the deficiency. Interviews with facility staff revealed a lack of communication and coordination in addressing the resident's wound care needs. The Director of Nursing acknowledged the absence of documentation and timely interventions, while the Registered Nurse and Licensed Practical Nurse involved in the resident's care confirmed the lack of wound assessment and nutritional interventions. The facility's dietitian was no longer employed, and the consultant dietetic technician had not yet assessed the residents, further highlighting the gaps in care coordination and oversight.
Failure to Conduct Quarterly Care Plan Conferences
Penalty
Summary
The facility failed to conduct quarterly care plan conferences for residents and/or their representatives, affecting six out of seven residents reviewed. The facility's policy requires that care plan conferences be held regularly to discuss the plan of care with the resident or their representative. However, the review of medical records and interviews with Social Services revealed that several residents had fewer than the required number of care conferences over the past year. For instance, Resident #14 had only two care conferences, while Resident #49 had none. The residents involved had various medical conditions, including cognitive impairments, dementia, and other chronic illnesses. Despite these conditions, the facility did not adhere to its policy of holding regular care plan conferences. Interviews with Social Services confirmed the lack of compliance, as they verified the insufficient number of care conferences for each resident. This deficiency indicates a failure to ensure that residents and their representatives are adequately informed and involved in their care planning process.
Failure to Monitor Psychotropic Medication Effectiveness
Penalty
Summary
The facility failed to monitor the effectiveness of psychotropic medications for five residents, leading to deficiencies in care. Resident #26, diagnosed with anxiety disorder, borderline personality disorder, major depression disorder, and insomnia, was on multiple medications including venlafaxine, trazodone, bupropion, sertraline, and buspirone. Despite a care plan addressing behavior problems and the need for monitoring medication side effects and effectiveness, there was no documentation of behavior tracking or non-pharmacological interventions in the medical record. Interviews with staff confirmed the lack of documentation and monitoring. Resident #45, with diagnoses including major depressive disorder, schizoaffective disorder, and insomnia, was also not monitored for medication effectiveness. The resident was on medications such as trazodone, wellbutrin, viibryd, and invega. Despite a care plan that included monitoring for side effects and effectiveness, there was no evidence of such monitoring in the medical record. Interviews revealed that the resident had been experiencing increased depression and insomnia, yet no non-pharmacological interventions were attempted, and the physician was not informed. Similarly, Residents #15, #34, and #10 were not monitored for the effectiveness of their psychotropic medications. Resident #15, with schizophrenia and bipolar disorder, had no documentation of daily monitoring for behaviors and medication effectiveness. Resident #34, with vascular dementia and schizoaffective disorder, also lacked documentation of behavior monitoring. Resident #10, diagnosed with depression and anxiety, had no evidence of behavior monitoring or the use of non-pharmacological interventions. Interviews with the Director of Nursing confirmed the absence of a process for monitoring behaviors related to psychotropic medications.
Failure to Sanitize Hands Between Meal Services
Penalty
Summary
The facility failed to ensure proper hand hygiene practices were followed by staff during meal service, affecting four residents out of 26 reviewed for dining services. During an observation, an LPN was seen delivering meal trays to residents without sanitizing her hands between serving each resident. Specifically, the LPN was observed passing a meal tray to a resident, touching a bedside table and a used cup, and then continuing to serve other residents without hand sanitizing. This occurred while delivering meal trays to residents in their rooms, and the LPN confirmed in an interview that she did not sanitize her hands between serving the meal trays.
Facility Fails to Maintain Clean and Functional Environment
Penalty
Summary
The facility failed to maintain a clean and functional environment for its residents, as evidenced by multiple observations and interviews. Several residents, specifically seven out of thirteen reviewed, were affected by broken window blinds in their rooms. These residents expressed dissatisfaction with the condition of their blinds, which were confirmed to be broken by the Maintenance Supervisor. Additionally, one resident resorted to placing gloves in the holes of the blinds to block sunlight, indicating a lack of proper maintenance and repair. Further observations revealed additional environmental issues, such as a slightly opened window with dirt buildup on the windowsill in one resident's room and loose wiring above another resident's bed. The Housekeeping Supervisor confirmed the dirt buildup, acknowledging that housekeeping was responsible for daily cleaning, including windowsills. The facility's policies and job descriptions indicated that maintenance and housekeeping were expected to ensure a clean and well-maintained environment, yet these standards were not met, leading to the deficiencies observed.
Failure to Maintain Resident Dignity During Meal Assistance
Penalty
Summary
The facility failed to ensure that residents were treated in a dignified manner, specifically affecting one resident. The resident, who was admitted with diagnoses including polyosteoarthritis, dementia, and the presence of a cerebrospinal fluid drainage device, was assessed as severely cognitively impaired and required assistance with activities of daily living, including supervision and set-up assistance with meals. During an observation, a CNA was seen standing over the resident while providing assistance with eating, which involved giving the resident a bite of a banana and two spoonfuls of yogurt. The CNA confirmed this practice during an interview, stating that the resident sometimes needed assistance with eating and that she would offer a few bites at a time. The facility's policy on promoting and maintaining resident dignity emphasizes the importance of respecting resident rights, which was not adhered to in this instance.
Inaccessible Call Lights for Residents
Penalty
Summary
The facility failed to ensure that call lights were accessible to residents, affecting two residents. Resident #49, who was admitted with diagnoses including Parkinson's disease and dementia, was observed in an uncomfortable position in bed with the bed remote and call light out of reach. The resident expressed discomfort and inability to adjust the bed due to the inaccessibility of the remote and call light. The Unit Manager LPN confirmed the inaccessibility of these items. Resident #70, with diagnoses including anoxic brain damage and epilepsy, was dependent on staff for all activities of daily living. The care plan specified that the call light should be placed in the resident's right hand, but observations revealed it was consistently placed on the left side, out of reach. LPNs were unaware of the care plan requirements, and the Director of Nursing confirmed the call light should be on the right side. The facility's policy required staff to ensure call lights were within reach, which was not adhered to in these cases.
Failure to Provide Timely Access to Medical Records
Penalty
Summary
The facility failed to provide timely access to medical records as requested by a resident. Resident #26, who was admitted with diagnoses including anxiety disorder, borderline personality disorder, and insomnia, requested access to dental information in his medical record due to experiencing dental pain and concerns. The resident, who had intact cognition and no recorded behaviors, made a verbal request to the Director of Nursing (DON) approximately two weeks prior to the interview conducted on 03/03/25. Despite the request, the DON confirmed that the copies of the dental records had not yet been provided. The facility's policy on the release of medical records states that records should be accessible within 24 hours (excluding weekends and holidays) following an oral or written request.
Failure to Provide Adequate ADL Assistance
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADL) for residents who were dependent on staff for grooming and hygiene. Resident #42, who had multiple diagnoses including chronic obstructive pulmonary disease and morbid obesity, required substantial assistance with bathing and personal hygiene. Despite being scheduled for showers twice a week, documentation revealed that Resident #42 received only bed baths and there was no record of hair washing or facial hair grooming. Observations confirmed the resident's hair was matted and greasy, and facial hair was long, which the resident preferred to have removed. Resident #14, with a history of paraplegia and traumatic brain injury, was also dependent on staff for showers. The care plan indicated a need for total assistance with bathing, yet the resident reported not receiving showers as scheduled. Documentation showed inconsistencies in the provision of showers and bed baths, and there was no record of refusals, despite the Director of Nursing acknowledging the resident's occasional refusals. Resident #60, who was cognitively intact but dependent on staff due to conditions like hemiplegia and congestive heart failure, was scheduled for showers twice a week. However, the resident reported not receiving a shower for over a month, citing a broken shower cot as the reason. Interviews with staff revealed conflicting information about the condition of the shower cot, with some staff unaware of any issues and others suggesting alternative equipment was available. The facility's policy required necessary services for ADLs, but the lack of showers for Resident #60 was confirmed by the Administrator and DON.
Non-Compliance with Physician Orders for Wound and Edema Management
Penalty
Summary
The facility failed to adhere to physician orders for wound care and edema management for two residents. Resident #44, who has a history of encephalopathy, diabetes, congestive heart failure, and leg contractures, was observed with a wound dressing on the left knee that had not been changed as per the physician's order. The dressing, dated 02/26/25, was supposed to be changed every Monday, Wednesday, and Friday, but was found unchanged on 03/03/25. This oversight was confirmed by both a Licensed Practical Nurse and a Wound Specialist Physician, who verified the dressing change schedule. Resident #42, diagnosed with chronic obstructive pulmonary disease, diabetes, morbid obesity, and lymphedema, did not receive lymphedema pump treatments as ordered. The medical record lacked specific pump settings and times for application, and the resident reported that the pumps were not applied daily and caused pain when used. An LPN documented the application of the pumps despite the resident's refusal, and the Director of Nursing confirmed the absence of a setting order. Subsequent observations revealed the pump settings were incorrect, further indicating non-compliance with physician orders.
Failure to Provide Ordered Range of Motion Exercises
Penalty
Summary
The facility failed to ensure that range of motion (ROM) exercises were provided as ordered by the physician for a resident with bilateral lower extremity contractures. Resident #44, who was admitted with diagnoses including encephalopathy, type II diabetes mellitus, congestive heart failure, and contractures, had a physician order dated 04/22/24 for gentle ROM exercises to be performed twice daily. Despite this order, observations over several days revealed that the resident was consistently found lying in bed with legs in a flexed position, indicating a lack of ROM exercises. Interviews with the resident and staff confirmed the deficiency. Resident #44 reported not receiving the prescribed ROM exercises daily. Certified Nurse Aides (CNAs) frequently assigned to the resident admitted they did not perform the exercises and had not observed nurses doing so either. The Unit Manager LPN verified the CNAs' lack of knowledge regarding the provision of ROM exercises, highlighting a breakdown in communication and adherence to the care plan for the resident's contracture management.
Failure to Report and Monitor Falls in Residents
Penalty
Summary
The facility failed to timely report and monitor a fall incident involving Resident #18, who was at risk for falls due to conditions such as dementia and gait problems. On the evening of 01/21/25, Resident #18 was lowered to the floor by a CNA after becoming unsteady while standing. Despite the resident expressing hand pain, the RN on duty did not document the incident as a fall or report it, believing it was not a fall since the resident was lowered to the ground. The following day, the resident was found to have a fracture in the right distal radius, requiring emergency room evaluation. In another incident, Resident #68, who had impaired cognition and was dependent on staff for mobility, was found face down on the floor next to her bed. Although interventions were developed to place her in common areas during periods of restlessness, observations revealed that she was left alone in a dining room, positioned unsafely in a Broda chair. Staff interviews confirmed that Resident #68 was not consistently placed in common areas due to her disruptive behavior, contrary to her care plan. The facility's policy on fall prevention was not followed, as evidenced by the lack of documentation and reporting of Resident #18's fall and the failure to implement and monitor interventions for Resident #68. These deficiencies were identified during a complaint investigation, highlighting lapses in the facility's adherence to its fall prevention program.
Failure to Provide Adequate Hydration to Resident
Penalty
Summary
The facility failed to ensure that water was readily available for proper hydration for a resident with severe cognitive impairment and multiple health conditions, including aphasia, chronic obstructive pulmonary disease, chronic kidney disease, and dementia. Observations over several days revealed that the resident often did not have access to water, both in his room and while in common areas such as the dining room. On multiple occasions, the resident was observed without water, and staff interviews confirmed that water had not been consistently provided. Despite the facility's policy requiring staff to offer a variety of fluids between meals and ensure beverages are within reach, the resident was frequently found without water. Staff interviews revealed inconsistencies in the provision of water, with some staff unsure if water had been passed or if the resident had taken water to meals. The resident expressed thirst, and staff confirmed the absence of water in his room. The deficiency was identified under Complaint Number OH000162077.
Failure to Maintain and Apply Oxygen Equipment as Ordered
Penalty
Summary
The facility failed to ensure that oxygen equipment was maintained and applied as ordered by the physician for Resident #42, who was admitted with diagnoses including chronic obstructive pulmonary disease (COPD), morbid obesity, acute and chronic respiratory failure, shortness of breath, and congestive heart failure. The resident required substantial to maximal assistance with activities of daily living and received oxygen therapy. Physician orders specified the use of an Auto C-Pap with specific settings and oxygen therapy to be applied at bedtime and during naps. Additionally, the orders required the change of C-pap/Bi-Pap tubing and oxygen tubing weekly and as needed for infection control, and to monitor oxygen saturation levels every shift. Observations on March 3, 2025, revealed that Resident #42's CPAP machine was not being used as ordered due to the absence of distilled water for humidification, which staff were unaware of. The resident reported that this resulted in the CPAP machine not being applied each night. Furthermore, there was no documentation of oxygen saturation levels being obtained every shift, and the resident was found with a heavily soiled oxygen nasal cannula. The Unit Manager LPN confirmed that the oxygen equipment and monitoring were not maintained as required. The facility's policies on Noninvasive Ventilation and Oxygen Administration, which included infection control measures and equipment maintenance, were not adhered to, leading to this deficiency.
Inadequate Dialysis Care and Documentation for a Resident
Penalty
Summary
The facility failed to provide adequate dialysis care and services for Resident #75, who was diagnosed with bilateral pleural effusion and end-stage chronic kidney disease. The resident required dialysis three times a week, and the care plan included monitoring fluid intake and output, as well as the dialysis access port for signs of infection, swelling, or bleeding. However, the facility did not document the monitoring of the dialysis port every shift, nor did they track the resident's fluid intake and output daily. Additionally, communication with the dialysis center was only documented twice over a period of several weeks, indicating a lack of consistent communication regarding the resident's care. Interviews with facility staff revealed further deficiencies in the care provided to Resident #75. An LPN stated that the facility sent the resident to dialysis with necessary documentation and medication, but there was no confirmation of whether the medication was administered at the dialysis center. The Director of Nursing confirmed that there was no documentation of the resident's fluid intake during meals and that communication with the dialysis center was insufficient. Furthermore, the facility lacked a dialysis policy, which contributed to the inadequate monitoring and documentation of the resident's dialysis care.
Failure to Provide Prescribed Pain Medication
Penalty
Summary
The facility failed to ensure that a resident's prescribed pain medication, tramadol, was available and administered as ordered by the physician. Resident #60, who was admitted with diagnoses including hemiplegia, acute cholecystitis, and chronic systolic congestive heart failure, was cognitively intact and required scheduled and as-needed pain medication. However, the Medication Administration Record for March 2025 showed that the resident did not receive the prescribed tramadol on four occasions over two days. Interviews revealed that the resident was aware of the lack of medication, stating that the facility had been out of tramadol for two days. The Unit Manager RN was unaware of the issue, while the Unit Manager LPN confirmed that the nurse practitioner was notified about the need to order the medication. Despite the controlled medication being accessible in the facility, a physician's completion of a controlled medication form was necessary. The facility's policy on pain management emphasized the need to provide pain management services consistent with professional standards and the resident's care plan, which was not adhered to in this case.
Failure to Respond to Pharmacy Recommendations
Penalty
Summary
The facility failed to ensure timely physician responses to pharmacy recommendations for three residents, leading to deficiencies in medication management. Resident #15, diagnosed with conditions including chronic obstructive pulmonary disease and schizophrenia, was recommended by the pharmacist to receive a calcium supplement alongside Alendronate for bone health. Despite repeated recommendations on four separate occasions, there was no documentation of the physician's response or any orders for the supplement. Similarly, Resident #34, with diabetes mellitus and related complications, was advised to adjust their diabetic medication regimen to reduce the risk of hypoglycemia. Although there were notations of some medication adjustments, the facility did not respond promptly to the pharmacist's recommendations. Resident #10, diagnosed with depression, anxiety, and vascular dementia, was recommended to have their Donepezil dosage increased and to undergo laboratory assessments for Depakote levels. The facility did not act on these recommendations, and there was no physician response documented. The Director of Nursing confirmed the lack of action on these recommendations, which were only addressed during the annual survey. The facility's policy stated that physicians should act on pharmacy recommendations, but this was not adhered to, resulting in the identified deficiencies.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to ensure medications were administered per physician's orders, resulting in a medication error rate of 20 percent, which is significantly above the acceptable threshold of 5 percent. This deficiency was observed during medication administration for two residents. For Resident #37, an LPN spilled three pills on the medication cart, discarded one, and failed to notice the other two, which were later identified as vitamin B1 and magnesium oxide. These medications were not administered to the resident as the LPN was unaware of the spill until surveyor intervention. For Resident #64, the LPN did not have the prescribed Flonase nasal spray available and failed to administer it. Additionally, the LPN did not adhere to the required five-minute interval between administering the Incruse inhaler and the Breo inhaler, as per the manufacturer's guidelines and facility policy. The Director of Nursing confirmed that the nurses should follow these guidelines, which were not adhered to in this instance.
Medication Management Deficiencies
Penalty
Summary
The facility failed to ensure proper medication management, as observed during a medication administration session. An LPN was seen disposing of medications improperly by throwing them into a trash can attached to the medication cart. This included a Lasix tablet and other medications that were spilled on the cart. The LPN acknowledged that the medications should not have been disposed of in this manner. Additionally, several medications on the medication cart and in the storage room were found to be opened without being dated, which is against the facility's policy. Another LPN was observed leaving a medication card unattended on top of a medication cart while administering medications in a resident's room. Further inspection revealed that several bottles of medications on the medication cart were opened and not dated. The facility's policy on medication storage requires that all drugs be stored in locked compartments and under direct observation during medication passes, but it lacked guidelines for dating medications when opened. This oversight affected two residents identified as cognitively impaired and independently mobile, posing a potential risk to their safety.
Failure to Provide Double Portions as Ordered
Penalty
Summary
The facility failed to provide a resident with his food preference of double portions, as per his physician's order and personal request. The resident, who was cognitively intact and required assistance with eating, was admitted with diagnoses including hyperlipidemia, anxiety disorder, hypoglycemia, bipolar disorder, hypotension, and paranoid schizophrenia. Despite the physician's order for a regular diet with double portions, the resident reported feeling hungry and not receiving enough food. Observations confirmed that during a dinner meal, the resident received only a single portion of a chicken quesadilla, rice, and peaches, and during a breakfast meal, he did not receive double portions of French toast and sausage links. Interviews with CNAs verified that the resident did not receive the double portions as ordered.
Failure to Adhere to Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure that staff adhered to Enhanced Barrier Precautions (EBP) when providing care to residents, specifically affecting one resident. This resident, who was admitted with diagnoses of cerebral palsy and a gastrostomy status, required EBP due to the presence of a feeding tube. The care plan for this resident included the implementation of EBP during personal care, which necessitated the use of gloves and gowns by staff during high-contact activities such as feeding tube care. An observation revealed that an LPN provided medications to the resident without wearing the required gown, despite a sign outside the resident's room indicating the need for gloves and a gown during feeding tube care. The LPN confirmed the omission, attributing it to nervousness, although PPE was available. This failure to follow EBP was noted in the context of CDC guidance, which emphasizes the importance of targeted gown and glove use to prevent the transmission of multidrug-resistant organisms in skilled nursing facilities.
Incompatible Mattress and Bed Frame
Penalty
Summary
The facility failed to ensure that a mattress was compatible with a bed, affecting a resident with anoxic brain damage, tracheostomy status, and generalized idiopathic epilepsy. The resident, who had moderate cognitive impairment and was dependent on staff for all activities of daily living, was observed to have a mattress that did not fit the bed, leaving a large gap between the end of the bed footboard and the mattress. The Maintenance Supervisor was unsure if the bed was a rental or a bariatric bed from the facility and noted a nine-inch gap between the mattress and the end of the bed. The facility lacked a program for regular inspections of bed frames, mattresses, and bedrails. The Director of Nursing confirmed the bed was a rental and acknowledged the need for an extender or longer mattress, verifying that there should not be a space between the mattress and the bed. The manufacturer's guidelines indicated that the mattress should be sufficiently wide and long enough to prevent any part of the patient's body from falling between the bed and mattress.
Failure to Provide Transfer/Discharge Notices
Penalty
Summary
The facility failed to provide timely notification of transfer or discharge to residents and their representatives, as required by policy. This deficiency was identified during a review of medical records, staff interviews, and policy review. Four residents were affected by this oversight, as they were transferred to the hospital without receiving the necessary notice of transfer or discharge. The facility's policy mandates that such notices be provided in a language and manner understandable to the resident and their representative, but this was not adhered to in these cases. Resident #78 was sent to the hospital for shortness of breath, Resident #180 for abnormal laboratory values, Resident #181 for an unspecified reason, and Resident #79 for a change in condition requiring evaluation. In each instance, there was no documentation indicating that the residents or their representatives were informed of the transfer or discharge. The facility administrator confirmed the lack of notification for these residents during an interview, highlighting a systemic issue in the facility's adherence to its transfer and discharge policy.
Failure to Provide Bed Hold Notices at Time of Transfer
Penalty
Summary
The facility failed to provide bed hold notices to residents or their representatives at the time of transfer to a hospital, as required by their policy. This deficiency was identified during a review of medical records, staff interviews, and policy review. Four residents were affected by this oversight, as there was no documentation of bed hold notices being provided at the time of their transfer to the hospital. The facility's policy, revised in September 2024, mandates that a written notice specifying the duration of the bed-hold policy and information about the resident's return to the next available bed should be given at the time of transfer. The specific cases involved residents who were transferred to the hospital for various medical reasons, including shortness of breath, abnormal laboratory values, and changes in condition. Interviews with the facility's Administrator confirmed that the bed hold notices were not provided to the residents or their representatives at the time of transfer. This issue affected all four residents reviewed for transfer/discharge, and the facility had identified a total of 12 residents sent to the hospital in the past 90 days, with a census of 75.
Failure to Notify Resident of Roommate Change
Penalty
Summary
The facility failed to notify a resident, identified as Resident #85, before a change in roommate occurred, which is a violation of the resident's rights. Resident #85, who has multiple sclerosis, kidney cancer, and chronic kidney disease, was not informed prior to Resident #22 moving into her room. The facility's policy requires that all residents involved in a room change be notified verbally or in writing, in a manner they understand, but this was not adhered to in this instance. Resident #22, who has intellectual disabilities, schizophrenia, dementia, and bipolar disease, was informed of the room change, but Resident #85 was not. The Business Office Manager confirmed that Resident #22 received a written notice, but Resident #85 did not receive any notification until the new roommate arrived. This oversight was identified during a complaint investigation, highlighting a lapse in the facility's adherence to its own policy regarding room changes.
Neglect in Wound Care Leads to Immediate Jeopardy and Potential Harm
Penalty
Summary
The facility failed to ensure Resident #59, admitted on hospice care, was free from neglect as staff did not provide ongoing wound assessments, care, and services to prevent a significant decline in a wound on the left lower extremity. This led to a situation where emergency services were called due to a deteriorating mental status, and it was found that the wound was infected and necrotic. Resident #59 required inpatient hospital admission, surgical debridement, and prolonged antibiotic therapy due to the severity of the wound. The deficiency was classified as Immediate Jeopardy due to the potential for serious life-threatening harm. Additionally, the facility also failed to provide ongoing wound assessments for Resident #42, placing the resident at potential risk for more than minimal harm. Despite having a surgical incision, Resident #42 did not receive proper monitoring and documentation of wound measurements and descriptions as required by policy. The deficiency was noted in the lack of weekly skin assessments and wound monitoring for Resident #42, with the last assessment documented on 02/29/24. The deficiency was classified as Severity Level 2, indicating potential for more than minimal harm that is not Immediate Jeopardy.
Failure to Provide Appropriate Pressure Ulcer Care and Monitoring
Penalty
Summary
The facility failed to provide appropriate care, assessments, and ongoing monitoring of a pressure ulcer for Resident #9, who had multiple diagnoses including paraplegia and a stage IV pressure ulcer to the left ischium. The resident's care plan included interventions such as a low air loss mattress, pressure-relieving cushion, and assistance with transfers and repositioning. However, the facility did not complete weekly skin assessments as required, and there were inconsistencies in the documentation of wound care treatments and assessments. The medical record lacked weekly nursing skin assessments, and the Director of Nursing confirmed that these assessments had not been completed as they should have been. The review of the medical record and physician orders revealed that the treatment for the pressure ulcer changed multiple times between December 2023 and March 2024. Despite these changes, the wound care notes and weekly wound evaluations showed varying measurements and descriptions of the wound, indicating a lack of consistent monitoring and documentation. For instance, the wound was noted to have 100% necrosis with no drainage on one occasion and later described with 50% necrosis and a small amount of serosanguineous drainage. Additionally, the wound care notes indicated that the pressure ulcer was healed at one point, only to be described as a stage IV pressure ulcer again in subsequent notes. During an observation of a dressing change, the LPN followed proper procedures, but it was verified that the LPN had not documented the wound appearance with each dressing change. The facility's policies on wound treatment management and skin assessment required documentation of wound treatments and full body assessments, including measurements and descriptions of wounds. The failure to adhere to these policies and the lack of consistent documentation and monitoring led to the deficiency identified in the report.
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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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