Divine Rehabilitation And Nursing At Toledo
Inspection history, citations, penalties and survey trends for this long-term care facility in Toledo, Ohio.
- Location
- 1011 North Byrne Road, Toledo, Ohio 43607
- CMS Provider Number
- 366328
- Inspections on file
- 56
- Latest survey
- March 16, 2026
- Citations (last 12 mo.)
- 17
Citation history
Health deficiencies cited at Divine Rehabilitation And Nursing At Toledo during CMS and state inspections, most recent first.
A dependent hospice resident with Alzheimer’s disease, severe cognitive impairment, underweight status, and documented need for full assistance with eating did not receive required mealtime support. At breakfast, a CNA set up the tray, cut the food, and opened milk but left the room and did not return to feed the resident, who made no attempts to eat and only intermittently tried to drink from the milk carton; the tray was later removed with the food untouched. At lunch, the CNA provided limited hand-feeding, after which the resident consumed only a small amount of ice cream and a bite of beans, and no alternative food choices were offered despite the resident’s dependence on staff for eating, as confirmed by staff interviews and the care plan.
A resident with T1DM was prescribed and administered Trulicity, a medication only approved for T2DM, despite being on both long-acting and short-acting insulin. Multiple staff, including a pharmacist and physician, confirmed Trulicity was not appropriate for T1DM, and interviews revealed a lack of awareness among staff regarding its use. The facility failed to ensure the resident's medication regimen was free from unnecessary drugs.
A resident with a history of abuse and PTSD was administered a second dose of the influenza vaccine by an RN, despite having previously received the vaccine and verbally refusing it. The nurse dismissed the resident's objections and those of her husband, then administered the vaccine in error instead of the ordered pneumococcal vaccine. The incident left the resident fearful and concerned for her health, and the facility administrator confirmed the medication error and violation of the resident's rights.
A resident with a history of alcohol dependence and mental health issues was subjected to excessive physical force by an LPN during an attempt to confiscate alcohol in the smoking area. The LPN physically restrained and struck the resident's arm multiple times, resulting in the resident experiencing fear, mental anguish, and a sense of being unsafe. The incident was confirmed by video surveillance and staff interviews, and the resident required increased observation due to reported depression and thoughts of self-harm.
The facility did not maintain effective pest control, resulting in persistent flies, gnats, and mice in resident rooms and common areas. Staff and residents reported frequent pest sightings, and staff used fly swatters during care. Despite recommendations from the pest control vendor for more aggressive treatment and environmental repairs, the facility relied on in-house remedies, leaving several issues unresolved.
A resident with multiple comorbidities was scheduled for a bone marrow biopsy, but the facility failed to follow pre-procedure physician orders, including NPO status and holding anticoagulant and aspirin therapy. Due to these omissions, the resident was served breakfast and received medications that should have been held, resulting in the cancellation and repeated rescheduling of the procedure. Staff interviews confirmed lapses in order entry, documentation, and communication.
A resident with multiple wounds, including a right heel pressure ulcer, did not receive timely assessment, measurement, or documentation of the wound. Physician-ordered treatments and interventions for the right heel were not consistently initiated or documented, and required skin checks were missed. The wound was not properly monitored, leading to a severe decline in condition that was only discovered upon hospital transfer.
A resident did not receive food prepared in a form that met their individual needs, as the facility did not consistently modify meals to accommodate specific dietary requirements or physical abilities.
The facility did not maintain proper food storage temperatures, as the walk-in refrigerator consistently operated above safe levels and staff resorted to opening the freezer door to cool it, causing ice buildup. Maintenance requests for repairs were pending, and some perishable items were moved to the freezer, but other foods remained at risk of spoilage. All residents except two were potentially affected, though no foodborne illnesses were reported.
A resident with complex medical needs returned from the hospital with a new order for Augmentin oral suspension to treat aspiration pneumonia. Due to the receiving nurse not including the hospital discharge order for the antibiotic, the resident did not receive any oral antibiotic for four days, resulting in eight missed doses until a new order for Amoxicillin was started. The DON confirmed the omission was due to the hospital order not being transcribed.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
A resident with cognitive impairment and physical care needs was left unsupervised outside overnight without staff supervision or personal care. The incident was not reported to the State Survey Agency within the required timeframe, as the facility delayed submitting the Self-Reported Incident for two days, contrary to its own policy.
A resident with multiple medical conditions and moderate cognitive impairment was not assessed for smoking safety upon admission or during required assessments, despite facility policy mandating such evaluations for all smokers. The oversight was discovered only after the Administrator observed the resident smoking on facility camera footage.
Two residents did not receive required care as documented in their medical records, including medication administration, g-tube flushes, and weekly skin assessments. The MARs were falsified to indicate that care was provided when it was not, as confirmed by interviews with the Administrator and DON.
Two residents experienced deficiencies in accident prevention and supervision: one suffered a lumbar fracture after falling from a mechanical lift due to a worn and improperly laundered sling pad, while another was left unattended during a bed bath and fell from an unlocked bed. Additionally, the facility failed to thoroughly investigate multiple falls for one resident, with incident reports lacking key details and follow-up.
The facility did not have an RN on duty for eight consecutive hours as required, with staffing records and postings confirming the absence of RN coverage for all shifts during a period when 77 residents were present. The Administrator verified the lack of RN presence during this time.
A resident with multiple chronic conditions did not receive timely incontinence checks or proper perineal care as required by care plans and facility policy. Staff failed to check and change the resident for several hours and did not cleanse the perineal area after an episode of incontinence, resulting in non-compliance with established protocols.
A resident with Full Code status was found unresponsive and without vital signs. Two LPNs assessed the resident but did not initiate CPR or call 911, instead pronouncing death without physician direction. The resident's care plan and physician orders required CPR and EMS notification, and family members confirmed they did not refuse life-saving measures. This failure to follow protocol resulted in the resident's death without attempted resuscitation.
A resident with a history of elopement and schizoaffective disorder was able to leave the facility unsupervised after a visitor opened the front door, as required 15-minute checks were not performed or documented and the WanderGuard was left on the wheelchair. Staff were unaware of the resident's absence until a CNA found her offsite. Additionally, two residents who smoked were not assessed for smoking safety upon admission or quarterly, contrary to facility policy.
A resident experienced a 24-hour delay in treatment for a hip fracture after the facility failed to receive and follow up on stat X-ray results, resulting in unmanaged severe pain and delayed hospital transfer. Additionally, another resident did not receive required weekly wound assessments, with no documentation of monitoring for over a month, placing the resident at risk for harm.
Multiple failures occurred in the facility, including an LPN not initiating CPR or contacting a physician for a resident with Full Code status, a resident with a history of elopement leaving undetected due to missed supervision checks, staff refusing to provide care resulting in delays, and ongoing substance use by residents with minimal intervention. These actions and inactions led to deficiencies in supervision, adherence to policy, and reporting, impacting the well-being and safety of all residents.
Surveyors found that staff did not keep call lights within reach for two residents who required assistance, including one with impaired mobility and another who was legally blind, despite care plans specifying this need. Additionally, there was a shortage of clean linens, leading to delayed care for a resident and the potential to affect others, with staff and management unaware of the issue.
Surveyors identified multiple environmental maintenance issues, including water-stained ceiling tiles, peeling wallpaper, and dirty, worn flooring throughout the facility. The Director of Maintenance confirmed these findings and noted that repairs had not been completed, with no scheduled date for service.
A resident who was dependent on TPN due to an intestinal blockage did not receive a scheduled dose, and the physician was not notified of the missed administration. Staff interviews revealed confusion over responsibility for clarifying and administering the TPN, and documentation confirmed that the required physician notification did not occur, contrary to facility policy.
Two residents with significant visual impairments did not have working overbed lights in their rooms for approximately three weeks, despite facility policy requiring adequate lighting. Staff and maintenance were aware of the issue, which was attributed to broken underground electrical wires, but repairs had not been completed, leaving the residents without proper lighting.
The facility did not report two critical incidents to the SSA: one involving a resident with Full Code status who did not receive CPR when found unresponsive, and another involving a cognitively intact resident who eloped from the facility and required emergency services. In both cases, required self-reported incidents were not submitted, and the Administrator confirmed the lack of reporting.
A resident with a history of mental health conditions and identified as an elopement risk exited the facility unsupervised after a visitor entered, later exhibiting delusional behavior at a nearby store. The facility did not initiate an immediate investigation of the elopement, and the DON was unaware of the incident until days later, resulting in a deficiency for failure to respond appropriately to an alleged violation.
Several dependent residents did not receive scheduled showers or timely assistance with ADLs, as required by facility policy. Documentation and interviews revealed that staff sometimes refused to provide care, leading to extended periods without bathing for residents with significant medical and cognitive needs. Management was aware of staff refusals, and residents reported delays and confusion regarding who was responsible for their care.
A resident who was dependent on staff for toileting and incontinent of bowel and bladder did not receive timely incontinence care as required by her care plan and facility policy. Staff interviews and observation confirmed that the resident had not been checked or changed for several hours, resulting in a heavily saturated incontinence brief. Multiple CNAs acknowledged not providing care during their shifts, and a staffing shortage was noted.
A resident with complex medical needs, including an intestinal blockage and chronic kidney disease, did not receive a scheduled dose of TPN as ordered by the physician. Although the TPN solution was available and RNs were present in the facility, confusion among nursing staff regarding order clarification and administration responsibilities led to the missed dose. Facility policy required verification and administration of TPN by nursing staff, but this was not followed.
Nursing staff failed to demonstrate competency in following advanced directives and acted outside their scope of practice by not initiating CPR and pronouncing death for a Full Code resident. Additionally, staff lacked knowledge of procedures for obtaining and acting on stat radiology results, resulting in delayed care for another resident. These deficiencies were identified through record review and staff interviews.
Three residents with histories of substance use were repeatedly found using or possessing illicit drugs and alcohol within the facility. Staff and resident interviews confirmed ongoing substance use, and documentation showed that interventions were limited to education and removal of substances or paraphernalia, without the provision of specialized behavioral health or substance use disorder services.
A resident with diabetes did not receive multiple scheduled doses of both long-acting and fast-acting insulin as ordered by the physician, with no documentation of refusal or reason for omission. Nursing staff confirmed that missing initials on the MAR indicated the medications were not given, contrary to facility policy requiring administration as ordered.
A resident with intact cognition and dependent on staff for personal care reported being sexually abused by a CNA during showers. The abuse involved inappropriate contact, occurring multiple times over a month, leading to the resident's anxiety and anger. The incident was reported by another CNA who noticed the resident's discomfort, prompting an investigation and police involvement.
A resident with intact cognition reported repeated sexual abuse by a CNA during personal care, which was not reported in a timely manner by the facility staff. The abuse involved inappropriate actions during care, and the resident expressed distress and anxiety. The accused CNA was terminated for unrelated reasons before the allegations were known.
A resident with conditions such as morbid obesity and diabetes, dependent on staff for personal care, was left in a soiled brief overnight due to staff's refusal to provide care, fearing accusations of sexual abuse. Despite using the call light, the resident was not attended to until the morning, violating the facility's ADL policy.
A facility employed an STNA without proper Ohio certification, affecting 77 residents. The STNA worked multiple shifts with an expired out-of-state certificate, contrary to facility policy requiring state-approved training and certification within four months of hire.
The facility failed to conduct timely fall reviews for four residents identified as high fall risks. A resident with dementia experienced a fall resulting in a laceration, but the post-fall evaluation was delayed. Another resident fell without injury, yet the evaluation was also delayed. A third resident experienced two falls, with evaluations not completed within the required timeframe. Additionally, a resident was overdue for a quarterly fall risk assessment. The facility's policy requires timely assessments to minimize fall risks.
A resident with dementia, identified as an elopement risk, exited the facility through a fire safety door and was found outside in the parking lot. Despite having a wander bracelet, the alarm was not heard by staff. The resident was outside for a few minutes before being brought back inside without injury. The facility failed to report the incident to the state agency as required.
A resident with cognitive impairment and identified as an elopement risk managed to exit the facility despite having a wander bracelet. Staffing issues contributed to the incident, with only one nurse covering multiple units. The facility's investigation was incomplete, lacking staff interviews and details about the incident, and the Director of Nursing and Administrator were unable to provide specifics.
The facility failed to provide timely shower assistance to three residents dependent on staff for bathing. Despite being scheduled for regular showers, these residents missed several bathing opportunities, with no documentation explaining the omissions. Interviews with staff revealed that showers were not completed timely due to staffing issues or unwillingness to perform the task. The DON confirmed that showers were only completed about 40% of the time, contrary to the facility's policy.
The facility failed to perform weekly skin assessments for two residents as per physician orders, affecting their care. One resident with dementia and diabetes did not receive skin checks in September, while another with morbid obesity and chronic kidney disease had only two checks in two months. Interviews confirmed the assessments were not completed timely, contrary to facility policy.
The facility failed to prime insulin pens before administration, leading to significant medication errors for two residents. An RN administered insulin to both residents without priming the pens, which is necessary to ensure the correct dose. The RN was unaware of this requirement, despite the facility's policy and manufacturer's instructions emphasizing the need for priming.
A resident with multiple health issues experienced a delay in receiving appropriate treatment due to the facility's failure to promptly notify the physician of lab results. The LPN who collected the urine sample was off duty and did not review the results upon returning, leading to a four-day delay in notifying the physician and obtaining an antibiotic order.
The facility failed to provide vegetables as per the planned menu during a noon meal service, affecting several residents. A staff member did not have enough vegetables for the last few meal trays and did not prepare an alternative, such as a side salad, as confirmed by the Dietary Manager. This issue was part of a complaint investigation and noted as continued non-compliance from a previous survey.
The facility failed to conduct comprehensive fall investigations and post-fall assessments for two residents, leading to a deficiency in accident prevention and supervision. One resident with dementia experienced two unwitnessed falls without further investigation. Another resident with multiple diagnoses had several falls, some resulting in injuries, with incomplete investigations and missing neurological checks. The facility lacked adherence to its Fall Prevention Program and Head Injury policies.
A facility failed to ensure antibiotics were prescribed appropriately for a resident with a UTI. The resident, with dementia and congestive heart failure, was given Bactrim ds without a confirmed UA C&S due to a leaked urine specimen. The facility did not follow the Antibiotic Stewardship Protocol, as confirmed by the Infection Preventionist.
The facility failed to ensure proper hand hygiene during food preparation, affecting nearly all residents. Staff members were observed not changing gloves after handling unsanitized items and using bare hands to prepare food, contrary to facility policy. The Dietary Manager confirmed these practices were inappropriate.
The facility failed to establish an effective Quality Assessment and Assurance committee, leading to repeated deficiencies in providing necessary assistance with ADLs. This issue affected all 67 residents, as confirmed by medical record reviews and staff interviews. The Administrator acknowledged the ongoing deficiencies.
The facility failed to ensure that all required members of the QAA committee attended meetings at least quarterly, as the Medical Director or designee did not attend any meetings in the second quarter of 2023. This deficiency had the potential to affect all 67 residents in the facility.
Failure to Assist Dependent Hospice Resident With Meals and Offer Alternatives
Penalty
Summary
The deficiency involves the facility’s failure to provide required assistance with eating to a dependent resident. The resident had diagnoses including Alzheimer’s disease, dementia, moderate protein calorie malnutrition, mixed incontinence, osteoarthritis, and cerebral ischemia, and was admitted to hospice with cerebral atherosclerosis. The nursing and nutritional plans of care, MDS, and functional abilities assessment all documented that the resident had severe cognitive impairment, was rarely/never understood, was dependent on staff for all ADLs including eating, received a mechanically altered therapeutic diet, and was on physician-ordered supplements and a weight gain regimen due to being underweight with a BMI of 11.8. Care plan interventions included assisting with feeding, providing and serving supplements and diet as ordered, and monitoring and recording intake at every meal. On the morning of the observed deficiency, a CNA delivered the resident’s breakfast tray, elevated the head of the bed, uncovered the plate and hot cereal, cut up the food, added sugar to the cereal, placed a spoon in the bowl, opened the milk carton, and then left the room. Over the next several minutes, the resident was observed looking toward the television, then with eyes closed, and made no attempts to feed herself. The food remained uncovered and untouched. The resident later attempted only to drink from the milk carton, with no attempts to eat the food. During this time, the CNA was observed seated at a computer in the lounge and did not return to assist with feeding until nearly an hour later, at which point the CNA removed the tray with the food still untouched. The CNA confirmed in interview that the resident had not eaten any of the breakfast meal and that no assistance with breakfast had been provided. At lunchtime the same day, the CNA again delivered the meal tray, repositioned the resident in bed, uncovered and set up the meal, and this time sat next to the resident and provided spoon-fed bites, instructing the resident to take a bite of each item before refusing the meal. The CNA later reported to an RN that the resident consumed only half a portion of ice cream and a bite of beans, and then removed the tray, leaving the remaining ice cream on the overbed table. No alternative food choices were offered after the resident’s limited intake at lunch. In interviews, both the CNA and the RN verified that the resident was dependent on staff for eating, had not been assisted with breakfast, and had not been offered alternative food choices when refusing most of the lunch meal. The deficiency was cited as continued non-compliance from prior surveys.
Unnecessary Medication Administered to Resident with Type I Diabetes
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medications. A resident with a diagnosis of Type I diabetes mellitus (T1DM) was prescribed and administered Trulicity, a medication only approved for use in Type II diabetes mellitus (T2DM). Medical record review showed the resident was cognitively intact, required insulin injections, and had multiple diagnoses related to T1DM. Despite this, physician orders and the Medication Administration Record confirmed that Trulicity was administered on several occasions during the resident's stay. Interviews with facility staff, including a pharmacist, nurse practitioner, physician, LPN, and RN, revealed a lack of awareness regarding the appropriateness of Trulicity for T1DM. Both pharmacists and the physician confirmed that Trulicity is not approved or effective for T1DM due to its mechanism of action, which requires endogenous insulin production. The nurse practitioner who prescribed the medication admitted to treating T1DM and T2DM similarly and was unaware of the resident's specific needs. The facility's policy required that residents' medication regimens be managed to avoid unnecessary drugs, but this was not followed in this case.
Resident Rights Violated When Nurse Administers Unwanted Second Influenza Vaccine
Penalty
Summary
A facility failed to honor a resident's right to self-determination and a dignified existence when a nurse administered a second dose of the influenza vaccine to a resident against her will. The resident, who had a history of abuse and PTSD, had previously declined the influenza and pneumococcal vaccinations upon admission, with her declination witnessed and documented. Despite this, the resident later consented to and received the influenza vaccine in October. In November, a physician order was placed for a pneumococcal vaccine, but the vaccine was not yet available in the facility. On the day of the incident, a registered nurse approached the resident to administer what was supposed to be the pneumococcal vaccine. The resident verbally refused the vaccination, stating she had already received the influenza vaccine, and her husband, present via video call, also expressed concern. The nurse dismissed their objections, insisted they did not know what they were talking about, and proceeded to inject the resident with the influenza vaccine a second time, despite her clear refusal and previous administration. This action was documented as a medication error, as the nurse administered the wrong vaccine and did so without the resident's consent. The resident reported feeling afraid of the nurse following the incident and expressed concerns about her health due to receiving two influenza vaccinations within a short period. The facility's policies confirmed residents' rights to refuse immunizations and required medications to be administered as ordered and in accordance with professional standards. The administrator verified that the nurse administered the influenza vaccine against the resident's will and that a medication error had occurred.
Resident Subjected to Excessive Physical Force During Alcohol Confiscation
Penalty
Summary
A deficiency occurred when a resident with a history of alcohol dependence, anxiety, depression, and other medical conditions was subjected to excessive physical force by a staff member. The resident, who was moderately cognitively impaired and independently mobile in a wheelchair, was found drinking alcohol in the designated smoking area without a physician's order. When approached by staff, the resident became agitated and was accused of threatening staff, but video surveillance later showed that a Licensed Practical Nurse (LPN) used physical force to search the resident and confiscate alcohol, including pulling on the resident's coat and arms multiple times. The incident escalated when the LPN, after being instructed by another nurse to confiscate the alcohol, repeatedly reached into the resident's coat and physically restrained the resident's arm. The situation further deteriorated when the LPN struck the resident's arm multiple times after the resident pointed a finger at her. Other staff present intervened by removing a cigarette from the resident's hand, citing safety concerns. The resident subsequently reported feeling unsafe, fearful, and experiencing mental anguish as a result of the altercation. The facility's investigation confirmed the events as seen on video and through staff and resident interviews. The LPN involved had received prior training on abuse prevention but nonetheless engaged in actions that resulted in mental harm and a sense of insecurity for the resident. The incident was reported to the facility administration and state agency, and the resident was placed on one-to-one observation due to expressed feelings of depression and thoughts of self-harm following the event.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to ensure effective pest control, resulting in the presence of flies, gnats, and mice in multiple areas, including resident rooms and common spaces. Staff interviews revealed that excessive numbers of flies were present in the halls, and both staff and residents reported frequent sightings of mice, particularly in two residents' rooms. Staff resorted to using fly swatters during medication passes and in resident rooms, and residents who were able kept fly swatters at hand. Reports of mice in resident rooms were made to administration, and staff noted that the pest control measures in place were not effective. Observations confirmed the presence of multiple flies and gnats in at least one resident's bedroom, with flies seen on drinking cups and bedside tables. Residents reported direct encounters with mice, including a mouse on a bed and daily sightings in their rooms. Maintenance staff acknowledged ongoing issues with mice and flies, and stated that organic peppermint oil spray was used in an attempt to address the problem, but mice continued to be seen. The pest control vendor had provided recommendations for more aggressive treatment, but the facility opted to try in-house remedies instead. Review of pest control records showed that while monthly standard services were performed, several recommendations from the pest control vendor remained unaddressed by the facility. These included repairing door gaps, fixing water leaks, cleaning debris, and cutting overgrown vegetation, all of which were identified as the facility's responsibility. The facility's pest control policy stated that appropriate chemicals and methods would be used to control pests, but the ongoing presence of pests and unaddressed recommendations indicated a failure to maintain an effective pest control program.
Failure to Follow Pre-Procedure Orders Results in Canceled Biopsies
Penalty
Summary
The facility failed to follow pre-procedure physician orders for a resident scheduled for a bone marrow biopsy, resulting in the procedure being canceled and rescheduled multiple times. The resident, who had diagnoses including heart failure, peripheral vascular disease, and acute respiratory failure, was on anticoagulant therapy and required significant assistance with activities of daily living. After returning from an oncology appointment, the resident had new orders for a bone marrow biopsy, including instructions to be NPO (nothing by mouth) starting at midnight before the procedure and to hold certain medications, such as apixaban and aspirin, prior to the procedure. Despite these orders, the facility did not properly enter the NPO status or medication holds into the Medication Administration Record (MAR), and the resident was served breakfast on the morning of the scheduled procedure. As a result, the bone marrow biopsy was canceled. When the procedure was rescheduled, the facility again failed to hold the resident's anticoagulant and aspirin as instructed, leading to a second cancellation. Documentation confirmed that the resident received the medications on the days they were supposed to be held. Interviews with facility staff revealed that there were delays in uploading important documents into the electronic medical record (EMR), and communication of new orders was primarily verbal. The Director of Nursing confirmed that pre-procedure instructions were not entered into the EMR, and the dietary staff were only verbally informed of NPO orders. The unit manager acknowledged that the process for reviewing and entering new orders after appointments was not completed as required, directly contributing to the failure to follow pre-procedure instructions.
Failure to Assess, Document, and Treat Pressure Ulcer on Right Heel
Penalty
Summary
A resident with a history of anemia, Type II diabetes mellitus, and chronic kidney disease was admitted to the facility with multiple wounds, including a left below-the-knee amputation, a stage IV pressure ulcer, a stage III pressure ulcer, and a venous ulcer. Upon admission, the resident was noted to have black eschar on the right heel and second toe, but there was no evidence that these wounds were assessed, described, or measured. Physician orders for offloading pressure boots and daily skin prep to the right heel were in place, but documentation showed inconsistent application and monitoring of these interventions, with several days lacking evidence of treatment or documentation of refusals. Throughout the resident's stay, required skin assessments and wound documentation were not completed as ordered. Skin observation tools and progress notes repeatedly failed to assess or mention the right heel pressure ulcer, and weekly skin checks were not consistently performed or documented. When a new open wound was discovered on the right heel, there was no immediate documentation of the wound's characteristics, and the new treatment order was not initiated until two days later. Wound care notes and treatment administration records did not reflect timely or complete implementation of physician-ordered treatments for the right heel wound. The resident was eventually transferred to the hospital, where the right heel wound was found to be gangrenous and infested with maggots. Interviews with facility staff confirmed that the right heel wound was not monitored or assessed from admission until it was seen by the wound care physician, and that required treatments and interventions were not consistently documented or performed. Facility policy required ongoing assessment and documentation of wound care, but these procedures were not followed for the resident's right heel pressure ulcer.
Failure to Provide Food in Appropriate Form for Individual Needs
Penalty
Summary
The facility failed to ensure that each resident received food prepared in a form designed to meet their individual needs. This deficiency indicates that meals were not consistently modified or adapted to accommodate the specific dietary requirements or physical abilities of residents, such as those needing pureed, chopped, or otherwise altered food textures.
Failure to Maintain Safe Food Storage Temperatures
Penalty
Summary
The facility failed to ensure that all food was stored at appropriate temperatures, as required by professional standards. Review of temperature logs for the walk-in refrigerator in August 2025 showed recorded temperatures ranging from 50 to 65 degrees, which is above the recommended maximum of 42 degrees for safe food storage. During a kitchen tour, the walk-in refrigerator was observed to be at 50 degrees, and there was no internal thermometer present. Staff interviews confirmed that the refrigerator had not been functioning properly since July 2025, and maintenance requests for repairs had been submitted but not yet approved or completed. To compensate, staff had been opening the freezer door to cool the refrigerator, resulting in ice accumulation in the freezer due to condensation. The Director of Dietary confirmed that eggs, raw meat, and dairy were being stored in the freezer instead of the refrigerator to reduce spoilage risk, but acknowledged that other items in the refrigerator could potentially spoil due to inconsistent temperatures. The Director of Maintenance verified that the refrigerator did not maintain safe temperatures, especially during times when staff were not present to monitor and adjust conditions. The Regional Administrator confirmed that the refrigerator was not maintaining appropriate temperatures according to facility logs and observations. The deficiency had the potential to affect all residents except two who did not receive food from the kitchen, but there were no reports of residents exhibiting symptoms of foodborne illness at the time of the investigation.
Failure to Administer Physician-Ordered Antibiotic Following Hospital Discharge
Penalty
Summary
A resident with multiple complex medical conditions, including sepsis, heart failure, dysphagia, and a gastric ulcer, was admitted to the facility and later experienced a choking episode that required hospital transfer. Upon discharge from the hospital, the resident was prescribed Augmentin oral suspension to be administered every 12 hours for nine days to treat aspiration pneumonia. However, upon the resident's return to the facility, the receiving nurse did not include the hospital discharge orders for the Augmentin antibiotic in the resident's medication orders. As a result, the resident did not receive any oral antibiotic from the time of readmission until four days later, when a new order for a different antibiotic, Amoxicillin, was entered and started. The Medication Administration Record confirmed that no oral antibiotics were administered during this period, resulting in eight missed doses. The Director of Nursing verified that the omission occurred due to the failure to transcribe the hospital discharge order for the Augmentin antibiotic upon the resident's return.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Timely Report Alleged Neglect to State Survey Agency
Penalty
Summary
A deficiency occurred when the facility failed to report an allegation of neglect in a timely manner to the State Survey Agency (SSA). A resident with multiple diagnoses, including stroke, parkinsonism, cognitive impairment, and incontinence, was found to have been left unsupervised outside on the smoking patio overnight without staff supervision or personal care. The incident was discovered by a registered nurse during morning medication rounds, after another resident indicated the individual was outside. The resident, who experienced periods of confusion, stated he was cleaning, but required assistance for toileting and transfers and was always incontinent. The facility's Self-Reported Incident (SRI) was created two days after the event was discovered, and the summary investigation confirmed the report to the SSA was not made until two days after the incident. According to facility policy, all alleged violations should be reported immediately, but not later than two hours if abuse or bodily injury is involved, or within 24 hours if not. The administrator confirmed the delay in reporting the incident to the SSA, which was not in accordance with the facility's policy.
Failure to Complete Smoking Assessment for Resident
Penalty
Summary
The facility failed to ensure that a smoking assessment was completed for a resident who smoked, as required by facility policy. The resident, who had a history of cerebral infarction, traumatic brain injury, difficulty walking, anxiety disorder, urinary incontinence, parkinsonism, cognitive communication deficit, and nicotine dependence, was moderately cognitively impaired and dependent on staff for toileting and transfers. Despite these conditions, there was no evidence that a Smoking Safety Screen was completed upon admission or during subsequent assessments until several months later. The deficiency was identified when the Administrator, while reviewing camera footage for an unrelated investigation, observed the resident smoking outside. This led to the discovery that the resident's smoking status had not been identified or assessed during the admission process or quarterly assessments, contrary to facility policy. The policy required all residents to be asked about tobacco use at admission and during each MDS assessment, with further assessment for those who smoked to determine supervision needs. This lapse was noted as a continued non-compliance from previous surveys.
Failure to Maintain Accurate Medical Records and Documentation
Penalty
Summary
The facility failed to ensure the accuracy of medical records for two residents. For one resident with multiple diagnoses including stroke, parkinsonism, and cognitive impairment, the Medication Administration Record (MAR) documented that various medications, enteral feedings, and g-tube flushes were administered as ordered. However, interviews with the Administrator and DON confirmed that no medications or treatments were actually provided during a specified time period, and the MAR had been falsified by a nurse. The facility's investigation into a neglect allegation revealed that the resident's physician-ordered treatments were not carried out as documented. For another resident with diagnoses including diabetes, COPD, dementia, and hypertension, the MAR indicated that weekly skin assessments were completed on several dates. However, review of the medical record and interviews with the DON and Administrator confirmed that no skin assessments had been performed since a prior date, despite documentation to the contrary. These findings demonstrate that the facility did not maintain accurate medical records in accordance with accepted professional standards.
Failure to Prevent Accidents and Inadequate Fall Investigation
Penalty
Summary
A deficiency occurred when a resident who required transfers with a mechanical lift was not transferred safely, resulting in actual harm. The resident, with a history of morbid obesity, heart disease, and osteoporosis, was dependent on staff and a mechanical lift for transfers. During a transfer from a shower bed to her regular bed, the sling pad used with the mechanical lift broke, causing the resident to fall and sustain a lumbar vertebral compression fracture. Staff interviews and documentation revealed that the sling pad had visible signs of wear, including frayed and distressed straps, and had been improperly laundered in a commercial dryer, which contributed to the deterioration of the material. Despite warnings on the sling pad label and in the instruction manual to inspect for wear and avoid drying in a dryer, the facility had not replaced sling pads regularly or ensured proper inspection before use. Another deficiency was identified regarding the supervision and assistance provided to a second resident during bathing and in the investigation of multiple falls. This resident, with diagnoses including bipolar disorder, spinal stenosis, and Parkinsonism, was at risk for falls and required substantial assistance for bed mobility and bathing. On one occasion, the resident fell from bed while being left unattended by a CNA who had failed to lock the bed wheels. The incident report and staff interviews confirmed that the bed was left unlocked and the resident was left alone, leading to the fall. The facility's documentation did not show that a thorough investigation or formal education for the CNA was completed beyond immediate verbal instruction. Additionally, the facility failed to conduct thorough investigations into several other falls experienced by the same resident. Incident reports for multiple unwitnessed falls lacked critical information, such as the resident's location prior to the fall, whether safety interventions like a perimeter mattress or call light were in place or used, and whether the fall mat was present. The facility's fall prevention policy required post-fall assessments and documentation but did not provide specific guidance for comprehensive investigations. The lack of detailed investigation and documentation placed the resident at risk for further harm.
Lack of Required RN Coverage
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was present and working for eight consecutive hours daily, as required. Review of staffing schedules and timekeeping records for the period of 06/02/25 through 06/08/25 showed that there was no RN coverage for eight consecutive hours on 06/03/25, with a gap in RN staffing from the beginning of the third shift on 06/02/25 until the second shift on 06/04/25. The nursing staff information posting for 06/03/25, when the facility census was 77 residents, also indicated no RN coverage on any shift. The Administrator confirmed in an interview that no RN worked eight consecutive hours in the facility on 06/03/25. This deficiency affected all residents in the facility on that date.
Failure to Provide Timely and Appropriate Incontinence and Perineal Care
Penalty
Summary
A deficiency occurred when a resident, admitted with multiple diagnoses including coronary artery disease, congestive heart failure, peripheral vascular disease, morbid obesity, and chronic kidney disease, did not receive timely incontinence care and appropriate perineal hygiene. The resident was care planned for incontinence of bowel and bladder, requiring checks and changes every two hours and as needed, with specific instructions for perineal cleansing and use of moisture barrier. Documentation showed the last incontinence check was at 4:55 A.M., and by 8:14 A.M., the resident reported being soiled and not having been checked since approximately 5:00 A.M. The CNA who assumed care at 6:30 A.M. was unaware of the last incontinence check and had not checked the resident since starting her shift, despite knowing the resident required frequent checks. During observation, two CNAs provided a bed bath and incontinence care but failed to cleanse the resident's perineum after an episode of bowel and urinary incontinence. The resident's brief was found to be heavily soiled, and while the buttocks were cleansed and barrier cream applied, the perineal area was not cleaned according to facility policy. The CNA later confirmed that perineal cleansing was not performed. Facility policies required thorough perineal care to prevent infection, but these were not followed, resulting in non-compliance.
Failure to Initiate CPR and Contact EMS for Full Code Resident
Penalty
Summary
The facility failed to initiate Cardiopulmonary Resuscitation (CPR) or call 911 for Emergency Medical Services (EMS) for a resident who was found unresponsive, not breathing, and without a pulse, despite having advance directives and a physician order indicating Full Code status. Two LPNs responded to the resident's room after being alerted by a CNA, assessed the resident, and confirmed the absence of vital signs. Neither nurse initiated CPR nor contacted EMS, and instead, they called the time of death without physician direction or the involvement of a qualified health professional. The resident involved had multiple diagnoses, including chronic obstructive pulmonary disease (COPD), dementia, prostate cancer, hypertension, congestive heart failure, and orthostatic hypotension. The resident's care plan and physician orders clearly indicated Full Code status, with interventions specifying to call 911 and initiate CPR in the absence of a pulse. At the time of the incident, a family member was present at the bedside, but there was no documentation or confirmation that the family member or the resident's Power of Attorney (POA) had authorized withholding CPR. Interviews with the resident's daughter and granddaughter confirmed that neither directed staff to withhold life-saving measures. Staff statements revealed that the LPNs did not initiate CPR because they believed the family at bedside refused it, but this was not corroborated by the family members involved. The LPNs also called the time of death, which was outside their scope of practice, and did not seek direction from a physician. The facility's policy required staff to provide basic life support, including CPR, for residents with Full Code status prior to EMS arrival, in accordance with the resident's advanced directives. This failure to follow established protocols and physician orders resulted in the resident passing away without life-saving measures being attempted.
Failure to Prevent Elopement and Complete Smoking Safety Assessments
Penalty
Summary
A deficiency occurred when a resident with schizoaffective disorder, a history of numerous elopement attempts, and an identified risk for elopement was able to leave the facility without staff knowledge. The resident had a WanderGuard device attached to her wheelchair, as she had previously removed the device from her person multiple times. Despite being on 15-minute supervision checks, there was no evidence that these checks were completed on the day of the incident. The resident was able to exit the facility when a visitor used a code to open the locked front door, and she left her wheelchair and the attached WanderGuard in the lobby before walking out unaccompanied. The resident walked approximately 0.2 miles to a local carryout, traversing a sidewalk with broken concrete and rocks along a busy five-lane road. Staff were unaware of her absence until a CNA, who was on a lunch break, happened to find her sitting on the floor of the carryout about 35 minutes after she had left the facility. At the time, the resident was actively hallucinating and expressing delusional thoughts. Documentation and interviews confirmed that staff did not perform or document the required 15-minute supervision checks on the day of the elopement, and staff were not aware the resident had left until notified by the CNA who found her. Additionally, the facility failed to complete required admission and quarterly smoking safety assessments for two residents who smoked, as mandated by facility policy. These assessments are necessary to determine if residents can smoke unsupervised or require safety measures. The lack of timely assessments placed these residents at risk for potential harm, as their ability to safely smoke was not evaluated upon admission or at required intervals.
Delayed X-ray Result Follow-up and Incomplete Wound Monitoring
Penalty
Summary
The facility failed to ensure timely receipt and follow-up of stat X-ray results, resulting in a delay in treatment for a resident who suffered a right hip fracture. After a fall, the resident initially complained of knee pain, prompting a stat X-ray order for the knee. The following morning, the resident reported severe hip pain, and a stat X-ray of the hip was ordered and completed. The radiology vendor faxed the results, which confirmed a right femoral neck fracture, to the facility within the hour. However, the facility did not receive or act upon these results until approximately 24 hours later, despite the expectation that staff should follow up with the vendor if results were not received within four to six hours. During this period, the resident experienced severe pain and was not transferred to the hospital for evaluation and treatment until the results were finally reviewed the next day. Additionally, the facility failed to ensure weekly wound monitoring and assessments for another resident with a venous ulcer. Although there was an order for regular wound care and the facility policy required weekly documentation of wound assessments, there was no evidence in the medical record that such assessments or monitoring were completed for over a month. The responsible LPN stated that wound measurements were not uploaded into the electronic medical record and that, during her absence, no documentation was available to confirm ongoing monitoring or assessment of the wound, including from outside wound care providers. These deficiencies were identified through medical record review, staff and vendor interviews, and policy review. The failures resulted in actual harm to one resident due to delayed treatment of a hip fracture and placed another resident at risk for more than minimal harm due to lack of wound monitoring.
Failure to Administer Facility to Ensure Resident Well-Being and Safety
Penalty
Summary
The facility failed to administer its operations in a manner that enabled effective and efficient use of resources to maintain the highest practicable well-being of its residents. In one instance, a resident with Full Code status was found without vital signs, and two LPNs did not initiate CPR, failed to call EMS, and called the time of death without contacting a physician, which was outside their scope of practice. The LPNs reported that the resident's family refused life-saving measures, but investigation revealed the Power of Attorney was not present at the time, contrary to what was initially reported to the Administrator. Another resident with a history of elopement was able to leave the facility undetected by leaving her wheelchair, which had a WanderGuard, in the lobby and ambulating out the front door. Staff failed to perform required 15-minute supervision checks and were unaware these checks were still required. The incident was not reported to the State Survey Agency as potential neglect, and the DON was unaware of the elopement until the complaint investigation began. No investigation or additional interventions were implemented at the time to ensure the resident's safety. Additional deficiencies included staff refusing to provide care for a resident, resulting in delayed care, and ongoing substance use issues within the facility. One resident was reported to use crack cocaine in the building daily, with administration aware but only providing education and removing paraphernalia when found. Other residents were observed with open containers of alcohol on facility premises, despite facility policies prohibiting routine alcohol consumption. These events demonstrate failures in supervision, adherence to policy, and reporting requirements, affecting the care and safety of all residents.
Failure to Ensure Call Light Accessibility and Adequate Linen Supply
Penalty
Summary
Surveyors identified that staff failed to ensure call lights were within reach for two residents who required assistance, despite care plans specifying this intervention. One resident, with a history of stroke, impaired mobility, and dependence for toileting and personal hygiene, was observed with her call light on the floor, out of reach. Another resident, who was legally blind and at risk for falls, was found with her call light draped over a chair or pinned above her head, both times inaccessible. Both residents confirmed they could not reach their call lights, and staff interviews verified the call lights were not within reach as required by facility policy and care plans. Additionally, the facility failed to maintain a sufficient supply of clean linens for resident use. Observations revealed a lack of clean towels and washcloths in multiple shower rooms, and a resident reported delayed morning care due to the unavailability of clean towels. Staff interviews confirmed the shortage and indicated a lack of awareness among management and laundry staff regarding the insufficient linen supply, resulting in delayed care for at least one resident and the potential to affect others.
Environmental Maintenance Deficiencies Identified
Penalty
Summary
The facility failed to maintain the environment in good repair, as evidenced by observations of water-stained ceiling tiles surrounding a sprinkler head, peeling wallpaper throughout the hallways, dirty and stained flooring, and patches of flooring that were worn and discolored from use. These deficiencies were confirmed during an interview with the Director of Maintenance, who stated that the sprinkler was no longer leaking but the stained ceiling tile could not be replaced until the sprinkler company completed their work, with no known date of service for the repair. The Director of Maintenance also indicated that the ceiling tile had been in this condition since he began working at the facility approximately one and a half months prior. Review of the facility's policy confirmed that the facility was required to provide a safe, clean, and comfortable environment, including necessary housekeeping and maintenance services.
Failure to Notify Physician of Missed TPN Dose
Penalty
Summary
The facility failed to notify a resident's physician of a missed dose of total parenteral nutrition (TPN) for a resident who was dependent on intravenous nutrition due to an intestinal blockage and was on a NPO (nothing by mouth) diet. The resident was admitted for TPN therapy and had multiple diagnoses, including intestinal blockage, intestinal fistula, colon cancer, hypertension, and chronic kidney disease. On the date in question, the Medication Administration Record indicated that the TPN was not administered, and nursing progress notes confirmed the missed dose, citing the need for an RN to administer the medication and that the on-call nurse was aware. Interviews with staff revealed that there was confusion regarding responsibility for clarifying TPN orders and administration, with LPNs directed to consult with RNs, and RNs expected to clarify orders with the physician or pharmacy. Despite these communications, there was no documentation that the resident's physician was notified of the missed TPN dose, as required by facility policy. The Director of Nursing confirmed that the physician was not informed of the missed dose, and the facility's policy mandates prompt notification of the physician in such situations.
Failure to Provide Functional Lighting for Visually Impaired Residents
Penalty
Summary
The facility failed to ensure that residents had working lights in their rooms, affecting two residents who were both cognitively intact and had significant visual impairments. One resident, admitted with a history of stroke, glaucoma, peripheral vascular disease, and heart disease, was dependent on staff for toileting and personal hygiene and required glasses for full-time use. Observations revealed that this resident's overbed light was not functioning, and the resident reported that the light had been out for approximately three weeks, even after being temporarily relocated due to a non-working bed. Another resident, diagnosed as legally blind, also did not have a functioning overbed light, with only the bathroom light operational in the room. This resident similarly reported that the room lights had not worked for three weeks. Staff interviews confirmed the non-functioning lights, and the Director of Maintenance acknowledged awareness of the issue, attributing it to broken underground electrical wires and indicating that repairs were pending. Facility policy required the maintenance of adequate and comfortable lighting levels, but periodic rounds to ensure functioning lights did not prevent this prolonged outage.
Failure to Report Elopement and Failure to Initiate CPR for Full Code Resident
Penalty
Summary
The facility failed to report two significant incidents to the State Survey Agency (SSA) as required by policy and regulation. In the first incident, a resident with a Full Code status was found not breathing and without a pulse, but staff did not initiate CPR as ordered. Both the LPN and the Administrator confirmed that CPR was not started, and review of the facility's reporting system showed no evidence that a self-reported incident (SRI) was submitted regarding this failure to implement life-saving measures. The resident's medical history included COPD, dementia, prostate cancer, and congestive heart failure, and the care plan specifically directed staff to initiate CPR and call 911 in such situations. In the second incident, another resident, who was cognitively intact and had multiple diagnoses including angina, depression, and schizoaffective disorder, exited the facility without staff knowledge and went to a nearby store. The resident exhibited delusional behavior and required emergency services, though ultimately returned to the facility with staff assistance. Video surveillance confirmed the resident left the building unaccompanied. Despite management being made aware and the incident being documented, there was no evidence that an SRI was submitted to the SSA regarding this elopement. The Administrator confirmed she was not notified of the elopement and that no report was made.
Failure to Investigate Resident Elopement Incident
Penalty
Summary
The facility failed to investigate an incident of elopement involving a resident who was identified as an elopement risk and had a care plan in place with specific interventions, including the use of a WanderGuard device and regular monitoring. The resident, who had diagnoses including schizoaffective disorder, depression, and anxiety, was cognitively intact according to the most recent MDS assessment. On the date of the incident, the resident exited the building without staff knowledge after a visitor entered the facility, and went to a nearby store. The resident exhibited delusional behavior, refused to return, and emergency services were contacted but later canceled. The resident eventually returned to the facility with staff assistance. Despite the incident, the facility did not initiate an immediate investigation as required by its own policy on abuse, neglect, and exploitation. The DON was not aware of the unsupervised elopement until several days after the event, and an investigation was not started until that time. This lapse in timely response and investigation of the elopement constituted the deficiency cited by surveyors.
Failure to Provide Scheduled Showers and Timely ADL Assistance
Penalty
Summary
The facility failed to ensure that dependent residents received scheduled showers and timely assistance with activities of daily living (ADLs), as evidenced by medical record reviews, resident and staff interviews, and policy review. Three residents were affected, each with varying degrees of cognitive and physical impairment, and all were dependent on staff for bathing and other ADLs. Documentation showed significant gaps between scheduled showers and actual bathing events, with some residents going up to 11 days without a shower or bed bath, and no evidence that care was offered or refused during these periods. For one resident with chronic respiratory and cardiac conditions, staff were documented as refusing to provide care due to frustration with the resident's behavior, resulting in the resident waiting extended periods for assistance and sometimes not being offered showers as scheduled. Interviews with CNAs, a unit manager, and the DON confirmed that staff frequently refused to care for this resident, and that the issue was ongoing and known to management. The resident also reported delays in receiving nighttime care, with staff claiming uncertainty about who was assigned to assist her. Another resident with severe cognitive impairment and a third resident requiring moderate staff assistance for bathing also experienced missed or delayed showers, with documentation showing long intervals without care and no record of refusals. The DON confirmed that these residents were not offered or provided showers as required. Facility policy required staff to provide care and services for all ADLs, including bathing, but this was not consistently followed for the residents reviewed.
Failure to Provide Timely Incontinence Care
Penalty
Summary
A deficiency occurred when a resident, who was cognitively intact and dependent on staff for toileting due to incontinence of bowel and bladder, did not receive timely incontinence care as required by her care plan and facility policy. The resident, with a history of congestive heart failure, diabetes mellitus, and chronic kidney disease, reported that her last incontinence care was provided at approximately 5:00 A.M. and that she had not been checked or changed since then. Staff interviews confirmed that the resident had not received incontinence care during the morning shift, despite the facility's policy to check and change incontinent residents every two hours and as needed. Observation later in the morning revealed the resident was wearing a heavily saturated incontinence brief, and staff present at the time verified the resident's report and the condition of the brief. Multiple CNAs interviewed acknowledged that they had not provided incontinence care to the resident during their shifts, with one CNA noting a staffing shortage due to a call-off. Review of the facility's Activities of Daily Living policy confirmed the expectation for necessary services to maintain personal hygiene for residents unable to perform ADLs.
Failure to Administer TPN per Physician Orders
Penalty
Summary
The facility failed to ensure that total parenteral nutrition (TPN) was administered according to physician orders for one resident who required this therapy. The resident, who had diagnoses including intestinal blockage, intestinal fistula, colon cancer, hypertension, and chronic kidney disease, was admitted specifically for TPN therapy. Physician orders specified the administration of a TPN Electrolytes Solution intravenously over a 14-hour period with detailed infusion rates. On one occasion, documentation on the Medication Administration Record indicated that the TPN was not administered, and nursing progress notes confirmed the missed dose, citing the need for an RN to administer the medication and a lack of clarification regarding the order. Interviews with staff revealed that there was confusion among the nursing staff regarding responsibility for clarifying and administering the TPN. The on-call LPN directed the in-house LPN to consult with the RNs present, as RNs were responsible for TPN administration. The Director of Nursing confirmed that two RNs were present and responsible for the administration, and that the TPN solution was available in the facility at the time. Facility policy required verification of practitioner orders for TPN, but the missed administration occurred despite the medication being on site and staff being present.
Failure to Ensure Staff Competency in Advanced Directives and Radiology Procedures
Penalty
Summary
The facility failed to ensure that nursing staff demonstrated appropriate competencies in the implementation of advanced directives and acted within their scope of practice. In one instance, a resident with diagnoses including COPD, dementia, prostate cancer, hypotension, and hypertension with congestive heart failure was documented as Full Code, meaning all life-saving measures should be implemented if cardiac arrest occurs. When this resident was found without vital signs, two LPNs did not initiate CPR and instead pronounced the resident dead, which is outside their scope of practice and contrary to facility policy and state regulations. Both LPNs had current CPR certifications, and one acknowledged in an interview that she should have performed CPR regardless of family wishes due to the Full Code status. The facility policy required staff to provide basic life support in accordance with the resident's advanced directives, and state law specifies that LPNs are not authorized to pronounce death. In another case, the facility failed to ensure staff were knowledgeable about procedures for obtaining and acting on radiology results. A resident with multiple diagnoses, including heart failure and a history of cancer, reported severe hip pain and received a stat X-ray order. Although the X-ray was completed and the results were available within an hour, the facility did not receive or act on the results until the following day. The DON confirmed that the results should have been followed up within four to six hours, and the nurse on duty reported not knowing where else to check for the results beyond the medical record system. The delay in receiving and acting on the X-ray results was attributed to a lack of staff knowledge regarding the facility's procedures for obtaining radiology reports. These deficiencies were identified through medical record review, staff interviews, review of job descriptions, educational consultation forms, and facility policy. The incidents affected two of four residents reviewed for staff competencies, with a facility census of 79 at the time of the survey.
Failure to Provide Adequate Behavioral Health Services for Substance Use Disorders
Penalty
Summary
The facility failed to provide necessary behavioral health care and services to residents with substance use disorders, as evidenced by multiple documented incidents involving three residents. One resident with a history of cocaine use and moderate cognitive impairment was repeatedly found smoking unknown substances, suspected to be crack cocaine, both in his room and in designated smoking areas. Staff interviews confirmed that the resident regularly smoked crack inside the facility, and paraphernalia consistent with crack cocaine use was found in his possession. Despite these findings, the only interventions implemented were education and removal of paraphernalia, with no additional behavioral health services or substance use interventions provided. Another resident, also moderately cognitively impaired, was repeatedly found in possession of and consuming alcohol within the facility. Nursing notes and staff interviews documented several occasions where alcohol was confiscated from the resident, and the resident was re-educated about facility policy and the dangers of drinking while on medication. However, the care plan interventions were limited to education and general support, with no evidence of specialized substance use disorder treatment or behavioral health services being provided. A third resident with a history of alcohol and illegal substance use, as well as multiple medical and psychiatric diagnoses, was observed drinking beer in the facility's smoking area. Staff verified the presence of alcohol, and the resident's care plan included only encouragement to express feelings and maintain contact with supportive family and friends. There was no documentation of targeted behavioral health interventions or substance use disorder treatment. The facility's policy acknowledged the risks of alcohol use but did not outline or implement comprehensive behavioral health services for residents with substance use disorders.
Failure to Administer Insulin as Ordered
Penalty
Summary
A deficiency was identified when a resident with a diagnosis of diabetes mellitus did not receive insulin medications as ordered by the physician. Medical record review showed that the resident was cognitively intact and had physician orders for both long-acting and fast-acting insulin, including scheduled doses and sliding scale coverage. The Medication Administration Record (MAR) for March 2025 revealed multiple instances where the resident did not receive the prescribed insulin glargine and insulin lispro at scheduled times. There was no documentation in the nursing progress notes indicating that the resident refused these medications. During an interview, a registered nurse confirmed that missing initials on the MAR indicated the medications were not administered. The facility's policy required medications to be administered as ordered by the physician and in accordance with professional standards. The failure to administer insulin as ordered and the lack of documentation for missed doses or refusals led to the identified deficiency.
Resident Sexual Abuse by CNA
Penalty
Summary
The facility failed to protect a resident from sexual abuse by a staff member, resulting in actual harm. The resident, who had intact cognition and was dependent on staff for personal care, reported being sexually abused by a Certified Nursing Assistant (CNA) during showers. The abuse involved inappropriate and non-consensual contact, which occurred multiple times over a month. The resident expressed feelings of anxiety and anger following the incidents. The abuse was discovered when another CNA noticed the resident's discomfort during care and inquired about it. The resident disclosed the inappropriate actions of the first CNA, who had been rough and had inserted a gloved finger into the resident's anus multiple times. This disclosure led to an immediate report to the facility's administration and the initiation of an investigation. The facility's investigation revealed that the abusive CNA had previously made inappropriate comments about the resident to other staff members, which were initially dismissed as rumors. The abusive CNA was terminated for unrelated insubordination before the abuse allegations came to light. The police were contacted, and an investigation was initiated. The facility's policy on abuse defines such actions as willful infliction of injury and non-consensual sexual contact, which aligns with the reported incidents.
Failure to Timely Report Suspected Sexual Abuse
Penalty
Summary
The facility staff failed to report suspected sexual abuse in a timely manner, affecting one resident. The resident, who had intact cognition and was dependent on staff for personal care, reported that a Certified Nursing Assistant (CNA) had been sexually inappropriate during care. The resident expressed distress and anxiety during interviews, indicating that the inappropriate behavior occurred multiple times in December. The incident came to light when another CNA, who had overheard the accused CNA making inappropriate comments about the resident, was informed by the resident about the abuse. The resident described the inappropriate actions during personal care, which included the insertion of a gloved finger into the resident's rectum. Despite the resident's initial belief that the actions were accidental, the repeated nature of the incidents led to the realization of abuse. The facility's investigation revealed that the accused CNA had been assigned to care for the resident on specific dates and had made inappropriate comments to other staff members. The accused CNA was terminated for unrelated insubordination before the abuse allegations were known. The facility's failure to report the abuse promptly was identified as a deficiency, highlighting a lapse in the timely reporting of suspected abuse.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care to a dependent resident, identified as Resident #46, who was unable to perform activities of daily living independently. Resident #46, who had intact cognition, was dependent on staff for personal care due to conditions such as morbid obesity, congestive heart failure, asthma, and diabetes mellitus. On the night of 01/07/25, Resident #46 experienced a bowel movement at 12:15 A.M. but was not changed until 8:00 A.M. the following morning. Despite using the call light throughout the night, the resident reported that staff opened the door but refused to provide care, citing fear of being accused of sexual abuse. Interviews with staff confirmed that third shift CNAs refused to care for Resident #46 due to concerns about potential accusations of sexual assault, following a self-reported incident of sexual abuse by a staff member that was under investigation. The resident's room was observed to have a strong odor of feces, and the sheets were soiled, indicating neglect in providing necessary incontinence care. The facility's policy on Activities of Daily Living (ADLs) mandates that residents unable to perform these activities should receive necessary services to maintain hygiene, which was not adhered to in this case.
Unlicensed STNA Employed Without Ohio Certification
Penalty
Summary
The facility failed to ensure that a State Tested Nursing Aide (STNA) was properly licensed with the State of Ohio, which had the potential to affect all 77 residents. A review of the personnel file for STNA #200 revealed that the aide was hired with an expired nursing assistant registration from another state and had no current or expired licensure in Ohio. Despite this, STNA #200 worked multiple shifts, as evidenced by the clock in/out report, without the necessary certification. An interview with the Administrator confirmed that STNA #200 was employed and providing care to residents without being certified with the State of Ohio Nurse Aide Registry. The facility's policy requires that nurse aides must have completed a State-approved nurse aide training or competency evaluation program and provide documentation of certification within four months of hire. However, STNA #200 did not meet these requirements, as they were not certified in Ohio and had an expired out-of-state certificate.
Failure to Conduct Timely Fall Reviews and Assessments
Penalty
Summary
The facility failed to conduct timely fall reviews for four residents, all of whom were identified as high fall risks. Resident #70, who had dementia and required extensive assistance for mobility, experienced a fall resulting in a laceration. However, the post-fall evaluation was not completed until eight days later. Similarly, Resident #71, also with dementia, fell without injury, but the post-fall evaluation was delayed by 13 days. Resident #5, with multiple diagnoses including dementia and chronic obstructive pulmonary disease, experienced two falls on the same day, yet the post-fall evaluations were not completed within the required 72-hour timeframe. Additionally, Resident #62, who had chronic kidney disease and dementia, was overdue for a quarterly fall risk assessment, with the last assessment completed several months prior. The facility's policy mandates that fall risk assessments be conducted every 90 days and post-fall evaluations be completed within 72 hours. The Director of Nursing confirmed these lapses in compliance with the facility's fall prevention program, which aims to minimize fall risks through timely assessments and interventions.
Failure to Report Resident Elopement
Penalty
Summary
The facility failed to report a resident elopement to the state agency as required, affecting one resident identified as Resident #3. Resident #3, who was admitted with diagnoses including dementia and was identified as an elopement risk, managed to exit the facility through a fire safety door. The resident was found outside in the parking lot by a staff nurse and was brought back into the facility without injury. Despite the incident, the facility did not report the elopement to the state agency, as confirmed by the facility's administrator. Resident #3 had a history of wandering and was admitted to the facility due to increased wandering and safety concerns at home. Upon admission, the resident was assessed as cognitively impaired and independently mobile, with a wander bracelet placed on the resident's leg. On the day of the incident, the resident exited the building, and although the Wanderguard alarm was supposed to alert staff, it was not heard by the LPN who noticed the resident outside. The resident was outside for approximately three to five minutes before being escorted back inside. Interviews with staff revealed that the DON was notified of the elopement, and staff education was initiated. However, the staff statements regarding the incident were missing, and no self-reported incident was submitted to the state agency. The facility's policy on elopements and wandering residents requires adequate supervision and reporting to the state agency, which was not adhered to in this case.
Resident Elopement Due to Inadequate Investigation and Staffing
Penalty
Summary
The facility failed to conduct a complete and thorough investigation following the elopement of a resident identified as being at risk for wandering and elopement. The resident, who had a history of cognitive impairment and was independently mobile, was admitted to the facility with a diagnosis of dementia and other medical conditions. Despite being identified as an elopement risk and having a wander bracelet placed, the resident managed to exit the building through a fire safety door, triggering the Wanderguard alarm. On the day of the incident, staffing issues were noted, with one aide calling off and another arriving late, leaving only one nurse to cover both the Memory Care unit and another hall. The resident was found outside by a staff member who was on break and noticed the resident walking in the grass. The staff member did not initially recognize the resident and did not hear the alarm, which was unusual given the resident's Wanderguard. The resident was eventually brought back inside without injury, but there was no immediate follow-up or discussion about the incident among staff. The facility's investigation into the elopement was inadequate, lacking staff interviews and details about when the resident was last seen before the elopement. The Director of Nursing was informed of the incident and mentioned that staff education on elopement was being provided, but staff statements were missing. The Administrator was aware of the elopement but could not provide specifics about the incident or the investigation, indicating a lack of thoroughness in addressing the deficiency.
Failure to Provide Timely Shower Assistance
Penalty
Summary
The facility failed to provide timely assistance with showers to three residents who were dependent on staff for bathing. Resident #8, diagnosed with dementia and other conditions, was scheduled for showers twice a week but missed several scheduled showers and bed baths in September 2024, with no documentation explaining the omissions. Resident #57, with intact cognition and multiple health issues, was also dependent on staff for bathing. Despite being scheduled for showers twice a week, she received only one bed bath in September 2024 and was not offered or given a bath on several occasions. Resident #57 reported having to wait for family visits to receive bathing care. Resident #22, who was cognitively intact and had a self-care deficit due to various health conditions, was scheduled for showers twice a week. However, she missed several scheduled showers and bed baths in September 2024, with no refusals documented. Interviews with staff, including LPNs and STNAs, revealed that showers were not completed timely due to a lack of staff or unwillingness to perform the task. The DON confirmed that showers were only completed about 40% of the time, contrary to the facility's policy to assist residents with bathing as per schedule or request.
Failure to Complete Weekly Skin Assessments
Penalty
Summary
The facility failed to complete weekly skin assessments as per physician orders for two residents, affecting their care. Resident #8, who had diagnoses including dementia and diabetes mellitus, was dependent on staff for personal care and had a care plan indicating the need for regular skin inspections due to fragile skin. However, the resident's Weekly Skin Observation Sheets showed that skin checks were not performed in September 2024, and there was no documentation explaining the omission. Similarly, Resident #57, with diagnoses such as morbid obesity and chronic kidney disease, required skin inspections every shift and as needed. Despite a physician's order for weekly skin assessments, the resident's records indicated that skin checks were only performed twice in August and September 2024. Interviews with LPNs and the DON confirmed that the skin assessments were not completed timely, and the facility's policy required weekly assessments to prevent pressure injuries.
Failure to Prime Insulin Pens Leads to Medication Errors
Penalty
Summary
The facility failed to ensure that insulin pens were primed prior to administration, resulting in a significant medication error affecting two residents. Resident #42, who was cognitively intact and diagnosed with dementia, anxiety, and type II diabetes mellitus, was observed receiving insulin Lispro without the pen being primed by RN #208. The nurse removed the cap, attached the needle, and administered the insulin without priming the pen, which is necessary to remove air from the needle and ensure the correct dose is delivered. Similarly, Resident #38, also cognitively intact and diagnosed with hypertension, type II diabetes mellitus, and hypothyroidism, received insulin Aspart without the pen being primed. RN #208 verified the order and dose, but did not prime the pen before administration. The nurse was unaware of the need to prime insulin pens, as confirmed in an interview. The Director of Nursing verified that insulin pens require priming and that nurses receive education on medication administration, including the use of insulin pens. The manufacturer's instructions for both types of insulin pens emphasize the importance of priming to ensure proper dosing.
Delayed Physician Notification of Lab Results
Penalty
Summary
The facility failed to ensure timely physician notification of laboratory results for a resident, leading to a deficiency. The resident, who was cognitively intact but dependent on staff for activities of daily living and incontinent, had a physician order for a urinalysis with culture and sensitivity due to confusion. The urine was collected and sent to the laboratory, with results indicating a urinary tract infection caused by Klebsiella pneumoniae. However, the results were not communicated to the physician until four days after they were available, delaying the initiation of appropriate antibiotic treatment. The delay occurred because the Licensed Practical Nurse (LPN) responsible for collecting the urine was off duty for a few days and did not review the results upon returning. The facility's policy requires prompt notification of laboratory results that fall outside the clinical reference range, which was not adhered to in this case. This deficiency was identified during an investigation under Complaint Number OH00157792.
Failure to Provide Vegetables as Per Planned Menu
Penalty
Summary
The facility failed to provide vegetables as per the planned menu during the noon meal service, affecting seven residents. During the observation of the meal service, it was noted that the staff member responsible for plating meals did not have enough vegetables to include on the last few meal trays. This was confirmed through an interview with the staff member, who was unable to provide an explanation for the shortage or why additional vegetables were not prepared. The planned menu indicated that residents should receive a one-half cup portion of Italian blend mixed vegetables with their meal. Further investigation revealed that two residents received nothing from the kitchen during the meal service. The Dietary Manager later confirmed that the staff member should have prepared a side salad as an alternative when the cooked vegetables ran out. The staff member was new and likely unaware of this protocol. This deficiency was identified under a complaint investigation and was noted as a continued non-compliance issue from a previous annual survey.
Failure to Conduct Comprehensive Fall Investigations and Assessments
Penalty
Summary
The facility failed to ensure comprehensive fall investigations and post-fall assessments for two residents, leading to a deficiency in accident prevention and supervision. Resident #12, diagnosed with dementia and congestive heart failure, experienced two unwitnessed falls. Despite being assessed for injuries and receiving pain medication after the first fall, no further investigation or root cause analysis was conducted. The Director of Nursing (DON) confirmed that no additional fall investigation was completed beyond the initial incident reports. Resident #14, with diagnoses including alcohol abuse, epilepsy, and spinal stenosis, experienced multiple falls, some resulting in injuries such as abrasions and contusions. The facility's incident reports lacked detailed information on potential contributing factors like lighting, footwear, and call light accessibility. The DON confirmed that fall investigations were incomplete for several incidents and that neurological checks, required for unwitnessed falls, were not performed according to protocol. Additionally, no Fall Risk Assessments were completed following these incidents. The facility was unable to provide a policy regarding fall investigation processes, and the existing Fall Prevention Program policy was not adhered to, as post-fall assessments and care plan reviews were not consistently completed. The Head Injury policy, which mandates neurological checks after head injuries, was also not followed. This deficiency was identified during a complaint investigation, highlighting non-compliance with established protocols for fall prevention and management.
Failure to Ensure Appropriate Antibiotic Use for UTI
Penalty
Summary
The facility failed to ensure antibiotics were prescribed appropriately for the treatment of Urinary Tract Infections (UTI) for Resident #12. Resident #12, who had diagnoses of dementia and congestive heart failure, was admitted to the facility and required substantial assistance for daily activities. On June 13, 2024, hospice ordered Bactrim ds, an antibiotic, for 10 days and requested a urine sample for urinalysis and culture and sensitivity (UA C&S) to determine the appropriate antibiotic. However, the urine specimen leaked during transport, and no new specimen was obtained. Despite this, Resident #12 continued to receive the antibiotic as ordered without confirmation of the bacteria present or the appropriate antibiotic needed. The Infection Preventionist confirmed that the facility did not follow the Antibiotic Stewardship Protocol by failing to obtain a UA C&S. This oversight was discovered during a complaint investigation, highlighting a deficiency in the facility's antibiotic prescribing practices.
Inadequate Hand Hygiene During Food Preparation
Penalty
Summary
The facility failed to maintain appropriate hand hygiene practices during food preparation and service, affecting nearly all residents except two who did not receive food from the kitchen. During meal service, a staff member, after washing hands and donning gloves, engaged in multiple activities such as removing lids from the steam table, handling a food thermometer, and using oven mitts without changing gloves. The staff member then proceeded to plate food, using the same gloves to touch various utensils and even using her fingers to slide food onto plates. This was confirmed during an interview where the staff member acknowledged not changing gloves throughout the process. In another instance, a dietary staff member was observed preparing a turkey sandwich without changing gloves after touching unsanitized kitchen items such as the refrigerator handle and a mayonnaise container. The staff member was unaware of the need to change gloves before handling food. Additionally, another staff member was seen using bare hands to sprinkle cheese onto salads, which was against the facility's policy. The Dietary Manager confirmed that bare hand contact with ready-to-eat food was inappropriate. The facility's policy emphasized the importance of washing hands after contamination and changing gloves appropriately to prevent infection spread.
Failure to Provide Adequate ADL Assistance
Penalty
Summary
The facility failed to establish an effective Quality Assessment and Assurance committee to identify and address quality deficiencies, which had the potential to affect all 67 residents. The facility had previously received deficiencies for failing to provide necessary assistance with activities of daily living (ADLs) during multiple complaint surveys conducted over the past two years. During the annual survey conducted in May 2024, medical records for four residents revealed that the facility failed to provide timely and adequate assistance with ADLs. This was confirmed through observation and staff interviews. The Administrator acknowledged the repeated deficiencies related to ADL assistance since the previous annual survey.
QAA Committee Attendance Deficiency
Penalty
Summary
The facility failed to ensure that all required members of the Quality Assessment and Assurance (QAA) committee attended meetings at least quarterly. Specifically, the Medical Director or their designee did not attend any QAA committee meetings during the second quarter of 2023, from April to June. This was confirmed through a review of the QAA committee meeting sign-in sheets for 2023 and an interview with the Administrator, who verified the absence of the Medical Director or designee during this period. This deficiency had the potential to affect all 67 residents residing in the facility, as the facility census was 67.
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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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