Dixon Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Wintersville, Ohio.
- Location
- 135 Reichart Avenue, Wintersville, Ohio 43953
- CMS Provider Number
- 365629
- Inspections on file
- 35
- Latest survey
- January 21, 2026
- Citations (last 12 mo.)
- 13 (1 serious)
Citation history
Health deficiencies cited at Dixon Healthcare Center during CMS and state inspections, most recent first.
A cognitively intact hospice resident with multiple chronic conditions reported that two gold rings, one with a purple stone and one with a green stone, went missing after a room change. The concern was not entered into the grievance or missing items logs, and although an Ombudsman and an anonymous complainant raised the issue, the Administrator initially denied awareness of any such grievances. The Administrator later acknowledged knowing of the allegation but did not complete a grievance form or self-report to the state, questioning the resident’s account, while the Social Worker’s search and staff inquiries were not documented and the family was not contacted to verify the jewelry, resulting in a failure to protect the resident from misappropriation.
A resident with multiple chronic conditions and intact cognition reported that two gold rings, including an antique amethyst birthstone ring, went missing after a room change. An anonymous complaint and a volunteer Ombudsman raised the concern to facility staff, but the Administrator initially denied awareness of any grievances and later acknowledged knowing of the allegation without completing a grievance form or self-reporting the incident to the state agency. The Social Worker stated she searched the room and spoke with staff but had no documentation of an investigation, and neither the Administrator nor Social Worker contacted the resident’s family to verify the jewelry. These actions did not follow the facility’s policy requiring immediate reporting, timely investigation, and submission of results to the state agency for alleged misappropriation.
A cognitively intact resident with multiple chronic conditions and on hospice services reported that two gold rings, one with a purple stone and one with a green stone, went missing after a room change. An anonymous complainant and the Ombudsman raised the concern to facility staff, but the Administrator did not complete a grievance form, expressed doubt that the resident had owned the rings, and the Social Worker’s search and staff inquiries were not documented. The facility did not contact the resident’s family to verify the jewelry or complete the investigation steps outlined in its misappropriation policy, including formal documentation and required reporting.
A resident with multiple comorbidities, right-sided hemiplegia, and hospice care had physician orders and ADL documentation for bilateral enabler bars to assist with turning and repositioning, but after a room change and delivery of a new bed, the enabler bars were never installed. Over this period, staff continued to sign MAR/TAR entries indicating the bars were in place, even though the bed had no rails. The resident experienced two falls from bed and reported having repeatedly requested assist bars, while an anonymous complaint and an Ombudsman contact also raised concerns about the missing assist bars. The DON later confirmed that the ordered bilateral enabler bars had not been in place since the room change, despite being part of the resident’s plan of care.
A resident with chronic pain and multiple complex conditions did not receive prescribed opioid pain medication for approximately 30 hours due to delays in pharmacy processing and medication ordering following a pharmacy transition. The resident missed five scheduled doses, expressed concern about withdrawal, and staff were unable to access emergency stock during this period.
A deficiency was cited when a resident was not protected from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, due to insufficient safeguards and oversight by the facility.
The facility did not maintain an effective pest control program, resulting in ongoing issues with cockroaches in the kitchen and a persistent gnat infestation in a resident's room. Structural deficiencies such as cracked tiles, loose wall coverings, and a missing door seal were not repaired, allowing pests to enter and remain. Staff and residents confirmed the continued presence of pests, and pest control measures outlined in facility policy were not adequately followed.
The facility did not ensure residents could access their personal funds after business hours or on weekends. Only one staff member was responsible for distributing funds, and no process was in place for other staff to provide access outside of regular hours. Multiple staff and residents confirmed that this led to frustration and delays in accessing personal money, with some residents waiting days or being unable to obtain funds when needed.
A resident was not adequately protected from the wrongful use of their belongings or money, as required by facility policy. The report identifies a failure to safeguard personal property or funds, resulting in unauthorized use.
A resident with multiple behavioral and neurological diagnoses developed a skin tear and a bruise on the left arm, with no documentation or timely investigation into how these injuries occurred. Facility staff confirmed that an investigation was not initiated as required by policy, resulting in non-compliance.
A resident did not receive treatment and care in accordance with physician orders and their stated preferences and goals, resulting in a deficiency related to the delivery of individualized care.
A resident in need of pain management did not receive safe and appropriate pain management services, resulting in a deficiency related to the facility's failure to meet the resident's needs.
The facility did not ensure pharmaceutical services were provided to meet each resident's needs and failed to employ or obtain a licensed pharmacist, resulting in noncompliance with regulatory requirements.
A resident with complex medical conditions experienced a significant decline, including hypoxemia, tachycardia, and lethargy, which was observed by therapy staff and reported to the ADON and NP. Despite these findings, no comprehensive assessment or timely intervention was performed, and the resident's condition was not escalated to the medical provider. The resident was later found unresponsive and died from acute hypoxic and hypercapnic respiratory failure, with the facility's failure to recognize and respond to the acute change in condition resulting in actual harm.
A resident with multiple chronic conditions and severe cognitive impairment experienced a fall that was observed by her daughter via an electronic monitoring device. The facility failed to notify both the family and the physician of the incident, with inconsistent accounts from nursing staff regarding notification. Documentation of the fall was missing from the medical record on the date of the event, and a late entry was made days later. The DON confirmed there was no evidence of physician notification, in violation of facility policy.
A resident who was fully dependent on staff for care and had a documented preference for daily showers did not receive showers as requested, with records showing a mix of bed baths and showers and no evidence of shower refusals. Staff confirmed the lack of daily showers and absence of refusal documentation, resulting in non-compliance with the resident's care plan and facility policy.
Two residents experienced lapses in supervision and safety: one with dementia suffered a fall that was not documented or assessed according to policy, and another, cognitively intact, left the facility in a wheelchair and was found in the street without adequate staff monitoring. Both incidents involved failures to follow established protocols for accident prevention and resident supervision.
A resident with multiple chronic conditions did not have any in-person examination notes documented by the attending physician since admission. Instead, the Medical Director only co-signed notes from a Physician Assistant or Nurse Practitioner, contrary to facility policy requiring a physician's own progress note during visits. The DON confirmed the absence of required physician documentation.
The facility did not maintain accurate and timely medical records for two residents, including one with multiple chronic conditions whose fall was not documented until days later, and another who left the facility and was found in the street, with no record of the incident or staff interventions. The DON confirmed that required documentation was missing for both events.
A resident with a history of multiple chronic conditions and a wound infected with carbapenem-resistant Acinetobacter Baumannii was not placed on contact precautions despite uncontained drainage. Staff inconsistently used PPE, and the resident's wound drainage contaminated therapy and common areas. The facility also failed to promptly notify the health department and had confusion among staff regarding the correct isolation protocols.
The facility did not ensure that concerns raised by the Resident Council, such as call light wait times and ice water issues, were addressed or resolved in a timely manner. Meeting minutes lacked documentation of resolutions, required concern forms were not used, and there was no process to communicate outcomes back to the Council. A resident reported ongoing long call light wait times, and staff confirmed that concerns were not formally tracked or resolved.
A resident with intact cognition and requiring hemodialysis was neglected when staff failed to prevent complications from the resident picking at his fistula site, leading to hemorrhage and death. Despite being informed of the behavior, nursing home staff did not implement adequate interventions. Additionally, a staff member was involved in an inappropriate romantic relationship with another resident, raising concerns about professional conduct. These issues highlight deficiencies in monitoring, communication, and staff-resident boundaries.
A facility failed to report an alleged incident of staff-to-resident sexual abuse involving a resident with multiple medical conditions and a CNA. The incident, which was reported by another CNA, involved a kiss in the parking lot. Despite denials from the involved parties, text messages suggested a possible romantic involvement. The facility suspended and later terminated the CNA but did not report the incident to the State agency, believing it was not sexual abuse.
A facility failed to follow physician's orders to monitor a resident's dialysis fistula bruit and thrill every shift. The resident, with end-stage renal disease, had no documentation of this monitoring in the MAR or TAR. The DON confirmed the oversight was due to the order not being transcribed. The resident was later discharged to the hospital, where he expired.
The facility exceeded the acceptable medication error rate with two errors out of 29 opportunities, affecting two residents. Both residents, with chronic respiratory conditions, were administered Fluticasone propionate and salmeterol inhalation powder without being instructed to rinse and spit after use, as required by the manufacturer's guidelines. These oversights were confirmed by the staff involved.
The facility failed to properly handle isolation laundry and implement enhanced barrier precautions (EBP) during tracheostomy care and medication administration. Laundry staff did not use appropriate PPE, and isolation linens were not placed in biohazard bags. A resident with a tracheostomy did not receive proper care, as the RN failed to maintain a sterile environment and did not wear a gown. Another resident with a PEG tube did not receive proper infection control measures during medication administration, as the RN only wore gloves and did not don a gown.
The facility failed to provide adequate hot water for residents' hygiene needs, affecting four residents. Inconsistent hot water availability led staff to obtain hot water from the shower room for bed baths. The Maintenance Director, new to the role, identified a faulty thermostat in one of the hot water tanks and did not document temperature checks. Observations confirmed water temperatures below the required 105-120°F range, with some rooms taking several minutes to reach even the lower end. Despite equipment replacements, the facility lacked an action plan to address the issue.
The facility failed to notify the physician of significant weight loss for two residents. One resident lost 36.4 pounds in 29 days, and another experienced a 10.3% weight loss. Despite these significant changes, there was no documentation of physician notification, contrary to facility policy.
The facility failed to conduct quarterly care conferences for two residents, as required. One resident with multiple health issues had only two documented care conferences, while another had only one documented meeting since admission. The Social Services Designee admitted to not documenting several meetings and not having a formal process for inviting residents. The facility's policy lacked specific time frames for care conferences.
A facility failed to complete a discharge summary for a resident upon discharge or transfer. The resident had multiple diagnoses, including a displaced fracture and diabetes. A review revealed no discharge summary, instructions, or progress note in the medical record. The Administrator confirmed the lack of documentation, stating the family initiated the discharge.
A resident with a lumbar surgical wound did not receive timely and appropriate care due to missing and inconsistent wound care orders. The facility failed to document and follow specific wound care instructions, leading to discrepancies in treatment. The Visiting Wound NP lacked access to the resident's medical records, and the facility's wound nurse did not conduct comprehensive assessments, contributing to the deficiency.
A resident with a sacral pressure ulcer did not receive prescribed treatments, including Triad paste and Santyl, due to documentation and communication failures. The wound worsened, becoming unstageable with slough. The facility's LPN confirmed treatments were not administered as ordered, and the Wound NP's orders were not entered into the electronic medical record due to a system glitch.
A facility failed to monitor and assess a resident's restorative nursing program, leading to a deficiency in care. The resident, with multiple diagnoses, was supposed to receive passive ROM exercises but lacked initial and quarterly assessments, and progress notes. Observations showed incorrect exercises were performed, and the resident reported inadequate assistance. The facility's policy was not adhered to.
The facility failed to maintain hot water temperatures within safe limits, with two residents' rooms having water temperatures of 123.6°F, exceeding Ohio's regulatory requirement. The Maintenance Director confirmed the temperature, and the facility lacked a procedure for addressing such deviations. An interview with the Administrator revealed no action plan for when water temperatures exceed acceptable parameters.
The facility failed to assess and treat urinary incontinence for a resident with multiple health issues, lacking a comprehensive bladder assessment and care plan. Another resident had an indwelling urinary catheter without documented justification, with no known reason for its use confirmed by staff and representatives.
A facility failed to assist a resident in obtaining a state photo ID, necessary for accessing his bank account and maintaining Medicaid eligibility. Despite being notified months earlier, the facility had not provided the required assistance, risking the resident's Medicaid eligibility. The resident had an intact cognition level and was admitted with conditions including a pressure ulcer and diabetes.
A resident with multiple medical conditions, including osteomyelitis, required an eight-week course of IV cefazolin, which was not administered as ordered on several occasions. The facility's DON confirmed the missed doses, and there was no documentation explaining the omissions, despite the facility's policy requiring such documentation.
A facility failed to administer a pneumonia vaccine to a resident who had consented to it. The resident, with multiple health conditions, consented to the vaccine, but the Medication Administration Records for two consecutive months showed it was not given. An interview with the Infection Preventionist confirmed the vaccine was not administered.
A resident with multiple medical conditions experienced significant weight loss due to the facility's failure to provide a comprehensive and individualized plan for monitoring and addressing her nutritional needs. The facility did not consistently weigh the resident or document her intake of nutritional supplements, leading to a deficiency in care.
A facility failed to thoroughly investigate missing narcotic medications prescribed to a resident with rheumatoid arthritis and other conditions. The resident was prescribed morphine sulfate, and discrepancies were found between the Medication Administration Record and the actual amount remaining in the bottle. The facility's investigation revealed documentation errors, but did not account for all missing doses. The Director of Nursing and Administrator confirmed the investigation's shortcomings.
A facility failed to accurately document the administration of morphine sulfate for a resident, leading to discrepancies between the Medication Administration Record (MAR) and the controlled drug administration record. The hospice provider identified a significant difference between the expected and actual remaining medication, and the facility's investigation revealed that several doses were not properly signed out by staff.
A long-term care facility failed to prevent sexual abuse by a Maintenance Director (MD) against a resident with mental incapacity. The MD was witnessed in a compromising position with the resident, leading to his suspension and confession to sexual interactions over several months. The resident's mental health conditions indicated she was unable to consent, and the MD was arrested and charged with sexual assault.
The facility failed to timely report an allegation of sexual abuse involving a resident and a staff member, as well as an allegation of misappropriation involving another resident's bank card. The incidents were not reported to the state survey agency within the required timeframe, resulting in non-compliance.
The facility failed to serve palatable chicken, affecting nearly all residents. Observations showed the chicken was dry and tough, leading some residents to order substitutes or meals from outside. The kitchen ran out of asparagus, substituting it with green beans. A test tray confirmed the chicken's dryness and fibrous texture. The Culinary Director and kitchen staff acknowledged the issue, and the DON reported resident complaints to the Administrator.
The facility failed to provide consistent transportation for residents due to an inoperable van, affecting their access to medical appointments and activities. The van was only operational for four out of the last 25 months, and the facility did not take adequate measures to address the issue, such as purchasing another vehicle or sharing a van with a sister facility.
The facility failed to ensure proper sanitary pericare technique and lacked soap at the kitchen handwashing sink. An STNA did not change gloves after cleaning a bowel movement before touching bedcovers, contrary to policy. Additionally, the kitchen lacked soap at the handwashing sink, confirmed by staff, potentially affecting meal hygiene.
The facility failed to provide adequate transportation for residents, affecting their right to self-determination. A resident missed a mammogram appointment due to lack of transport, while two others faced banking issues as they couldn't visit the bank in person. The facility's lack of a functioning van for over a year contributed to these issues, impacting residents' ability to manage personal affairs and participate in community activities.
The facility failed to ensure residents' mail and packages were delivered unopened and on weekends, affecting three residents. A resident received opened mail from the Social Security office, and another received opened mail in a manila envelope. A third resident experienced a delay in receiving a package from Walmart. The facility lacked a mail policy, and mail was not delivered on weekends, contributing to these deficiencies.
A facility failed to implement new interventions for a resident experiencing recurring UTIs despite having an indwelling urinary catheter and multiple medical conditions. The resident had seven UTIs over nine months, but the facility did not update the care plan or provide additional education on incontinence care. Observations revealed improper glove use during pericare, and there was no evidence of increased nursing measures to prevent further infections.
A resident with multiple health conditions received inadequate meals due to the facility's failure to manage dietary preferences effectively. The resident's dislike list led to meal trays lacking entrees, as the facility's system eliminated all disliked items without providing alternatives. Interviews revealed a lack of policy to handle such situations, resulting in non-compliance with dietary requirements.
Failure to Investigate and Document Resident’s Report of Missing Jewelry
Penalty
Summary
The facility failed to protect a resident from misappropriation of personal belongings when staff did not appropriately respond to the resident’s report of missing jewelry following a room change. The resident, who had multiple medical conditions including COPD, lung cancer, hemiplegia, dementia, and chronic respiratory failure, was under hospice services but had an intact cognitive status with a BIMS score of 14/15. After being moved to a different room, the resident reported that two gold rings, one with a purple stone and one with a green stone, were missing. The resident stated she reported the missing rings to the Administrator on the day of the room change. An anonymous complaint later alleged that several items were missing after the room change, including an antique amethyst birthstone ring that was described in detail and characterized as irreplaceable, and that the Administrator refused to replace it or reach an amicable solution. Despite these reports, there was no documentation of the concern in the grievance/complaint log or the missing items log for the relevant months, and the Administrator initially stated there were no grievances or concerns filed and that he was unaware of missing jewelry. The Ombudsman reported that a volunteer Ombudsman had informed the Unit Manager about the missing rings, and the Unit Manager believed the facility was already aware. The Administrator later confirmed he knew of the allegation a few days after the room change but did not complete a grievance/concern form or self-report the incident to the state agency because he felt the resident could not adequately describe the rings or when she last saw them and questioned whether the rings existed. The Social Worker reported searching the resident’s room and speaking with staff but had no documentation to show an investigation was completed, and neither the Administrator nor the Social Worker contacted the resident’s family to verify the presence of the rings. These actions and omissions occurred despite a facility policy defining misappropriation as wrongful use of a resident’s belongings or money without consent.
Failure to Timely Report and Investigate Alleged Misappropriation of Resident Jewelry
Penalty
Summary
The deficiency involves the facility’s failure to timely report an allegation of misappropriation of a resident’s property to the state agency, as required by policy and regulation. The affected resident was admitted with multiple significant diagnoses, including COPD, lung cancer, hemiplegia and hemiparesis after stroke, depression, urinary incontinence, anxiety, dysphagia, aphasia, dementia, chronic respiratory failure with hypoxia and hypercapnia, and stage 2 chronic kidney disease, and was receiving hospice services. A quarterly MDS showed the resident had a BIMS score of 14/15, indicating intact cognition. The resident was moved from one room to another on Unit 2, and following this room change, the resident reported that several personal items, including two gold rings (one with a purple stone and one with a green stone), were missing. An anonymous complaint later alleged that after the room change, several items were missing, including an antique amethyst birthstone ring described as real gold with a [NAME]-cut stone that was beveled from years of wear, and another gold ring with a green stone. The complaint stated the missing items had been reported to social services but had not been located or replaced, and that the resident reported the Administrator refused to replace the ring or reach an amicable solution. The volunteer Ombudsman visited the facility and spoke with a Unit Manager about the missing rings; the Unit Manager stated she would relay the concern to management. When interviewed, the Administrator initially reported there were no grievances or concerns filed in the last three months and that he was not aware of any concerns regarding missing jewelry. Subsequent interviews and record review showed that the resident had, in fact, reported the missing rings to the Administrator on the day of the room change, and the rings remained missing at the time of survey. The Administrator later confirmed he was aware of the allegation a few days after the room change but did not complete a concern/grievance form and did not submit a self-reported incident to the state agency because he felt the resident could not adequately describe the rings or when she last saw them and was not convinced the resident had the rings. The Social Worker reported searching the resident’s room and speaking with staff but had no documented evidence of an investigation. Neither the Administrator nor the Social Worker contacted the resident’s family to confirm the presence of the rings at the facility. These actions and omissions were inconsistent with the facility’s written policy, which required immediate reporting of misappropriation allegations (no later than two hours after the allegation), timely investigation with documented statements and findings, and submission of investigation results to the state agency within five working days.
Failure to Investigate Allegation of Misappropriated Jewelry
Penalty
Summary
The deficiency involves the facility’s failure to investigate an allegation of misappropriation of a resident’s personal property in accordance with its own abuse, neglect, and misappropriation policy. Resident #3, who had multiple medical conditions including COPD, lung cancer, hemiplegia, dementia, chronic respiratory failure, and was on hospice services, was assessed as cognitively intact with a BIMS score of 14/15. After being moved to a different room on Unit 2, the resident reported that two gold rings, one with a purple stone and one with a green stone, were missing. The resident stated she reported the missing rings to the Administrator on the day of the room change. An anonymous complaint later alleged that several items, including an antique amethyst birthstone ring and another gold ring with a green stone, were missing after the room change, and that the Administrator refused to replace the items or reach an amicable solution. The Ombudsman’s volunteer reported the concern about the missing rings to the Unit Manager, who believed the facility was already aware. The Administrator initially stated he was not aware of concerns regarding missing jewelry, but later confirmed that the resident had reported missing rings a few days after the room change. He acknowledged he did not complete a concern/grievance form and stated he was not convinced the resident had the rings because she could not provide details. The Social Worker reported she searched the resident’s room and spoke to staff but had no documentation to show an investigation was completed, and neither the Administrator nor the Social Worker contacted the resident’s family to confirm the presence of the rings at the facility. Review of the facility’s misappropriation policy showed that each occurrence of misappropriation was to be reported, investigated timely, with statements obtained, documentation in the medical record, and a formal investigation report completed and submitted to the state, none of which were documented for this allegation.
Failure to Provide Ordered Enabler Bars Resulting in Two Bed Falls
Penalty
Summary
The deficiency involves the facility’s failure to ensure that ordered bilateral enabler bars were in place on a resident’s bed to prevent falls. The resident had multiple significant diagnoses, including COPD, lung cancer, hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side, depression, urinary incontinence, dysphagia, aphasia, dementia, chronic respiratory failure, and stage two chronic kidney disease, and was receiving hospice services. A quarterly MDS showed the resident was cognitively intact with a BIMS score of 14, used a wheelchair, and required supervision or touching assistance for transfers. The resident’s ADL documentation from late August and late November indicated bilateral enablers to assist with turning and repositioning, and physician orders dated January showed bilateral enabler bars had been ordered since late August for this purpose. Despite these orders, the resident experienced two falls from bed after a room change. Progress notes documented that in December the nurse was called and found the resident on the floor near the bed, with the resident stating she was trying to get up from bed when she fell; neurological status and vital signs were assessed and the resident denied pain. A subsequent clarification indicated this fall was unwitnessed. In mid-January, another progress note recorded the resident lying on her right side on the floor next to the bed, stating she had slid; she denied attempting to get out of bed and denied hitting her head, and a bruise was noted on the left lower extremity. Neuro checks were within normal limits, and the resident was assisted back to a wheelchair while bed linens were changed. Record review showed that staff had been signing the medication and treatment administration records in December and January indicating that bilateral enabler bars were in place, even though no bars were actually on the bed. An anonymous complaint reported that the resident had fallen out of bed because she did not have assist bars, and that she had requested assist bars multiple times since mid-December. The resident confirmed during interview that she had not had enabler bars on her bed since moving to the new room until a half rail was installed the day before the surveyor’s observation, and she stated she preferred an enabler bar. The DON confirmed that when the resident’s room was changed in November, the resident did not take the prior bed, and when hospice delivered a new bed in December, it did not include enabler bars, leaving the resident without the ordered bilateral enabler bars despite ongoing documentation that they were in place and despite two falls from bed during this period.
Failure to Ensure Timely Ordering and Availability of Pain Medication
Penalty
Summary
The facility failed to ensure that medications were ordered in a timely manner and available for administration, resulting in a resident not receiving prescribed pain medication as ordered. The resident, who had a history of traumatic brain injury, quadriplegia, neuropathy, muscle spasms, and chronic pain, was dependent on staff for most activities of daily living and received opioid medication for pain management. The care plan included both pharmacological and non-pharmacological interventions for pain, and the resident was scheduled to receive Percocet multiple times daily. On one occasion, the resident was out of Percocet for approximately 30 hours, missing five scheduled doses. Documentation showed that the facility had recently switched to a new pharmacy, which led to issues with the timely delivery of narcotic medications. Staff were unable to access emergency stock, and there was a delay in the pharmacy receiving and processing the prescription from the pain management clinic. During this period, the resident expressed concern about withdrawal symptoms and was offered transport to the emergency room, which was declined. Interviews with staff and review of records confirmed that the medication was not available due to the pharmacy transition and delays in prescription processing. The resident reported that this was not the first time such an incident had occurred and was told that future orders would be placed earlier to prevent recurrence. The deficiency was confirmed by the DON, who verified the missed doses and the duration the resident went without the ordered pain medication.
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 protective measures and oversight.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by multiple documented concerns and observations of pest activity affecting both the kitchen and resident areas. Pest control invoices and state survey agency complaints revealed ongoing issues with cockroaches in the kitchen, including German and oriental roaches, as well as structural deficiencies such as loose wall coverings, cracked tiles, gaps between baseboards and walls, and a missing door seal that allowed light and pests to enter. Despite pest control services and repeated identification of these issues, the necessary repairs to prevent pest entry and harboring were not completed. Staff interviews confirmed the persistence of these problems, and the facility was without a Maintenance Director at the time, further delaying resolution. Additionally, a resident with a colostomy bag who was bedbound reported a significant gnat infestation in his room, which was confirmed by both a medical provider and facility staff. Observations documented the presence of multiple gnats on the resident's pillow, bedside table, and wall, with the issue persisting over at least two weeks. Staff and residents reported ongoing problems with both gnats and roaches throughout the building, particularly in the kitchen and the affected resident's room. The facility's pest control policy required regular monthly treatments and prompt response to pest problems, but these measures were not effectively implemented, resulting in continued pest presence.
Failure to Provide Resident Access to Personal Funds After Hours
Penalty
Summary
The facility failed to ensure that residents had access to their personal funds after business hours and on weekends. Four residents with personal funds accounts managed by the facility were affected. Observations and interviews revealed that only one staff member, HR #153, was responsible for dispensing resident funds, and she did not leave the money box accessible to other staff after her shift ended at 5:00 P.M. on weekdays or on weekends. Multiple staff members, including RNs, LPNs, and CNAs, confirmed they did not have access to the funds box outside of business hours, and residents were required to withdraw money before HR #153 left for the day. Residents reported being unable to access their funds after hours and on weekends, with some stating they had to wait days to receive money or that the facility had run out of money in the personal funds box. Staff interviews corroborated that residents voiced frustration and concerns about not having timely access to their funds. Review of the facility's policy indicated a requirement to comply with federal and state regulations regarding resident funds, but the observed practices did not align with this policy.
Failure to Protect Resident's Belongings or Money
Penalty
Summary
A deficiency was identified regarding the protection of residents from the wrongful use of their belongings or money. The report notes that there was a failure to safeguard a resident's personal property or funds, resulting in unauthorized or inappropriate use. Specific details about the actions or omissions that led to this event are not provided in the report excerpt.
Failure to Timely Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to timely investigate an injury of unknown origin for a resident with multiple complex diagnoses, including Alzheimer's disease, dementia with behavioral disturbances, conversion disorder with seizures, anxiety, depression, paranoid schizophrenia, and a nontraumatic intracerebral hemorrhage. Medical record review showed the resident was admitted with fragile skin and later developed a skin tear on the left elbow, as well as a bruise on the left lower arm. There was no documentation in the resident's record explaining how the skin tear or bruise occurred, nor was there evidence of an investigation into these injuries at the time they were discovered. Observation of the resident revealed a dressing on the left elbow, a dark purple bruise on the left lower arm, scratches on the upper arm, scabs above the dressing, and slight edema to the left arm. Interviews with facility staff confirmed that no investigation had been conducted to determine the cause of the injuries, and the facility's policy required timely identification and investigation of injuries of unknown origin. The lack of timely investigation and documentation regarding the injuries constituted non-compliance with facility policy and regulatory requirements.
Failure to Provide Care According to Orders and Resident Preferences
Penalty
Summary
The deficiency involves a failure to provide appropriate treatment and care according to physician orders, as well as the resident’s preferences and goals. The report indicates that care was not delivered in alignment with the established plan or the expressed wishes and objectives of the resident, as required.
Failure to Provide Safe, Appropriate Pain Management
Penalty
Summary
A resident who required pain management services did not receive safe and appropriate pain management. The report identifies a deficiency in the facility's provision of necessary pain management for a resident in need, but does not provide further details regarding the specific actions or omissions that led to this deficiency, nor does it include information about the resident's medical history or condition at the time.
Failure to Provide Required Pharmaceutical Services
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated by regulations.
Failure to Respond to Acute Change in Condition Resulting in Resident Death
Penalty
Summary
The facility failed to provide timely, necessary, and adequate care and services following an acute change in condition for a resident with multiple complex medical diagnoses, including morbid obesity, heart failure, sleep apnea, and respiratory failure. The resident was noted by therapy staff to have a significant decline in health, including hypoxemia, tachycardia, excessive daytime sleepiness, and lethargy while in therapy. Despite these abnormal findings, there was no evidence that a comprehensive nursing assessment was performed, nor were individualized interventions implemented. The therapy staff notified the Assistant Director of Nursing (ADON), who observed the resident and communicated with the on-site nurse practitioner (NP), but the NP did not assess the resident, and no further action was taken to address the acute change in condition. Throughout the day, the resident continued to exhibit increased somnolence, lethargy, and loud snoring, which were not comprehensively addressed by nursing staff. Documentation showed that the resident's oxygen saturation levels were critically low and heart rate was elevated during therapy, and the resident was unable to participate in therapy due to these symptoms. Despite these clear signs of deterioration, there was no evidence of timely communication with the medical provider, no comprehensive assessment, and no escalation of care. Nursing documentation was incomplete, and staff interviews revealed a lack of awareness and follow-through regarding the resident's change in condition. Later that evening, the resident was found unresponsive and without vital signs by an LPN during medication administration. Cardiopulmonary resuscitation was initiated, and emergency services were called, but the resident was pronounced deceased. The cause of death was determined to be acute hypoxic and hypercapnic respiratory failure. The facility's failure to recognize, assess, and respond to the resident's acute change in condition, as well as the lack of communication and documentation, directly contributed to the deficiency and resulted in actual harm and death.
Failure to Notify Family and Physician of Resident Fall
Penalty
Summary
A deficiency occurred when the facility failed to notify both the family and physician of a resident's fall. The resident, who had multiple diagnoses including chronic diastolic congestive heart failure, diabetes, hypertension, and dementia, was admitted with significant cognitive and physical impairments, requiring staff assistance for most activities of daily living. On the date of the incident, the resident's daughter, who monitored her mother via an electronic camera, observed her mother on the floor and reported not receiving any notification from the facility about the fall. The Director of Nursing (DON) confirmed that the daughter presented video evidence of the fall, and the nurse involved gave inconsistent accounts regarding whether the family was notified, including stating that he was told not to call the family and later claiming to have sent a text, which the daughter did not receive. Review of the medical record showed no documentation of the fall on the date it occurred, and a late entry was made several days later, indicating the resident was found slanted in her wheelchair and that the daughter was texted. However, there was no evidence that the physician was notified of the fall, as required by the facility's policy on notification of changes in condition. The DON verified that there was no documentation of physician notification and acknowledged the inconsistencies in the nurse's account of family notification.
Failure to Provide Showers per Resident Preference
Penalty
Summary
A resident with multiple complex medical conditions, including chronic diastolic congestive heart failure, diabetes, hypertension, dementia, and other diagnoses, was admitted to the facility and was totally dependent on staff for activities of daily living, including bathing. The resident's care plan and admission assessment documented that the resident or their representative preferred daily showers. Despite this documented preference, review of bathing records showed that the resident did not receive showers daily; instead, the resident received a combination of bed baths and showers, with at least one day where no bath was documented. There was no documentation of the resident refusing showers, and staff confirmed that no refusal sheets existed for this resident. Facility policy required routine daily care, including bathing, to be provided by certified nursing assistants under the supervision of a licensed nurse. However, the facility failed to ensure that the resident received showers according to their stated preference. This deficiency was identified through record review, hospice communication, and staff interview, and it affected one resident reviewed for showers during the survey.
Failure to Prevent Accidents and Provide Adequate Supervision
Penalty
Summary
The facility failed to ensure that accident hazards were minimized and adequate supervision was provided to prevent accidents, as evidenced by two separate incidents involving two residents. In the first case, a resident with multiple diagnoses including dementia, congestive heart failure, and impaired decision-making experienced a fall in her room. The fall was discovered by the resident's daughter via electronic monitoring, but there was no documentation of the incident in the medical record, no immediate intervention, and no post-fall assessment or follow-up as required by facility policy. The Director of Nursing confirmed that the nurse on duty did not document the fall, complete an incident report, or implement any new interventions until days later, after being shown the camera footage by the resident's daughter. In the second case, another resident with a history of pulmonary embolism, chronic pain, and no cognitive impairment left the facility in his wheelchair and was found in the middle of a public street. Staff were aware the resident intended to leave to purchase alcohol and attempted to redirect him, but he signed himself out for a leave of absence and remained outside for several hours. Staff did not maintain supervision or check on the resident during this time. The situation escalated to the point where law enforcement and the facility administrator had to intervene to return the resident to the facility. Documentation showed the resident had never previously signed out for a leave of absence, and staff did not contact the physician regarding the resident's request for alcohol. Both incidents demonstrate a lack of adherence to facility policies regarding fall prevention, post-incident assessment, and supervision of residents, particularly those with known risks or behavioral concerns. The facility's failure to document, assess, and intervene appropriately after the fall, as well as the lack of supervision and monitoring of a resident who left the premises, contributed to the deficiencies cited in the report.
Lack of Physician In-Person Examination Documentation
Penalty
Summary
The facility failed to provide evidence that the attending physician conducted in-person examinations for all residents as required. Specifically, for one resident with multiple complex diagnoses including Type 2 Diabetes Mellitus with neuropathy, asthma, morbid obesity, bipolar disorder, atrial fibrillation, acute respiratory failure, hypertension, and hyperlipidemia, there were no physician progress notes documented in the medical record since admission. The medical record review showed that the Medical Director, who was the attending physician, only co-signed notes written by a Physician Assistant or Nurse Practitioner and did not write any direct physician notes for the resident. The facility's policy requires the physician to review the resident's plan of care during visits and to write and sign a progress note, but this was not followed in this case. The Director of Nursing confirmed the absence of physician notes for the resident.
Failure to Maintain Accurate and Timely Medical Records for Significant Resident Events
Penalty
Summary
The facility failed to maintain accurate and timely medical records for two residents, resulting in incomplete documentation of significant events. For one resident with multiple chronic conditions, including congestive heart failure, diabetes, and dementia, there was no documentation of a fall that occurred in her room until three days after the incident, when her daughter presented video evidence to the DON. The nurse did not document the fall, complete an incident report, or implement immediate interventions, leaving the resident's medical record incomplete and inaccurate. In another case, a resident with a history of pulmonary embolism, pleural effusion, and chronic pain left the facility in a wheelchair and was found in the middle of a street. Police and facility administration were involved in returning the resident to the facility. Despite the seriousness of the event, the medical record did not include any documentation of the resident being in the street, the involvement of law enforcement, or the efforts made by staff and administration to return the resident to the facility. Interviews with the DON confirmed that in both cases, the medical records did not accurately reflect the events that occurred, nor did they include timely or complete documentation as required by facility policy. The lack of documentation failed to provide a truthful and current account of the residents' status and the care provided during these incidents.
Failure to Implement Contact Precautions for Resident with Uncontained MDRO Drainage
Penalty
Summary
A deficiency occurred when the facility failed to implement appropriate contact isolation precautions for a resident with a multi-drug resistant organism (MDRO) infection, specifically Acinetobacter Baumannii Carbapenem Resistant, whose wound drainage was not contained. The resident had a complex medical history including cellulitis, morbid obesity, congestive heart failure, chronic kidney disease, and lymphedema, and was admitted for skilled care with ongoing wound management. Despite orders for enhanced barrier precautions, the resident was not placed on contact precautions even after the wound culture confirmed the presence of a highly resistant organism with uncontained drainage. Staff interviews and record reviews revealed that the resident's wound was actively draining, resulting in wet footprints and contaminated surfaces in therapy and common areas. Staff used gloves and sometimes gowns during therapy, but there was no consistent use of contact precautions, no dedicated equipment, and no requirement for staff to gown and glove upon entering the resident's room. The resident was observed to move independently through the facility, leaving wet areas from the wound drainage, indicating a failure to contain infectious material and prevent potential transmission. Additionally, the facility did not promptly notify the local health department as required after the identification of the MDRO, and there was confusion among staff regarding the implementation and discontinuation of enhanced barrier versus contact precautions. Documentation inconsistencies were noted, with forms indicating contact precautions were in place when only enhanced barrier precautions had been implemented. The infection control oversight was in transition, with responsibilities shifting between staff, contributing to the lack of appropriate infection prevention measures for the resident.
Failure to Address Resident Council Concerns in a Timely Manner
Penalty
Summary
The facility failed to address concerns raised by the Resident Council in a timely manner, as evidenced by a review of Resident Council meeting minutes, policy documents, and staff and resident interviews. Concerns about call light wait times were repeatedly mentioned in several meetings, and issues with ice water were also raised. However, the minutes did not document any resolutions to these concerns, and the facility's policy requiring concerns to be documented, distributed to department heads, and followed up through the Resident Grievance Procedure was not followed. Staff interviews confirmed that concern forms were not used, concerns were not formally presented to department heads, and there was no process to communicate resolutions back to the Resident Council. A resident reported ongoing issues with excessive call light wait times, including a specific instance of a two-hour wait. The Director of Activities, who presides over Resident Council meetings, acknowledged that resolutions to concerns were not brought back to the Council. The Social Service Designee maintained a separate concern log for other issues but did not handle Resident Council concerns. The Administrator confirmed there was no documentation of complaint resolution for Resident Council issues, and the last call light audit was conducted prior to the most recent meeting where call light concerns were still being reported. This deficiency was identified during an investigation under a specific complaint number and had the potential to affect all residents in the facility.
Neglect and Inappropriate Staff-Resident Relationship
Penalty
Summary
The facility failed to prevent an incident of neglect involving a resident who required hemodialysis. The resident, who had intact cognition, was observed by dialysis staff picking at his fistula site. Despite being educated not to pick at it, the resident continued to do so. The dialysis staff communicated this incident to the nursing home staff, but no adequate measures were taken to prevent complications. The night shift nurse only applied a dressing without further assessment or intervention. Subsequently, the resident was found unresponsive, hemorrhaging from the fistula site, and later passed away. The facility's failure to implement effective interventions after identifying the resident's behavior of picking at his fistula site led to the resident's death. The resident's call light was activated, but it is unclear for how long before he was found unresponsive. The facility's documentation revealed no evidence of staff checking the dialysis graft site for bruit and thrill every shift as ordered. Additionally, the facility investigation showed that the last staff to see the resident alive did not observe any picking at the fistula site, indicating a lack of proper monitoring and communication among staff. Another concern identified was the facility's failure to prevent potential staff-to-resident abuse when a staff member was involved in an inappropriate romantic relationship with another resident. This issue, although not rising to the level of Immediate Jeopardy, affected two residents. The facility's investigation into this matter revealed conflicting statements and text message exchanges between staff members, indicating a lack of clear boundaries and professional conduct within the facility.
Removal Plan
- The DON began collecting statements from all staff who worked on Resident #72's unit in last 24 hours. All statements were collected.
- The Director of Human Resources #260 gave the DON all cardiopulmonary resuscitation (CPR) cards of the nurses completing CPR.
- Licensed Practical Nurse (LPN) Unit Manager (UM) #208 completed assessments on residents who had dialysis ports or fistulas. The assessments included checking for any signs of infection, any bleeding, dry and intact dressings, and bruit and thrill for Resident #71's arteriovenous (AV) fistula and Resident #64's right upper cervical (RUC) hemodialysis (HD) port.
- The DON initiated education to all 24 licensed nurses. The education pertained to the policy titled Hemodialysis Care and Monitoring with emphasis on the assessment of ports and shunts, pre and post assessments on dialysis residents, all dialysis orders, and on dialysis monitoring orders. The education also included communication between the facility and dialysis center every dialysis day and to initiate immediate dialysis interventions. New licensed nurses would be educated by the DON or designee during new hire orientation.
- The DON initiated education of the facility's Abuse, Neglect, and Misappropriation Policy. The education was completed for all 24 licensed nurses and all 29 CNA's. New nurses and CNAs would be educated during new hire orientation.
- The DON initiated an audit on all dialysis residents to validate dialysis orders to monitor residents' dialysis sites. Orders were corrected for Resident #71's left upper arm fistula and added to the treatment record. A physician order to check Resident #71's dialysis graft site for bruit and thrill every shift was initiated.
- The DON reviewed and revised care plans for dialysis residents to ensure accuracy and Resident #71's was updated to ensure accuracy related to the type of fistula he had.
- An Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting was held with the Administrator, DON, Regional Director of Operations (RDO) #217, Regional Director of Clinical Operations (RDCO) #218, Diversional Director of Clinical Operations (DDCO) #219, President (VP) of Risk #220, VP of Operations #221, and VP of Clinical Operations #222.
- A Root Cause Analysis was completed by the DON, Administrator, Assistant Director of Nursing (ADON) #213, Divisional Director of Risk #223, and LPN UM #208. Licensed nurses CPR licenses were verified. The analysis determined the problem to be cardiac arrest secondary to hypovolemic shock due to hemorrhage from AV fistula per hospital documentation. Care plans, orders, and code statuses were reviewed for accuracy, dialysis patients were assessed, and nurses received education on Hemodialysis Care and Monitoring and medication administration.
- The facility initiated audits for neglect through Angel Rounds (monitoring completed by department heads Monday through Friday on the residents) through observation and interviews of three staff and three residents, five days a week for four weeks.
- The DON/designee would audit three dialysis residents, three times a week for four weeks then randomly thereafter to ensure dialysis orders were in place to monitor the shunt site with the schedule, pre/post dialysis forms were completed, and care plans and orders reflected dialysis recommendations, and any monitoring needed. The DON/designee will validate that the facility received communication forms from the dialysis center three days a week for four weeks then randomly thereafter.
- Education to all staff on answering call lights in a timely fashion was completed by the DON/designee. New staff would be educated during new hire orientation.
- The ED/designee would initiate call light audits on three call lights, three days a week and interview five residents a week on call light response times for four weeks then randomly thereafter.
- The results of audits will be forwarded to the facility QAPI committee for further review and recommendations until substantial compliance is maintained. The Medical Director will give input into any data presented and plans proposed by the Committee.
Failure to Report Alleged Staff-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to report an allegation of staff-to-resident sexual abuse to the State agency, affecting one resident. The incident involved a resident with multiple medical conditions, including end-stage renal disease and major depressive disorder, who was reported to have kissed a Certified Nursing Assistant (CNA) in the parking lot after her shift. The facility's investigation revealed conflicting accounts from the involved parties, with the resident and the CNA denying any inappropriate behavior, while another CNA reported witnessing the incident. The facility's investigation included reviewing text messages between the CNAs, which suggested a possible romantic involvement between the resident and the CNA. Despite the denial from both the resident and the CNA, the facility suspended the CNA pending investigation and later terminated her employment for violating company policy. The facility updated the resident's psychosocial care plan to address potential psychosocial issues. Interviews with staff and residents revealed that there were rumors and observations of inappropriate behavior between the CNA and the resident. The facility's Administrator was aware of these rumors but did not report the incident to the State agency, believing it was not sexual abuse due to the denials from the involved parties. The facility's policy required reporting of non-consensual sexual contact, but the Administrator did not consider the incident to meet this criterion.
Failure to Monitor Dialysis Fistula as Ordered
Penalty
Summary
The facility failed to follow physician's orders to monitor the dialysis fistula bruit and thrill for a resident who required such services. The resident, who had multiple diagnoses including end-stage renal disease with dialysis, was admitted to the facility and had an order to check his dialysis graft site for bruit and thrill every shift. However, the review of the Medication Administration Records (MAR) and Treatment Administration Records (TAR) revealed no documentation of staff checking the dialysis graft site for bruit and thrill every shift for the resident. An interview with the Director of Nursing confirmed that the resident had an order to check his dialysis bruit and thrill every shift, but the nurse had not been performing this task because it was never transcribed onto the MAR or TAR. The facility's policy on Hemodialysis Care and Monitoring emphasized the importance of monitoring the vascular access device for signs such as thrill and bruit, but this was not adhered to in the case of the resident. The resident was later discharged to the hospital, where he expired.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a rate of 6.9% due to two medication errors out of 29 opportunities. This affected two residents who were observed for medication administration. Resident #66, diagnosed with chronic respiratory failure, COPD, dyspnea, and schizophrenia, was administered Fluticasone propionate and salmeterol inhalation powder without being instructed to rinse and spit after use, as per the manufacturer's guidelines. This oversight was confirmed by Medication Technician #200 during an interview. Similarly, Resident #59, with diagnoses including COPD, acute respiratory failure, asthma, cerebral ischemia, dependence on supplemental oxygen, and emphysema, was also administered the same medication without being instructed to rinse and spit. This was confirmed by Intern Registered Nurse #201. Both instances of non-compliance with the manufacturer's instructions contributed to the facility's medication error rate exceeding the acceptable threshold, as investigated under Complaint Number OH00163468.
Infection Control Deficiencies in Laundry and Resident Care
Penalty
Summary
The facility failed to properly handle and sanitize isolation laundry, as well as implement enhanced barrier precautions (EBP) during tracheostomy care and medication administration. Laundry staff did not use appropriate personal protective equipment (PPE) such as gowns or face protection while sorting linens, and they were unaware of the procedures for handling isolation laundry. The facility's policy required all soiled linen to be treated as contaminated, but staff interviews revealed that isolation linens were not being placed in biohazard bags, leading to improper washing procedures. Resident #53, who had multiple medical conditions including a tracheostomy, was not provided with proper tracheostomy care. The registered nurse (RN) did not use a complete tracheostomy cleaning kit, failed to maintain a sterile environment, and did not wear a gown as required by the resident's physician's orders. The RN set up a sterile field directly on the resident's bed and used non-sterile gloves and containers during the procedure, which was against the facility's policy for maintaining aseptic technique. Resident #37, who had a PEG tube and required EBP, did not receive proper infection control measures during medication administration. The RN only wore gloves and did not don a gown as required by the EBP policy. The facility's policy for medication administration by enteral tube required the use of gloves and any other necessary PPE, but this was not followed, leading to a breach in infection control protocols.
Inadequate Hot Water Temperatures for Resident Hygiene
Penalty
Summary
The facility failed to maintain adequate hot water temperatures for residents' personal hygiene needs, affecting four out of fifteen residents interviewed. Residents reported inconsistent hot water availability, with some having to rely on staff to obtain hot water from the shower room for bed baths. The Maintenance Director, who had been in the position for two weeks, acknowledged the issue and noted that one of the three hot water tanks was not functioning due to a faulty thermostat control unit. The Maintenance Director was unsure which tank serviced specific parts of the building and did not document water temperature checks, which ranged from 98 to 117 degrees Fahrenheit. Observations confirmed that water temperatures in various rooms were below the regulatory requirement of 105-120 degrees Fahrenheit, with some rooms taking several minutes to reach even the lower end of this range. The Maintenance Director used a digital thermometer to verify these temperatures in the presence of a surveyor. Despite replacing one hot water tank and a mixing valve, the facility lacked an action plan to address the low water temperatures. The facility's policy did not include procedures for addressing non-compliance with regulatory water temperature requirements.
Failure to Notify Physician of Significant Weight Loss
Penalty
Summary
The facility failed to notify the physician of significant weight loss for two residents, which was a deficiency in their care. Resident #73 experienced a weight loss of 36.4 pounds over 29 days, with no evidence of being weighed during two weeks in October. Despite this significant weight loss, there was no documentation that the resident's physician was notified. The resident's family member reported taking her sister to the emergency room immediately after discharge, where she weighed only 96 pounds. Interviews with the Director of Nursing and the Nurse Practitioner confirmed the lack of notification to the physician about the resident's weight loss. Similarly, Resident #45 experienced a 10.3% weight loss, dropping from 172.4 pounds to 154.6 pounds. The nutritional assessment noted a significant weight loss of 15.4 pounds over three months, which was discussed with the Interdisciplinary Team. However, there was no evidence in the medical record that the physician or nurse practitioner was informed of this significant weight loss. The facility's policy required that any weight loss concerns be reported to the practitioner and discussed at the weekly clinical meeting, which was not adhered to in these cases.
Failure to Conduct Quarterly Care Conferences
Penalty
Summary
The facility failed to ensure that care conferences were completed quarterly for two residents, as required. Resident #56, who has diagnoses including a pressure ulcer, diabetes mellitus, and chronic kidney disease, was admitted on an unspecified date. The resident's medical record showed care conferences documented only twice within the year, and the resident confirmed not attending any care conferences. The Social Services Designee (SSD) verified that the required quarterly care conferences were not completed for this resident. Additionally, the facility's policy lacked specific time frames for when care conferences should be conducted. Resident #34, with multiple diagnoses including chronic kidney disease, anxiety, and depression, had only one documented care conference since admission, which the resident did not attend. The SSD confirmed that the resident was supposed to have quarterly care conferences but failed to document several of them. The SSD also admitted to not having a formal process for inviting residents or documenting their attendance. The facility's policy required that care plan meetings be scheduled with the resident and responsible party, and a care plan note should be created, but these procedures were not consistently followed.
Failure to Complete Discharge Summary for Resident
Penalty
Summary
The facility failed to ensure a discharge summary was completed for a resident upon discharge or transfer. This deficiency was identified during a closed record review and interview, affecting one of two residents reviewed for discharge. The resident in question was admitted with multiple diagnoses, including a displaced fracture, hypertension, atrial fibrillation, and diabetes, among others. Upon discharge, there was no evidence in the medical record of a discharge summary, discharge instructions, or a progress note indicating the resident's discharge or transfer. An interview with the Administrator confirmed the absence of necessary documentation, noting that the family had initiated the discharge or transfer process.
Inadequate Surgical Wound Care for Resident
Penalty
Summary
The facility failed to provide timely and appropriate surgical wound care for a resident with a lumbar surgical wound. Upon admission, there were no wound care orders for the surgical incision on the spine, except for a wound vac application. The initial order lacked details on the type of foam to be used and the suction settings. On 09/22/24, a specific order was given for wound care, but it was discontinued the same day, leaving a gap in treatment orders from 09/22/24 to 09/26/24. During this period, the Visiting Wound Nurse Practitioner (NP) changed the wound vac dressing, but there were no documented orders in the resident's medical record. The resident's wound care was inconsistent, with discrepancies in the type of foam used and the frequency of dressing changes. The Treatment Administration Record (TAR) indicated a missed treatment on 09/29/24, with no evidence of completion on 09/28/24. Subsequent wound assessments by the Visiting Wound NP showed that the white foam was not applied as per the orders, and the wound vac pump settings were adjusted without proper documentation. The facility's wound nurse confirmed that there were issues with entering orders into the electronic medical record, leading to further inconsistencies in wound care. Interviews with facility staff revealed that the Visiting Wound NP did not have full access to the resident's medical records and could not enter her own orders. The facility's wound nurse admitted to entering the NP's orders but was unaware of discrepancies until questioned by surveyors. The facility's policy on skin care and wound management was not followed, as daily rounds to verify wound treatments were not conducted. The lack of comprehensive assessments and documentation contributed to the deficiency in providing appropriate wound care for the resident.
Failure to Administer Pressure Ulcer Treatments as Ordered
Penalty
Summary
The facility failed to ensure that pressure ulcer treatments were completed according to orders for a resident with multiple medical conditions, including a pressure ulcer to the sacral region. Upon admission, the resident had a suspected deep tissue injury on the sacrum, but there was no evidence that the hospital's order to apply Triad hydrophilic paste was administered. Subsequent orders to cleanse the sacrum with normal saline and cover with a foam dressing were not consistently followed, as treatments were missed on specific days. The resident's wound condition worsened, with the wound becoming unstageable and covered with slough. Despite new orders from the Wound Nurse Practitioner (NP) to apply Santyl and antifungal cream, these treatments were not documented as completed in the Treatment Administration Record (TAR). The LPN responsible for wound care confirmed that the treatments were not administered as ordered and that the facility did not conduct its own weekly wound assessments, relying instead on the Wound NP's entries. Interviews with facility staff revealed communication and documentation issues, including the Wound NP's inability to enter orders directly into the electronic medical record due to a system glitch. The facility's policy on skin care and wound management was not adhered to, as evidenced by the lack of documentation and communication of treatment interventions. The deficiency was confirmed by the facility's administrator and corporate RN, who acknowledged the failure to implement the Wound NP's orders.
Failure to Monitor and Assess Restorative Nursing Programs
Penalty
Summary
The facility failed to ensure that restorative nursing programs were properly monitored and assessed quarterly for a resident, leading to a deficiency in care. The resident, who had diagnoses including cellulitis, legal blindness, arthritis, hypertension, and depression, was supposed to receive a passive range of motion (PROM) exercise program for his lower extremities five to seven days per week. However, there was no initial assessment or quarterly monitoring assessments documented since the initiation of the program. Additionally, there were no progress notes available to track the resident's progress or decline in mobility. Observations revealed that a Certified Nursing Assistant (CNA) performed an active range of motion (ROM) exercise instead of the prescribed passive ROM exercise. Interviews with the resident and the Director of Nursing (DON) confirmed the lack of assessments and progress notes. The resident reported that facility staff did not assist with the daily exercise program as required. The facility's policy on restorative programs was reviewed, which outlined the definitions and purposes of active and passive ROM exercises, but the policy was not followed in practice for this resident.
Failure to Maintain Safe Water Temperatures
Penalty
Summary
The facility failed to maintain hot water temperatures within safe limits, resulting in a potential hazard for residents. During an observation, the water temperature in the rooms of two residents was found to be 123.6 degrees Fahrenheit, exceeding the regulatory requirement of 105-120 degrees Fahrenheit in Ohio. The Maintenance Director confirmed the elevated temperature using the facility's digital thermometer in the presence of the surveyor. The facility's policy on water temperatures did not include procedures for addressing temperatures that fall outside of acceptable parameters. An interview with the Administrator revealed that the facility lacked an action plan for when water temperatures exceed the acceptable range. The Centers for Medicare and Medicaid Services (CMS) guidance highlights that hot water can pose a significant risk of burns, especially for residents with conditions such as decreased skin thickness, sensitivity, or mobility. The report notes that at 120 degrees Fahrenheit, a third-degree burn can occur within five minutes, and at 124 degrees Fahrenheit, within three minutes, underscoring the potential danger posed by the facility's failure to control water temperatures.
Inadequate Assessment and Care for Urinary Incontinence and Catheter Use
Penalty
Summary
The facility failed to adequately assess and treat urinary incontinence for Resident #73, who was admitted with multiple diagnoses including osteomyelitis, endocarditis, diabetes, and pressure ulcers. Upon admission, the resident was noted to be incontinent of bladder and bowel, yet there was no comprehensive bladder assessment conducted to identify the type of incontinence. Additionally, there was no plan of care developed to address the resident's incontinence. The resident's records showed a significant number of incontinence episodes, and interviews with the Director of Nursing and Corporate RN confirmed the lack of assessment and care planning. For Resident #57, the facility failed to provide an adequate indication for the use of an indwelling urinary catheter. The resident, who had diagnoses including end-stage renal disease and diabetes, was readmitted with orders for a urinary catheter without documented justification. Medical records, including physician and nurse practitioner assessments, lacked evidence of a valid indication for the catheter's use. Observations during the survey confirmed the presence of the catheter, and interviews with the Director of Nursing and the resident's representative revealed no known reason for its use.
Failure to Assist Resident in Obtaining State ID
Penalty
Summary
The facility failed to provide timely assistance to a resident in obtaining a state photo identification, which was necessary for the resident to access his personal bank account. This deficiency was identified through interviews with the facility Ombudsman, the resident, and staff members, as well as a review of the resident's medical record. The resident, who was admitted with diagnoses including a pressure ulcer, diabetes mellitus, and chronic kidney disease, had an intact and independent cognition level according to his Minimum Data Set (MDS) 3.0 quarterly assessment. The Business Office Manager (BOM) was informed by a case worker from the local Job and Family Services (JFS) office that the resident needed to reapply for Medicaid and spend down his bank account balance to maintain eligibility. Despite being notified in July, the facility had not yet assisted the resident in obtaining the necessary identification by December, putting the resident at risk of losing Medicaid eligibility by the end of the month. The Social Services Designee confirmed the delay in providing the required assistance.
Failure to Administer IV Medication as Ordered
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically regarding the administration of intravenous (IV) cefazolin. The resident, who had multiple medical diagnoses including osteomyelitis, opioid use, and type two diabetes mellitus, was admitted with a surgical dehiscence wound and required an eight-week course of IV cefazolin. Despite the clear orders for administration every eight hours, the medication was not administered on several occasions, including multiple missed doses in September, October, and November. There were no documented reasons for these missed doses, and the facility's Director of Nursing (DON) confirmed the lapses in administration. The resident's Medication Administration Records (MAR) showed numerous instances where the cefazolin was not signed off as administered, and there were no corresponding notes to explain the omissions. The facility's policy on medication administration requires that medications be administered as prescribed and documented accordingly, including any refusals or withheld doses. However, the facility's use of medication techs who were unable to administer IV medications contributed to the failure, as the DON had to arrange for staff to administer the medication, which was not consistently documented or executed.
Failure to Administer Pneumonia Vaccine After Consent
Penalty
Summary
The facility failed to administer a pneumonia vaccine to Resident #45 despite having obtained consent for the vaccination. Resident #45 was admitted to the facility with multiple diagnoses, including hypokalemia, bulbous ureteral stricture hematuria, benign prostatic hyperplasia, retention of urine, diabetes, hyperlipidemia, respiratory failure, atrial fibrillation, osteoarthritis, major depressive disorder, and dementia. The medical record showed that the resident consented to the pneumonia vaccine on June 28, 2024, but the Medication Administration Records for June and July 2024 indicated that the vaccine was not administered. An interview with the Infection Preventionist confirmed the oversight in administering the vaccine after consent was given.
Failure to Monitor and Address Significant Weight Loss
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident #73, was provided with a comprehensive and individualized plan to monitor and address significant weight loss. The resident, who had multiple medical conditions including osteomyelitis, endocarditis, diabetes, and heart failure, experienced a weight loss of 36.4 pounds over 29 days. The resident was on a regular diet with specific calorie and protein needs, but there was no evidence that the facility consistently monitored the resident's weight or dietary intake as ordered. The resident's dietary assessments indicated that she was consuming between 50-100% of most meals, and her estimated nutritional needs were being met. However, there were discrepancies in the resident's height measurements, which affected the accuracy of her nutritional assessments. The facility failed to weigh the resident during two critical weeks, and there was no documentation of the intake percentages for nutritional supplements like Juven and Med Pass, which were part of her dietary plan. Interviews with the Director of Nursing and the Registered Dietician revealed that the facility staff did not accurately document the resident's height and failed to monitor her weight and supplement intake as required. The Registered Dietician confirmed the unexplained weight loss and noted that the resident's pain and infection could have increased her calorie needs. Despite these factors, the facility did not adjust the resident's care plan to address her significant weight loss, leading to the deficiency cited in the report.
Failure to Investigate Missing Narcotic Medications
Penalty
Summary
The facility failed to thoroughly investigate an allegation of missing narcotic medications, specifically morphine sulfate (Roxanol), prescribed to a resident with rheumatoid arthritis, adult failure to thrive, and hypertension. The resident was prescribed 0.25 ml of morphine sulfate every two hours as needed for pain. A review of the Medication Administration Record (MAR) indicated that 31 doses were administered, which should have left 22.25 ml remaining in the 30 ml bottle. However, the controlled drug administration record showed 29 doses were documented, which should have left 22.75 ml remaining. A discrepancy was noted when a hospice employee observed only 16 ml remaining in the bottle, indicating 6.5 ml was unaccounted for. The facility's self-reported incident investigation revealed that eight doses were not signed out by staff on the controlled drug administration record, and three doses were not signed out on the MAR. This documentation error accounted for only two ml, not the 6.5 ml discrepancy. The Director of Nursing confirmed the documentation concerns, and the Administrator acknowledged that the investigation did not thoroughly address the missing doses. The facility's policy required nurses to sign both the MAR and the Drug Count sheet when administering controlled substances, which was not adhered to in this case.
Medication Administration Documentation Discrepancy
Penalty
Summary
The facility failed to accurately document medication administration in the medical record and controlled drug administration records for a resident prescribed morphine sulfate for pain management. The resident, who had diagnoses including rheumatoid arthritis, adult failure to thrive, and hypertension, was prescribed morphine sulfate to be administered as needed. A review of the Medication Administration Record (MAR) and the controlled drug administration record revealed discrepancies in the documentation of the doses administered. Specifically, there was a mismatch between the recorded doses and the actual remaining medication in the bottle, indicating unaccounted doses. The hospice provider's self-reported incident highlighted a discrepancy in the controlled drug administration record, noting a significant difference between the expected and actual remaining medication. The facility's investigation found that several doses were not signed out by staff on both the controlled drug administration record and the MAR, leading to the discrepancy. Interviews confirmed that staff failed to document medication administration properly, resulting in inconsistencies between the two records.
Failure to Prevent Staff-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to prevent staff-to-resident sexual abuse, resulting in Immediate Jeopardy and potential harm. The incident involved a Maintenance Director (MD) and a resident with mental incapacity and a history of hypersexual tendencies. A Hospitality Aide (HA) witnessed the MD in a compromising position with the resident, leading to the MD's suspension and subsequent confession to sexual interactions with the resident over several months. The resident, who had a court-appointed legal guardian due to mental incapacity, was found in her room with the MD standing in front of her, adjusting his clothing. The MD initially denied any wrongdoing, claiming he was helping the resident off the floor. However, the police investigation revealed the MD confessed to receiving oral sex from the resident and having a sexual relationship with her for nine to twelve months. The resident's medical history included schizophrenia, anxiety, and other mental health issues, indicating she was unable to consent to such interactions. The facility's investigation confirmed the incident of sexual abuse, and the MD was arrested and charged with sexual assault. Interviews with staff and residents revealed that the MD had been spending an unusual amount of time with the resident behind closed doors, and some staff had previously felt uneasy about his behavior. Despite these concerns, no prior reports were made until the incident was witnessed by the HA.
Failure to Timely Report Allegations of Abuse and Misappropriation
Penalty
Summary
The facility failed to timely report an allegation of sexual abuse involving Resident #1 and an allegation of misappropriation involving Resident #50 to the state survey agency. Resident #1, who was adjudged incapacitated with diagnoses including schizophrenia and anxiety, was involved in an incident where a staff member, MD #300, was found adjusting his clothing in a suspicious manner in her room. The incident was reported internally, and the resident was assessed with no physical abnormalities noted. However, the facility did not file a Self-Reported Incident (SRI) with the state survey agency until several hours later, exceeding the two-hour reporting requirement. In the case of Resident #50, who was cognitively intact and managed his own finances, there was an allegation of misappropriation of his bank card. The Social Service Designee (SSD) was informed by the resident's Medical Power of Attorney (MPOA) and the MPOA's spouse about unauthorized purchases made by a family member using Resident #50's card. Despite advising the resident and MPOA to cancel the card and initiate a bank investigation, the SSD did not report the incident to the administration, and no SRI was filed. The facility's policy requires immediate reporting of alleged violations involving abuse, neglect, exploitation, or misappropriation of resident property, with a specific timeframe of two hours for incidents involving abuse or serious bodily injury. The failure to adhere to these reporting requirements resulted in non-compliance, as investigated under the specified complaint numbers.
Facility Fails to Serve Palatable Chicken
Penalty
Summary
The facility failed to serve palatable chicken, affecting all residents except two who do not receive nourishment from the kitchen. During meal service, the chicken breast served appeared dry, prompting some residents to order substitutes or meals from outside. Observations in the kitchen revealed that the tray line was finishing, and the facility ran out of asparagus, substituting it with green beans. The chicken breasts remaining had no juice in the pan and appeared dry. A test tray confirmed the chicken was tough to cut and chew, with dry and crispy ends. Interviews with kitchen staff and the Culinary Director verified the chicken's dryness and fibrous texture. The Director of Nursing reported several resident complaints about the lunch chicken to the Administrator, requesting substitutes for them. This deficiency was investigated under Complaint Number OH00155294.
Facility Fails to Provide Consistent Resident Transportation
Penalty
Summary
The facility failed to ensure effective and efficient use of its resources, specifically regarding transportation for residents. The facility's transport van has been unavailable for resident use for over a year, affecting the ability to transport residents to medical appointments and activities. The van's lift broke in June 2022, and although it was repaired in April 2023, it was only in service for a short period before becoming inoperable again in August 2023 due to a rusted door and inability to engage in drive. The facility did not take adequate measures to address the transportation issue, such as purchasing another vehicle or establishing a routine sharing arrangement with a sister facility. The investigation revealed that the facility's van was only operational for four out of the last 25 months. Despite the administrator's acknowledgment of the long wait times for parts and potential delays in acquiring a new van, there was no evidence of proactive steps taken to mitigate the transportation deficiency. The facility's failure to provide consistent transportation services had the potential to impact all 77 residents, as it hindered their access to necessary medical appointments and community outings. This deficiency was identified during a complaint investigation under Complaint Number OH00155294.
Infection Control Deficiencies in Pericare and Kitchen Hygiene
Penalty
Summary
The facility failed to ensure proper sanitary pericare technique for a resident and did not have soap available at the kitchen handwashing sink. During an observation, two State Tested Nurse Aides (STNAs) provided pericare to a resident. After cleaning a bowel movement, one of the STNAs pulled the sheet and blanket up to the resident's chest before changing her gloves, which was against the facility's policy. The policy required gloves to be removed and hand hygiene to be performed before repositioning bedcovers. The STNA confirmed that she touched the resident's bedsheets and blanket with the same gloves used to clean the bowel movement. Additionally, an observation in the kitchen revealed the absence of soap at the handwashing sink, which is essential for maintaining hygiene standards. A staff member confirmed the lack of soap and mentioned that housekeeping was responsible for changing it. Another staff member indicated that she washed her hands in the bathroom instead. This deficiency could potentially affect all meals provided to residents, except for two residents who do not receive nourishment from the kitchen.
Transportation Deficiency Affects Resident Rights
Penalty
Summary
The facility failed to ensure residents' right to self-determination by not providing adequate transportation for residents to attend necessary appointments and community activities. Resident #6, who was independent in daily decision-making and required supervision for walking, had a mammogram appointment scheduled. Despite notifying the facility a week in advance, transportation was not arranged, forcing the resident to use a taxi at her own expense. Interviews with staff confirmed the oversight, and the facility's lack of a functioning van for over a year contributed to the issue. Resident #2, who was severely impaired in daily decision-making, needed to visit a bank to resolve issues with his debit card. The facility's inability to provide transportation due to the lack of a van hindered his ability to manage his finances. The resident's son, who lived four hours away, could not assist in person, and the bank required the resident's physical presence to address the account issues. The facility's reliance on external transport services, which only catered to medical needs, further complicated the situation. Resident #10 also faced challenges due to the facility's transportation shortcomings. Despite being independent in decision-making, the resident needed to visit a bank to resolve issues with his debit card, which was sent to an old address. The facility's lack of a van prevented the resident from accessing necessary banking services. Additionally, the facility's activity program was limited, as they could not transport residents to off-site activities, affecting the overall quality of life for all residents.
Failure to Ensure Timely and Secure Delivery of Resident Mail and Packages
Penalty
Summary
The facility failed to ensure that residents' mail and packages were delivered unopened and on weekends, affecting three residents. Resident #6, who was independent in daily decision-making, reported receiving opened mail from the Social Security office, which was delivered by the Social Services Designee (SSD) #105. The SSD stated that the mail was already opened when handed to her by the Business Office Manager (BOM) #89, who was unavailable for interview due to illness. The Administrator confirmed the incident and noted the absence of a mail policy. Resident #2, who was severely impaired in daily decision-making, received opened mail in a manila envelope, which he did not report. SSD #105 observed the envelope was dirty and torn but was unaware of when it was damaged. Resident #7, who was independent in daily decision-making, reported a delay in receiving a package from Walmart, which was left at the front door and not delivered until the following Monday by Maintenance. Maintenance #103 confirmed seeing the package in the foyer but was unsure if packages were delivered on weekends. Interviews with Activities staff revealed that mail is not delivered on weekends, and any mail left from Friday might be delivered on Saturday. Human Resources #145 confirmed that mail is not delivered on Saturdays and was unaware of anyone responsible for weekend package deliveries. The facility lacked a mail policy, contributing to these deficiencies.
Failure to Implement New Interventions for Recurring UTIs
Penalty
Summary
The facility failed to implement new interventions to prevent recurring urinary tract infections (UTIs) for a resident with multiple medical conditions, including chronic congestive heart failure, type 2 diabetes, and obstructive and reflux uropathy. The resident, who was dependent on staff for toileting and had an indwelling urinary catheter, experienced seven UTIs over nine months. Despite these recurring infections, the facility did not update the resident's plan of care or provide additional education on incontinence care. The plan of care, initiated in December 2023, included basic interventions such as checking for incontinence and washing the perineum, but these were not revised or enhanced in response to the frequent UTIs. The resident's medical records showed multiple positive urinalysis results for different bacteria, yet there was no evidence of increased nursing measures or surveillance to prevent further infections. The facility also did not provide inservice education on pericare after a positive urinalysis for Escherichia Coli. An observation of pericare revealed improper glove use by a nurse aide, which could contribute to infection risk. Despite the resident's daughter expressing concerns and a urologist consultation, the facility maintained that the initial plan of care was sufficient, without demonstrating any additional efforts to address the recurring UTIs.
Failure to Provide Adequate Nourishment Due to Dietary Preference Management
Penalty
Summary
The facility failed to provide a nourishing, palatable, well-balanced diet to a resident, as required. The resident, who was admitted with diagnoses including major depressive disorder, Vitamin D deficiency, muscle weakness, alcoholic polyneuropathy, iron deficiency anemia, and anxiety disorder, reported receiving inadequate meals on two occasions. On one occasion, the resident received only a roll and mashed potatoes for supper, and on another, plain spaghetti noodles and peaches. The facility's computer program, Mealtracker, used to manage dietary preferences, eliminated all disliked items from the resident's meal tray, resulting in meals without an entree. Interviews with the Culinary Director and Dietician revealed a lack of policy or procedure to address situations where a resident's dislikes include all available entrees. The Culinary Director acknowledged that the system could result in trays with few or no food choices if both entrees are on a resident's dislike list. The Dietician was unaware that trays were being served without an entree and indicated that common sense should prevent such occurrences. The facility's Dining and Food Preference policy requires the dietitian to adjust meal plans to ensure nutritional adequacy, but this was not effectively implemented in this case.
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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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