Gardens Of Mayfield Village
Inspection history, citations, penalties and survey trends for this long-term care facility in Mayfield Heights, Ohio.
- Location
- 6757 Mayfield Rd, Mayfield Heights, Ohio 44124
- CMS Provider Number
- 365355
- Inspections on file
- 43
- Latest survey
- February 4, 2026
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Gardens Of Mayfield Village during CMS and state inspections, most recent first.
A resident with complex medical needs did not receive meals according to their documented food preferences and care plan, and the facility also failed to serve meals consistent with the planned menu for all residents. Staff served incorrect food items and made substitutions without following the established menu, as confirmed by interviews and meal observations.
A resident with severe dementia and multiple psychiatric diagnoses alleged physical abuse by another resident. The resident's guardian reported the allegation and requested to be informed of the investigation's outcome. Despite multiple follow-up requests, the facility did not notify the guardian of the investigation results, nor was there documentation of the communication or the incident in the clinical record.
A resident with severe dementia and behavioral issues alleged physical abuse by another resident. The facility did not document the incident, the abuse allegation, or communication with the resident's guardian regarding the investigation and its outcome, resulting in an incomplete and inaccurate medical record.
A resident reported feeling cold, and observations confirmed that ambient air temperatures in several areas of the facility's second floor were below the required 71°F minimum, with readings as low as 63°F. The Maintenance Director was unaware of concerns, and the Administrator verified the low temperatures using two thermometers. This deficiency affected one resident and had the potential to impact 24 others.
A resident with dementia and bladder dysfunction did not have a required urinary catheter securement device in place during catheter care, despite physician orders and care plan directives. Staff interviews and record reviews confirmed the absence of the device and lack of documentation regarding its removal, resulting in noncompliance with facility policy.
Three residents with cognitive impairment and high risk for pressure ulcers did not receive timely or effective wound care, including missed or incomplete skin assessments, lack of required pressure-relieving devices, and failure to implement or document prescribed treatments. Observations revealed wounds without dressings, malfunctioning equipment, and poor communication among staff, resulting in the development and worsening of pressure ulcers.
The facility failed to prevent accidents and provide adequate supervision for high-risk residents, including those with fall risks, cognitive impairment, and those requiring supervised smoking. One resident suffered a fracture after repeated falls from a motorized wheelchair without individualized interventions, while another did not have a required perimeter mattress in place. Several residents requiring supervision while smoking were left unsupervised, and a resident on LOA was not properly monitored, with staff failing to document or follow up on expected return times.
The facility did not ensure its QAPI committee identified and followed through on quality concerns in a timely manner. Action plans for late medication administration, incomplete wound and skin assessments, and resident falls were created, but there was no evidence of completed audits or continued corrective action. Leadership interviews confirmed a lack of oversight and documentation, resulting in ongoing deficiencies in medication administration, pressure areas, and falls with major injury.
The facility did not follow infection prevention protocols, including proper catheter care for a resident with an indwelling device, timely pre-employment TB testing for several staff, and required hand hygiene during medication administration by an LPN. PPE was not used as required, and hand hygiene policies were not followed.
The facility did not screen, educate, or offer the COVID-19 vaccine to several residents with complex medical conditions, and failed to document vaccination status, consent, or education in their medical records, as confirmed by facility leadership and record review.
The facility did not follow required background check procedures, resulting in the hiring of two staff members with disqualifying criminal offenses, including aggravated robbery, assault, domestic violence, and drug abuse. This failure to adhere to policy and state law was confirmed through personnel file review and staff interviews, potentially affecting all residents.
The facility did not complete required nurse aide registry checks and background checks prior to employment for multiple staff members, including an LPN, activity director, maintenance supervisor, human resource manager, business office manager, and CNA. These checks were either missing or performed after staff had already been hired, contrary to facility policy and state requirements.
Surveyors identified widespread sanitation and food storage deficiencies, including unlabeled and expired food, soiled kitchen equipment, improper thawing practices, and lack of required hair coverings among dietary staff. Expired and moldy food was found in both common and resident refrigerators, and cleaning schedules and logs were not in place or implemented.
The facility experienced ongoing elevator malfunctions, with one elevator out of service and the other requiring users to manually return it to the first floor, causing significant delays and access issues for residents and staff. Staff interviews confirmed the impact on daily operations, including a resident unable to use the working elevator due to wheelchair size, and activities primarily held on the inaccessible floor. Maintenance and repair staff were not consistently aware of all issues, and documentation showed repeated, unresolved mechanical failures.
Surveyors found widespread unsanitary and unsafe conditions, including broken fixtures, strong odors, leaking equipment, soiled linens, overflowing trash, and unclean resident rooms and common areas. Staff, including an LPN and housekeeper, confirmed that rooms and shared spaces were not being cleaned daily due to insufficient housekeeping staff, and facility policy for regular cleaning was not followed.
Multiple residents experienced water temperatures below the required range during care, with staff confirming that water remained cold even after running for several minutes. Temperature checks in several rooms showed water well below the required 105–120°F, and staff acknowledged this was a common occurrence.
Several residents were affected by inaccurate MDS 3.0 assessments, including errors in documenting pressure ulcers, cognitive status, insulin administration, and enteral feeding compliance. Staff interviews and record reviews revealed discrepancies between actual care provided and what was recorded, with some residents' refusals and care needs not properly reflected in the assessments.
Several dependent residents were not assisted with essential ADLs, including eating and bathing, as required by their care plans. Meal trays were left untouched without staff help, and multiple residents missed scheduled showers or had no documentation of care provided. Observations showed residents with unkempt appearances, dirty nails, and unchanged clothing, while staff interviews confirmed lapses in care and documentation.
Several residents with chronic conditions such as dementia, schizophrenia, heart failure, and COPD did not have documentation of being offered, screened, educated, or administered influenza and pneumococcal vaccines as required by facility policy and CDC guidance. Staff interviews confirmed the absence of vaccination records, consents, refusals, or education in the medical records for these residents.
A resident with severe vision impairment and multiple diagnoses was allowed to self-administer medications without the required annual reassessment to confirm ongoing safety and capacity, as mandated by facility policy. The initial assessment was not updated, and the interdisciplinary team did not complete the necessary review.
A resident with multiple chronic conditions was not given a complete Notice of Medicare Non-Coverage when skilled services ended. The notice lacked details about the specific services being discontinued and did not include required appeal contact information or a phone number, as confirmed by facility leadership.
A resident with cognitive impairment and psychiatric diagnoses received a PRN order for Hydroxyzine for anxiety that lacked a required 14-day stop date. The medication was administered on multiple occasions, and facility policy required practitioner documentation to extend PRN psychotropic medications beyond 14 days, which was not present. This was confirmed by the RN/Regional Director of Clinical Services.
The facility did not include self-management of colostomy care and self-administration of medications in the care plans for two residents, despite both residents independently managing these aspects of their care and staff being aware of this. The omissions were confirmed through record review and staff interviews, and the facility also lacked a policy for self-administration of medications.
Two residents who required limited or moderate assistance with bathing did not consistently receive scheduled showers, as confirmed by documentation and resident interviews. One resident received only two documented bathing events over several months, while another received eight out of 21 scheduled showers. Staff shortages and communication lapses contributed to missed showers, and required documentation was not consistently completed.
A resident with an indwelling urinary catheter did not receive required catheter care every shift, as evidenced by observations of the catheter bag placed in the resident's lap and on the floor, thick sediment in the tubing, and dried debris at the insertion site. Staff interviews confirmed that care had not been provided as ordered and that facility policy for catheter bag positioning was not followed.
A resident with cognitive impairment and multiple diagnoses experienced a significant weight loss of over 18% within a month, but the facility failed to notify the physician or implement appropriate nutritional interventions as required by policy, despite ongoing monitoring and high meal consumption.
A resident with quadriplegia and a tracheostomy did not have physician orders for oxygen and suction transcribed into the medical record, resulting in insufficient documentation and monitoring of respiratory care. Staff confirmed the absence of these orders and limited oxygen saturation readings, contrary to facility policy requiring ongoing assessment of respiratory status.
The facility did not address pharmacy recommendations in a timely manner for two residents, including one with anxiety and depression who continued to receive Xanax despite pharmacist suggestions to discontinue, and another who did not have timely physician responses to recommendations regarding Trazodone and Enoxaparin. Facility policy required monthly medication reviews and prompt action on pharmacist findings, which was not met.
A resident with multiple medical conditions did not have laboratory tests completed as ordered by the physician, with only a few results present in the record and several missing. The DON and an RN confirmed that required lab results were not available in the medical record, and the physician had not been updated on some findings.
The facility experienced ongoing elevator malfunctions, with one elevator out of service for an extended period and the other requiring users to manually return it to the first floor. As a result, several residents with mobility impairments were unable to access activities or areas on the second floor, and staff reported delays and workarounds to manage elevator use. Most activities were held on the second floor, further restricting participation for affected residents.
A resident with multiple psychiatric and medical conditions became agitated after being denied a smoke break by an LPN, leading to an altercation where the resident threw water on the LPN, who then retaliated by throwing ice water on the resident. Multiple staff and resident interviews confirmed the LPN's actions, but the facility failed to conduct a thorough investigation and did not immediately remove the LPN from duty as required by policy.
The facility did not timely report or respond to multiple allegations of abuse, including an incident where a resident and an LPN threw water on each other and another involving a physical altercation between two residents during a supervised smoke break. In both cases, required self-reported incidents were not submitted within the mandated timeframe, and staff involved in alleged abuse were not immediately suspended, contrary to facility policy.
A facility failed to conduct a thorough investigation after a resident with multiple psychiatric and medical diagnoses alleged that an LPN threw water on her during a dispute over smoking times. The facility's documentation was incomplete, with missing witness interviews and statements, and later interviews revealed conflicting accounts about the incident. The investigation did not meet the facility's own policy requirements for abuse allegations.
Three residents experienced deficiencies in care, including failures in tube feeding management, monitoring and documentation of changes in condition, and adherence to physician orders. One resident repeatedly refused tube feedings and medications, consumed enteral nutrition orally without proper orders, and had inconsistent documentation of intake and care. Another resident returned from the hospital without required documentation of a change in condition, and a third had a possible seizure event that was not directly observed or properly documented by an LPN. These actions and inactions resulted in lapses in quality of care and treatment.
A resident with end stage macular degeneration did not receive a timely follow-up appointment with a retina specialist as ordered by a physician. Although an LPN entered the referral order and passed it to the unit manager, there was no evidence the appointment was scheduled or completed, and the resident reported repeatedly requesting the appointment without resolution. Facility staff confirmed the lapse, and required documentation and coordination per facility policy were not found.
A resident with severe cognitive impairment and complex medical needs did not have documented physician visits as required. Only an admission visit and a physician order were found in the record, and facility leadership could not provide evidence of additional required visits, despite the physician stating that notes had been sent.
A resident with epilepsy and other complex conditions did not receive several prescribed medications, including seizure and blood thinner medications, because the facility failed to obtain them from the pharmacy in a timely manner. Nursing staff documented the missed doses, and the DON confirmed the medications were not available as required by facility policy.
A medication pass observation revealed that an LPN failed to administer two prescribed medications to a resident with multiple chronic conditions, resulting in a medication error rate of 7.69%, which exceeds the required threshold of less than 5%. The omission was confirmed through interview and record review.
A resident with multiple medical conditions and intact cognition did not have her food preferences honored or updated, despite physician orders and repeated requests. The resident continued to receive food items she disliked, and her dietary tray ticket lacked any indication of her preferences. Staff interviews revealed that changes in dietary management and lack of resident visits contributed to the failure to update and communicate dietary preferences as required by facility policy.
Two residents did not have required outside medical appointments properly coordinated or scheduled, including an orthopedic consult and nephrology visits, due to failures in arranging appointments and transportation as ordered by physicians. Staff interviews and record reviews confirmed that appointments were missed or not scheduled, and facility policies for arranging and documenting such services were not followed.
Multiple residents experienced lapses in medication administration and documentation due to conflicting orders, technical outages in the electronic medical record system, and unclear staff responsibilities. These deficiencies included missed medication doses, incomplete wound care documentation, and missing pain and behavioral assessments, with staff unable to provide evidence that required care was delivered or properly recorded.
A resident with advanced dementia and multiple health issues was admitted to hospice, but the facility failed to coordinate care with hospice staff. The resident developed a pressure injury that was not communicated to hospice, and documentation from both facility and hospice staff was incomplete or inaccurate. There was minimal communication between LPNs, hospice nurses, and the resident's family, and required protocols for care coordination and documentation were not followed.
The facility did not provide required notifications to the ombudsman or proper documentation for several residents who were transferred, discharged, or hospitalized, including missing bed-hold notices and incomplete medical records. Interviews with leadership confirmed the absence of these records, and facility policy was not followed in multiple cases.
The facility failed to conduct timely care conferences for four residents, impacting their comprehensive care planning. Medical records showed incomplete or missing care conferences, despite policy requirements for timely development of care plans. The Regional Director confirmed the facility's non-compliance with scheduling care conferences every three months or with MDS assessments.
The facility failed to accurately document medication administration and enteral feedings for several residents, and did not maintain controlled medication disposition records. A resident's Ativan administration was not documented, and records for Tramadol were missing. Another resident's Morphine Sulfate and Ativan records were unavailable, and a third resident's Tramadol records were also missing. Additionally, discrepancies in enteral feeding documentation and an incorrect order were identified for a resident. These issues were confirmed by facility staff.
The facility failed to provide adequate wound care and medication administration for several residents. A resident with a chronic ulcer did not receive daily wound treatments as prescribed, leading to a decline in the wound's condition. Another resident receiving hospice care developed untreated skin tears, with no communication to hospice or the physician. Additionally, multiple residents did not receive their prescribed medications on various dates, as confirmed by records and staff interviews.
The facility failed to conduct thorough investigations and implement timely interventions after falls involving three residents. One resident with hemiplegia was found on the floor without new interventions added to their care plan. Another resident with severe malnutrition experienced an unwitnessed fall, and interventions were delayed. A third resident with cognitive impairment rolled out of bed during care, and the investigation lacked clarity and staff statements. The facility did not adhere to its fall management policy.
The facility failed to ensure that residents were seen by a general physician or NP at least once every 60 days, affecting two residents. One resident with legal blindness, anxiety disorder, and hypertension had not been seen since February, as confirmed by the resident. Another resident with multiple health issues, including congestive heart failure and diabetes, also had not been seen since February, confirmed by the DON and Regional Director of Clinical Services. Both residents were cognitively intact.
A facility was found to have a medication error rate of 9.67%, exceeding the acceptable threshold. Errors included failure to prime an insulin pen, incorrect substitution of Basaglar for Lantus insulin without physician approval, and incorrect administration of vitamin B-12. These actions affected a resident with dementia and diabetes, highlighting significant deviations from proper medication protocols.
A resident in an LTC facility experienced significant medication errors, including incorrect insulin administration without priming and substitution of Basaglar for Lantus without a physician's order. Additionally, a vitamin B-12 tablet was given orally instead of sublingually and at a lower dose. These actions violated the facility's medication administration policy and were identified during a complaint investigation.
Failure to Follow Resident Food Preferences and Planned Menu
Penalty
Summary
The facility failed to honor a resident's documented food preferences and did not ensure that meals served were consistent with the planned four-week menu. Specifically, a resident with multiple diagnoses, including chronic non-pressure ulcers, diabetes mellitus, malnutrition, morbid obesity, and cognitive communication deficit, had a care plan and meal ticket specifying preferred foods for each meal. Despite these clear instructions, the resident reported receiving incorrect food items for breakfast, such as sausage links and one piece of bread with butter, instead of the specified two pieces of white toast, scrambled eggs with cheese, and cereal. The resident had previously communicated these concerns to the Assistant Director of Nursing and provided photographic evidence of the incorrect meal. Further review and observation revealed that the kitchen staff did not follow the planned menu for other residents as well. On one occasion, residents were served scrambled eggs or hard-cooked eggs, raisin toast, oatmeal, orange, grape juice, and milk, instead of the planned egg sandwich, cereal of choice, banana, and other items. The Kitchen Manager confirmed that substitutions were made due to missing food deliveries but could not explain why available menu items were not served as planned. These failures affected at least one resident and had the potential to impact all residents in the facility.
Failure to Notify Guardian of Abuse Investigation Results
Penalty
Summary
The facility failed to provide timely notification to a resident's guardian regarding the results of an investigation into an allegation of physical abuse. The resident, who had diagnoses including psychosis, malnutrition, severe dementia with agitation, cognitive communication deficit, drug-induced dyskinesia, mood disorder, bipolar disorder, and anxiety, resided on a secured nursing unit due to safety concerns and a history of elopement. The resident's care plan included interventions for her cognitive and behavioral needs. On the date in question, the resident alleged that another resident had assaulted her in her room. The guardian, present at the time, reported the allegation to facility staff and requested to be informed of the investigation's outcome. Despite the guardian's repeated requests for updates via email and in person, there was no documentation that the facility notified the guardian of the investigation results. The facility's records did not reflect any communication with the guardian regarding the outcome, nor did they document the alleged altercation or the abuse allegation in the resident's clinical record. The investigation concluded that no assault had occurred, but this information was not relayed to the guardian until it was brought to the attention of the surveyors during the interview process.
Failure to Maintain Complete and Accurate Medical Record Following Abuse Allegation
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for a resident with multiple diagnoses, including psychosis, severe dementia, and mood disorder. The resident was admitted with significant cognitive and behavioral issues and resided on a secured unit due to safety concerns. Despite an incident in which the resident alleged physical abuse by another resident, there was no documentation in the clinical record regarding the altercation, the abuse allegation, or communication with the resident's guardian about the incident and its investigation. The care plan and progress notes did not reflect the reported event or the guardian's concerns. A review of the facility's self-reported incident and interviews confirmed that an investigation was conducted, but the results and related communications were not documented in the resident's medical record. The guardian made multiple requests for updates regarding the investigation, but only received unrelated information about the resident's personal items. Interviews with facility staff and the guardian verified that the medical record was incomplete and did not accurately reflect the events or follow-up related to the abuse allegation.
Failure to Maintain Required Ambient Air Temperatures
Penalty
Summary
The facility failed to maintain a comfortable and regulatory-compliant environment for a resident, as evidenced by ambient air temperatures below the required range. During interviews, the Maintenance Director stated that he believed the highest ambient air temperature should be 71°F and as low as 65°F, and was unaware of any resident concerns regarding temperature. However, a resident reported feeling cold, especially at night and in the early morning. Observations conducted with the Administrator confirmed that the ambient air temperatures in several areas of the second floor were below the regulatory minimum of 71°F, with readings as low as 63°F and 67°F in different locations. The Administrator verified these low temperatures during the observation and questioned the accuracy of the thermometer, but a second, newly purchased thermometer measured even lower temperatures. Review of the facility's environmental temperature policy confirmed that the required range is 71°F to 81°F. This deficiency affected one resident directly and had the potential to affect an additional 24 residents residing on the second floor. The issue was identified during a complaint investigation and was a repeat deficiency from a previous annual survey.
Failure to Ensure Catheter Securement Device in Place During Care
Penalty
Summary
A deficiency was identified when a resident with dementia and neuromuscular dysfunction of the bladder did not have a urinary catheter securement device in place during a catheter care procedure, despite an active physician order and care plan requiring its use to prevent movement and urethral traction. The care plan specified that the securement device should be monitored every shift, and documentation indicated compliance earlier in the day. However, during direct observation by surveyors, the securement device was not present, and staff interviews confirmed its absence at that time. Further review of the resident's records, including progress notes and the care plan, revealed no documented behaviors indicating that the resident removed the securement device. Staff members, including a CNA, DON, and LPN, acknowledged having seen the device in place previously but did not verify its presence during the shift in question. The facility's catheter care policy required the use of a leg strap to secure the catheter, which was not followed during the observed care, resulting in noncompliance with established protocols.
Failure to Provide Timely and Effective Pressure Ulcer Prevention and Care
Penalty
Summary
The facility failed to provide adequate and effective pressure ulcer prevention and care for three residents, resulting in the development and worsening of pressure ulcers. One resident with a pressure ulcer on the left heel did not receive wound care as ordered, as observed during a wound care session where no dressing or treatment was present and the area had a large amount of dried, crusted debris. The wound nurse practitioner confirmed that the prescribed daily wound care had not been completed, and the facility's policy requiring ongoing evaluation and documentation of skin changes and interventions was not followed. Another resident, who was cognitively impaired and dependent on staff for activities of daily living, developed a pressure ulcer on the buttocks due to prolonged sitting without adequate repositioning. The care plan did not reflect the presence of a Stage III pressure ulcer, and interventions were not updated. Weekly skin assessments were missed, and wound care orders were not consistently implemented, as evidenced by the absence of dressings during observations. The resident was also found without required heel boots and on a malfunctioning air mattress, with staff confirming these lapses in care. A third resident, also cognitively impaired and at high risk for pressure ulcers, did not have an air mattress in place as ordered for prevention. Weekly skin assessments were not completed as scheduled, and documentation of skin integrity was inconsistent and sometimes inaccurate. The resident developed a deep tissue injury that progressed to a Stage III and then to an unstageable pressure ulcer, with repeated observations showing that wound treatments were not in place as ordered. Communication failures between facility staff and hospice care further contributed to the lack of appropriate interventions and monitoring.
Failure to Prevent Accidents and Ensure Supervision for High-Risk Residents
Penalty
Summary
Multiple deficiencies were identified in the facility's management of accident hazards and supervision to prevent accidents among residents. One resident with a history of falls and poor safety awareness was provided a motorized wheelchair without a documented safety assessment at the time of receipt. This resident experienced several falls from the motorized wheelchair, including an incident resulting in a closed fracture of the fibula. The care plan was not updated to include interventions specific to the use of the motorized wheelchair, and therapy records did not address the resident's safety in using the device, despite repeated falls and documented poor safety awareness. Another resident, identified as being at risk for falls due to decreased cognition, weakness, and malnutrition, had a perimeter mattress ordered as a fall intervention. However, observations revealed that the perimeter mattress was not in place as required by the care plan, and no other fall interventions were visible in the resident's environment. This lack of implementation of care plan interventions was confirmed by facility staff during the survey. The facility also failed to ensure safe smoking practices and adequate supervision for residents requiring such oversight. Several residents who required supervision while smoking were observed out on the smoking patio without staff supervision, and some were found in possession of cigarettes and lighters, contrary to facility policy. Additionally, a resident with an order for leave of absence (LOA) was allowed to leave the facility without documenting an expected time of return, and staff did not consistently monitor the LOA log or follow up in a timely manner when the resident did not return as expected. These lapses in supervision and policy adherence affected multiple residents and were confirmed through record review, staff interviews, and direct observation.
Failure to Follow Through on QAPI Action Plans and Audits
Penalty
Summary
The facility failed to ensure its Quality Assurance and Performance Improvement (QAPI) committee identified and followed through on quality concerns in a timely manner, affecting all 59 residents. Review of QAPI minutes and Performance Improvement Plan (PIP) documentation showed that action plans addressing late medication administration, incomplete wound and skin assessments, and resident falls with fractures were created with root causes, responsible parties, and audit plans. However, there was no evidence of continued corrective action, revision of plans when necessary, or documentation of completed audits to verify the effectiveness of these plans. Deficiencies in medication administration, significant medication errors, pressure areas, and falls with major injury were cited during the current annual survey, indicating ongoing issues in these areas. Interviews with facility leadership revealed that the Administrator was responsible for implementing and overseeing audits as part of the QA process, but there was a lack of awareness and follow-through regarding the required audits and oversight. The Regional Director of Operations and Vice President of Operations confirmed that no audits corresponding to the QAPI plans were available for surveyor review. The facility's policy required systematic gathering of information and documentation of PIPs, but this was not followed, resulting in unaddressed and unverified corrective actions for identified quality concerns.
Infection Control Lapses in Catheter Care, Staff TB Testing, and Hand Hygiene
Penalty
Summary
The facility failed to implement and maintain effective infection prevention and control practices in several areas. For one resident with an indwelling urinary catheter, observations revealed the catheter bag was left on the floor for an extended period, and the catheter insertion site and tubing had black dried debris, indicating inadequate catheter care. The assigned CNA was unable to confirm when catheter care was last provided and did not don personal protective equipment (PPE) as required for enhanced barrier precautions during care. Facility policy required the use of gown and gloves for residents on enhanced barrier precautions, but this was not followed. Additionally, signage and PPE supplies were present, but not utilized during care activities. Personnel file reviews showed that multiple staff members, including CNAs, LPNs, and the Activity Director, did not have timely pre-employment tuberculosis testing completed as required. During a medication administration observation, an LPN failed to perform hand hygiene before and after medication administration, wore the same gloves throughout multiple tasks, and did not remove gloves or clean hands before leaving the resident's room. The facility's hand hygiene policy required handwashing as the primary means to prevent infection, but this was not adhered to during the observed medication pass.
Failure to Screen, Educate, and Document COVID-19 Vaccination for Residents
Penalty
Summary
The facility failed to ensure that residents were screened for COVID-19 immunization, educated on the risks and benefits of the COVID-19 vaccine, or offered and received the vaccine as required. Record reviews for five residents with various diagnoses, including dementia, schizophrenia, muscle weakness, congestive heart failure, asthma, morbid obesity, diabetes, respiratory failure, and COPD, revealed no documentation of COVID-19 vaccination status, consent or declination, or education provided regarding the vaccine. These findings were confirmed during interviews with the President of Operations and a Regional Registered Nurse, who stated they were unable to locate any vaccination records, refusals, or education documentation for the affected residents in the electronic medical records. CDC guidance reviewed during the survey indicated that everyone over six months of age should receive the 2024-2025 COVID-19 vaccination to protect against circulating strains and prevent severe health outcomes. Despite these recommendations, there was no evidence in the medical records that the five residents had been screened, educated, or offered the COVID-19 vaccine, nor was there documentation of their vaccination status or any refusals.
Failure to Screen Staff for Disqualifying Offenses
Penalty
Summary
The facility failed to ensure that staff hired were free of disqualifying offenses as required by Ohio law and facility policy. During a review of personnel files, it was found that a Certified Nursing Assistant (CNA) was hired despite having a background report showing charges for aggravated robbery, aggravated assault, and domestic violence, all occurring in Ohio. Additionally, a Maintenance Supervisor was hired with a background report indicating prior charges for aggravated robbery and drug abuse. These findings were confirmed during an interview with the Human Resource Manager, who acknowledged that the disqualifying offenses were disregarded during the hiring process. The facility's policy requires background checks to be conducted in accordance with Ohio law and to verify that applicants are not excluded from federally funded programs. However, the review revealed that these procedures were not followed for two out of eleven personnel files reviewed, potentially affecting all 59 residents in the facility. The deficiency was identified during a complaint investigation and was substantiated by documentation and interviews.
Failure to Complete Pre-Employment Registry and Background Checks
Penalty
Summary
The facility failed to implement its abuse prevention policies and procedures regarding the screening of potential employees. Specifically, personnel file reviews revealed that nurse aide registry checks were either not completed prior to employment or were missing entirely for several staff members, including an activity director, an LPN, a maintenance supervisor, a human resource manager, a business office manager, and a CNA. In several cases, the registry checks were only completed months after the staff had already been hired. The human resource manager confirmed that these checks were performed retroactively when documentation was found to be missing during a file review. Additionally, the personnel file for an LPN did not contain evidence of a required background check, as mandated by both facility policy and Ohio law. The facility's abuse prevention policy and hiring policy require that background checks and nurse aide registry verifications be completed prior to employment to ensure that applicants are not excluded from federally funded programs and do not have a history of abuse or neglect. The failure to follow these procedures affected seven out of eleven personnel files reviewed and had the potential to impact all residents in the facility.
Widespread Sanitation and Food Storage Deficiencies in Dietary Services
Penalty
Summary
Surveyors observed multiple sanitation and food safety deficiencies in the facility's kitchen and food storage areas. During a kitchen tour, they found a Ziploc bag containing leftover ham dated over two weeks prior, a box of mushrooms with visible spoilage, and several containers of food that were unlabeled and undated, including fruit punch, gravy, peas, and mashed potatoes. The kitchen equipment, such as the oven, cooktop, and dishwasher, was heavily soiled with caked-on food debris and grease. The kitchen floor was dirty and appeared unswept and unmopped. Additionally, pork loins were observed thawing in a sink without being covered in water, contrary to safe thawing practices. The Dietary Manager, who had recently started, confirmed the lack of cleaning logs and stated that a cleaning schedule had only just been created but not yet implemented. Further inspection of a refrigerator in the second-floor activity room revealed expired food items, including a vanilla shake, grape jelly, strawberry syrup, juice containers, and yogurt, as well as two containers with visible mold. The Regional Culinary Director confirmed these findings. In a resident's personal room refrigerator, which belonged to a resident with a physician order for nothing by mouth, surveyors found visible mold, dried spills, stains, and expired food items, including pudding, chocolate chips, and enteral feeding containers. The Regional Culinary Director confirmed that these items should have been disposed of and that enteral feedings should be stored by nursing staff. Additional observations included a dietary aide working in the kitchen without a required hair net, which he acknowledged was against policy. Review of facility policies confirmed that the Dietary Manager is responsible for sanitation and that food should be properly labeled, dated, and stored. Policies also require the use of hair coverings and proper thawing and storage of food. The lack of adherence to these policies and procedures led to unsanitary conditions and improper food handling throughout the facility.
Failure to Maintain Safe and Functional Elevators
Penalty
Summary
The facility failed to ensure that both elevators were maintained in safe operating condition, resulting in ongoing malfunctions and service interruptions affecting all residents. Documentation review revealed a pattern of elevator failures, including both elevators being unresponsive, stuck on various floors, and requiring frequent repairs from November through May. Service invoices detailed repeated issues such as elevators not responding, being stuck with doors closed, low oil sensor trips, faulty switches, and power issues. Preventative maintenance was performed, but problems persisted, with elevator two eventually being taken completely out of service due to motor and starter failures. There was also an incident involving the fire department responding to a reported entrapment, though the elevator was operational upon their arrival. Observations confirmed that elevator two was out of service, and elevator one was only partially functional. Elevator one required users to manually press the button to return it to the first floor after use on the second floor; otherwise, it would remain on the second floor, causing delays for residents and staff. Staff interviews corroborated these issues, with multiple LPNs and the DON acknowledging the malfunction and the impact on residents, including one resident who could not fit into elevator one due to the size of their wheelchair. Activities were primarily held on the second floor, further complicating access for residents with mobility needs. Maintenance and elevator repair staff interviews indicated a lack of timely communication and follow-up regarding the ongoing issues, particularly with elevator one. The elevator repair supervisor and maintenance director were not consistently aware of the problems, and there was confusion about whether an electrician was needed for power issues. The facility posted signs instructing users to send the elevator back to the first floor, and staff were in-serviced on this workaround, but the underlying mechanical and operational deficiencies remained unresolved at the time of the survey.
Failure to Maintain Clean, Sanitary, and Safe Environment
Penalty
Summary
Surveyors observed multiple instances of unclean, unsanitary, and unsafe conditions throughout the facility, affecting both resident rooms and common areas. On the first floor, a bathroom was found with a broken toilet paper holder, and on the second floor memory care unit, strong odors of urine and feces were present. An ice machine was leaking water, with towels and bath blankets used to soak up the spill. Several resident rooms were found in poor condition: one room had heavily soiled and odorous bed linens with the call light on the floor, another unoccupied room contained food debris and soiled incontinence products, and additional rooms had debris, unclean bedpans, overflowing trash, dirty linens, and unclean urinals on the floor. Residents reported that staff did not return to clean up after providing care, and trash was observed under beds and on floors in multiple rooms. Housekeeping staff confirmed that there was insufficient staffing to ensure daily cleaning of resident rooms and common areas. Observations also revealed overflowing trash cans, lack of toilet paper in bathrooms, and handrails at the nurse's station contaminated with food, band-aids, trash, and other debris. Facility policy required regular cleaning of surfaces, but these standards were not met. The findings were verified by various staff members, including the DON, LPNs, and the Business Office Manager. The deficiency was investigated under multiple complaint numbers.
Failure to Maintain Required Water Temperatures in Resident Rooms
Penalty
Summary
The facility failed to maintain resident room water temperatures at a comfortable and required level, as evidenced by observations and interviews. During incontinence care, a resident reported that the water was cold, and a CNA confirmed that the water had been running for five minutes but was still not hot enough for the resident's preference. Subsequent temperature checks in multiple resident rooms revealed water temperatures of 88 and 96 degrees Fahrenheit, both below the required range of 105 to 120 degrees Fahrenheit, even after allowing the water to run for five minutes. Staff verified these low temperatures and indicated that this was typical during care. Facility records showed that previous water temperature audits had recorded acceptable temperatures, but the current findings demonstrated a failure to consistently provide water at a comfortable temperature for residents.
Inaccurate MDS Assessments and Documentation Errors
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) 3.0 assessments were completed accurately for five residents. In one case, a resident was incorrectly documented as having a Stage III pressure ulcer present on admission, despite medical records and staff interviews confirming that no such ulcer was present at that time. Another resident was inaccurately assessed as being dependent on staff for activities of daily living, when nursing progress notes indicated the resident was independent or only required supervision for most tasks. A third resident's MDS assessment underreported the number of insulin injections received, stating only one injection in the look-back period when medication records showed daily administration. For another resident, the MDS inaccurately reflected severe cognitive impairment and enteral feeding compliance, despite multiple staff interviews and observations revealing the resident refused enteral feedings, consumed nutrition orally against orders, and was not receiving the documented amounts via the feeding tube. The staff responsible for the assessment did not document refusals or update the MDS to reflect the resident's actual intake and behavior. Additionally, a resident with a documented pressure wound and high risk for pressure sores was not accurately represented in the MDS, which failed to note the presence of the wound or the interventions in place. Staff interviews confirmed the inaccuracies in the assessments and a lack of awareness among clinical leadership regarding the residents' actual conditions and care needs. These findings demonstrate a pattern of incomplete or incorrect MDS documentation based on inconsistent or unverified information from the medical record and staff observations.
Failure to Assist Dependent Residents with Activities of Daily Living
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for several dependent residents, as evidenced by record reviews, observations, and staff interviews. One resident, admitted with epilepsy and cognitive deficits, was care planned to require total assistance with eating and was at risk for malnutrition. Despite this, his meal trays were delivered and left untouched in his room on multiple occasions, with staff confirming that no assistance was provided during mealtimes. Another resident, with a history of seizures and repeated falls, was scheduled for showers twice weekly but documentation showed that he missed nine out of twelve scheduled showers in a month, with no evidence of refusal or completed care. Observations revealed the resident appeared unkempt, with dirty nails and dried food on his clothing, and he reported not receiving showers as scheduled. Staff interviews confirmed the lack of documentation and completion of required bathing care. Additional residents with significant cognitive and physical deficits were also not assisted as required. One resident received only two documented showers in a month despite requiring extensive assistance, and was repeatedly observed with long, dirty fingernails and unchanged clothing. Another resident, totally dependent for ADLs, had no documentation of bathing care, and staff could not confirm when or if care was provided. Facility policy required documentation of bathing and skin observation at least twice weekly, which was not followed for these residents.
Failure to Document and Administer Required Influenza and Pneumococcal Vaccinations
Penalty
Summary
The facility failed to ensure that residents were offered, screened, educated, and received influenza and pneumococcal vaccinations as required by both facility policy and CDC guidance. This deficiency was identified through record reviews, policy reviews, and staff interviews, affecting five residents who were reviewed for vaccinations, with the potential to impact all 59 residents in the facility. For each of the five residents, there was no documentation in the medical records regarding the administration of influenza or pneumococcal vaccines, nor any record of consent, declination, or education provided about these vaccines. Specifically, the medical records for residents with various diagnoses, including dementia, schizophrenia, muscle weakness, congestive heart failure, asthma, morbid obesity, diabetes, respiratory failure, and COPD, lacked any evidence of vaccination status or related documentation. Interviews with the President of Operations and the Regional Registered Nurse confirmed that they were unable to locate any vaccination records, refusals, or educational materials for these residents in the electronic medical records. This absence of documentation was consistent across all five residents reviewed. Facility policies required that for residents who received vaccines, the date, lot number, expiration date, person administering, and site of vaccination be documented in the medical record, and that refusals also be documented. Additionally, policies stated that residents should be assessed for vaccine eligibility upon or prior to admission and offered the vaccine series within thirty days unless contraindicated. The CDC guidance reviewed also emphasized the importance of following recommended immunization schedules for at-risk populations, but there was no evidence that these requirements were met for the residents in question.
Failure to Complete Required Annual Self-Administration Medication Assessment
Penalty
Summary
The facility failed to ensure that a resident was properly assessed for the ability to self-administer medications as required by policy. Record review showed that a resident with legal blindness, absence of one eye, and peripheral vascular disease was cognitively intact and had severe vision impairment. The resident was self-administering several medications, including Calcium-Vitamin D, Ammonium Lactate lotion, and Omega-3, with physician orders allowing medications at bedside. However, the Medication Self-Administration Safety Screen assessment had not been updated since the initial assessment, and no annual reassessment had been completed as required. Interview with the President of Clinical Operations confirmed that the required annual reassessment was not performed. Policy review indicated that self-administration should only occur if the physician and interdisciplinary team determine the resident can do so safely, but this process was not followed for the resident in question.
Incomplete Medicare Non-Coverage Notice Provided to Resident
Penalty
Summary
The facility failed to provide a complete and accurate Notice of Medicare Non-Coverage (NOMNC) to a resident whose skilled services under Medicare A were ending. The resident, who had a history of heart disease, falls, and chronic obstructive pulmonary disease, remained in the facility after Medicare A services were discontinued. Review of the NOMNC signed by the resident showed that it did not specify the type of services being discontinued, nor did it include information on who to contact for an appeal or provide a phone number. This deficiency was confirmed during an interview with the President of Operations, who acknowledged the notice was incomplete.
PRN Psychotropic Medication Order Exceeded 14-Day Limit Without Rationale
Penalty
Summary
The facility failed to ensure that as-needed (PRN) psychotropic medication orders were limited to 14 days, as required by policy, for one resident. A review of the medical record for a resident with diagnoses including bipolar disorder, schizoaffective disorder, restlessness, and agitation showed a physician's order for Hydroxyzine 25 mg by mouth every eight hours as needed for anxiety, without a stop date. The medication was administered on two occasions, and the resident's care plan included monitoring for side effects and effectiveness of psychotropic medications. The facility's policy required that continuation of PRN psychotropic medications beyond 14 days must be accompanied by practitioner documentation of the rationale, which was not present in this case. An interview with the RN/Regional Director of Clinical Services confirmed the absence of a stop date and acknowledged the requirement for a 14-day limit on PRN psychotropic medications.
Failure to Include Self-Management in Resident Care Plans
Penalty
Summary
The facility failed to ensure that comprehensive, person-centered care plans were developed and implemented to address all resident needs, specifically regarding self-management of colostomy care and self-administration of medications. For one resident with a colostomy, the care plan included interventions for gastrointestinal status but did not address the resident's self-management of her colostomy, despite documentation and staff interviews confirming that the resident independently performed her own colostomy care and received supplies from staff. The omission was verified by the Regional Director of Clinical Services, who acknowledged that a care plan for self-management should have been in place. Additionally, another resident who was cognitively intact and legally blind had physician orders permitting unsupervised self-administration of several medications, including fish oil, calcium-vitamin D, and Systane Gel, with medications allowed at bedside. However, the care plan did not include self-administration of medications, and staff interviews confirmed this omission. The facility also lacked a self-administration of medication policy, as confirmed by the President of Clinical Services. These findings were based on record review, staff interviews, and policy review, and affected two of forty resident records reviewed.
Failure to Provide Scheduled Showers and Document Bathing Care
Penalty
Summary
The facility failed to ensure that residents received showers as scheduled and according to their preferences, as evidenced by the experiences of two residents who required limited or moderate assistance with bathing. One resident, admitted with diagnoses including heart disease, a history of falls, and chronic obstructive pulmonary disease, was independent in several activities of daily living but required limited staff assistance for personal hygiene and physical help only with transfers for bathing. Despite being scheduled for showers twice weekly, documentation showed only two recorded bathing events over a three-month period, with one being a bed bath and another date left blank. The resident reported not receiving scheduled showers and stated that his family had to assist with shaving due to lack of staff support. Facility leadership confirmed the lack of documentation for additional showers during this period. Another resident, with diagnoses such as adjustment disorder, chronic respiratory failure, morbid obesity, dysphagia, and depression, and who was cognitively intact, required moderate staff assistance for bathing, dressing, and personal hygiene. Although scheduled for showers twice weekly, facility records could only verify eight showers out of 21 scheduled opportunities. The resident reported not receiving scheduled showers and being told to wash up at the sink. Staff interviews revealed that when the shower aide was reassigned to other duties, scheduled showers were not completed, and communication lapses occurred regarding missed showers. The Director of Clinical Services confirmed that showers were not being provided as scheduled. Facility policy required documentation of showers or refusals, but this was not consistently followed.
Failure to Provide Adequate Catheter Care and Proper Bag Positioning
Penalty
Summary
Staff failed to provide adequate catheter care and proper positioning of a urinary catheter bag for a resident with an indwelling catheter. The resident, who had impaired cognition and required maximum assistance with toileting, was observed on multiple occasions with the catheter bag improperly placed—once in the resident's lap and on two separate occasions on the floor under the bed. The catheter tubing was noted to contain a large amount of thick sediment, and the insertion site and tubing had black dried debris around them. The resident was unable to recall when care was last provided, and a CNA confirmed that catheter care had not been performed since the start of her shift. Review of the resident's care plan and physician orders indicated that catheter care was to be provided every shift and as needed, and facility policy required that catheter bags be kept off the floor and positioned lower than the bladder. Despite these directives, observations and staff interviews confirmed that these standards were not met, resulting in inadequate catheter care and improper catheter bag positioning for the resident.
Failure to Address Significant Weight Loss in Resident
Penalty
Summary
A resident with diagnoses including Alzheimer's disease, diabetes mellitus type two, and bipolar disorder was admitted to the facility with a weight of 178 lbs. The resident was identified as being at risk for malnutrition, with care plan interventions to monitor weights and notify of any significant changes. Over the course of approximately one month, the resident experienced a significant weight loss of 18.43%, dropping from 178 lbs. to 145.2 lbs. Despite this notable change, there was no evidence in the medical record that the resident's physician was notified of the significant weight loss, as required by facility policy. The resident required set-up assistance and cueing for meals due to impaired cognition and was observed to consume a high percentage of meals. The registered dietician questioned the accuracy of the initial weight but still recommended continued weekly weight monitoring. Facility policy required the physician and multidisciplinary team to identify and address weight loss, but the lack of physician notification and absence of documented interventions addressing the weight loss constituted a failure to implement appropriate nutritional interventions for the resident.
Failure to Monitor and Document Respiratory Care Orders
Penalty
Summary
The facility failed to ensure proper monitoring and administration of respiratory care for a resident with significant medical needs, including quadriplegia, a tracheostomy, and a cervical spine injury. Physician orders for oxygen at two liters humidified air via trach mask, suction every shift and as needed, and monthly trach inner cannula changes were not transcribed into the medical record, resulting in a lack of documentation regarding when these interventions were completed and monitored. Additionally, there was limited documentation of oxygen saturation readings in the resident's vital records. Interviews with nursing staff and the President of Clinical Services confirmed that the necessary respiratory care orders were missing from the medical record, leading to insufficient monitoring and documentation of the resident's respiratory status. Facility policy requires monitoring of oxygen saturation to assess and respond to respiratory changes, but this was not followed in this case.
Delayed Response to Pharmacy Recommendations for Medication Regimen Reviews
Penalty
Summary
The facility failed to address pharmacy recommendations in a timely manner for two residents reviewed for unnecessary medications. For one resident with multiple diagnoses including anxiety and depression, the pharmacist recommended a trial discontinuation of Xanax while titrating buspirone upward. Although the prescriber indicated agreement, there was no identifiable signature or date, and the recommendation was not addressed in a timely manner, with the medication only discontinued several months later. Nurses' notes did not mention the pharmacy recommendations during this period, and facility leadership confirmed the delay in addressing the pharmacist's input. For another resident with epilepsy and a history of encephalitis, the pharmacist recommended adjusting the administration schedule of Trazodone and monitoring for adverse effects, but the physician did not respond to the recommendation, and the medication was eventually discontinued by a hospital physician. Additionally, the pharmacist recommended clarifying the duration and monitoring requirements for Enoxaparin, but the physician did not respond until approximately two months later. Facility policy required monthly medication regimen reviews and timely physician responses to pharmacist recommendations, which were not followed in these cases.
Failure to Complete and Document Physician-Ordered Laboratory Testing
Penalty
Summary
The facility failed to ensure that laboratory testing for a resident was completed as ordered by the physician. The resident, who had diagnoses including epilepsy, cognitive communication deficit, a need for assistance with personal care, and a history of encephalitis, had multiple active laboratory orders for monitoring various conditions and medications. These orders included regular Albumin levels, CBC, BMP, Depakote levels, and other specific tests at weekly, biweekly, monthly, and multi-month intervals. Review of the resident's medical record revealed that many of these laboratory tests were not completed as ordered, with only a few laboratory results present in the record for specific dates. Further review and interviews with the DON and an RN confirmed that several laboratory results were missing from the medical record, and the physician had not been updated on some of the laboratory findings. During the survey, the RN was observed printing some missing results from the laboratory services website, but the DON was unable to provide evidence of other required laboratory testing being completed. This failure to complete and document laboratory testing as ordered constituted the deficiency.
Failure to Maintain Functional Elevators Limits Resident Access and Participation
Penalty
Summary
The facility failed to ensure a properly functioning elevator system to accommodate the needs and preferences of its residents, particularly those with mobility impairments. Multiple invoices and service records indicated ongoing issues with both elevators over several months, including repeated instances where elevators were unresponsive, stuck on various floors, or required significant repairs such as motor and valve replacements. Despite ongoing maintenance and service calls, one elevator remained out of service for an extended period, while the other exhibited operational issues, such as not returning to the first floor unless a specific button was pressed on the second floor. Staff and residents were required to implement workarounds, such as posting signs instructing users to send the elevator back to the first floor, but these measures did not resolve the underlying problems. Three residents were directly affected by the elevator deficiencies. One resident with morbid obesity and a large wheelchair was unable to fit into the smaller, functioning elevator, limiting his ability to participate in activities held on the second floor. Another resident with a motorized wheelchair also could not use the smaller elevator and reported feeling isolated due to being unable to go outside or access other areas. A third resident, who used a wheelchair due to paraplegia, expressed reluctance to use the malfunctioning elevator out of concern for being trapped. Interviews with staff confirmed that the elevator issues caused delays and required additional staff intervention, and that some staff were unaware of the full extent of the problems. Observations confirmed that the majority of facility activities were held on the second floor, with only a small fraction conducted on the first floor, further limiting access for residents unable to use the elevator. Documentation and interviews revealed that the elevator company and facility maintenance were aware of the ongoing issues, but communication gaps and delays in addressing the problems persisted. The elevator malfunction also led to at least one incident where the fire department was called for a possible entrapment, although no one was found to be trapped upon their arrival.
Failure to Prevent and Investigate Staff-to-Resident Physical Abuse
Penalty
Summary
A deficiency occurred when the facility failed to prevent staff-to-resident physical abuse involving a resident with schizoaffective disorder, anxiety, depression, anemia, and PTSD. The resident, who was cognitively intact but exhibited disorganized thinking and was frequently incontinent, became agitated after being told by an LPN that she could not go outside to smoke outside of scheduled times. The situation escalated when the resident threw water on the LPN, and according to multiple staff interviews, the LPN retaliated by throwing ice water back on the resident, soaking her gown. The incident resulted in the resident calling the police and expressing distress over the nurse's actions. The facility's investigation into the incident was incomplete and lacked thorough documentation. The Regional Director of Operations was unable to provide a comprehensive investigation, and only a few resident and staff statements were available. Interviews with staff and the resident confirmed that the LPN had thrown water on the resident in response to the resident's actions. The facility's policy required immediate removal of staff accused of abuse pending investigation, but the LPN was allowed to finish her shift after the incident, and the allegation was not reported in a timely manner. The facility's policy on abuse, neglect, and exploitation outlined specific steps for investigating allegations, including immediate suspension of accused staff and thorough interviews with all potential witnesses. However, these procedures were not followed, as evidenced by the incomplete investigation and the LPN's continued presence in the facility after the incident. The failure to promptly and thoroughly investigate the allegation and to remove the accused staff member from duty contributed to the deficiency.
Failure to Timely Report and Respond to Allegations of Abuse
Penalty
Summary
The facility failed to timely report allegations of abuse involving three residents out of seven reviewed for abuse. In one incident, a resident with schizoaffective disorder, anxiety, depression, anemia, and PTSD became agitated after being denied a cigarette outside of scheduled smoking times. The resident threw water on an LPN, who, according to multiple staff and resident interviews, retaliated by throwing ice water back on the resident. The resident subsequently called the police. Despite the incident, the LPN was allowed to finish her shift and was not suspended immediately after the allegation was made, and the self-reported incident (SRI) was not submitted until several hours after the event. Another incident involved two residents with significant cognitive and behavioral diagnoses, including dementia, depression, and schizoaffective disorder. During a supervised smoke break, one resident asked another for a light, which was refused, leading to an altercation where one resident attempted to throw a chair and the other responded by hitting. Staff intervened and separated the residents, but the SRI documenting the resident-to-resident altercation was not opened until more than 24 hours after the incident, exceeding the required reporting timeframe. Nursing progress notes did not document the incident for one of the residents involved. Facility policy requires immediate reporting of all allegations of abuse, neglect, exploitation, or misappropriation of resident property to the Administrator or designee and to the state health department, with a maximum reporting window of 24 hours. Interviews with facility leadership confirmed that the incidents were not reported within the required timeframe and that staff involved in the alleged abuse were not suspended immediately as required by policy. These failures resulted in non-compliance with state and federal regulations regarding the timely reporting and handling of abuse allegations.
Failure to Thoroughly Investigate Alleged Abuse Incident
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving a resident with schizoaffective disorder, anxiety, depression, anemia, and PTSD. The incident began when the resident, who was cognitively intact but had disorganized thinking and an ostomy, became agitated after being told she could not go outside to smoke outside of scheduled times. According to documentation, the resident threw water on an LPN, and there were conflicting accounts regarding whether the LPN retaliated by throwing water back on the resident. The resident subsequently called the police, and the LPN was later terminated for not de-escalating the situation. The facility's investigation into the incident was incomplete. The available documentation included only a few resident statements, one staff statement, and lacked comprehensive interviews with all potential witnesses. Interviews with staff and residents conducted by surveyors after the fact revealed that some staff had witnessed the LPN throw water on the resident in response, contradicting the facility's initial determination that the allegation was unsubstantiated. The Regional Director of Operations confirmed that the investigation was not thorough, and the Vice President of Operations acknowledged that required documentation was not completed or available for review. The facility's policy required a thorough investigation of all alleged violations, including interviews with the resident, accused, and all witnesses, as well as proper documentation of the investigation. In this case, the facility did not follow its own policy, as key witness interviews and statements were missing, and the investigation was not adequately documented. This failure affected one resident out of seven reviewed for abuse, in a facility with a census of 59.
Deficient Care in Tube Feeding Management, Change in Condition Monitoring, and Documentation
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, resident preferences, and goals for three residents. For one resident with a history of oropharyngeal cancer and severe dysphagia, there were multiple failures in the management of tube feeding and NPO status. Despite physician orders for enteral feeding via PEG tube and NPO status, the resident consistently refused tube feedings, medications, and flushes, instead consuming enteral nutrition orally and other foods. Staff provided bottles of enteral feeding for the resident to consume orally without a corresponding physician order, and there was no evidence of a signed medical waiver. The resident's refusals and actual intake were inconsistently documented, and weekly weights ordered by the physician were not completed or tracked. The resident's room contained a refrigerator with expired and inappropriate food items, and the PEG tube site was observed to be red, inflamed, and without proper dressing, indicating a lack of monitoring and care. Another resident returned from the hospital with a diagnosis of aggressive behaviors, but there was no documentation of a progress note or change in condition assessment prior to the hospital discharge. Facility leadership confirmed that such documentation should have been completed according to policy, but review of the medical record showed no evidence of this. This lack of documentation failed to ensure proper monitoring and continuity of care during a significant change in the resident's condition. A third resident with a history of convulsions, stroke, and traumatic brain injury experienced a possible seizure and hypotension, as reported by the resident's son and documented by an LPN. However, the LPN later admitted she had not directly observed the seizure and had documented based on the son's report. There was no progress note authored prior to the resident's hospital admission, and blood pressure readings were significantly low. Facility policy required detailed observation and documentation of changes in condition, which was not followed. These failures in documentation, assessment, and adherence to physician orders resulted in deficiencies in the quality of care and treatment provided to the residents.
Failure to Coordinate Follow-Up Vision Appointment
Penalty
Summary
A deficiency occurred when the facility failed to coordinate a follow-up vision appointment with a retina specialist for a resident diagnosed with end stage macular degeneration. The resident, who had intact cognition and required moderate assistance with activities of daily living, was seen by an eye doctor at the facility who recommended a follow-up with a retina specialist within one to two weeks. A physician order was entered for this referral, and the order was given to the unit manager to schedule the appointment. However, there was no evidence that the appointment was ever scheduled or completed, and the unit manager responsible for this task was no longer employed at the facility. The resident reported having requested the appointment multiple times and not being informed of any scheduled visit. Review of facility policy indicated that social services should collaborate with nursing staff to arrange such referrals and document them in the medical record, but no documentation of the referral or appointment was found. Interviews with facility staff confirmed the lack of follow-through on the physician's order, resulting in the resident not receiving the recommended specialist care.
Failure to Ensure Required Physician Visits for Resident
Penalty
Summary
The facility failed to ensure that physician visits were provided as required for a resident with multiple complex medical diagnoses, including osteonecrosis, gastrostomy, a history of malignant neoplasm, and nicotine dependence. The resident, who had severe cognitive impairment and was dependent on a feeding tube for the majority of nutritional needs, had documentation of an admission physician visit and a subsequent physician order fax, but no other physician visits were found in the medical record. During interviews, the attending physician stated that a visit had been completed and notes sent to the facility, but facility leadership was unable to provide evidence of any required physician visits beyond the initial documentation. This lack of documentation and evidence of ongoing physician visits constituted the deficiency.
Failure to Obtain and Administer Medications as Ordered
Penalty
Summary
The facility failed to ensure that medications were obtained from the pharmacy and administered as ordered for a resident with multiple complex medical conditions, including epilepsy, cognitive communication deficit, a need for assistance with personal care, and a history of encephalitis. Record review showed that on several occasions, the resident did not receive prescribed medications such as clobazam, enoxaparin sodium injection, and phenobarbital because the facility did not have these medications available from the pharmacy. Nursing staff documented these missed doses on the Medication Administration Record (MAR), and the physician was not notified when the medications were unavailable. The Director of Nursing confirmed that the medications were not available from the pharmacy at the times indicated. The facility's policy stated that the pharmacy would supply and deliver needed medications, but this was not followed in these instances. The deficiency was identified during a review of the resident's medical record and MAR, as well as through staff interviews, and was investigated under multiple complaint numbers.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as required. During observation of medication administration, a total of 26 medication opportunities were reviewed, and two errors were identified, resulting in a 7.69% error rate. Specifically, a resident with diagnoses including diabetes, hypertension, and depression was observed during morning medication administration. The LPN on duty administered 16 different medications, totaling 18 pills, but omitted two prescribed medications: Lisinopril 20 mg and Claritin 10 mg. The omission was confirmed during an interview with the LPN, who acknowledged not administering the two medications as ordered by the physician. Review of the facility's medication administration policy indicated that medications must be given in accordance with physician orders. This incident was documented as part of an investigation under multiple complaint numbers, and the facility census at the time was 59.
Failure to Update and Honor Resident Food Preferences
Penalty
Summary
The facility failed to ensure that a resident's food preferences were honored and updated as required. The resident, who had diagnoses including adjustment disorder, chronic respiratory failure, morbid obesity, dysphagia, and depression, was cognitively intact and required set up for meals. Despite a physician order specifying a regular diet with no oatmeal, a preference for cold cereal, and a request for chef's salad, the resident reported that her preferences were not being followed. She stated that she continued to receive oatmeal, which she disliked, and her dietary tray ticket did not list any preferences or dislikes. Observation confirmed that her tray ticket did not reflect her stated preferences. Interviews with facility staff revealed that the Registered Dietitian completed nutrition assessments but did not update resident preferences, which was the responsibility of the Dietary Manager. The Regional Dietary Manager acknowledged that there had been several changes in the Dietary Manager position and that she had not been visiting residents to obtain or update preferences since starting in her role. It was also unclear if previous dietary managers had fulfilled this responsibility. Facility policy required that food preferences be assessed upon admission and documented in the care plan, but this was not done for the resident in question.
Failure to Coordinate and Arrange Required Outside Medical Appointments
Penalty
Summary
The facility failed to ensure that required outside professional services were obtained and appointments were coordinated for two residents. For one resident with diagnoses including adjustment disorder, chronic respiratory failure, morbid obesity, dysphagia, and depression, there was an order for an orthopedic consult following the identification of a benign cyst in the right knee. Despite the physician's order, the appointment was not scheduled, and there was no documentation in the nursing progress notes regarding the order or the scheduling of the consult. The resident reported not having the suggested follow-up, and staff interviews confirmed that the appointment was not arranged as required. For another resident with chronic respiratory failure, COPD, diabetes with neuropathy, morbid obesity, and stage 4 chronic kidney disease, there were multiple missed or rescheduled nephrology appointments. The resident required bariatric transportation, and staff interviews and documentation revealed that transportation issues led to the rescheduling of appointments. Although transportation was confirmed for some appointments, others were cancelled or rescheduled, and staff could not consistently recall the reasons for these changes. The facility's own policies required collaboration and documentation for arranging such services, but these were not followed. The deficiency was identified through record reviews and staff interviews, which showed that the facility did not ensure timely scheduling and coordination of outside appointments as ordered by physicians. This affected both residents reviewed for appointment coordination, with failures in both arranging necessary consults and providing appropriate transportation for medical appointments.
Failure to Maintain Accurate and Complete Medical Records and Medication Administration Documentation
Penalty
Summary
The facility failed to ensure accurate and complete medical records for multiple residents, resulting in noncompliance with accepted professional standards. For one resident with multiple chronic conditions and complex wound care needs, there were conflicting and overlapping physician orders for wound treatments, and previous orders were not properly discontinued. This led to confusion among staff regarding which dressing protocol to follow, as confirmed by the RN/Regional Director of Clinical Services, who stated that the wound nurse had not discontinued outdated orders. Several residents did not receive their prescribed medications on a specific date, and there was no documentation in the medical records or nursing progress notes explaining the missed doses. The DON confirmed that the electronic medical record system was not functioning on the first floor during the relevant medication administration times, but was operational on the second floor. Despite the system being fixed during the medication pass, there was no evidence that the medications were administered or any documentation to support administration for these residents. Additional documentation lapses were identified for other residents, including missing pain evaluations, bowel documentation, and behavioral observations due to intermittent outages of the electronic medical record system. In one case, a resident was documented as having received two different Omega-3 supplements, but the resident reported self-administering all medications and the nurse could not account for the administration. The facility's IT department confirmed technical issues with the electronic record system, resulting in missing documentation for several days. Facility policy requires that medication administration be documented immediately after each dose, but this was not consistently done.
Failure to Coordinate Hospice Services and Ensure Continuity of Care
Penalty
Summary
The facility failed to coordinate care and services with hospice for a resident who had been admitted with multiple diagnoses, including severe dementia, malnutrition, and a history of falls. The resident was under palliative care and later enrolled in hospice, but the hospice care plan was incomplete, listing only assistance with feeding and lacking other necessary interventions. Documentation showed that the resident developed a pressure injury, but there was no evidence that hospice was notified of this change in condition, nor was there documentation of hospice involvement in the resident's ongoing care. Multiple assessments by facility staff and wound care practitioners identified and tracked the progression of the resident's pressure injury, including changes in wound stage and size. Despite these findings, hospice staff were not informed, and their own documentation failed to reflect the presence of the wound. Communication between facility staff and hospice was minimal or absent, with nurses reporting unsuccessful attempts to contact hospice and no updates or care coordination occurring. Hospice staff also did not communicate with facility staff or the resident's family, and their assessments did not accurately reflect the resident's condition. Interviews with facility staff, hospice staff, and the resident's family confirmed a lack of communication and coordination. There was no communication binder or process in place for sharing updates, and hospice staff did not follow established protocols for documenting visits or care provided. The facility's policy and the hospice contract both required collaboration and communication, but these were not followed, resulting in a lack of continuity of care for the resident.
Failure to Provide Required Transfer, Discharge, and Bed-Hold Notifications and Documentation
Penalty
Summary
The facility failed to provide required documentation and notifications related to resident transfers, discharges, and bed-hold policies for multiple residents. Specifically, there was no evidence that the Long-Term Care Ombudsman was notified of several residents' transfers to the hospital or discharges, as required by facility policy and regulations. For example, one resident with significant medical needs, including paraplegia and dementia, was hospitalized multiple times, but the facility could not provide documentation of ombudsman notification for these events. Additionally, bed-hold notices were only available for some hospitalizations, not all, and written discharge notices were not consistently provided to residents or their representatives prior to transfer or discharge. Another resident with intellectual disabilities and behavioral issues was transferred to the hospital, but the facility failed to document the transfer in the medical record as required. The policy mandates that the date, time, and personnel involved in the discharge be recorded, but this information was missing. In another case, a resident left the facility against medical advice, and the facility did not notify the ombudsman of the discharge, contrary to policy. Similarly, for a resident discharged after exhausting bed-hold days, the facility could not provide documentation that the required notice was sent to the ombudsman. These deficiencies affected all residents reviewed for transfer and discharge requirements. The facility's failure to provide proper documentation and notifications, including ombudsman notification and bed-hold notices, was confirmed through interviews with facility leadership and review of medical records and facility policies. The lack of required documentation and notification was observed in each case, with staff confirming the absence of these records during interviews.
Failure to Conduct Timely Care Conferences
Penalty
Summary
The facility failed to complete care conferences in a timely manner for four residents, affecting their comprehensive care planning process. The medical records for these residents revealed that care conferences were either incomplete or not conducted within the required timeframe. For Resident #25, the care conference assessment was signed and locked months after the initial assessment, with no evidence of a care conference between May and July 2024. Similarly, Resident #35's care conference assessment was incomplete, and no care conference was documented between May and July 2024. Resident #40 and Resident #63 also lacked evidence of care conferences during the same period, despite having comprehensive care plans reviewed in July 2024. The facility's policy requires the development of a comprehensive care plan within seven days of the completion of the resident's MDS assessment, with the resident or their representative encouraged to participate. However, the Regional Director of Operations confirmed that the facility does not complete care conferences every three months or in conjunction with MDS assessments. This deficiency was identified during a complaint investigation, highlighting a failure to adhere to the facility's care planning policy and affecting the quality of care provided to the residents.
Documentation Deficiencies in Medication and Enteral Feeding
Penalty
Summary
The facility failed to accurately document medication administration and enteral feedings for several residents, as well as maintain controlled medication disposition records. For Resident #18, there was a lack of documentation for the administration of Ativan on a specific date, despite the medication being removed for administration. Additionally, the facility could not provide controlled medication disposition records for Tramadol for Resident #18 from June to July 2024. Interviews with facility staff confirmed these documentation gaps. Resident #22 also experienced issues with documentation, as the facility failed to provide controlled medication disposition records for Morphine Sulfate and Ativan for July 2024. This lack of documentation was confirmed by the Regional Director of Operations. Similarly, Resident #43's controlled medication disposition records for Tramadol from June to July 2024 were not available for review, which was also verified by the facility's staff. For Resident #69, there were inaccuracies in the documentation of enteral feedings. The medication administration record showed discrepancies in the administration and refusal of enteral feeds and continuous enteral feeding of Isosource 1.5. Furthermore, an incorrect order regarding the conditions under which tube feeding should be held was identified. Interviews with the Unit Manager LPN and the acting Director of Nursing confirmed these documentation inaccuracies.
Deficiencies in Wound Care and Medication Administration
Penalty
Summary
The facility failed to provide adequate individualized wound care and medication administration as ordered by physicians, affecting several residents. Resident #36, who had multiple medical conditions including diabetes and a chronic ulcer, did not receive daily wound treatments as prescribed on multiple occasions. The wound, initially improving, showed signs of decline due to missed treatments, with increased measurements and the presence of slough. Despite changes in treatment orders, the facility did not consistently administer the necessary care, as confirmed by interviews and treatment administration records. Resident #40, who was receiving hospice care, developed multiple skin tears that were not assessed or treated, and there was no evidence that hospice or the physician was informed of these new conditions. This lack of communication and treatment initiation was verified by the Unit Manager, who could not confirm any actions taken regarding the skin tears. The facility's policy required any alteration in skin integrity to be assessed and communicated to the physician, which was not followed in this case. Additionally, the facility failed to administer medications as ordered for several residents, including Residents #18, #25, #30, and #63. These residents did not receive their prescribed medications on various dates, as confirmed by medication administration records and interviews with facility staff. The facility's policy on administering medications required accurate documentation and adherence to physician orders, which was not upheld, leading to multiple instances of non-compliance.
Failure to Conduct Thorough Fall Investigations and Implement Interventions
Penalty
Summary
The facility failed to conduct thorough investigations and implement appropriate interventions following falls involving three residents. Resident #31, who had a history of hemiplegia, morbid obesity, and muscle weakness, was found on the floor next to his bed. Despite being high risk for falls, no new interventions were added to his care plan, and the fall investigation lacked staff statements or a completed fall risk assessment. Similarly, Resident #40, with diagnoses including congestive heart failure and severe malnutrition, experienced an unwitnessed fall and was found on the floor in pain. The investigation did not result in immediate new interventions, and a fall risk assessment was not completed until eight days later. Resident #66, who had severe cognitive impairment and required substantial assistance, rolled out of bed during care by an unnamed STNA. The investigation did not clarify how the fall occurred or include staff statements, and the intervention to keep the bed low did not address preventing falls during care. The acting DON and RDCS confirmed that thorough investigations were not completed, and appropriate interventions were not implemented timely for these residents. The facility's policy on managing falls was not adhered to, as underlying causes were not identified, and interventions were not promptly adjusted.
Failure to Ensure Timely Physician Visits
Penalty
Summary
The facility failed to ensure that residents were seen by a general physician or nurse practitioner at least once every 60 days, affecting two residents out of three reviewed for physician visits. Resident #16, who was admitted with diagnoses including legal blindness, anxiety disorder, and hypertension, had not been seen by a general practitioner since 02/29/24, as confirmed by the resident during an interview on 07/31/24. The quarterly Minimum Data Set (MDS) assessment dated 06/29/24 indicated that Resident #16 was cognitively intact. Similarly, Resident #51, with diagnoses including congestive heart failure, type two diabetes, and other significant health issues, had not been seen by a general practitioner since 02/29/24. This was confirmed by the Acting Director of Nursing and the Regional Director of Clinical Services during an interview on 08/06/24. The quarterly MDS assessment dated 07/10/24 also showed that Resident #51 was cognitively intact. This deficiency was investigated under Complaint Number OH00155844.
Medication Administration Errors Lead to High Error Rate
Penalty
Summary
The facility was found to have a medication error rate exceeding the acceptable threshold of 5 percent, specifically reaching 9.67 percent. This was identified during a complaint investigation and involved multiple instances of improper medication administration. One resident, diagnosed with dementia and type 2 diabetes mellitus, was affected by these errors. The errors included the failure to prime an insulin pen before administration, which is necessary to ensure the correct dosage is delivered, and the administration of an incorrect dose and route of vitamin B-12. During the observation, a Unit Manager administered insulin lispro without priming the pen, contrary to the manufacturer's instructions, which could lead to incorrect dosing. Additionally, a Licensed Practical Nurse administered Basaglar insulin instead of the prescribed Lantus insulin without a physician's approval, despite both being long-acting insulins. This substitution was not FDA-approved as interchangeable, highlighting a significant deviation from proper medication administration protocols. Further errors were noted when the same resident received a vitamin B-12 dose that was both incorrect in quantity and administered via the wrong route. The facility's policy requires medications to be administered according to the physician's orders, with checks to ensure the right resident, medication, dosage, time, and method. These lapses in following established procedures contributed to the high medication error rate observed.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to prevent a significant medication error for a resident when insulin was inappropriately administered, and a medication was given using the wrong dose and route. The resident, who had diagnoses including dementia and diabetes mellitus type 2, was observed receiving insulin lispro without priming the pen injector, contrary to the manufacturer's instructions. The Unit Manager confirmed that the insulin pen was not primed, believing it unnecessary due to the absence of visible air bubbles, despite the manufacturer's instructions requiring priming to ensure correct dosage. Additionally, a Licensed Practical Nurse administered a vitamin B-12 tablet orally instead of the prescribed sublingual route and at a lower dose than ordered. The same nurse also substituted Basaglar insulin for the prescribed Lantus insulin without a physician's order, assuming interchangeability due to both being long-acting insulins. However, a pharmacist confirmed that these insulins are not FDA-approved as interchangeable, and no standing orders or physician-approved lists of interchangeable medications were available. The facility's policy on administering medications requires verification of the right resident, medication, dosage, time, and method before administration. This deficiency was identified during a complaint investigation and was noted as an example of continued noncompliance from a previous survey.
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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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