Gardens Of North Olmsted
Inspection history, citations, penalties and survey trends for this long-term care facility in North Olmsted, Ohio.
- Location
- 23225 Lorain Rd, North Olmsted, Ohio 44070
- CMS Provider Number
- 365310
- Inspections on file
- 33
- Latest survey
- February 17, 2026
- Citations (last 12 mo.)
- 19
Citation history
Health deficiencies cited at Gardens Of North Olmsted during CMS and state inspections, most recent first.
Surveyors found that several nurses lacked proper CPR certification required to support residents with full code status. Some LPNs and an RN had no CPR certification documented in their personnel files, while other LPNs held CPR cards that, although covering adult, child, infant, and AED use, did not specify BLS or healthcare provider-level training. The DON confirmed these gaps, which were inconsistent with facility policies requiring verification of necessary licenses and certifications at hire and ongoing BLS CPR certification for key clinical staff involved in resuscitative efforts.
A resident with a trach, chronic respiratory failure, and laryngeal cancer experienced respiratory distress when the trach inner cannula became dislodged. A CNA promptly reported the issue to an LPN, but the LPN delayed assessment to continue a med pass, while the CNA waited several minutes and then left the room to notify another CNA. When the LPN finally assessed the resident, the resident was in distress and pulled out the entire trach tube; the LPN was unable to reinsert it and left the resident alone to seek help from other nurses on different units. When multiple LPNs returned, the resident was grey and not breathing, CPR was started, and EMS was called, with documentation and staff interviews revealing unclear and delayed timelines in responding to the change in condition.
A resident with rheumatoid arthritis, failure to thrive, depression, and documented pain had scheduled Oxycodone ordered every four hours and PRN Acetaminophen. On multiple occasions, the Oxycodone doses were not administered because the facility was waiting for pharmacy delivery, and several additional scheduled doses were left blank on the MAR without any explanatory documentation. The DON confirmed that the resident did not receive the ordered Oxycodone on several shifts due to pharmacy delivery delays, contrary to facility policy requiring medications to be administered safely, timely, and as prescribed.
The facility failed to maintain accurate and complete medical records for two residents. For one resident with multiple behavioral health diagnoses and functional dependence, nursing documentation described hallucinations and accusations against staff but did not record that the physician initiated a pink slip for psychiatric evaluation, although the hospital record later confirmed the resident arrived with a pink slip citing agitation, threats, refusal of care, hallucinations, and paranoia. For another cognitively impaired resident with Alzheimer’s disease, a self-reported incident documented a resident-to-resident altercation in a secured unit, with staff intervention and assessment, but there was no corresponding progress note entry about the allegation or incident, despite facility policy requiring documentation of such events.
Staff failed to provide consistent food portions and palatable meals, with some residents receiving smaller servings as food ran low and others receiving food at inappropriate temperatures. Food temperature logs were not properly maintained, and staff were unsure of correct serving temperatures, resulting in meals that did not meet facility policy for nutrition and palatability.
Surveyors observed overflowing trash bins, bags of trash on the ground, strong mold odors, flying insects, and water leaks in the basement and laundry areas. Staff confirmed ongoing issues with mold, mildew, and water intrusion due to a leaking sewage pipe and a cracked foundation. Black mold was also found in the first-floor shower room. These conditions were not in accordance with the facility's policy for a clean and safe environment and had the potential to affect all residents.
Multiple residents at high risk for falls did not have their falls properly documented or assessed, and required fall prevention interventions were not consistently implemented. Staff were sometimes unaware of care plan interventions, and post-fall assessments such as vital signs, neurological checks, and pain evaluations were often missing or incomplete. Facility policy for fall management was not consistently followed, as confirmed by staff interviews and record reviews.
Two residents were affected when the facility failed to provide timely access to appropriate stoma supplies for a resident with a urostomy, resulting in leakage and distress, and did not ensure a working television for another resident after a room change due to a water pipe break. Staff and family reported miscommunication, delays, and lack of documentation, impacting the residents' ability to have their needs and preferences met.
A resident with severe cognitive impairment had several personal items, including a phone, abdominal binder, and dentures, go missing. Despite family and staff awareness of the missing items and facility policy requiring immediate reporting, there was no evidence that these incidents were reported to administration or the State agency, nor that an investigation was initiated.
A resident with severe cognitive impairment and multiple health conditions had several personal items, including phones, an abdominal binder, and dentures, go missing. Despite reports from the resident's family and documentation in the missing items log, staff and administration did not initiate or document any investigation into the missing property, as required by facility policy. Interviews with staff revealed uncertainty about the reporting and status of the items, and observations confirmed the items were not found.
A resident with multiple complex medical conditions did not have a care conference scheduled within the required timeframe, as confirmed by record review and facility schedules. The Social Services Designee, who was new to the role and had limited training, was unaware of the quarterly requirement and had not scheduled care conferences for several residents, resulting in noncompliance with facility policy.
Three dependent residents did not receive timely incontinence care, skin care, or oral hygiene as required. One resident waited over 20 minutes for incontinence care after activating the call light, while another was left in soiled conditions for hours during a temporary relocation, resulting in a bleeding wound and lack of skin and oral care. A third resident with severe cognitive impairment was found with dry, flaky skin and red buttocks, but was not offered lotion or mouth care. Staff interviews and observations confirmed that facility policies for ADL, skin, and oral care were not consistently followed.
Two residents experienced significant changes in condition that were not properly assessed or communicated by staff. One resident with a history of multiple health issues reported chest pain and later became unresponsive, with staff failing to document follow-up care or timely notify the physician. Another resident on hospice care became unresponsive after staff failed to assess or notify hospice or the physician about his declining status, partly due to confusion about his code status. Facility policy requiring prompt recognition and communication of acute changes was not followed in these cases.
Two residents with significant urinary health risks did not receive timely identification and treatment for UTIs due to missed or delayed urine specimen collection, lack of follow-up on lab results, and poor documentation. One resident's specimen was discarded and not resent, while another's repeat specimen was not collected as recommended, leading to hospitalization for UTI and sepsis.
A resident with end stage renal disease and cognitive impairment missed multiple scheduled dialysis appointments due to failures in transportation arrangements and communication among staff and the transportation provider. The resident was not transported as ordered, resulting in hospitalization for missed dialysis. Facility policy required safe transportation to dialysis, but this was not consistently followed.
A resident with severe cognitive impairment and multiple comorbidities was left without dentures for an extended period after they were reported missing. Staff were unclear about when the dentures were lost, and the resident did not receive a timely dental referral or intervention as required by facility policy. The delay in dental care and lack of documentation regarding interim measures led to a deficiency in providing appropriate dental services.
A resident with dementia and a history of wandering eloped from the facility, prompting an endangered missing adult alert. Despite facility policies requiring investigation and reporting of missing residents, the incident was not reported to the State Agency or entered into the Ohio Department of Health's system. The facility's policies were found to be vague regarding state reporting requirements, and required notifications were not made following the resident's elopement.
A resident with moderate dementia and impaired safety awareness eloped from the facility without staff knowledge, walking several miles and spending the night in a car during cold weather. The resident was not discovered missing until hours later, and there was a lack of timely documentation and reporting in the medical record and incident log. Staff accounts of the resident's whereabouts were inconsistent, and required elopement protocols were not fully followed.
A resident with moderate cognitive impairment and a history of wandering left the facility undetected and was later found after spending the night away. Staff failed to document the resident's absence, notifications to family and authorities, or the resident's return in the medical record, contrary to facility policy requiring such documentation.
The facility failed to keep the courtyard clean and safe, with broken and dirty furniture, overgrown walkways, malfunctioning doors, and structural hazards such as a hole in the roof and fallen gutter. Residents and staff reported limited use of the area due to these issues, and outdoor activities were not conducted because of the unsafe conditions.
Three residents with cognitive and behavioral impairments were not comprehensively assessed for their activity preferences, and their care plans lacked specific interventions to meet their needs. Staff relied mainly on passive activities like television, with inaccurate or missing documentation of participation. The Activities Director reported no comprehensive assessment process and difficulty obtaining supplies, resulting in vague activity calendars and unmet resident needs.
The facility failed to ensure proper hair covering practices in the kitchen, potentially affecting all 75 residents receiving food. The Dietary Manager's dreadlocks were not covered by his hair net, and two dietary staff members had uncovered beards. The facility's policy requires all dietary staff to wear effective hair restraints covering all exposed body hair, including facial and head hair.
The facility failed to maintain a clean and homelike environment, with issues in the outdoor smoking area, dining room, and resident rooms. Overflowing trash, food particles, and inappropriate cleaning equipment were observed in common areas. Resident rooms had dirt, odors, broken furniture, and exposed wires. A room previously occupied by a discharged resident was not cleaned. Housekeeping practices did not align with the facility's policy.
A resident with severe cognitive impairment and multiple diagnoses was improperly placed in a secured unit without documented justification. Despite being assessed as low risk for elopement and having no wandering behaviors, the resident was admitted to the secured unit due to a lack of available rooms and the Admissions Coordinator's decision, who lacked medical training. The facility's policy required evaluations for wandering and elopement risks, which were not followed in this case.
Two residents in the facility did not receive scheduled showers and personal hygiene assistance, missing six out of sixteen opportunities. Both residents, who required substantial assistance due to medical conditions, were observed with poor hygiene and reported inconsistent care. Staff interviews revealed that shower aids were often reassigned, leading to missed showers without proper documentation, contrary to facility policy.
The facility failed to maintain clean and sanitary shower rooms, affecting 53 residents. Observations revealed dirt, debris, cracked tiles, and mold in the shower areas. Staff and residents confirmed the unsanitary conditions, with some staff avoiding the use of the shower rooms. Despite a new cleaning schedule, issues persisted, and residents expressed dissatisfaction with the facilities.
Failure to Ensure Nursing Staff Held Proper BLS CPR Certification
Penalty
Summary
The deficiency involves the facility’s failure to ensure that nursing staff held appropriate and current Cardiopulmonary Resuscitation (CPR) certification consistent with facility policy and the needs of residents who had elected full code status. Surveyors reviewed personnel records and found that multiple nurses, including several LPNs and an RN, either had no CPR certification on file or held CPR cards that did not specify Basic Life Support (BLS) or healthcare provider-level training. Specifically, LPNs with certain hire dates had no CPR certification in their files, and an RN also lacked any documented CPR certification. Other LPNs possessed CPR cards that covered adult, child, infant, and AED use, but the cards did not indicate that the training was BLS or designated for healthcare providers. The Director of Nursing confirmed during interview that several identified staff members had no current CPR certification on file and that others had CPR certifications that did not include BLS or healthcare provider designation. Facility policy on Licensure, Certification, and Registration of Personnel required staff who need a license or certification to present verification to Human Resources prior to or upon employment. Another policy on Emergency Procedure Cardiopulmonary Resuscitation required key clinical staff, including non-licensed personnel who would direct resuscitative efforts, to obtain and maintain American Red Cross or American Heart Association certification in BLS CPR. These findings affected residents who had chosen full code status, as the facility did not ensure that staff responsible for providing resuscitation met the specified CPR certification requirements.
Delayed Response to Resident Respiratory Distress After Dislodged Tracheostomy
Penalty
Summary
The deficiency involves the facility’s failure to timely address a resident’s change in respiratory condition after the resident’s tracheostomy inner cannula became dislodged. The resident had a history of tracheostomy, chronic respiratory failure with hypoxia, laryngeal cancer, malnutrition, and received oxygen therapy, trach care, suctioning, and enteral nutrition. The care plan included maintaining oxygen saturation at or above 92% with humidified oxygen via trach mask and providing suctioning and positioning for easier breathing. The resident was cognitively intact, dependent on staff for several ADLs, and had a full code order, later electing hospice with orders to discontinue labs and not hospitalize. On the morning of the incident, the resident’s trach inner cannula became dislodged around 5:50 A.M., and a CNA observed the resident waving and pointing to the disconnected trach equipment, indicating difficulty breathing. The CNA immediately notified an LPN, who was passing morning medications, that the resident was having trouble breathing and that the trach hose was disconnected. The LPN told the CNA to give him a few minutes to finish medication administration instead of immediately assessing the resident. The CNA remained with the resident for about eight minutes, then left to notify another CNA that the LPN had not yet come, and then resumed care of other assigned residents. During this period, the resident remained without timely nursing assessment or intervention for the reported respiratory distress. When the LPN eventually entered the room, he observed the resident in respiratory distress and attempted suctioning, at which point the resident pulled out the entire trach tube. The LPN was unable to reinsert the trach tube and left the resident to go to other units to obtain help from additional nurses, leaving the resident alone. Multiple LPNs then returned to the room together, at which time the resident was described as grey and not breathing, with the trach tube lying on his chest. CPR was initiated and EMS was called, but staff accounts and documentation showed inconsistencies and lacked clear times for the onset of distress, initiation of CPR, and EMS contact. The facility’s own investigation and leadership interviews confirmed there was a delay in addressing the resident’s change in condition, that a staff member did not remain with the resident, and that a code was not called through the overhead paging system as expected by facility policy.
Failure to Ensure Availability and Administration of Ordered Pain Medication
Penalty
Summary
Surveyors identified a failure to ensure ordered pain medications were available and administered as prescribed for Resident #58. The resident was admitted on 09/01/24 with diagnoses including rheumatoid arthritis, failure to thrive, depression, and post cholecystectomy syndrome. A quarterly MDS dated 01/07/26 documented intact cognition, dependence on staff for toileting and transfers, and the presence of pain managed with scheduled and PRN pain medications. Physician orders for January 2026 included Oxycodone 15 mg every four hours and Acetaminophen 500 mg every six hours as needed. Review of the January 2026 MAR showed that on 01/20/26, multiple scheduled Oxycodone doses at 6:00 A.M., 10:00 A.M., 2:00 P.M., and 6:00 P.M. were marked as not administered with directions to see progress notes. Progress notes on 01/20/26 at 10:07 A.M., 1:13 P.M., and 5:42 P.M. documented that Oxycodone doses were not given because the facility was waiting for the pharmacy to deliver the medication. Further review of the MAR revealed additional missed Oxycodone doses on 01/25/26 at 10:00 P.M. and on 01/26/26 at 2:00 A.M., 6:00 A.M., and 2:00 P.M., which were left blank with no explanatory documentation. In an interview on 01/29/26 at 5:00 P.M., the DON confirmed that Oxycodone was not administered on 01/20/26, 01/25/26, and 01/26/26 due to delays in pharmacy delivery and acknowledged there were no notes explaining the missed doses on 01/25/26 and 01/26/26. Facility policy on administering medications, revised December 2012, required medications to be administered safely, timely, and in accordance with prescribed orders, including required time frames. This deficiency was cited under Complaint Number 2711748.
Incomplete and Inaccurate Documentation of Behavioral Event and Resident Altercation
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate and complete medical records in accordance with its charting and documentation policy. For one resident with rheumatoid arthritis, failure to thrive, depression, anxiety, and PTSD, the quarterly MDS showed the resident was cognitively intact with moderate depression and dependent on staff for toileting hygiene, showers, and transfers. A progress note documented that the resident was exhibiting hallucinations and making accusations that staff were stealing belongings, drugging her, and transferring her against her will, and that she had called EMS to report people were “messing with” and stealing her furniture. However, this progress note did not document that the resident was pink slipped by the physician for psychiatric evaluation. A hospital summary later showed that the resident arrived via EMS with a pink slip from the facility citing agitation, threats toward staff, refusal of care, hallucinations, and paranoia, indicating a discrepancy and omission in the facility’s medical record. For another resident with type II diabetes, Alzheimer’s disease, cognitive communication deficit, hip pain, and anxiety, the quarterly MDS indicated cognitive impairment and a need for limited assistance with eating, toileting, showering, and transfers. The care plan identified impaired cognitive function and thought processes related to Alzheimer’s disease, with interventions including medication administration as ordered and cueing, reorientation, and supervision as needed. A Self-Reported Incident documented a resident-to-resident altercation in a secured unit, in which this resident reported being pushed by another resident; staff intervened, separated, and redirected both residents, and assessed them with no injuries, and the incident was ultimately unsubstantiated. Despite this, there was no corresponding documentation in the resident’s progress notes regarding the allegation of resident-to-resident abuse or the altercation. The DON confirmed the absence of documentation for both the pink slip for the first resident and the altercation involving the second resident, contrary to the facility’s policy requiring documentation of changes in condition, events, incidents, or accidents involving residents.
Failure to Provide Consistent, Palatable, and Appropriately Portioned Meals
Penalty
Summary
The facility failed to ensure that food portions were appropriate and that meals served were palatable for residents, with the exception of one resident who did not consume meals from the kitchen. Observations during a lunch tray line revealed inconsistencies in portion sizes, with residents on pureed diets receiving different amounts of food compared to those on regular diets, and the last group of residents served receiving smaller portions as food supplies ran low. Additionally, food items such as pureed spaghetti, salad, and garlic bread were not kept within the steam tables, and some food temperatures were not recorded or were recorded incorrectly. The temperature log was not consistently updated, and not all required food temperatures were obtained prior to meal service. Further observations showed that as meal service continued, the quality of the food deteriorated, with spaghetti noodles hardening and becoming crusty. Staff confirmed they were attempting to stretch limited food supplies to serve all residents, resulting in inconsistent portion sizes that did not match the recommended amounts listed on the facility's spreadsheet. A test tray revealed that some food items were served at inappropriate temperatures, and staff were unsure of the correct serving temperatures. Review of facility policy indicated that meals should be nourishing, palatable, well-balanced, and served at safe and appetizing temperatures, but these standards were not met during the observed meal service.
Building Disrepair, Trash Accumulation, and Mold in Resident and Staff Areas
Penalty
Summary
The facility failed to maintain the building in good repair and free of trash buildup, as evidenced by multiple observations in the basement and laundry areas. Surveyors observed two large bins of trash overflowing, several large bags of trash on the ground, and a housekeeping room with a strong odor of mold, flying insects, and approximately ten clear bags of trash piled along the wall. Additionally, two large tubs were collecting water leaking from a sewage pipe, which the Maintenance Director confirmed had not been successfully repaired. The laundry area was found to have water running down a brick wall next to the dryer, with a black mold-like substance present, and staff confirmed persistent mold or mildew odors in the basement. The Maintenance Director also confirmed that the water intrusion in the laundry room was due to a crack in the foundation, allowing melting snow to enter and cause mold buildup. Further observations included a first-floor nursing unit shower room where black mold was visible between the tiles near the floors of both shower areas, as confirmed by a CNA. The facility's policy on providing a safe, clean, and odor-free environment was reviewed, which was not being followed as evidenced by the unsanitary conditions, trash accumulation, and presence of mold and insects. These deficiencies had the potential to affect all 75 residents in the facility and were investigated under multiple complaint numbers.
Failure to Complete Fall Assessments, Documentation, and Interventions
Penalty
Summary
The facility failed to ensure that fall assessments were completed, falls were documented in the medical record, fall prevention interventions were in place, and fall investigations were thorough for multiple residents. For one resident with a history of syncope, falls, and diabetic neuropathy, there were several instances where falls were either not documented in the medical record, follow-up assessments were missing, or interventions such as non-skid strips were not implemented as care planned. Staff interviews confirmed a lack of awareness regarding required interventions, and documentation did not consistently include vital signs, neurological checks, or pain assessments after falls. Another resident with vascular dementia and a high risk for falls experienced a fall that was not documented in the progress notes until the following day, with no evidence of vital signs being recorded or a comprehensive assessment of a resulting skin tear. The care plan interventions, such as therapy for transfers and keeping the room free of clutter, were not consistently documented as being followed or evaluated after incidents. Staff interviews confirmed gaps in documentation and assessment following falls. Additional residents with cognitive impairment and a history of falls also experienced similar deficiencies. Falls were not consistently documented in the medical record, and there was a lack of detail regarding the circumstances of the falls, whether they were witnessed, and the assessments performed afterward. In one case, neurological checks were not continued as required, and there was no documentation of immediate interventions or witness statements. Facility policy required thorough documentation and assessment after falls, but these procedures were not consistently followed, as confirmed by staff interviews and record reviews.
Failure to Accommodate Resident Needs: Stoma Supplies and Television Access
Penalty
Summary
The facility failed to reasonably accommodate the needs and preferences of two residents, specifically regarding timely access to appropriate stoma supplies and the availability of a working television. For one resident with a urostomy due to a malignant neoplasm of the urinary organs and severe cognitive impairment, there were repeated issues with the availability and appropriateness of urostomy pouches. The resident's care plan required specific stoma care and monitoring, but staff and family reported that the correct supplies were not consistently available. The facility initially provided generic pouches that did not function properly, leading to leakage and distress for the resident. Staff interviews revealed miscommunication and delays in ordering the correct supplies, with insurance approval and administrative turnover contributing to the problem. The resident's family had to supply pouches upon admission and expressed frustration over the lack of communication and continuity of care. Observations confirmed that the resident's urostomy pouch was frequently overfilled, contrary to manufacturer instructions that it should be emptied when one-third to one-half full. Staff acknowledged that when the pouch was not emptied in a timely manner, the resident would manipulate it, causing further leakage. Documentation and interviews indicated that the facility was aware of the issue for several weeks before the correct supplies were consistently ordered and available. The resident's daughter reported that she was not informed when supplies ran out and had to instruct staff on proper pouch application, as improper technique led to excessive use of supplies and further complications. For another resident with severe cognitive impairment and multiple chronic conditions, the facility failed to ensure the availability of a working television after the resident was temporarily relocated due to a water pipe break. The resident, who preferred watching television as a primary activity, was moved to a room without a functioning television, and there was no documentation in the medical record regarding the move or the lack of television. The administrator confirmed the absence of documentation and the non-functioning television during the survey. These failures affected the residents' ability to have their needs and preferences accommodated as required.
Failure to Report Alleged Misappropriation of Resident Property
Penalty
Summary
The facility failed to report an allegation of misappropriation of property for a resident to the State agency, as required by policy. The resident, who was severely cognitively impaired and dependent on staff for most activities of daily living, had multiple personal items go missing, including a phone, an abdominal binder, and dentures. Documentation showed that the resident's daughter reported the missing phone and abdominal binder to staff, and the missing items were noted in the facility's log. However, there was no evidence that these incidents were reported to administration or the State agency as required. Staff interviews confirmed awareness of the missing items but could not confirm if they had been reported or investigated appropriately. The facility's policy required immediate reporting of alleged misappropriation of resident property to the administrator or designee, and to the State agency within specified timeframes. Despite this, the administrator confirmed that no self-reported incident had been completed for the missing items, and there was no documentation of efforts to remedy the situation or determine whether the items were misappropriated or misplaced. The deficiency was identified during a complaint investigation and was a repeat finding from a previous survey.
Failure to Investigate Missing Resident Property
Penalty
Summary
The facility failed to thoroughly investigate missing personal items for a resident with severe cognitive impairment, including two phones, an abdominal binder, and dentures. The resident's daughter reported the missing phone and abdominal binder to staff, and the missing items were noted in the facility's log. However, there was no evidence that these incidents were reported to or investigated by administration, nor was there documentation of any formal investigation or self-reported incident (SRI) being completed. Staff interviews revealed uncertainty about the whereabouts of the items and whether they had been reported missing, despite the facility's policy requiring immediate reporting and investigation of such incidents. The resident in question had diagnoses of heart disease, dementia, anxiety, and depression, and required significant assistance with daily activities. The care plan indicated the dentures had been missing for several months, but there was no documentation of an investigation or administrative follow-up. Observations confirmed the missing items were not present in the resident's room or designated storage areas. The administrator acknowledged that no investigation had been initiated for the missing items, contrary to facility policy, which mandates investigation and documentation of alleged misappropriation of resident property.
Failure to Schedule Timely Care Conferences
Penalty
Summary
The facility failed to ensure that a resident's care conference was scheduled within the required timeframe, as mandated by facility policy and federal regulations. Record review showed that the resident, who had diagnoses including type 2 diabetes mellitus, multiple sclerosis, and neuromuscular dysfunction of the bladder, was admitted on 07/09/20 and had significant care needs, including dependence on staff for hygiene and an indwelling catheter. Despite these needs and a care plan revision on 06/26/25, there was no evidence in the medical record or facility care conference schedule that a care conference had been held or scheduled for the resident during the required period. The quarterly MDS assessment confirmed the resident had moderate cognitive impairment and required substantial assistance with daily activities. Interviews with the Social Services Designee (SSD) revealed a lack of understanding regarding the required frequency of care conferences, with the SSD stating she believed they were annual rather than quarterly and had only recently learned of the correct schedule. The SSD also indicated she was new to the role, had minimal training, and was attempting to catch up on overdue care conferences left by the previous SSD. The facility identified additional residents who were also overdue for care conferences. Facility policy requires the care plan to be developed and reviewed by an interdisciplinary team within seven days of the comprehensive assessment, with participation from the resident, family, or legal representative encouraged.
Failure to Provide Timely and Appropriate ADL, Skin, and Oral Care for Dependent Residents
Penalty
Summary
The facility failed to provide appropriate care and services to three residents who were dependent on staff for activities of daily living (ADL), including incontinence care, skin care, and oral hygiene. One resident with multiple diagnoses, including respiratory failure, stroke, and reduced mobility, was observed to have her call light activated for over 20 minutes before staff responded to provide incontinence care. Staff interviews confirmed that call lights were not always answered within the expected timeframe due to staffing constraints, and the resident herself reported sometimes waiting up to three hours for incontinence care. Another resident, admitted with chronic respiratory failure, diabetes, and morbid obesity, was dependent on staff for all ADLs and had a history of skin issues. During a temporary relocation due to a water leak, this resident and two others were not provided with timely incontinence care, resulting in prolonged exposure to soiled conditions. Observations revealed the resident had very dry, peeling skin on her feet, a bleeding open area on her buttock, and was not offered lotion or oral care during routine care. Staff interviews indicated that aides did not consistently apply prescribed creams or offer mouth care, and there was a lack of documentation regarding the open wound. A third resident with severe cognitive impairment and hemiplegia was also dependent on staff for most ADLs. During care, this resident was found to have very dry, flaky skin on the lower legs and feet, and red buttocks, but no lotion or mouth care was provided or offered. Staff confirmed that lotion was typically only applied on shower days and mouth care was not routinely performed. Facility policies required that lotion or cream be offered during care and that mouth care be provided, but these were not followed. The DON confirmed that staff should have offered these services according to policy.
Failure to Address Changes in Condition and Ensure Timely Intervention
Penalty
Summary
The facility failed to properly address changes in condition for two residents, resulting in deficiencies related to timely assessment, intervention, and communication with medical providers. One resident with a history of bipolar disorder, morbid obesity, stroke, and other conditions reported chest pain and was observed grabbing at her chest. Despite being a full code, she refused hospital transport multiple times, was given an antacid without a physician's order, and the physician was notified only after administration. Later that evening, she was found on the floor, assessed for injury, and again refused hospital evaluation. She was subsequently found unresponsive in her wheelchair and CPR was initiated, but she could not be revived. Documentation revealed that she had refused assessments and vital signs throughout the day, and there was a lack of documented follow-up care or assessment after her initial complaint of chest pain. Another resident, who was moderately cognitively impaired and receiving hospice services, experienced a change in condition characterized by unresponsiveness, altered mental status, and abnormal breathing. Although the nurse practitioner was eventually notified and ordered hospital transfer, prior to this event, staff failed to assess or notify hospice or the physician about the resident's declining condition. Interviews revealed that staff were unaware of the resident's code status and did not know where to locate it, leading to a lack of timely intervention. The resident was ultimately found unresponsive and sent to the hospital, where he was intubated and later passed away. Facility policy required staff to recognize and communicate significant changes in residents' health status, make detailed observations, and report pertinent information to the physician. However, in both cases, staff did not follow these protocols, resulting in missed assessments, delayed notifications, and inadequate documentation of the residents' conditions and care provided during acute changes.
Failure to Timely Identify and Treat Urinary Tract Infections
Penalty
Summary
The facility failed to timely identify and treat urinary tract infections (UTIs) for two residents, resulting in deficiencies related to the management of urinary health. For one resident with vascular dementia and a history of urinary tract infections, a urine specimen was collected as ordered, but the results were not completed or reported to the physician or nurse practitioner. The specimen, collected on a Friday, was likely discarded because the lab did not pick up specimens on weekends, and it was not resent. There was a significant delay before a new specimen was collected and processed, during which time the resident did not receive appropriate follow-up for potential infection. Another resident with multiple sclerosis, diabetes, and a neurogenic bladder had an indwelling catheter and was at risk for catheter-associated complications. This resident exhibited confusion, prompting an order for a urine specimen. The initial specimen was collected and reported as probably contaminated, with a recommendation to repeat the test. However, there was no evidence that a repeat specimen was collected or sent to the lab as ordered. Documentation was lacking regarding the collection and handling of urine specimens, and the resident subsequently experienced discomfort, required catheter replacement, and was hospitalized with a diagnosis of UTI and sepsis. Both cases demonstrated failures in following up on laboratory results, ensuring timely specimen collection, and maintaining adequate documentation. The deficiencies were compounded by changes in medical staff and poor communication, resulting in lapses in care for residents with significant urinary health risks.
Failure to Ensure Timely Transportation for Dialysis Appointments
Penalty
Summary
A deficiency occurred when the facility failed to ensure a resident requiring dialysis was transported to scheduled dialysis appointments as ordered by the physician. The resident, who had end stage renal disease, type 2 diabetes, and vascular dementia, was dependent on staff for mobility and personal care, and required dialysis three times per week. Documentation revealed that the resident missed multiple dialysis appointments due to failures in transportation arrangements and communication among facility staff and the transportation provider. On at least two occasions, the resident missed dialysis appointments. On one occasion, the transportation company did not arrive, and on another, the transportation provider reported that the driver arrived on time but could not locate staff to bring the resident to the lobby, resulting in the resident not being transported. There was conflicting information from staff regarding whether the resident was waiting in the lobby, but no documentation supported that the resident was present and ready for pick-up. The facility's process for notifying and preparing residents for transportation was inconsistent, with some staff unaware of scheduled appointments and others not following established procedures for confirming transportation. As a result of missed dialysis, the resident experienced a decline in condition and required hospitalization for missed dialysis, where she received two sessions of dialysis. Interviews with staff and the resident's family member confirmed that the resident had missed dialysis appointments while at the facility. The facility's policy required arrangements for safe transportation to and from dialysis, but this was not consistently implemented, leading to the deficiency.
Failure to Provide Timely Dental Services After Loss of Dentures
Penalty
Summary
The facility failed to provide appropriate dental services to a resident who was severely cognitively impaired and dependent on staff for personal care, including oral hygiene. The resident was admitted with multiple diagnoses, including heart disease, dementia, anxiety, and depression, and had upper and lower dentures identified as missing. Despite facility policy requiring referral for dental services within three days of lost dentures, the resident's dentures were not promptly replaced, and there was no evidence of timely dental intervention or documentation regarding measures taken to ensure adequate nutrition and hydration while awaiting dental services. Staff interviews revealed uncertainty about when the dentures were lost and a lack of awareness regarding the resident's current dental status. The Social Service Designee confirmed that the resident should have been seen by a dentist as soon as the dentures were found missing, but the first dental appointment occurred months after the loss. The facility's failure to follow its own policy and ensure timely dental care resulted in the resident being without dentures for an extended period.
Failure to Report Resident Elopement to State Agency
Penalty
Summary
The facility failed to report a resident elopement to the State Agency as required. A resident with diagnoses including chronic obstructive pulmonary disease, alcohol dependence with alcohol-induced dementia and psychotic disorder, and moderate dementia with psychotic disturbance was identified as being at risk for elopement due to disorientation, impaired safety awareness, and wandering behaviors. The resident's care plan included interventions such as distraction and structured activities, but no alarms or wander guards were in place. The resident was assessed as low risk for elopement, but an endangered missing adult alert was issued when the resident went missing. There were no nursing progress notes documenting the resident being missing or returning to the facility. During an interview, the Administrator confirmed that the facility did not notify the State Agency or open a self-reported incident through the Ohio Department of Health's Certification and Licensure System after being notified of the resident's absence. Facility policy required staff to investigate and report missing residents, but the policy was vague and did not specifically mention reporting elopements to the state agency. Another policy required notification of the Ohio Department of Health for all alleged violations involving abuse, neglect, or exploitation within 24 hours, but this was not followed in this case.
Failure to Prevent Resident Elopement and Ensure Adequate Supervision
Penalty
Summary
A deficiency occurred when a resident with a history of dementia, psychotic disturbance, and impaired safety awareness eloped from the facility without staff knowledge. The resident was assessed as having moderate cognitive impairment and required supervision for activities of daily living, but was considered low risk for elopement according to the facility's assessment. The care plan included interventions such as distraction from wandering and offering structured activities, but there were no alarms or wander guards in place, and no physician orders for safety monitoring devices or a secured unit. On the day of the incident, the resident was last seen by staff and other residents at various times in the afternoon, with the last confirmed sighting being when the resident was observed leaving the building through the front exit doors. Staff did not notice the resident was missing until several hours later when medication administration was attempted. A search was initiated inside and outside the facility, and the police and family were notified. The resident was eventually found the next morning by a staff member searching the surrounding area, having walked several miles to a previous address and spending the night in a car in cold weather. Documentation in the resident's medical record was lacking, with no evidence of the resident being observed missing, notifications, or details of the resident's return. The incident was also not recorded in the facility's incident/accident log. Staff interviews revealed inconsistent accounts of the resident's whereabouts and the timing of events, and the facility's policy on elopement required investigation and reporting of missing residents, which was not fully followed in this case.
Failure to Document Elopement and Related Events in Resident Medical Record
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident with multiple diagnoses, including chronic obstructive pulmonary disease, alcohol-induced dementia, and moderate cognitive impairment. The resident was identified as being at risk for elopement due to disorientation, impaired safety awareness, and wandering behaviors, as documented in the care plan. Despite these risks, the resident was able to leave the facility undetected and was later found by a staff member after having spent the night away from the facility. A review of the resident's medical record revealed significant gaps in documentation. There were no nursing progress notes related to the resident being observed missing, notifications to family, physician, or police, the resident being found, being taken to the hospital, or returning to the facility. The last progress note prior to the incident was dated several weeks before, and the next note was entered days after the resident's return, with no mention of the elopement event or related actions. Interviews with facility staff, including the ADON, DON, and Administrator, confirmed that documentation of the incident and subsequent notifications was not completed as required by facility policy. The policy specified that events, incidents, or accidents involving the resident, as well as changes in condition and notifications, should be documented in the medical record. The lack of documentation represented a failure to safeguard resident-identifiable information and maintain medical records in accordance with accepted professional standards.
Courtyard Not Maintained in Clean and Safe Condition
Penalty
Summary
The facility failed to maintain the courtyard in a clean and safe condition, as evidenced by multiple interviews, observations, and record reviews. Residents and staff reported limited use of the courtyard due to broken and dirty furniture, uneven ground, and malfunctioning doors. The Activities Director stated that outdoor activities had not been conducted this year because of these issues, and a grievance regarding the patio chairs had been submitted. Resident Council records also indicated requests for improved access and furniture in the outdoor area. Observations confirmed the presence of broken dining room chairs, dirty tables, trash, garden supplies covered in dust and cobwebs, and overgrown garden boxes and walkways. Additionally, there were structural issues such as a hole in the roof, missing shingles, a fallen gutter, and wood debris on the ground. Staff interviews revealed a lack of awareness regarding some of the hazards, such as the hole in the roof, and confirmed that residents only accessed the courtyard under supervision. The outside door's keypad was broken, requiring staff assistance for re-entry. The courtyard's condition, including blocked walkways, empty bird feeders, and unsafe furniture, had the potential to affect all 72 residents in the facility by limiting their access to a safe and clean outdoor environment.
Failure to Assess and Provide Activities to Meet Resident Needs
Penalty
Summary
The facility failed to comprehensively assess and provide for the activity preferences and needs of three residents with significant cognitive and behavioral impairments. For two residents, the Minimum Data Set (MDS) Section F, which addresses preferences for routine and activities, was not completed, and there was no evidence of further assessment or attempts to gather information from family members or significant others as required. For the third resident, while some activity preferences were documented on admission, there was no ongoing assessment or care plan in place to address these preferences. The care plans for the affected residents lacked specific details about the types of activities the residents were interested in, how these activities would be offered, or when they would occur. Observations and interviews revealed that residents on the secured unit, particularly those with severe cognitive impairment or behavioral issues, were not provided with a formal activity program tailored to their needs. Instead, staff primarily relied on passive activities such as watching television in common areas, and some residents were not engaged in any meaningful activities throughout the day. Activity logs were found to be inaccurate, with participation marked for days that had not yet occurred and for activities in which residents did not actually participate. Additionally, some residents had no documentation of activity participation at all. Staff interviews indicated a lack of knowledge about where to find information on residents' interests, and the Activities Director confirmed that no comprehensive assessment process was in place to identify or address activity preferences. The Activities Director also reported challenges in obtaining supplies for activities due to budget constraints and inconsistent approval of requested items. As a result, the activities calendar was kept vague, and planned activities were sometimes not carried out. The facility's policy required the interdisciplinary care team to evaluate residents' personal history and preferences, but this was not consistently implemented for the residents reviewed.
Improper Hair Covering Practices in Kitchen
Penalty
Summary
The facility failed to ensure proper hair covering practices in the kitchen area, which could potentially affect all 75 residents receiving food from the kitchen. During an observation, the Dietary Manager was seen wearing a hair net that did not cover his long dreadlocks, leaving them exposed. Additionally, both the Dietary Manager and two other dietary staff members had uncovered beards while working in the kitchen. One of the dietary staff members mentioned that they did not have beard covers available. The facility's policy requires all dietary staff to wear effective hair restraints that cover all exposed body hair, including facial and head hair, before entering the kitchen. This deficiency was identified during a complaint investigation under Complaint Number OH00161306.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean and homelike environment for its residents, as evidenced by several observations and interviews. In the outdoor smoking area, trash cans were overflowing with various debris, including styrofoam cups, cigarette packs, and used disposable gloves. Food particles and cigarette butts were scattered on the ground, and bottles of salad dressing and cheese sauce were left on a window ledge. Maintenance staff acknowledged the condition of the area, and the administrator mentioned that a plan was being developed to assign responsibility for cleaning the smoking area. In the dining room, a trash can was observed overflowing with meal tray waste, and the floor was covered with food crumbs and particles. A soiled plunger and dustpan were left in the corner, which residents found unappealing while eating their meals. The administrator and DON confirmed that the dining room should be cleaned after every meal, and the presence of cleaning equipment in the dining area was inappropriate. Resident rooms were also found in unsatisfactory conditions. One resident's room had scattered dirt, food, and trash, with a strong odor of body odor and urine. Another room had broken furniture and exposed wires due to a missing outlet cover. A third room contained dirty silverware, food particles, and a malfunctioning refrigerator with ice buildup. Additionally, a room previously occupied by a discharged resident had not been cleaned, with soiled sheets, trash, and sticky floors. Housekeeping staff indicated that resident rooms were cleaned twice a week, contrary to the facility's policy of cleaning surfaces regularly and when visibly soiled.
Improper Admission to Secured Unit
Penalty
Summary
The facility failed to ensure that a resident met the criteria to be admitted to and reside on the secured unit. This deficiency involved a resident who was admitted with multiple diagnoses, including anoxic brain damage, traumatic brain injury, and bipolar disorder, among others. The resident was severely cognitively impaired and required substantial assistance for daily activities. Despite being assessed as low risk for elopement and having no documented behaviors of wandering or exit-seeking, the resident was placed in the secured unit without documented justification. The decision to place the resident in the secured unit was made by the Admissions Coordinator, who lacked medical training and was unaware of specific guidelines for admission to the secured unit. The resident's parent was initially assured that the facility could address the resident's needs and provide therapy and socialization with peers of similar age. However, upon admission, the resident was placed in the secured unit due to a lack of available rooms and the Admissions Coordinator's belief that the resident would receive more attention there due to a seizure disorder. The Medical Director stated that the secured unit was intended for residents who were a threat to leave the facility or had dementia, and that placement should be determined on a case-by-case basis. The facility's policy for the secured unit emphasized providing a safe environment and preventing accidents related to wandering and elopement, with evaluations conducted as part of the preadmission process and upon changes in residents' conditions or functionality.
Failure to Provide Scheduled Showers and Personal Hygiene Assistance
Penalty
Summary
The facility failed to ensure that residents dependent on staff for activities of daily living received adequate assistance with showers and personal hygiene. Resident #24, who was admitted with diagnoses including fibromyalgia, hemiplegia, and muscle weakness, was found to have missed six out of sixteen scheduled showers/baths over a review period. Despite being cognitively intact and dependent on staff for personal hygiene, there was no documentation of make-up days for missed showers, and the resident reported not receiving baths consistently. Observations revealed a foul body odor and unkempt fingernails, indicating a lack of personal hygiene care. Similarly, Resident #70, with diagnoses including asthma, lymphedema, and type two diabetes mellitus, also missed six out of sixteen scheduled showers/baths. This resident required substantial assistance with personal hygiene and reported that staff were sometimes too busy to provide showers. Observations confirmed a strong body odor and dirty fingernails. Interviews with staff, including the DON and a CNA, revealed that shower aids were often reassigned to other duties, leading to missed showers without proper documentation of refusals or attempts to provide care. The facility's policy required documentation of care provided or refused, which was not adhered to in these cases.
Facility Fails to Maintain Clean and Sanitary Shower Rooms
Penalty
Summary
The facility failed to maintain a clean, sanitary, and well-repaired environment for its residents, affecting 53 out of 65 residents. Observations revealed that the main shower room on the first floor and the shower room in the secured unit were in poor condition. The floors were covered with dirt and debris, and there were cracked tiles with sharp edges. The shower stalls had black debris between the tiles, and the privacy curtains were stained. Additionally, there were safety strips that had rubbed off, and the presence of a brown substance that appeared to be stool was noted. The spa tub was cluttered with personal items and debris, and the drainpipe was surrounded by sharp wire netting. Interviews with staff and residents confirmed the unsanitary conditions, with some staff expressing reluctance to use the shower rooms due to their state. The Resident Council Meeting notes indicated ongoing complaints about the cleanliness of the shower rooms over several months. Despite the implementation of a new cleaning schedule by the new maintenance director, the issues persisted. Housekeeping staff acknowledged the challenges in maintaining cleanliness, particularly in removing mold from the grout. The lack of scheduled assignments for housekeeping staff prior to the new maintenance director's tenure contributed to the inconsistency in cleaning. Residents expressed dissatisfaction with the shower facilities, with some preferring bed baths due to the unsanitary conditions. The deficiency was investigated under specific complaint numbers, highlighting the facility's non-compliance with maintaining a homelike environment.
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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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
