Glendora Health Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Wooster, Ohio.
- Location
- 1552 North Honeytown Road, Wooster, Ohio 44691
- CMS Provider Number
- 366036
- Inspections on file
- 30
- Latest survey
- March 19, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Glendora Health Care Center during CMS and state inspections, most recent first.
A resident with Alzheimer's disease and DM, on a regular diet with dysphagia-advanced texture and thin liquids, was served an incorrect portion of ground chicken salad when dietary staff used a #16 scoop (2 oz) instead of the #10 scoop (3.75 oz) specified on the diet ticket and in the recipe. During lunch tray line service, the staff member plated the smaller portion and sent the tray to the cart, and the error was only recognized when the tray was later pulled. The dietary manager later acknowledged that serving utensils had not been checked before tray service, and this error had the potential to affect multiple residents receiving the same menu item.
The facility failed to properly label and store frozen food items, as observed during a kitchen tour. A plastic bag with 10 frozen pork fritters was found undated and loosely wrapped in the freezer. A staff member confirmed the oversight and discarded the fritters. The facility's policy mandates date marking of food when opened, which was not adhered to.
The facility failed to maintain respiratory care equipment for two residents, leading to a deficiency. One resident with a history of respiratory issues had nebulizer equipment improperly stored and unsecured, despite orders for regular cleaning and changing. Another resident receiving hospice care also had unsecured nebulizer equipment, contrary to physician orders. An LPN confirmed the improper storage, resulting in the identified deficiency.
The facility failed to store and monitor medications safely, affecting all residents. Expired bisacodyl suppositories were found, and refrigerator temperature logs were incomplete, with one instance of a temperature at 48°F not reported. The Alixa medication storage room had significant ice buildup, and an LPN used an undated insulin pen against policy.
The facility failed to properly store, label, and monitor food items, affecting all residents. Observations revealed unlabeled and moldy food, improper storage of staff and resident foods, and incomplete temperature logs. Staff interviews highlighted confusion over responsibility for monitoring refrigerator temperatures, contradicting facility policy.
The facility failed to implement Enhanced Barrier Precautions for residents with indwelling catheters and surgical wounds, lacked proper infection control in laundry services, and did not disinfect a glucometer after use. Staff did not use PPE during high-contact care, and clean and soiled laundry were improperly handled due to space constraints and broken equipment.
The facility failed to maintain comfortable temperatures on two units, affecting three residents who complained of feeling cold. Temperatures were recorded between 69 and 70 degrees Fahrenheit. Additionally, a resident's bed was missing a headboard, and a nearby heating unit had a broken cover, exposing the heating element. The Director of Maintenance confirmed these issues.
The facility failed to provide individualized activities for residents, leading to deficiencies in meeting their needs. A resident with cognitive and physical impairments reported not being offered activities, and observations confirmed the absence of an updated activity calendar. Another resident expressed interest in activities but was unaware of offerings beyond bingo. Other residents with cognitive impairments were observed without engagement in activities. The absence of the Activity Director and lack of a dedicated activity calendar contributed to the deficiency.
The facility failed to ensure psychotropic medications were administered only when necessary, did not address approvals for gradual dose reductions in a timely manner, and lacked documentation of non-pharmacological interventions and monitoring of target symptoms. This affected several residents, including one who continued receiving trazodone without a reduction attempt and another who received Ativan without prior non-pharmacological interventions. The facility's policy on psychotropic medication use was not followed, as required documentation and interventions were missing.
The facility failed to provide a working call system in three restrooms accessible to residents, potentially affecting seven residents with independent mobility. Observations confirmed that these restrooms, although wheelchair accessible and designated for male or female use, lacked call systems, contrary to the facility's policy requiring call lights in resident areas to ensure assistance can be summoned.
A facility failed to maintain consistent documentation of a resident's code status. The resident, with conditions such as vascular dementia and chronic kidney disease, had a signed DNR form indicating DNRCC status. However, the electronic health record, facility report sheet, and physician orders listed the status as DNRCC-A. This discrepancy was confirmed by the Administrator, indicating a lack of consistency in the resident's code status documentation.
A facility failed to provide a summary of the baseline care plan to a resident and their representative. The resident, with conditions such as epilepsy and dementia, was admitted without a baseline care plan initially located. The Administrator later confirmed the absence of evidence that a summary was provided, despite eventually locating the care plan.
The facility failed to develop individualized care plans for two residents, leading to deficiencies in their care. One resident's care plan lacked necessary details about nectar thickened liquids, despite physician orders and a nutritional risk assessment indicating the need for such interventions. Another resident's care plan inaccurately included an intervention to stop smoking, even though the resident was not a tobacco user. These errors were confirmed by facility staff.
A facility failed to update a resident's care plan to reflect changes in their functional abilities and weight-bearing status. The resident, with multiple fractures, had physician orders allowing weight bearing as tolerated for certain extremities and requiring a hoyer lift for transfers. Despite these updates, the care plan remained unchanged. Observations showed the resident independently propelling in a wheelchair and grooming, while an STNA confirmed the resident's ability to feed and wash independently. The administrator admitted the care plan was not revised accordingly.
A facility failed to address pharmacy recommendations for a resident receiving antipsychotic medications, olanzapine and risperidone. The pharmacist suggested discontinuing one medication to avoid duplicative therapy and highlighted the need for compliance with regulations on antipsychotic use. The physician's response did not address these recommendations, and AIMS testing was not conducted as advised. The DON confirmed that the pharmacy reviews were not fully responded to, contrary to the facility's policy.
Two residents in a LTC facility experienced medication administration errors, resulting in a 6.6% error rate. A nurse administered colace without a physician's order, failing to give the prescribed sennosides-docusate sodium. Another nurse used an undated insulin lispro pen without priming it, contrary to facility policy and manufacturer instructions.
A facility failed to address the use of a prophylactic antibiotic for a resident with a history of multiple antibiotic use. The resident, with several medical conditions, was prescribed cephalexin for infection prevention after a fall, despite not meeting infection criteria. The DON did not question the physician's order, and the facility's policy did not cover prophylactic antibiotic use, leading to a deficiency in antibiotic stewardship.
The facility failed to implement fall interventions for a resident at risk of falls and did not provide thickened liquids as ordered for another resident at risk of aspiration. Observations showed the absence of a fall mat for one resident, and multiple staff confirmed the lack of awareness of the order. Another resident received regular liquids despite a physician's order for nectar-thick liquids, with staff unaware of the requirement.
A resident with dementia fell into a pond due to inadequate supervision while outside watering plants. The facility failed to provide comprehensive elopement assessments and care plans for several residents, leading to inconsistencies in managing elopement risks. This deficiency affected multiple residents, highlighting the facility's inability to ensure proper supervision and safety measures.
A facility failed to maintain adequate staffing on its memory care unit, leading to incidents involving two residents. One resident fell into a pond while unsupervised, requiring emergency medical attention, while another resident exited the building. The facility's staffing schedules showed a pattern of understaffing, with only one RN and one STNA assigned to the unit. Interviews revealed the facility lacked a specific staffing policy for the memory care unit, and the LNHA confirmed staffing was based on census and resident needs.
Improper Portioning of Ground Chicken Salad on Diet Tickets
Penalty
Summary
The facility failed to ensure residents received proper portion sizes as specified on diet tickets during meal service. A resident with Alzheimer's disease and diabetes mellitus, admitted on 5/28/25, had an annual MDS assessment indicating moderate cognitive impairment and a need for setup assistance with eating. Physician orders for March 2026 specified a regular diet with dysphagia advanced texture and thin liquids. During observation of the lunch tray line on 03/19/26 at 12:15 P.M., the resident’s meal ticket indicated they were to receive ground chicken salad using a #10 scoop (3.75 oz). However, staff member #107 plated the ground chicken salad using a #16 scoop (2 oz), then completed the tray and placed it in the food cart. At 12:17 P.M., when Dietary Aide #109 pulled the tray from the cart, staff member #107 verified that the scoop used was a #16 (2 oz) instead of the required #10 (3.75 oz). In an interview at that time, staff member #107 acknowledged the serving size should have been three ounces and consulted the scoop chart, which confirmed the #16 scoop was only two ounces. The undated chicken salad recipe also specified that a #10 scoop of chicken salad should be placed between two slices of bread. In a later interview at 1:30 P.M., the Dietary Manager stated she believed staff member #107 was nervous and acknowledged she should have checked the serving utensils prior to tray service. This failure affected the identified resident and had the potential to affect eight other residents scheduled to receive ground chicken salad.
Improper Labeling and Storage of Frozen Food
Penalty
Summary
The facility failed to properly label and store frozen food items in the kitchen, which had the potential to affect all residents. During an initial kitchen tour, a plastic bag containing 10 frozen pork fritters was found sitting on top of a cardboard box on the second shelf of the freezer. The bag was neither dated nor sealed properly, as it was loosely wrapped. An interview with a staff member confirmed that the bag was not dated when opened or placed in the freezer, and the staff member subsequently discarded the fritters. The facility's policy requires that food be date-marked at the time it is opened or prepared, which was not followed in this instance.
Improper Maintenance of Respiratory Equipment
Penalty
Summary
The facility failed to properly maintain respiratory care equipment for two residents, leading to a deficiency in respiratory care. Resident #22, who had a history of opioid abuse, acute respiratory infection, anxiety, and shortness of breath, required staff assistance with activities of daily living, including medication administration. Despite having physician orders to clean and change nebulizer tubing and mask every Sunday night shift, observations revealed that the nebulizer and medication delivery device were not secured in a bag and were improperly stored on top of clothing and papers in the resident's room. The equipment was dated 02/03/25, indicating it had not been changed or secured as required. Similarly, Resident #23, who had diagnoses of congestive heart failure, high blood pressure, and shortness of breath, was receiving hospice services and required staff assistance with medication administration. Physician orders specified cleaning and changing the nebulizer tubing every three days and as needed. However, observations showed that the nebulizer and medication delivery device were left unsecured on a dresser in the resident's room, with tubing dated 02/10/25. Interviews with an LPN confirmed the improper storage and lack of securement for both residents' respiratory equipment, leading to the identified deficiency.
Medication Storage and Monitoring Deficiencies
Penalty
Summary
The facility failed to store and monitor medications safely, which had the potential to affect all residents. During an observation, it was found that two boxes of bisacodyl suppositories were expired, and the Director of Nursing (DON) confirmed they were stock medications for residents. Additionally, the refrigerator in the medication room had multiple boxes of influenza vaccines, tuberculin vials, haldol injection vials, and insulin pens, but the temperature logs were incomplete. The refrigerator temperature was not monitored on several occasions, and on one instance, it was recorded at 48 degrees Fahrenheit, which was not reported to the DON or maintenance personnel. Another observation revealed that the freezer in the Alixa medication storage room was over 50% solid ice, with ice buildup affecting the storage of medications. The temperature logs for this refrigerator were also incomplete, with no documentation since a specific date. Furthermore, an LPN was observed administering insulin to a resident using an undated insulin pen, which was against the facility's policy that required insulin pens to be disposed of after 28 days. The facility's policies on medication storage and insulin pen usage were not adhered to, leading to these deficiencies.
Deficiencies in Food Storage and Monitoring
Penalty
Summary
The facility failed to ensure proper storage, labeling, and monitoring of food items, which could potentially affect all 36 residents. During an initial tour of the kitchen, several deficiencies were observed, including an opened bag of raspberry gelatin mix and dry pasta without labels indicating the open date, and a bag of rolls with visible green mold. These observations were confirmed by a staff member at the time. Additionally, in the nurse's station refrigerator, both staff and resident foods were stored together, with significant ice crystallization and a brown substance spilled in the freezer. Further observations in the South unit's servery refrigerator revealed similar issues, including unlabeled food containers and an open popsicle covered in ice crystals. The temperature log for the freezer was incomplete, with no records for the first half of the month. Interviews with various staff members revealed confusion about responsibility for monitoring and recording refrigerator temperatures, with some staff unaware of the refrigerator's existence. The facility's policy indicated that dietary staff were responsible for monitoring temperatures, but this was contradicted by the Registered Dietitian, who stated it was actually the housekeeping staff's responsibility.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain proper infection control practices, particularly regarding Enhanced Barrier Precautions (EBP) for six residents. These residents had various medical conditions requiring EBP, such as indwelling catheters, surgical wounds, and colostomies. However, observations revealed that there were no isolation bins, PPE, or signage indicating EBP in the rooms of these residents. Staff interviews confirmed a lack of understanding and implementation of EBP, as staff did not use PPE during high-contact care activities, contrary to the facility's policy. Additionally, the facility's laundry services were found to be inadequate, with soiled and clean laundry coming into contact due to space constraints and a broken washing machine. This situation posed a risk of cross-contamination, as observed when a laundry aid moved clean laundry carts against soiled laundry and trash cans. The facility's housekeeping supervisor acknowledged the challenge of maintaining separation between clean and soiled laundry due to the limited space and non-functional equipment. The facility also failed to properly disinfect a glucometer used for blood sugar monitoring. An LPN was observed using a glucometer for a resident without cleaning it before or after use, despite the facility's policy requiring disinfection after each use. The LPN admitted to cleaning the glucometer only once per shift, and the DON confirmed that bleach wipes should have been used for disinfection. The facility's policy outlined specific disinfection procedures, which were not followed, increasing the risk of infection transmission.
Facility Fails to Maintain Comfortable Temperatures and Equipment
Penalty
Summary
The facility failed to maintain comfortable temperatures on two units, affecting three residents. Observations and interviews revealed that residents in the common area of the [NAME] unit complained of feeling cold and requested blankets. The temperature in the common area was recorded at 70 degrees Fahrenheit, while the South unit's hallway and resident rooms had temperatures ranging from 69 to 70 degrees Fahrenheit. The facility administrator acknowledged that the air conditioner had been adjusted in anticipation of hot weather, which contributed to the cold environment. Additionally, the facility failed to maintain resident equipment in good repair, specifically concerning a resident's bed and heating unit. The resident's bed was missing a headboard, which was found leaning against the wall with securing brackets on the floor. The baseboard heating unit near the bed had a broken front cover, exposing the heating element to the privacy curtain and bed linens. The Director of Maintenance confirmed these observations, indicating a lack of proper maintenance and repair of resident equipment.
Deficiency in Providing Individualized Activities
Penalty
Summary
The facility failed to provide individualized activities in accordance with assessments for several residents, leading to deficiencies in meeting their social, emotional, and physical needs. Resident #9, who was cognitively intact but had significant physical impairments due to a stroke, reported not being offered activities and rarely leaving his room. Observations confirmed the absence of an updated activity calendar in his room, and there were no documented one-on-one visits for August and September, despite the care plan's interventions. Resident #12, who was also cognitively intact and had a range of interests, expressed unawareness of activities beyond bingo and showed interest in participating if activities aligned with his preferences. However, the activity participation records indicated limited engagement, with refusals and lack of offerings for various activities. Observations showed Resident #12 spending most of his time in his room or briefly visiting a neighboring room, with no active participation in scheduled activities. Other residents, such as Resident #27 and Resident #32, also experienced a lack of engagement in activities. Resident #27, with dementia and behavioral disturbances, was observed lying in bed without interaction or activity offerings. Similarly, Resident #32, with severe cognitive impairment, was mostly observed sitting by the nursing station or in bed, with no evidence of activities being provided. The absence of the Activity Director due to medical leave and the lack of a dedicated activity calendar for the secure unit contributed to the deficiency in providing appropriate and individualized activities for the residents.
Deficiencies in Psychotropic Medication Management
Penalty
Summary
The facility failed to ensure that psychotropic medications were administered only when necessary, and did not address approvals for gradual dose reductions (GDR) in a timely manner. Additionally, the facility did not document the monitoring of target symptoms for residents receiving these medications. This affected three residents whose records were reviewed for medication use. For Resident #10, there was a lack of documentation and follow-up on a GDR for trazodone, despite a certified nurse practitioner (CNP) approving a reduction. The resident continued to receive the medication without a reduction attempt, and there was inconsistent documentation of non-pharmacological interventions prior to administering Ativan as needed. Resident #27's care plan required monitoring and recording of target behavior symptoms, but there was no documentation of non-pharmacological interventions being attempted before administering Ativan as needed. The Director of Nursing (DON) confirmed the lack of documentation regarding monitoring for antipsychotic use and target symptoms. The facility's policy on psychotropic medication use was not followed, as non-pharmacological interventions and target symptoms were not documented as required. For Resident #24, there was no documentation of behaviors or non-pharmacological interventions implemented, despite the resident receiving multiple psychotropic medications. The DON confirmed the absence of documentation for non-pharmacological interventions or daily behavior monitoring. Similarly, Resident #21's records lacked documentation of behaviors or non-pharmacological interventions before administering Ativan as needed. The facility's policy stated that psychotropic drugs should only be given when necessary and beneficial, with monitoring and documentation of the resident's response, which was not adhered to in these cases.
Absence of Call Systems in Resident Restrooms
Penalty
Summary
The facility failed to ensure that a working call system was available in three restrooms accessible to residents, which could potentially affect seven residents identified as independent with mobility and transfers. Observations conducted from September 15 to September 19, 2024, revealed that these restrooms, located near the middle of the extended hall and on the [NAME] residential hall, were unlocked at all times except when in use. Despite being wheelchair accessible and designated for male or female use, none of these restrooms had a call system installed. During an interview on September 19, 2024, the Maintenance Director confirmed that the restrooms were kept unlocked and could be locked from the inside. However, it was verified that no call system was in place in any of the three restrooms, allowing residents easy access to use them without the ability to call for assistance if needed. The facility's policy, titled 'Call Lights: Accessibility and Timely Response,' mandates that call lights be available at each resident's bedside, toilet, and bathing facility to ensure residents can call for assistance, which was not adhered to in this instance.
Inconsistent Code Status Documentation for a Resident
Penalty
Summary
The facility failed to ensure consistency in a resident's code status documentation, affecting a resident with multiple diagnoses including vascular dementia and chronic kidney disease. The resident had a signed Do Not Resuscitate (DNR) form indicating Do Not Resuscitate Comfort Care (DNRCC) status, effective immediately. However, the electronic health record and facility report sheet listed the resident's code status as Do Not Resuscitate Comfort Care Arrest (DNRCC-A), which allows for life-saving measures before cardiac or respiratory arrest but only comfort care afterward. Additionally, the physician orders dated January 18, 2024, also indicated a DNRCC-A code status. The discrepancy was confirmed by the Administrator, highlighting a failure to maintain consistent documentation of the resident's code status across different records.
Failure to Provide Baseline Care Plan Summary
Penalty
Summary
The facility failed to ensure that residents and their representatives were provided with a summary of the baseline care plan, affecting one of the four residents reviewed for baseline care plans. The medical record review and interview revealed that a resident with diagnoses including epilepsy, depression, delirium, dementia, and mood disorder was admitted to the facility on 05/10/24. However, no baseline care plan was initially located. On 09/18/24, the Administrator confirmed the absence of a baseline care plan or evidence that a summary was provided to the resident or their representative. Later, the Administrator provided the baseline care plan but still lacked evidence that a summary was given to the resident and their representative.
Deficiencies in Individualized Care Plans for Two Residents
Penalty
Summary
The facility failed to develop individualized care plans for two residents, leading to deficiencies in their care. For one resident, who was moderately cognitively impaired and at nutritional risk, the care plan did not include necessary details about nectar thickened liquids or instructions regarding thin liquids, despite physician orders and a nutritional risk assessment indicating the need for such interventions. The resident had a diagnosis of pneumonitis due to inhalation of food and vomit, requiring specific dietary modifications to prevent aspiration. The omission was confirmed by the Regional Clinical Director during an interview. For another resident with diagnoses including adjustment disorder, dementia, major depressive disorder, type two diabetes mellitus, and hypertension, the care plan inaccurately included an intervention to stop smoking, even though the resident was not a tobacco user according to multiple assessments. This error persisted across several care plan reviews over nearly two years. The facility's Administrator confirmed the inaccuracy, acknowledging that the resident had never been a smoker.
Failure to Revise Care Plan for Resident's Functional Abilities
Penalty
Summary
The facility failed to revise the care plan for a resident, identified as Resident #34, to accurately reflect their current functional abilities and weight-bearing status. Resident #34 was admitted with multiple fractures, including the right femur, tibia, fibula, and a displaced fracture in the left hand. Initially, the care plan indicated non-weight bearing for all extremities due to these fractures. However, subsequent physician orders updated the resident's weight-bearing status, allowing weight bearing as tolerated for certain extremities and requiring a hoyer lift with two assists for transfers. Despite these changes, the care plan was not updated to reflect the new weight-bearing instructions or the assistance needed for care. Observations and interviews conducted during the survey revealed discrepancies between the care plan and the resident's actual abilities. Resident #34 was observed propelling himself in a wheelchair and grooming himself using both upper extremities, indicating a level of independence not reflected in the care plan. An interview with a State Tested Nursing Assistant (STNA) confirmed that the resident was capable of feeding himself with setup, washing his upper body independently, and occasionally self-transferring, despite being advised against it. The facility's administrator acknowledged that the care plan had not been revised to reflect these changes in the resident's functional abilities and weight-bearing status.
Failure to Address Pharmacy Recommendations for Antipsychotic Medications
Penalty
Summary
The facility failed to ensure that all pharmacy recommendations were addressed by physicians, affecting a resident who was receiving two antipsychotic medications, olanzapine and risperidone. The pharmacist requested a diagnosis to support the use of these medications and suggested discontinuing one to avoid duplicative therapy. However, the physician's response only included a change in diagnosis to dementia, without addressing the recommendation to discontinue one of the medications. Additionally, the pharmacist highlighted the need for compliance with Centers for Medicare and Medicaid regulations regarding the use of antipsychotic medications, which require a prescriber evaluation for continued use beyond 14 days. This recommendation was acknowledged by the physician but not acted upon. Furthermore, the pharmacist recommended that Abnormal Involuntary Movements (AIMS) testing be conducted due to the use of antipsychotics, but no such test was found in the resident's electronic health record. The Director of Nursing (DON) confirmed that the pharmacy reviews for September and October 2023 were not fully responded to, and there was no additional documentation to indicate that the recommendations were addressed. The facility's Medication Regimen Review policy requires staff to act upon all recommendations, but this was not followed in this instance.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to ensure medications were administered in accordance with physician orders and policy, resulting in a medication error rate of 6.6%. This deficiency was observed in two residents. In the first instance, a Registered Nurse administered colace, a stool softener, to a resident without a physician's order for it. Instead, the resident had an order for sennosides-docusate sodium, which was not administered as prescribed. The facility's Medication Administration policy, which instructs staff to ensure the right drug is administered, was not followed. In the second instance, a Licensed Practical Nurse used an insulin lispro pen that was undated and not primed before administration. The nurse incorrectly believed the pen primed itself automatically. The facility's Insulin Pen policy requires insulin pens to be primed before each use and disposed of after 28 days, which was not adhered to. The manufacturer's instructions also specify that insulin lispro pens should be used within 28 days or discarded.
Failure to Address Prophylactic Antibiotic Use
Penalty
Summary
The facility failed to address the use of a prophylactic antibiotic for a resident who had a recent history of multiple antibiotic use. This deficiency was identified during a review of medical records, infection surveillance records, and facility policies, as well as through interviews. The resident in question had several diagnoses, including dementia with behavioral disturbance, benign prostatic hypertrophy (BPH), neuromuscular dysfunction of the bladder, and heart disease. Since admission, the resident had been prescribed multiple antibiotics for various conditions, including urinary tract infections and oral infections. Despite this extensive antibiotic history, the facility did not adequately address the use of a prophylactic antibiotic, cephalexin, which was ordered for infection prevention following a laceration post-fall. The Director of Nursing (DON) acknowledged that the resident did not meet the McGeer Criteria for infection, which is used for infection surveillance. The DON admitted that the facility's policy on Antibiotic Prescribing Practices did not address the use of prophylactic antibiotics, and she had not questioned the physician's order for the antibiotic, despite the risk of multi-drug resistant organisms. The facility's Antibiotic Stewardship Program indicated that the DON should ensure antibiotics are prescribed appropriately, but this was not done in this case. The deficiency was noted because the facility did not follow best practices and professional guidelines in prescribing antibiotics, particularly in the context of prophylactic use without clear justification.
Failure to Implement Fall and Nutrition Interventions
Penalty
Summary
The facility failed to implement fall interventions as per the care plan for Resident #12, who was at risk for falls due to conditions such as mild dementia, visual loss, and generalized muscle weakness. Despite an order for a fall mat to be placed on the exit side of the bed, observations on multiple occasions revealed that no mat was present. Interviews with staff, including a State tested Nursing Assistant (STNA), confirmed the absence of the fall mat and a lack of awareness of the order. The report sheet used by aides did not include instructions for the fall mat, indicating a communication breakdown in implementing the care plan. Additionally, the facility did not ensure that Resident #1 received thickened liquids as ordered, which was crucial due to the resident's risk of aspiration. Despite a physician's order for nectar-thick liquids, observations and interviews revealed that the resident was consistently provided with regular liquids. Multiple STNAs and an LPN confirmed the discrepancy, with some staff unaware of the thickened liquid requirement, and others indicating that the order had not been updated in the task record or diet card. This oversight resulted in the resident receiving inappropriate liquid consistency, contrary to the care plan and physician's orders.
Inadequate Supervision and Elopement Risk Management
Penalty
Summary
The facility failed to provide adequate supervision to a resident with dementia, resulting in the resident falling into a pond outside the facility. The resident, who was residing in the secured memory care unit, was left unattended while outside watering plants. During this time, the resident attempted to retrieve water from the pond, slipped, and fell into it. The resident was found with wet hair and clothing, coughing, and was subsequently transferred to the hospital for evaluation and treatment of aspiration pneumonia. The incident highlighted a lack of comprehensive, accurate, and individualized elopement assessments and care plans for several residents, including those with a history of wandering and exit-seeking behaviors. The facility's failure to ensure proper supervision and safety measures for residents at risk of elopement affected multiple residents, as evidenced by the lack of appropriate interventions and care plans. This deficiency was noted in the medical records and assessments of several residents, who were identified as being at risk for elopement but did not have corresponding care plans in place. The facility's assessment and care planning processes were found to be inconsistent and inaccurate, as demonstrated by the discrepancies in the elopement risk assessments and care plans for multiple residents. These inconsistencies contributed to the facility's inability to adequately supervise and protect residents from potential harm, as evidenced by the incident involving the resident who fell into the pond. The facility's failure to address these issues in a timely manner resulted in a deficiency that posed a risk of more than minimal harm to the residents.
Removal Plan
- Licensed Practical Nurse (LPN) #101 completed an assessment on Resident #1.
- The resident was transported to the emergency room.
- The Administrator/Director of Nursing (DON) provided 1:1 education to staff including Registered Nurse (RN) #103, LPN #102, and LPN #101 who were directly involved in the Resident #1's fall/incident. An emphasis was placed on ensuring residents were not left alone outside and had on proper footwear.
- The DON and/or designee educated all staff (three RNs, nine LPNs, 14 State tested Nursing Assistants) on facility Fall Prevention Program guidelines, following care plan/Kardex interventions, as well as all facility fall related policies including proper footwear and not leaving residents unattended outside. All nursing staff were educated except one LPN, LPN #100 who was out on medical leave and would be educated prior to her return to work.
- An audit revealed no other residents were at risk for being left alone outside as this and the root cause analysis determined that the fall would not have occurred had Resident #1 not been left alone outside.
- Immediate education provided to staff.
- Audits of risk management were conducted and would be reviewed by the LNHA twice weekly for four weeks to ensure no other incidents occur related to residents being left alone outside unattended twice weekly times four weeks.
- Resident #1's care plan was reviewed and updated to reflect Resident #1 was not to wear flip flops while outside.
- The LNHA conducted a formal and written Root Cause Analysis (RCA) with members of the AD HOC Quality Assurance and Performance Improvement (QAPI) that included the Medical Director, DON, Maintenance, LNHA and social service designee.
- A QAPI Performance Improvement Plan (PIP) was initiated to report on the above monitoring and auditing procedures. All findings from the PIP would be presented at the monthly Quality Assessment and Assurance (QAA) meeting. Monitoring/auditing and reporting would continue for a minimum of three months.
- Maintenance Director #150 filled in the pond with dirt.
- Assessments were completed by LPN #102 and LPN #108 for all 30 facility residents to identify residents who are at risk for elopement.
- Regional MDS Nurse #151 verified elopement assessments and care plans were completed to ensure accurate and consistent information and assessments.
- Regional MDS Nurse #151 verified fall assessments and care plan audit for all 33 residents were completed to ensure accurate and consistent information.
Inadequate Staffing Leads to Resident Incidents in Memory Care Unit
Penalty
Summary
The facility failed to maintain sufficient staffing levels on the secured memory care unit, affecting the care and supervision of residents. On the day of the survey, there were two licensed nurses and three State Tested Nursing Assistants (STNAs) for 33 residents, with only one Registered Nurse (RN) and one STNA assigned to the memory care unit. This staffing level was inadequate to meet the needs of the residents, as evidenced by the incident involving two residents. The facility's staffing schedules from May and June showed a consistent pattern of understaffing, with only one nurse assigned to the memory care unit without additional dedicated staff. An incident occurred where a resident, while watering plants in the courtyard, fell into a pond and required emergency medical attention for possible aspiration of pond water. The RN on duty, who was new and being oriented, was left alone on the unit when another resident exited the building, requiring the RN to leave the first resident unsupervised. This lack of supervision led to the resident slipping into the pond, highlighting the insufficient staffing and supervision on the memory care unit. Interviews with staff revealed that the facility had only recently started assigning an STNA to the memory care unit, and there was no specific staffing policy for the unit. The Licensed Nursing Home Administrator (LNHA) confirmed that staffing was based on census and resident needs, but the facility assessment did not specifically address the memory care unit. The deficiency was investigated under Complaint Number OH00155248, indicating non-compliance with staffing requirements.
Latest citations in Ohio
Surveyors found that multiple hazardous storage areas, including a closet near medical records, a beauty salon used to store chemical cases, a supply room in one nursing station, a room leading to a smoking area, a housekeeping room near therapy, and a lobby storage room, lacked required self-closing or automatic-closing doors. These conditions did not comply with NFPA 101 requirements for hazardous area enclosure and had the potential to affect all residents and staff in an emergency.
Surveyors found that the facility did not conduct fire drills on every shift each quarter and did not vary drill conditions as required by NFPA 101. Record review showed that one shift lacked a documented drill for an entire quarter, and the pattern of drill times and dates did not demonstrate varied conditions. The Maintenance Director confirmed the incomplete and noncompliant fire drill schedule, which affected all residents and staff emergency preparedness.
Surveyors found that the facility did not maintain clear egress corridors as required by NFPA 101, with a TV/video cart plugged into a corridor outlet and multiple unsecured chairs placed in the hallway near resident rooms and the secured unit dining room, including directly in front of a fire extinguisher. These items projected about 29 inches into an approximately eight-foot-wide corridor and were located in front of the handrail, potentially affecting 28 residents and staff’s ability to assist in an emergency. The Maintenance Director confirmed these corridor obstructions during the survey.
A resident with intact cognition receiving Medicare Part A skilled services for metabolic encephalopathy had services discontinued while benefit days remained, but the facility did not issue the required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN). The Social Services Director later confirmed that no SNF ABN was provided and reported she believed only a Notice of Medicare Non-Coverage (NOMNC) was needed when all skilled services were stopped. This practice conflicted with the facility’s written policy, which required SNF ABNs to be issued when extended care items or services were initiated, reduced, or terminated due to expected non-coverage by Medicare.
Surveyors identified that the facility exceeded the acceptable medication error rate when two residents with type 2 DM received insulin doses that were not administered according to orders or manufacturer instructions. In two separate observations, an LPN administered Novolog and another LPN administered insulin glargine and insulin lispro without priming the insulin pens, and the insulin lispro and Novolog were given after the residents had already consumed a significant portion of their breakfast meals, despite orders for administration before meals. Manufacturer information for both insulin products required priming before each injection to ensure accurate dosing, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and specified time frames.
The facility failed to maintain accurate and complete crash cart audits for multiple full-code residents. Surveyors, accompanied by the DON, found that daily crash cart checks did not include verification of supply expiration dates, and that an extension cord documented as present on several audit dates was not actually in the cart. Audit logs also conflicted with the cart’s contents by indicating that required items such as eye protection, saline, and clear plastic were present when they were not. These findings were inconsistent with the facility’s policy requiring the crash cart to be checked every 24 hours and after each use, with prompt replacement of equipment and supplies.
A resident with chronic respiratory failure on supplemental O2, COPD, and cognitive risk factors was repeatedly documented as non-compliant with the smoking policy, including going out to smoke outside designated times and retaining cigarettes and lighters provided by family. Despite prior assessments identifying this resident as unsafe to smoke without supervision, a later assessment classified the resident as safe to smoke independently without documented rationale or care plan update. The resident subsequently went outside alone with an O2 nasal cannula in place, lit a cigarette, and sustained facial burns when the cannula ignited, as observed by staff and confirmed by EMS and ED records. In a separate case, another cognitively impaired resident with a history of falls had a care-planned intervention for non-skid strips in front of a recliner, but observation and staff confirmation showed the strips were not present, despite remaining on the active fall-risk care plan.
Multiple dependent residents did not receive scheduled showers, bed baths, or shaving as outlined in their care plans and the facility’s routine care policy. One resident recovering from spinal surgery missed numerous scheduled showers over several months. Another resident who relied on staff for self-care repeatedly requested shaving but was not shaved, and visible facial hair was observed after a recent shower. A resident with chronic respiratory failure and a tracheostomy, requiring substantial/maximal assist with personal hygiene, had no documented showers for an extended period and was observed with long facial hair, which staff acknowledged should be removed during bathing or as needed. A cognitively impaired resident with ESRD and CHF, scheduled for twice-weekly showers, had multiple undocumented or missed showers and reported not getting showers despite asking aides who said they lacked time. Another cognitively intact resident with hemiplegia and multiple comorbidities, also scheduled for twice-weekly showers, had several dates where documentation showed no shower/bath/bed bath provided or no entry at all, and she reported feeling unclean and unimportant when her showers were missed.
A resident with an indwelling urinary catheter for urinary retention, and care plan interventions requiring the drainage bag to be properly secured with a dignity cover, was observed seated in a chair with the catheter drainage bag uncovered and containing visible dark yellow urine that could be seen from the hallway. Later, an LPN confirmed the catheter bag was lying directly on the floor without a dignity cover. This situation occurred despite facility policy requiring care to be provided in a manner that respects and enhances each resident’s dignity and personal privacy.
A cognitively intact resident with chronic orthopedic pain had a PRN oxycodone order, but multiple doses were signed out on the narcotic log by an RN without corresponding entries on the MAR or documented pain assessments. A CNA/med tech reported frequent problems with this RN’s narcotic counts and documentation, describing erratic behavior when handling narcotic keys. The resident reported taking oxycodone only once or twice daily and otherwise using Tylenol, which conflicted with the number of oxycodone doses signed out. The facility’s investigation found it was inconclusive whether narcotics were misappropriated or whether there was a failure of documentation, but confirmed there was no evidence that all signed-out doses were administered.
Failure to Maintain Self-Closing Doors for Multiple Hazardous Storage Areas
Penalty
Summary
Surveyors identified a deficiency related to hazardous area protection and door requirements under NFPA 101, 2012 Edition. During facility tours, they observed that multiple hazardous storage areas did not have self-closing or automatic-closing doors as required for hazardous areas such as combustible storage and chemical storage. These areas included a closet next to medical records, a beauty salon being used to store cases of chemicals, a supply room in Station #2, and the room leading to the smoking area in Station #3. On a subsequent tour, surveyors observed additional hazardous areas without self-closing doors. The housekeeping room across from therapy and the lobby storage room were both noted to lack self-closing door mechanisms. The facility census at the time was 59 residents, and the surveyors stated that this deficient practice had the potential to affect all residents and staff's ability to assist in an emergency. The Maintenance Director verified these findings at the time they were observed.
Plan Of Correction
K 0321 This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be admissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as its allegation of substantial compliance as of 06/12/2026 K-0321 Doors with Self-Closing Devices Corrective action for resident/s: 1. The closet door next to medical records was lacking a self-closing door on 5/19/2026. Maintenance director to add self-closing device to closet door next to medical records on or before 06/12/2026 in accordance with applicable code. 2. The beauty salon had chemicals stored in it on 5/19/2026. Maintenance director moved chemicals from beauty salon on 05/20/2026 in accordance with applicable code. 3. The supply room on station 2 was lacking a self-closing door on 5/19/2026. Maintenance director to add self-closing door to supply room on station 2 on or before 06/12/2026 in accordance with applicable code. 4. The room to the smoking area on station 3 was lacking a self-closing door on 5/19/2026. Maintenance director to add a self-closing door to the smoking are on station 3 on or before 06/12/2026 in accordance with applicable code. 4. The housekeeping room across from therapy was lacking a self-closing door on 5/19/2026. Maintenance director to add a self-closing door to the housekeeping room across from therapy gym on or before 06/12/2026 in accordance with applicable code. 5. The lobby storage room was lacking a self-closing door on 5/19/2026. Maintenance director to add a self-closing door to the lobby storage room on or before 06/12/2026 in accordance with applicable code. Identification of other residents who may be affected: LNHA and Maintenance director/designee completed a full facility audit for doors with self-closing devices on 05/26/2026. Any corrective action, including, doors identified as needing self-closures will be added on or before 06/09/2026 in accordance with applicable code. Measures for systemic change: LNHA educated Maintenance Director on 05/26/2026 regarding NFPA 101-2012 sections 19.3.2.1 and 19.3.5.9 specifically regarding doors with self-closing devices. How Corrective Action will be monitored Ongoing "Doors with Self-Closing device audit" to be completed weekly x 2 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 06/12/2026
Failure to Conduct Required Quarterly Fire Drills on All Shifts
Penalty
Summary
The facility failed to conduct fire drills in accordance with NFPA 101, 2012 Edition, sections 19.7.1 through 19.7.1.8, specifically by not holding drills every shift each quarter and not varying drill conditions as required. Record review on 06/09/25 at approximately 10:32 A.M. showed there was no fire drill conducted for the first shift during the third quarter. The documented first-shift fire drills occurred on 01/30/26 at 2:42 P.M., 04/30/26 at 1:51 P.M., and 10/31/25 at 10:58 A.M., indicating a missed quarter. Second-shift fire drills were recorded on 02/26/26 at 5:20 P.M., 06/03/25 at 4:35 P.M., 08/29/25 at 3:46 P.M., and 11/25/25 at 5:09 P.M., and third-shift drills on 02/28/26 at 11:47 P.M., 05/30/25 at 12:18 A.M., 07/22/25 at 11:34 P.M., 09/26/25 at 11:40 P.M., and 12/15/25 at 5:17 A.M. The surveyor determined that drills were not conducted under varied conditions and that the required quarterly drill on each shift was not consistently performed. The Maintenance Director confirmed these findings at the time they were identified, and the deficiency had the potential to affect all 59 residents and staff response in an emergency. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency related to facility-wide emergency preparedness practices and documentation of fire drills.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 05/29/2026 K-0712 Fire Drills Corrective action for resident/s: There were no records of a fire drill for the first shift of the third quarter of 2025. First shift fire drill completed on 5/24/2026 by maintenance director/designee with no findings or corrective action necessary. Identification of other residents who may be affected: On 5/26/2026 Maintenance director/designee completed 100% audit of the scheduled fire drills to ensure a drill is scheduled quarterly each shift with no findings or corrective action necessary. Measures for systemic change: LNHA educated Maintenance Director on 05/26/2026 regarding NFPA 101-2012 section 19.7.1.4 through 19.7.1.7. specifically including fire drill frequency requirements. How Corrective Action will be monitored Ongoing "Fire Drill Audit" to be completed weekly x 2 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 05/29/2026
Obstructed Egress Corridors Due to Equipment and Chairs
Penalty
Summary
The facility failed to maintain required clear egress widths in corridors in accordance with NFPA 101, 2012 Edition, sections 19.2.3.4 through 19.2.3.5 and 7.3.2 through 7.3.2.3, creating projections into the egress corridor that exceeded allowable limits. Surveyors observed that on one day in Station #3, a cart with a television and video equipment was plugged into an outlet in the corridor by room 38, and five activity room chairs were placed in the corridor near the secured unit dining room directly in front of a fire extinguisher. On the following day, surveyors again observed chairs in the Station #3 corridor, with four by room 35 and four by the activities room, and the same television cart still in the corridor; the chairs were not secured. The corridor was approximately eight feet wide, and the projections extended approximately 29 inches into the corridor in front of the handrail. These conditions had the potential to affect 28 residents in the facility and the staff’s ability to assist in an emergency, and the Maintenance Director confirmed the observations at the time of discovery. No specific resident medical histories or conditions were described in the report, only that 28 residents were potentially affected and the facility census was 59.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be subsequent remedial measures and should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 05/29/2026 K-0232 Clear path of egress Corrective action for resident/s: 1. On 05/18/2026 station 3 had a cart with a television parked in the corridor by room 38 that exceeded allowable limits. Maintenance director/designee moved the TV cart into the activity room, out to the corridor on 05/18/2026 in accordance with applicable code. 2. On 5/18/2026 station 3 had 5 chairs in the corridor near the dining room directly in front of the fire extinguisher. Maintenance director/designee moved the chairs into the dining room, out of the corridor on 5/18/2026 in accordance with applicable code. 3. On 5/19/2026 station 3 had 4 chairs by the activity room and 4 by room 35. In addition, the TV cart was in the corridor. The maintenance director/designee moved the chairs and TV cart into the dining room, out of the corridor on 5/19/2026 in accordance with applicable code. Identification of other residents who may be affected: Maintenance director/designee completed a 100% facility audit for clear paths of egress on 5/26/26 with no findings or corrective action necessary. Measures for systemic change: Maintenance Director/designee educated staff on 5/26/2026 regarding NFPA 101-2012 section 19.2.3.4 and 19.2.3.5 specifically including maintaining a clear path of egress. How Corrective Action will be monitored Ongoing "Path of Egress Audit" to be completed weekly x 2 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 05/29/2026
Failure to Issue Required SNF ABN When Discontinuing Medicare Part A Services
Penalty
Summary
The deficiency involves the facility’s failure to issue a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) when Medicare Part A services were discontinued for a resident who still had available benefit days. The resident was admitted with a diagnosis of metabolic encephalopathy and had intact cognition per the Minimum Data Set assessment. The facility’s own SNF Beneficiary Notification Review documented that Medicare Part A skilled services began on 02/11/26 and the last covered day was 03/11/26, and that the facility initiated discharge from Medicare Part A services before the resident’s benefit days were exhausted. Despite this, no SNF ABN was provided to the resident or the resident’s representative. During interviews, the Social Services Director stated that the SNF ABN was issued hours prior to the last covered day but, upon reviewing her files, confirmed that no SNF ABN had actually been issued for this resident. She further explained that she believed an SNF ABN was only required if one skilled service remained and that if all skilled services were being discontinued, only the Notice of Medicare Non-Coverage (NOMNC) needed to be issued. The Administrator, however, stated that a resident should always receive both a SNF ABN and a NOMNC when Medicare Part A services are discontinued and benefit days remain. Review of the facility’s written policy dated 03/28/23 showed that the facility was required to issue SNF ABNs for initiation, reduction, or termination of extended care items or services when Medicare payment was not expected, which did not occur in this case.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as its allegation of substantial compliance as of 05/29/2026 F-0582 Corrective action for resident/s: On 5/14/26 Resident #34 was informed of rights and responsibilities related to Advanced Beneficiary Notice and voiced understanding of information for future reference by administrator. Identification of other residents who may be affected: Any resident receiving skilled services from nursing or therapy services. The Administrator audited all residents who were discharged from skilled services in the past 30 days to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary Notice on 5/29/26. No non-compliance was noted. Measures for systemic change: On 5/14/2026 Business Office Manager, Director of Rehab, Minimum Data Set nurse, Director of Nursing and Social Services Director were educated on proper procedure of issuing of Notice Of Medicare Non Coverage and Advanced Beneficiary Notice by administrator. All upcoming discharges from skilled services will be reviewed weekly at Utilization Review meeting to ensure notices will be delivered timely. How Corrective Action will be monitored: Administrator or designee to complete audits of all residents being discharged from skilled services to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 5/29/26
Insulin Administration Errors and Failure to Prime Insulin Pens
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5%, with surveyors identifying 3 errors out of 28 medication administration opportunities, resulting in a 10.71% error rate. For one resident with type 2 diabetes mellitus and moderate cognitive impairment, the physician’s order directed Novolog insulin 10 units via subcutaneous pen-injector to be given before meals. During an observed medication pass, the LPN administered 10 units of Novolog insulin without priming the pen and did so after the resident had already consumed approximately 50% of the breakfast meal. The LPN later confirmed she did not prime the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer instructions for the Novolog FlexPen specified that an air shot (priming) must be performed before each injection to ensure proper dosing. Another resident, also diagnosed with type 2 diabetes mellitus and with intact cognition, had orders for insulin glargine 35 units subcutaneously twice daily and insulin lispro 20 units subcutaneously before meals, plus 12 units subcutaneously if blood glucose was between 251 mg/dL and 300 mg/dL. During an observed medication administration, an LPN administered 35 units of insulin glargine and 32 units of insulin lispro without priming the insulin pens and after the resident had consumed approximately 90% of the breakfast meal, despite orders for insulin lispro to be given before meals. The LPN later stated she could not remember if she had primed the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer information for insulin lispro stated that the pen must be primed before each injection to confirm insulin delivery and remove air, and that failure to prime could result in too much or too little insulin. The DON confirmed the expectation that insulin be administered as ordered, including priming each pen with two units before dialing the prescribed dose, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and required time frames.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 5/29/2026. F-0759 Corrective action for resident/s: Residents #21 and #22 were assessed and evaluated by nurse and Director of Nursing 5/14/26. Resident #21 and #22 both denied any adverse effects and none were noted upon assessment by the Director of Nursing on 5/14/2026. Notification made to physician on 5/14/2026. LPN # 2 competency Eval on insulin administration with the Director of Nursing completed 5/14/2026. Identification of other residents who may be affected: Diabetic residents on assignment of LPN #2/station 2 have the potential to be affected and were assessed by the DON/Designee on 5/14/26 and found to be within normal limits. Measures for systemic change: All Nurses were educated by the Director of Nursing on the steps for Insulin administration per competency, diabetes clinical protocol policy, Medication and treatment orders policy, administering medications policy, and Obtaining fingerstick Glucose Level policy On 5/14/2026. How Corrective Action will be monitored: Director of Nursing and Assistant Director of Nursing will complete insulin administration audits on 5 nurses. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance: 5/29/2026
Inaccurate Crash Cart Audits and Missing Emergency Equipment
Penalty
Summary
The facility failed to ensure accurate and complete crash cart audits for residents requiring basic life support, affecting eighteen of thirty-five residents who were designated as full code. During an observation of the crash cart with the DON, surveyors found that the daily audit documentation for the month did not include verification of expiration dates for crash cart supplies. Review of the crash cart audit logs showed that an extension cord was documented as being in the cart on multiple dates, but the extension cord was not present in the cart at the time of inspection. Additionally, the audit documentation indicated that required items, including eye protection, saline, and clear plastic, were not present in the crash cart, yet they were documented as being in the cart. The facility’s undated “Emergency Crash Cart” policy stated that the crash cart is to be checked every 24 hours and after every use, and that equipment and supplies are to be noted and replaced promptly, but the observed documentation and contents of the cart did not match these requirements. This deficiency was verified with the DON at the time of the survey and was cited under the requirement that personnel provide basic life support, including CPR, to residents requiring emergency care, subject to physician orders and advance directives, and was investigated under Complaint Number 2687380.
Plan Of Correction
Cridersville Care Center Provider Number:366171 Survey Type: Complaint Survey Survey Date: 04/29/26 This Plan of Correction (PoC) outlines the actions completed by the facility with regards to the deficiency citation. This Plan of correction does not constitute any admission of guilt or liability by the facility and is submitted only in response to the regulatory requirements. Please accept the following as the facility's credible allegation of compliance as of 4/30/26. F678 CPR All Full Code residents #18 have the potential to be affected by the alleged deficiency. On 4/27/26 the DON/ADON re-stocked the crash cart per the inventory sheet for all missing items. Crash cart inventory sheet updated and new one will go into effect on 5/1/26. All licensed nursing staff provided with training related to crash cart inventory being a daily audit review using inventory sheet on 4/27/26 per DON/designee. The DON/designee will conduct clinical rounds and conduct a random audit of crash cart three times per week for 4 (four) weeks to ensure compliance. The results of the audit will be documented. The facility conducted an Ad-Hoc QAPI meeting on 4/27/26 and discussed the alleged deficiency and corrective actions. Date when corrective action will be completed: 4/30/26
Unsafe Smoking Practices with Oxygen and Missed Fall-Prevention Interventions
Penalty
Summary
The deficiency involves the facility’s failure to provide a safe smoking environment, adequate supervision, and appropriate implementation of its smoking policy for a resident who used oxygen and smoked, as well as failure to implement fall-prevention interventions as care planned for another resident. One resident had multiple relevant diagnoses, including chronic respiratory failure with hypoxia, COPD, end-stage renal disease, dependence on supplemental oxygen, diabetes, and necrotizing fasciitis. Her care plans identified impaired visual function, risk for respiratory complications related to a history of smoking, and risk for cognitive decline, with interventions including use of oxygen per order and observation for understanding. A smoking-related care plan created earlier documented that she wished to use smoking products, had been assessed as safe to smoke "with supervision," and was non-compliant with the smoking policy, with family continuing to provide smoking supplies despite education and a verbal warning for non-compliance. Smoking assessments and progress notes showed a pattern of non-compliance and inconsistent classification of this resident’s smoking safety. Multiple smoking observation/assessments completed earlier in March documented that she had no cognitive loss, visual deficits, or dexterity problems but was unsafe to smoke without supervision because she did not return smoking materials and did not follow designated smoke times. Progress notes described her going out to smoke multiple times by herself or with family, including sneaking out next door with a cigarette and going out multiple times in one evening, with staff documenting that she was "reeducated" and that family brought in cigarettes and lighters which she did not return to staff. Despite this history, a smoking assessment completed after a three-day hospital stay assessed her as safe to smoke without supervision, with no documentation explaining how this conclusion was reached or evidence that her care plan was updated accordingly. On the day of the incident, the resident reported she had cigarettes and a lighter on her person after returning from dialysis and stated she "could not find a nurse" and went outside to smoke, saying she "guessed" she forgot she had her oxygen on. A CNA observed her outside and saw a flame coming through the resident’s oxygen nasal cannula tubing, turned off the oxygen tank, removed the tubing, and patted out sparks on the resident’s shirt sleeve. The resident’s face and hands appeared black in color, and EMS documented first-degree burns to the head and face, with the resident stating she lit a cigarette with her nasal cannula on, causing the burn. The hospital record described her face as black from smoke and her lips and mouth as "burnt and charred," with a recommendation for intubation that she refused. The facility’s incident report recorded that she went outside with oxygen on to smoke without notifying staff, that staff witnessed the occurrence as she walked through the dining room door to the courtyard, and that she stated she thought she had turned her oxygen off. The facility’s smoking policy required interdisciplinary evaluation to determine safe versus unsafe smokers, staff maintenance of all smoking paraphernalia for both safe and unsafe smokers, and progressive consequences for policy violations. A separate deficiency involved another resident at risk for falls whose care plan included use of non-skid strips on the floor in front of her recliner as a fall-prevention intervention. This resident had severe cognitive impairment, used a walker and wheelchair, required supervision or touching assistance for transfers and ambulation, and had experienced two or more falls without injury since the prior assessment. The fall-risk care plan, initiated at admission, specified non-skid strips in front of the recliner beginning in November. However, nursing staff interviewed were not familiar with all of the resident’s fall-prevention interventions without checking the record, and observation of the room showed two recliners with no non-skid strips on the floor in front of them. An LPN confirmed that the non-skid strips were not present despite the intervention remaining active in the care plan, and moving the recliners did not reveal any strips. The facility’s fall management policy required identification of hazards and risk factors, implementation of interventions to minimize falls and injuries, and development and implementation of a care plan based on interdisciplinary evaluation, with interventions related to identified risk factors.
Plan Of Correction
Smoking: On 03/21/26 at 3:16 P.M. 911 response was activated for Resident #11 and Medical Director #601 was notified by Registered Nurse (RN) #322. On 03/21/26 at 3:18 P.M. on-call Nurse/Social Services #423 immediately notified the Administrator and Director of Nursing (DON) #304 of the incident involving Resident #11. On 03/21/26 at 3:22 P.M. Emergency Medical Services (EMS) arrived onsite. At 3:30 P.M. Resident #11 was transported to the emergency room. On 03/21/26 at 3:30 P.M. RN #322 completed a smoking re-assessment of Resident #11 assessing the resident to be an unsafe smoker requiring supervision due to failure to remove oxygen prior to entering designated smoking area. On 03/21/26 from 3:38 P.M. through 7:57 P.M. Licensed Practical Nurse (LPN) #337, #336, #335, #338; RN #334, and DON #304 re-assessed residents (who smoke). This included Resident #22, Resident #3, Resident #47, Resident #50, Resident #60, Resident #150, Resident #86, and Resident #10 to determine smoking safety (via smoking assessment). Each resident was re-educated regarding the facility smoking policy and staff verified there were no smoking materials on their person. The residents' smoking materials would be maintained by facility staff and distributed per policy. On 03/21/26 at 4:30 P.M. DON #304 responded to facility and an Ad Hoc (not scheduled) Quality Assurance (QA) meeting was held via telephone with the Administrator, DON #304 and Medical Director #601 to review investigative findings and plan of action. A root cause analysis was completed and determined Resident #11 had smoking materials on her person (believed to be obtained from family without staff knowledge) and failed to remove her oxygen. The QA team discussed a corrective action plan. On 03/21/26 from 5:00 P.M through 03/22/26 at 3:00 P.M. 26 RNs, 13 LPNs, one medical technician (MT), 54 Certified Nursing Assistants (CNA) four activities staff, one central supply staff, 11 dietary staff, 12 housekeeping staff, three laundry staff, one medical records staff, two social designees, two maintenance staff, nine administrative staff, and 19 therapy staff (158 staff at the time of the incident) were provided education regarding the facility smoking policy by DON #304 and the Administrator. This was completed via 1:1, small group in-services or via phone. Newly hired staff would receive education during general orientation regarding the facility's smoking policy. On 03/21/26 at 5:00 P.M. DON #304 completed an audit of all residents who smoke (Resident #22, Resident #3, Resident #47, Resident #50, Resident #60, Resident #150, Resident #86, and Resident #10) to verify smoking evaluations and plans of care accurately reflected the residents' smoking safety needs. The residents were educated on the facility smoking policy, and smoking materials were to be maintained at the nurses' station. An audit was completed which included verification of required safety measures present in designated smoking areas, including an ash can, fire extinguisher, fire blanket, ash trays and no oxygen signs. There were no identified concerns or changes made because of the audits. On 03/21/26 at 8:55 P.M. Resident #11 returned from the ED. LPN #332 verbally educated the resident regarding the facility smoking policy which included the need for supervision, a smoking apron (to be worn) and the facility smoke times. LPN #332 verified no smoking materials were on the resident's person or in her room at this time. On 03/23/26 at 11:00 A.M. the Interdisciplinary Team (IDT) (Administrator, DON #304, Medical Director #601, RN #302, Social Services #427, Social Services #423, DON #300, and Maintenance #436) met in-person to review the plan of action with DON #304/designee to complete weekly monitoring of residents who smoke and designated smoking areas weekly for four weeks with Housekeeping responsible to complete the cleaning. Housekeeping staff were responsible for cleaning ashtrays and the designated smoking area daily. Audits to be reviewed and any further actions required to be directed by the Quality Assurance and Performance Improvement (QAPI) Committee during scheduled meetings. The IDT also reviewed all current smoking assessments and care plans for residents who smoke. Resident #50 required a change in supervision levels with smoking due to cognition levels and her plan of care as well as Resident #11's plan of care was updated to reflect supervision/safety. On 03/23/26 from 3:45 P.M. to 8:55 P.M. Social Services #423 re-educated residents who smoke (Resident #22, Resident #3, Resident #47, Resident #50, Resident #60, Resident #150, Resident #86, Resident #10) and responsible parties, if applicable regarding the facility smoking policy and supervision levels. On 03/23/26 at12:13 P.M. Social Services #427 contacted Resident #11's family member (#602) to schedule a care conference. Family member #602 and Family Member #603 were not available to meet until 03/27/26. On 03/23/26 at 1:00 P.M. staff education related to smoking areas, removal of oxygen prior to entering smoking area and maintaining smoking materials at the nurses' station for residents who smoke was initiated by DON #304 and the Administrator via 1:1, small group in-services or via phone call. Education was completed for all 158 staff by 03/24/26 at 1:00 P.M. Newly hired staff would be educated during general orientation regarding the facility's smoking policy. The facility does not utilize agency staff. On 03/27/26 at 11:00 A.M. a care conference was held with Resident #11 and Family Members #602 and #603, the Administrator, Social Services #423 and Social Services #427. The facility smoking policy was reviewed. The resident and family were informed an involuntary discharge would be initiated should the resident exhibit non-compliance moving forward and supervision would be increased beyond the two-hour standard of care to monitor more closely for non-compliance with the facility smoking policy. Family Member #602 stated he educated his siblings as well. On 04/10/26 at 2:00 P.M. DON #304 initiated education with 26 RNs and 13 LPNs (100% of nurses educated) regarding completion of the smoking evaluation via 1:1, small group in-services, or phone. The education was completed by 6:00 P.M. on 04/10/26. A new resident who smokes must remain supervised until the interdisciplinary team (IDT) reviews and determines smoking safety, at which time the care plan is developed and resident and family education is provided. The communication through the staff would be the care plan. Newly hired staff receive education during general orientation regarding the facility's smoking policy and completion of smoking evaluation via Point Click Care (PCC). On 04/10/26 at 4:29 P.M. DON #304 initiated an order in PCC for the nurse to verify, each shift, that Resident #11's smoking materials were maintained at the nurses' station. On 04/13/26 at 5:30 P.M. DON #304 initiated orders in PCC for nurses to verify, each shift, that all residents who smoke would have smoking materials maintained at the nurses' station. An updated list of smokers included: Resident #60, Resident #50, Resident #11, Resident #86, Resident #113, and Resident #151. On 04/13/26 at 5:45 P.M. DON #304 initiated questionnaires for staff regarding the smoking policy with re-education provided as needed via 1:1 and small group in-services for staff currently in the facility with all staff to be questioned/educated prior to working their next scheduled shift. Falls: On 4/9/26, Maintenance Director placed non-skid strips on the floor in front of Resident #12's recliner. Like Residents are identified as residents who have had a fall within the facility. Utilizing the Fall Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, an audit of falls and appropriate interventions for the past 30 days will be completed by the Director of Nursing or designee to ensure fall interventions are in place per plan of care. This audit along with identified corrections will be completed on or F 0689 before 5/13/26. The Director of Nursing or designee will re-educate licensed nurses and STNA/CNAs on the Fall Management Policy to include fall interventions to be in place per the care plan. This education will be completed on or before 5/13/26. Utilizing the Fall Management Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, the Director of Nursing or designee will complete an audit of new admissions, new readmissions and residents who experience a fall within the last 7 days, weekly for four weeks, beginning 5/14/26 to ensure fall safety interventions are in place per plan of care. Current fall interventions found to not be in place will be corrected with all intervention in place per plan of care. Negative findings to be addressed immediately and negative trends or system wide issues will be reported to the QAPI committee, and the action plan will be adjusted as needed.
Removal Plan
- Activated 911 response for Resident #11 and notified the Medical Director.
- On-call Nurse/Social Services immediately notified the Administrator and DON of the incident.
- EMS arrived onsite and Resident #11 was transported to the emergency room.
- Completed a smoking re-assessment of Resident #11, determining the resident was an unsafe smoker requiring supervision due to failure to remove oxygen prior to entering the designated smoking area.
- Re-assessed all residents who smoke (Residents #22, #3, #47, #50, #60, #150, #86, and #10) to determine smoking safety via smoking assessment.
- Re-educated residents who smoke regarding the facility smoking policy and verified there were no smoking materials on their person.
- Implemented that smoking materials would be maintained by facility staff and distributed per policy.
- Held an ad hoc QA meeting to review investigative findings and plan of action.
- Completed a root cause analysis determining Resident #11 had smoking materials on her person and failed to remove oxygen.
- Developed a corrective action plan.
- Provided facility-wide education to staff on the facility smoking policy.
- Implemented that newly hired staff would receive smoking policy education during orientation.
- Completed an audit of all residents who smoke to verify smoking evaluations and plans of care accurately reflected smoking safety needs.
- Ensured smoking materials were maintained at the nurses’ station.
- Audited designated smoking areas for required safety measures (ash can, fire extinguisher, fire blanket, ash trays, and no-oxygen signs).
- Provided verbal education to Resident #11 on smoking policy (supervision, smoking apron, smoke times).
- Verified no smoking materials were on Resident #11’s person or in her room.
- Conducted an in-person IDT meeting to implement weekly monitoring of residents who smoke and designated smoking areas weekly for four weeks.
- Assigned housekeeping to clean ashtrays and the designated smoking area daily.
- Directed audits to be reviewed by QAPI.
- Reviewed all current smoking assessments and care plans for residents who smoke.
- Updated Resident #50’s supervision level.
- Updated Resident #11’s plan of care to reflect supervision/safety.
- Re-educated residents who smoke and responsible parties (as applicable) regarding the facility smoking policy and supervision levels.
- Contacted Resident #11’s family to schedule a care conference.
- Initiated additional staff education regarding smoking areas, removal of oxygen prior to entering smoking area, and maintaining smoking materials at the nurses’ station.
- Held a care conference with Resident #11 and family to review smoking policy.
- Informed resident/family that involuntary discharge would be initiated for future non-compliance.
- Increased supervision beyond the two-hour standard of care to monitor more closely for non-compliance.
- Provided education to all nurses regarding completion of the smoking evaluation.
- Implemented that new residents who smoke must remain supervised until IDT review determines smoking safety and care plan/education are completed.
- Entered an order in PCC for nursing to verify each shift that Resident #11’s smoking materials were maintained at the nurses’ station.
- Entered orders in PCC for nursing to verify each shift that all residents who smoke have smoking materials maintained at the nurses’ station.
- Initiated staff questionnaires regarding the smoking policy with re-education as needed.
- Required all staff to be questioned/educated prior to working their next scheduled shift.
Failure to Provide Scheduled Bathing and Shaving Assistance for Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide scheduled and needed bathing and shaving assistance to multiple dependent residents in accordance with their care plans, preferences, and the facility’s routine care policy. One resident with spinal stenosis and recent L2–L5 decompression fixation fusion was care planned for substantial/maximal assistance with shower/bath and toileting hygiene and was scheduled for showers on Tuesdays and Fridays. Electronic documentation from early January through early April showed this resident did not receive a shower or bed bath on 11 identified scheduled days, and the DON confirmed these missed bathing events. Another resident with dysphagia and developmental issues, who required assistance with self-care and mobility, reported that she asked staff to shave her but they did not, which bothered her. During an observation following a recent shower, she stated she had not been shaved and that the hair "itched"; small gray hairs were visible on her chin. A CNA confirmed the presence of gray chin hairs and acknowledged the resident needed shaving, stating it would be addressed with the next scheduled shower. A further resident with chronic respiratory failure, tracheostomy status, heart failure, moderate intellectual disabilities, anxiety, depression, and PTSD required substantial/maximal assistance with personal hygiene and had a care plan for assistance with self-care, including personal hygiene. Her shower schedule called for showers on Monday and Thursday nights, with complete shaves for men and women. Review of documentation showed her last recorded shower/bath was nearly a year earlier, with no indication of additional personal hygiene or facial hair removal on that date. Observations on two separate days showed long white hairs on her chin and jaw line, which a CNA later confirmed, stating facial hair removal should occur with baths/showers or as needed. A resident with end stage renal disease, respiratory failure, hyperlipidemia, and congestive heart failure, who had impaired cognition and required partial/moderate assistance with bathing and personal hygiene, was scheduled for showers on Wednesdays and Saturdays. Review of shower documentation from admission through early April revealed no showers provided or refusals documented on at least ten scheduled shower days. In interviews, this resident reported not receiving scheduled showers, was unsure of his shower days, and stated he could use a good scrub down, adding that he had asked aides who told him they did not have time. A CNA explained that shower days appear on shower sheets and in the computer and that CNAs are supposed to document daily, with nurses checking the documentation; the DON verified the resident had not received showers per schedule or preference. Another resident with a fracture of the lower end of the left humerus, hemiplegia and hemiparesis after cerebral infarction, rheumatoid arthritis, hypertensive heart disease, urinary retention, and osteoarthritis was care planned as non–weight bearing to the left upper extremity and requiring substantial/maximal assistance with showering/bathing. Her electronic record showed she was scheduled for showers on Wednesdays and Saturdays. The shower task question "did the resident receive a shower/bath/bed bath?" was documented as "no" on three dates, indicating no shower/bath/bed bath was completed, and left unanswered on three additional dates. The DON confirmed that one missed shower was due to an outside appointment, that on two dates the "no" response meant no bathing of any type occurred, and that on three dates there was no documentation at all. The resident, who was cognitively intact, reported that missing showers made her feel unimportant compared to others and that she did not feel clean when her shower was missed. Facility policy on routine resident care stated that showers, tub baths, and shampoos are to be scheduled according to person-centered care or state guidelines, with additional showers given upon request, but the documented and observed care did not reflect consistent provision of scheduled bathing and shaving for these residents.
Plan Of Correction
1. Resident #5 received a shower by the STNA on 4/13/26. Resident #8 received a shower by the STNA on 4/8/26. Resident #9 received a shower and had their chin shaved by the STNA on 4/14/26. Resident #70 received a shower by the STNA on 4/13/26. Resident #76 received a shower and had their chin shaved by the STNA on 4/15/26. 2. Like residents are identified as residents who need assistance with showering and shaving. Utilizing the Shower Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, an audit of like residents will be completed by the Director of Nursing or designee to ensure that showers and resident shaving are completed. This audit along with identified corrections will be completed on or before 5/13/26. 3. The Director of Nursing or designee will re-educate licensed nurses and STNA's on the Routine Resident Care Policy to include bathing and shaving residents. This education will be completed on or before 5/13/26. 4. Utilizing the Shower Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, the Director of Nursing or designee will complete an audit of 4-6 residents weekly for four weeks, beginning 5/14/26 to ensure that showers and resident shaving are completed. Noncompliance found during audits will be addressed and assistance with showers and/or shaving provided. Negative findings to be addressed immediately and negative trends or system wide issues will be reported to the QAPI committee, and the action plan will be adjusted as needed.
Uncovered Urinary Catheter Drainage Bag Compromises Resident Dignity
Penalty
Summary
The facility failed to maintain a resident’s right to privacy and dignity related to management of an indwelling urinary catheter. A resident admitted with malignant neoplasm of the esophagus and type II diabetes mellitus had a care plan identifying risk for urinary tract infection and catheter-related trauma due to an indwelling catheter for urinary retention. The care plan interventions included ensuring the catheter tubing was secured and the drainage bag was properly secured with a dignity cover in place. Physician orders directed that the resident’s 16 French indwelling urinary catheter be changed every 30 days and as needed, and the comprehensive MDS documented that the resident had an indwelling catheter and was cognitively intact. During observation, the resident was seen seated in a chair with the urinary catheter drainage bag hanging from the chair without a dignity cover, and dark yellow urine was visible in the bag from the hallway. In a later observation and interview, an LPN confirmed that the catheter bag was lying directly on the floor and did not have a dignity cover. Attempts to interview the resident to confirm cognitive status were unsuccessful, as the resident was unable to answer screening questions. Review of the facility’s “Resident Dignity & Personal Privacy” policy stated that the facility should provide care in a manner that respects and enhances each resident’s dignity, individuality, and right to personal property, which was not followed in this instance when the catheter drainage bag was left uncovered and visible.
Plan Of Correction
The Laurels of Athens wishes to have this plan of correction submitted as our written allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission to nor agreement with, either the existence of, or the scope and severity of, any of the cited deficiencies or conclusions set forth in the statement of deficiencies. This plan is prepared and/or executed to ensure continuing compliance with regulatory requirements. Our alleged date of compliance is 5/13/2026. 1. On 4/6/26, Resident #92's catheter bag was removed from the floor, the bag changed and covered for dignity by the licensed nurse. Resident #92 discharged from the facility on 4/11/26. 2. Like Residents are identified as residents who utilize urinary catheters. An audit will be completed by the Director of Nursing or designee for like residents utilizing the Urinary Catheter Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC to ensure catheter bags are covered for dignity and not laying directly on the floor. This audit along with identified corrections will be completed on or before 5/13/26. 3. The Director of Nursing or designee will re-educate licensed nurses on the Indwelling Urinary Catheter Policy as well as Resident Dignity & Personal Privacy Policy to include privacy covers are in place for urinary catheters and that the catheter is not laying on the floor. This education will be completed on or before 5/13/26. 4. Utilizing the Urinary Catheter Audit Tool which was created on 4/20/26 by the Director of Nursing for purpose of this POC, the Director of Nursing or designee will complete an audit of all residents with catheters weekly for four weeks, beginning 5/14/26 to ensure catheter bags are covered for dignity and not laying directly on the floor. Any catheters found to be touching the floor or uncovered will be removed from the floor, the bag changed and covered for dignity. Negative findings to be addressed immediately and negative trends or system wide issues will be reported to the QAPI committee, and the action plan will be adjusted as needed.
Failure to Prevent Possible Misappropriation and Poor Documentation of PRN Narcotics
Penalty
Summary
The deficiency involves failure to prevent potential misappropriation of a resident’s narcotic medication and failure to ensure accurate documentation of controlled substance administration. A cognitively intact resident with chronic pain related to an internal orthopedic device and left knee pain had an order for oxycodone 5 mg PO every four hours PRN for pain and a care plan directing staff to administer medications as ordered and observe for effectiveness and side effects. The resident’s MDS showed she rated her pain as 7/10 and received opioid medication. However, review of the February MAR and the narcotic log revealed multiple discrepancies between narcotic sign-outs and documented administration. On several occasions, oxycodone doses were signed out on the narcotic log by an RN without corresponding documentation on the MAR. Specifically, oxycodone was signed out on one evening at 9:30 p.m. with no MAR entry, and again on a subsequent night at 1:30 a.m. and 5:30 a.m. with no MAR entries for those times. Another dose was signed out at 9:00 p.m. while the MAR reflected administration at 10:16 p.m., and a later dose at 5:30 a.m. was documented on both the narcotic log and MAR. There was also no documentation of pain assessments before or after PRN opioid administration. These documentation gaps meant there was no evidence that all narcotic doses signed out were actually administered to the resident. Staff interviews further highlighted concerns about the handling of narcotics. A CNA/med tech reported frequently taking the narcotic keys from the RN and described the RN’s behavior as erratic, with repeated problems involving incorrect narcotic counts and missing documentation on both the MAR and narcotic log. The resident stated she did not receive oxycodone more than once or twice a day, preferring to take Tylenol the rest of the time, which conflicted with the number of oxycodone doses signed out. When questioned, the RN gave inconsistent explanations about how often she pulled and administered PRN narcotics and acknowledged struggling with the new system, while also suggesting the resident may have received PRN tizanidine instead of remembering oxycodone. The facility’s investigation concluded that evidence was inconclusive as to whether misappropriation occurred or whether the issue was solely lack of documentation, but confirmed there was no evidence the resident received all doses signed out on the narcotic log.
Plan Of Correction
1. Resident #99 had a Self-Reported Incident submitted and investigated via the EIDC on 3/2/26. The investigation was inconclusive as we could not prove that misappropriation occurred. On 2/24/26, Resident #99 was interviewed and pain assessed by Director of Nursing and resident had no ill effects related to the inconsistent documentation in the medical record as it relates to her controlled substance pain medication. 2. Like Residents are identified as residents who utilize controlled substance PRN pain medications. An audit will be completed by the Director of Nursing or designee for like residents utilizing the Controlled Substance Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC to ensure PRN controlled substance pain medications that are signed off the control sheet are documented in the resident medical record as well. This audit along with identified corrections will be completed on or before 5/13/26. 3. The Director of Nursing or designee will re-educate licensed nurses on the Controlled Substances Policy to include appropriate documentation of controlled substances. In addition, the licensed nurses will be re-educated by the Director of Nursing or designee on the Abuse Prohibition Policy to include misappropriation of resident property. This education will be completed on or before 5/13/26. 4. Utilizing the Controlled Substance Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, the Director of Nursing or designee will complete an audit three controlled substance sheets from each of the nine medication carts for a total of twenty-seven sheets weekly for four weeks, beginning 5/14/26 to ensure PRN controlled substance pain medications that are signed off the control sheet are documented in the resident medical record as well. Inconsistencies noted from the audit will be investigated for misappropriation. Negative findings to be addressed immediately and negative trends or system wide issues will be reported to the QAPI committee, and the action plan will be adjusted as needed.
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