Greenbrier Health Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Parma Heights, Ohio.
- Location
- 6455 Pearl Rd, Parma Heights, Ohio 44130
- CMS Provider Number
- 365192
- Inspections on file
- 34
- Latest survey
- October 8, 2025
- Citations (last 12 mo.)
- 25 (1 serious)
Citation history
Health deficiencies cited at Greenbrier Health Center during CMS and state inspections, most recent first.
A cognitively impaired resident with a history of wandering and elopement exited the facility without staff knowledge and was found by police in a confused state over a mile away, after not receiving required 1:1 supervision due to a staff call-off that was not reported to administration. Additionally, the facility failed to secure smoking materials for several residents, with cigarettes and lighters found unsecured in resident rooms and combustible items present in the smoking area, contrary to facility policy.
Surveyors found expired medications in storage, improper refrigeration of temperature-sensitive drugs, and instances where an LPN left medications unsecured at a resident's bedside without confirming administration or documenting missed doses. These failures were confirmed by staff and affected at least one resident with multiple medical conditions.
Surveyors identified multiple deficiencies in facility cleanliness and maintenance, including chipped and rough hallway handrails, dusty and insect-filled light fixtures, missing light bulbs, water-stained ceiling tiles, stained privacy curtains, scuffed walls, dirty air conditioner filters, damaged bathroom doors, detached heat pipe covers, holes in wall coverings, extremely dirty wheelchairs, wall cracks, and exposed live telephone wires. These issues were observed in several resident rooms and common areas, impacting the safety and sanitation of the environment for all residents, staff, and visitors.
Multiple dependent residents did not receive scheduled showers as required by their care plans and facility policy, with documentation showing missed showers, incomplete records, and improper use of 'not applicable' in the MDS. Residents and staff confirmed that showers were not consistently provided, and observations noted poor hygiene in some cases. The deficiency was widespread and involved failures in both care delivery and documentation.
Multiple residents did not receive wound and device care as ordered, including missed or delayed dressing changes for wounds, central lines, and nephrostomy tubes, as well as inadequate incontinence care. Staff documented treatments that were not performed, and some residents were left in soiled briefs for extended periods, resulting in skin breakdown and wounds. The facility lacked clear policies and consistent practices for wound and device management.
The facility did not maintain sufficient nursing staff on the second floor, resulting in missed showers, delayed incontinence care, and prolonged wait times for assistance. Multiple residents reported unmet care needs, and staff confirmed that daily CNA coverage was consistently below the facility's own minimum requirements. Observations included a resident with a worsening wound due to infrequent care and another with a tracheostomy who was not suctioned as needed.
The facility did not update care plans to reflect the current needs of two residents. One resident with dementia and a rare brain disorder experienced multiple elopement incidents, but the care plan was not revised after these events. Another resident with physical impairments had no documented care plan meetings for over a year, despite claims that meetings occurred. These deficiencies resulted in care plans that did not accurately address the residents' needs.
A resident with multiple stage three pressure wounds did not receive wound care dressings as ordered. Although documentation indicated that daily wound care was completed, an LPN confirmed that the dressings were not actually provided as scheduled, and the records were inaccurate. This failure resulted in non-compliance with the facility's wound care policy.
A resident with a history of hemiplegia, COPD, and diabetes, who required substantial assistance with toileting, was found with a saturated incontinence brief, deep red skin on the buttocks, and dried urine stains on the bedsheets. The resident reported not being changed since the previous evening, and staff interviews revealed inconsistent incontinence care, contrary to facility policy.
Surveyors observed two residents receiving insulin injections where LPNs failed to properly prime insulin pens according to manufacturer instructions, resulting in a medication error rate above 5%. Both residents were cognitively intact and required daily insulin, but staff did not follow correct priming procedures before administration.
Two residents experienced significant medication errors due to missed and improperly administered medications. One resident did not consistently receive a prescribed medication for short bowel syndrome because it was locked in a provider office and not accessible to nursing staff, while another resident missed several doses of a prescribed antibiotic due to pharmacy delivery delays and issues with medication removal from the dispensary. These errors were confirmed through record reviews, staff interviews, and pharmacy documentation.
A resident with chronic pain conditions did not receive pain medication as ordered due to an unfamiliar ADON working the floor. The resident, who was supposed to receive hydromorphone every four hours, waited over an hour for relief, causing distress. The Unit Manager intervened after concerns were raised, highlighting a failure to adhere to the facility's pain management policy.
The facility failed to ensure effective discharge planning for two residents, leading to deficiencies in their care transitions. One resident was discharged to an assisted living facility without proper documentation or updates to the care plan, while another resident's desire to move to South Carolina was not reflected in the discharge plan. The facility did not adequately document or update the discharge plans, violating its own policy.
A resident with multiple health conditions was injured during a transfer when a mechanical lift malfunctioned due to improper use by a single STNA, contrary to facility policy requiring two staff members. The resident dropped into her wheelchair, sustaining a forehead cut.
The facility failed to provide timely incontinence care for several residents, leading to situations where residents were found with urine and stool soaked through their incontinence briefs and bed sheets. Staff members were often unaware of when residents were last checked or changed, indicating a lack of communication and accountability in resident care assignments.
A resident in a LTC facility, dependent on staff for transfers, was left in her wheelchair for hours despite requesting assistance to return to bed. The resident contacted her son, who called the police, leading to her eventual assistance. Interviews revealed complaints about staff rudeness and unresponsiveness, highlighting a failure to honor resident rights and dignity.
The facility failed to maintain a clean and sanitary environment, affecting two residents. Soiled incontinence briefs were found on a resident's wheelchair, and a large pile of dirty linens with a foul odor was observed in another resident's room. Staff confirmed these observations and acknowledged the issues.
Elopement and Smoking Safety Deficiencies
Penalty
Summary
A cognitively impaired resident with a history of elopement exited the facility without staff knowledge and was found by local police in the middle of a residential street approximately 1.7 miles from the facility. The resident was confused, speaking in his native language, and seeking a local ethnic meat market. The resident was subsequently transported to a local hospital for evaluation. Prior to this incident, the resident had previously eloped from the facility's smoking area by kicking open a gate and was returned by emergency services. Despite being identified as an elopement risk with documented wandering and exit-seeking behaviors, the resident's care plan and interventions were not consistently updated to reflect the need for increased supervision, such as 1:1 monitoring, and behavior monitoring was not completed on the shift when the elopement occurred. Staff interviews revealed that the resident was known to be restless, had poor safety awareness, and required significant redirection. On the evening of the incident, the staff member assigned to provide 1:1 supervision for the resident called off, and administration was not notified, resulting in the resident not receiving the required supervision. The facility was unable to determine exactly how the resident exited the building, but it was believed the resident left through the front door, which was keypad-secured. The facility's elopement prevention policy included regular rounds, environmental modifications, and protected lists of at-risk residents, but these measures were not sufficient to prevent the incident. Additionally, the facility failed to maintain a safe environment related to resident smoking. Observations showed that smoking materials, including cigarettes and lighters, were not kept in locked areas as required by facility policy. Multiple residents were found with smoking paraphernalia unsecured in their rooms, and some did not have required smoking contracts or access to secure storage. The outdoor smoking area was observed to have cigarette butts and combustible items mixed in ash trays, further contributing to accident hazards.
Removal Plan
- Local police notified facility that Resident #117 was found outside and transported to the hospital.
- A headcount was completed by facility staff to ensure each resident was accounted for.
- Resident #117 returned to the facility and was immediately assessed by the nurse.
- Resident #117 was placed on one on one (1:1) supervision with a plan for 1:1 supervision to remain in place until the resident was no longer identified as high risk for elopement which would be assessed quarterly using the wandering observation tool.
- Maintenance Director completed an audit to validate all windows and doors were secure and functioning properly.
- The DON/designee reported to the facility Quality Assessment and Performance Improvement (QAPI) committee the concerns related to Resident #117's elopement.
- The QAPI committee met to complete a root cause analysis.
- Maintenance Director changed all secure door codes.
- LPN completed a wandering assessment, pain assessment and head to toe assessment on Resident #117.
- The Administrator conducted staff education for all facility staff in person, via Onshift software (e-learning platform) and via phone calls related to Elopement prevention and management overview and Unit Supervision with emphasis on safety and supervision.
- Resident #117's physician and emergency contact was notified.
- The clinical interdisciplinary team which consists of the Director of Nursing, assistant Director of Nursing and Unit Managers completed wandering/elopement assessments on all residents.
- Elopement/wandering care plans were reviewed for all residents at risk by the DON/designee.
- The facility elopement binder was reviewed by the DON/designee.
- Resident #117's care plan was updated by Minimum Data Set Nurse to include 1:1 supervision for an elopement intervention.
- Two residents (Resident #37 and Resident #100) care plans were updated with elopement interventions by Minimum Data Set Nurse.
- The facility implemented a plan to monitor for ongoing compliance, elopement drills would be completed twice weekly for two weeks, then weekly for two weeks. The drills would be conducted by the DON/designee on night shift, day shift, evening shift and day shift.
- The Administrator/DON/Designee began calling the facility at the start of each shift to ensure coverage of one-on-one (1:1) care providers for Resident #117 and others as needed. This would continue every shift indefinitely until the facility Quality Assessment and Performance Improvement (QAPI) committee deemed appropriate changes.
- The facility implemented a plan for the DON/designee to complete observation audits to ensure resident(s) who had one on one supervision were provided five days a week every three months.
- The DON/designee would complete observation audits to ensure interventions were in place for elopement risk residents, five days a week for three months.
Medication Storage and Administration Deficiencies Identified
Penalty
Summary
Surveyors identified multiple deficiencies related to medication management within the facility. During an observation of the medication storage room, expired stock medications intended for resident use were found, including Tylenol, enteric coated Aspirin, Geri Max antacid, and Docusate Sodium. The Unit Manager and Supply Coordinator confirmed the presence of these expired medications and acknowledged that expired drugs should have been removed and disposed of according to facility policy. Additionally, the medication storage refrigerator was found to be operating at 50°F, above the recommended range for medication storage, with water pooling inside. Several temperature-sensitive medications, such as insulin and Micafungin injection, were stored in this refrigerator, contrary to manufacturer recommendations. Further investigation revealed that a resident with a history of hemiplegia, epilepsy, insomnia, anxiety, and diabetes had medications left unsecured at the bedside by an LPN, without confirmation of administration. The resident reported that this was a recurring practice by the nurse, and interviews with staff and the resident's responsible party corroborated that medications were left at the bedside overnight and not administered as intended. The Medication Administration Record indicated the medications were signed as given, but there was no documentation of the missed doses or notification to the physician or family regarding the incident. The facility's failure to ensure medications were not expired, were stored at appropriate temperatures, and were not left unsecured at the bedside without proper administration or documentation affected at least one resident and had the potential to impact all residents. These findings were confirmed through observation, interviews with staff and residents, and review of facility policies and records.
Failure to Maintain Clean and Sanitary Environment
Penalty
Summary
The facility failed to maintain a clean and sanitary environment, as observed during an environmental tour and confirmed by the Housekeeping Director. Hallway handrails were chipped, scuffed, and rough, while light fixtures throughout the hallways contained dust, dirt, and dead insects. In several resident rooms, issues included missing light bulbs, water-stained ceiling tiles, stained privacy curtains, severely scuffed walls, and damaged or scraped bathroom doors. Wall-unit air conditioners in some rooms displayed a clean filter indicator light, with filters coated in dust. Additional deficiencies included detached protective covers on heat pipes, holes or gouges in wood wall coverings, extremely dirty wheelchairs with accumulations of food and debris, a visible wall crack, and a missing cover on a wall telephone line exposing live wires. These conditions were observed in multiple resident rooms and common areas, affecting the overall cleanliness and safety of the environment for all residents, staff, and the public.
Failure to Provide Scheduled Showers for Dependent Residents
Penalty
Summary
The facility failed to ensure that residents who were dependent on staff for activities of daily living (ADL), specifically bathing and showering, received showers as required by their care plans and facility policy. Multiple residents with varying degrees of cognitive and physical impairment, including those with diagnoses such as renal dialysis dependence, hemiplegia, dementia, and chronic obstructive pulmonary disease, were scheduled for regular showers but did not consistently receive them. Documentation revealed missed showers, incomplete records, and instances where showers were marked as 'not applicable' without evidence of refusal or alternative care, such as bed baths. Interviews with residents and staff confirmed that showers were not provided as scheduled, with some residents reporting not having been bathed for weeks and staff acknowledging the lack of proper documentation and completion of scheduled showers. In several cases, the Minimum Data Set (MDS) assessments marked bathing as 'not applicable' because the residents had not been bathed during the look-back period, further confirming the lack of care. Observations also noted poor hygiene, such as oily hair and dirty nails, in residents who had missed scheduled showers. The deficiency was widespread, affecting a significant number of residents reviewed for showers, and was corroborated by both record review and staff interviews. Facility policy required at least two showers per week for dependent residents, but this standard was not met for many individuals. The lack of documentation for missed showers, refusals, or alternative bathing methods indicated a systemic failure to provide and record essential ADL care as required.
Failure to Provide Comprehensive Wound and Device Care
Penalty
Summary
The facility failed to ensure a comprehensive wound management system was in place for multiple residents, resulting in deficiencies in wound care and treatment according to physician orders. One resident with a recent surgical amputation and moderate cognitive impairment was observed with a dressing on the left lower leg that was not changed as ordered, with documentation indicating the dressing was not current. Another resident with a central venous catheter and intact cognition was discharged with a central line dressing that was not intact and had not been changed as ordered, despite documentation in the facility records indicating otherwise. The home care nurse reported the dressing had not been changed for several weeks, and photographic evidence supported this finding. A third resident with a nephrostomy tube and intact cognition had physician orders for regular dressing changes, but interviews and observations revealed the dressing was not changed as ordered. Staff interviews confirmed that documentation of dressing changes was inaccurate, with nurses signing off on treatments that were not performed. The facility also lacked a policy for nephrostomy tube care, contributing to the inconsistency in treatment. Additionally, a resident with chronic conditions and limited mobility was not provided with timely incontinence care or wound assessments. Observations showed the resident remained in a soiled brief for extended periods, resulting in redness and open areas on the buttocks. Staff interviews confirmed that the resident was not checked or changed as required, and wound care was not performed according to orders. The wound care nurse had not assessed the resident for several weeks, and inappropriate application of wound care products was observed.
Failure to Provide Adequate Nursing Staff to Meet Resident Needs
Penalty
Summary
The facility failed to provide adequate nursing staff each day to meet the needs of all residents, as required by their own facility assessment and federal regulations. Staffing schedules for the second floor consistently fell below the minimum number of Certified Nursing Assistants (CNAs) needed, with multiple days showing only four to seven CNAs present when at least eight were required. The Human Resource Manager confirmed that the facility did not use agency staff and relied on an outsourced scheduling company, resulting in persistent understaffing. The Administrator acknowledged that staffing levels did not meet the facility's own assessment standards for the entire review period. Direct observations and interviews revealed that residents experienced significant delays in receiving care, including long waits for assistance, missed showers, and inadequate incontinence care. Several residents reported not receiving showers for weeks, waiting up to 1.5 to 2 hours for call lights to be answered, and not having their needs addressed in a timely manner. Staff interviews corroborated these concerns, with CNAs and LPNs stating that there were not enough staff to meet resident needs, leading to missed care and incomplete documentation. Specific resident cases highlighted the impact of insufficient staffing. One resident with chronic conditions and limited mobility developed a sacrococcygeal wound, with observations showing prolonged periods without incontinence care or repositioning, resulting in saturated briefs, foul odor, and open wounds. Another resident with a tracheostomy was observed with thick mucus accumulation and a dusty suction machine, with staff unable to confirm when suctioning last occurred. Multiple records confirmed that scheduled showers were not completed for several residents, and staff consistently reported that the number of CNAs on duty was inadequate to provide necessary care.
Failure to Revise and Document Resident Care Plans
Penalty
Summary
The facility failed to revise and update care plans to reflect the current needs of two residents. For one resident with diagnoses including Parkinsonism, a rare brain disease, and dementia, the care plan identified the resident as an elopement risk but was not updated after multiple incidents of elopement. The resident was involved in two separate elopement events: in the first, the resident exited through a gate in the smoking area and was found in the parking lot, and in the second, the resident was found by police approximately 1.7 miles away from the facility after being reported missing. Despite these incidents, the only direct intervention implemented was one-on-one supervision, and the care plan was not revised to include new interventions addressing the repeated elopement attempts. For another resident with cognitive intactness and physical impairments, there was no documentation of any care plan meeting being completed from admission through over a year later. Although the social worker reported that care conferences were scheduled and completed on two occasions, there was no documentation available to confirm these meetings. The lack of documented care plan meetings indicates that the resident's care plan was not reviewed or revised as required, failing to ensure that the care plan reflected the resident's current needs.
Failure to Complete Pressure Ulcer Wound Care as Ordered
Penalty
Summary
A resident with a history of quadriplegia, diabetes, and schizophrenia was admitted and later readmitted to the facility. The resident had multiple stage three pressure wounds, including on the mid-spine, right back, sacrum, and left buttock, all of which were documented as improving. Physician orders required daily wound care, including cleansing with wound cleanser, application of a collagen sheet, and securing with a bordered foam dressing to several wound sites. Survey findings revealed that the wound care dressings for the resident were not completed as ordered. Specifically, the dressings were signed off as completed on the medication and treatment administration records by an LPN, but the actual dressing dates did not match the documentation, confirming that the care was not provided as scheduled. The facility's wound care policy required treatment based on wound characteristics, but the records and staff interview confirmed a failure to follow the prescribed wound care regimen and maintain accurate documentation.
Failure to Provide Timely Incontinence Care
Penalty
Summary
Resident #119, who was admitted with diagnoses including hemiplegia and hemiparesis following a cerebral infarction, chronic obstructive pulmonary disease, and diabetes, was identified as being frequently incontinent of bowel and bladder and requiring substantial to maximal assistance with toileting hygiene. The resident's care plan reflected these needs. On observation, the resident was found with a saturated incontinence brief and deep red discoloration on both buttocks, with a large dried yellow stain on the bedsheets beneath her. The resident reported that she had not been changed since the previous evening and that staff did not respond to her call light requests. Interviews with staff revealed inconsistencies in the timing and frequency of incontinence care provided to the resident. One CNA stated the resident was last changed at 6:00 A.M. on the day of observation, while the resident herself reported the last change occurred the previous evening. The facility's perineal care policy requires regular care to maintain cleanliness, comfort, and skin integrity, but this was not followed, resulting in prolonged exposure to urine and compromised skin condition for the resident.
Failure to Properly Prime Insulin Pens Results in Medication Errors
Penalty
Summary
A medication error rate of 6.7% was identified during observation of medication administration, record review, and staff interviews. Two residents with diabetes, both cognitively intact and receiving daily insulin injections, were affected. For one resident, an LPN prepared and administered insulin using a pen-injector but failed to prime the pen before administration, contrary to manufacturer instructions. The LPN confirmed she did not prime the pen and stated she believed it was unnecessary. For another resident, a different LPN primed the insulin pen-injector before attaching the needle, then administered the insulin without priming after the needle was attached. The LPN confirmed this sequence and acknowledged not priming the pen after the needle was in place. Manufacturer instructions reviewed by surveyors specified that priming should occur after the needle is attached and before each injection to ensure the correct dose is delivered. These failures to follow proper insulin pen priming procedures resulted in medication administration errors.
Failure to Prevent Significant Medication Errors for Two Residents
Penalty
Summary
The facility failed to ensure that two residents were free from significant medication errors, as evidenced by missed and improperly administered medications. One resident with a history of Crohn's disease, chronic pain, and other related conditions was prescribed Gattex for short bowel syndrome. Despite physician orders and care plan interventions to provide medications as ordered, the resident received the medication inconsistently over several months. Documentation on the Medication Administration Record (MAR) indicated that the medication was often marked as unavailable or not given, with progress notes confirming that Gattex was either on order or not accessible to nursing staff. Interviews revealed that the medication was present in the facility but locked in a provider office, leading to miscommunication and failure to administer the drug as prescribed. Another resident, admitted with diagnoses including altered mental status and infection due to a central venous catheter, was prescribed amoxicillin-potassium clavulanate for a bacterial infection. The resident did not receive all ordered doses of the antibiotic, with the MAR and pharmacy records confirming that several doses were missed due to delays in pharmacy delivery and issues with medication removal from the facility's medication dispensary. Staff and pharmacy interviews corroborated that only a portion of the prescribed antibiotics were administered, and the resident ultimately received fewer doses than ordered. The facility's medication administration policy required medications to be administered within a specific time frame and properly documented. However, in both cases, the facility failed to follow these procedures, resulting in significant medication errors for two residents. These findings were confirmed through record reviews, staff interviews, and pharmacy documentation.
Failure to Administer Pain Medication Timely
Penalty
Summary
The facility failed to administer pain-relieving medications as ordered for a resident with chronic pain conditions, including Crohn's disease and intervertebral disc degeneration. The resident, who had intact cognition, was supposed to receive hydromorphone every four hours as needed for pain. On the day in question, the Assistant Director of Nursing (ADON) was working the floor due to a staff call-off and was unfamiliar with the medication administration on that unit. The ADON did not administer the pain medication in a timely manner, causing the resident to wait at least an hour for relief, despite the resident's request and visible distress. The incident was investigated after concerns were raised by staff, residents, and family members about the delay in medication administration. The Unit Manager took over the medication administration from the ADON and provided the resident with the overdue hydromorphone. The facility's policy on pain management and assessment requires staff to ensure residents receive treatment and care in accordance with professional standards, which was not adhered to in this case. This deficiency was investigated under a specific complaint number, indicating non-compliance with the facility's pain management protocols.
Deficient Discharge Planning for Two Residents
Penalty
Summary
The facility failed to ensure effective discharge planning for two residents, leading to deficiencies in their care transitions. Resident #125, who had intact cognition and required supervision for activities of daily living, was discharged to an assisted living facility without documented changes to the discharge plan or updates to the care plan. The social worker confirmed that no updates were made to the medical record regarding the discharge planning process, indicating a lack of proper documentation and planning. Resident #126, who also had intact cognition but required moderate to maximum assistance for activities of daily living, expressed a desire to move to South Carolina to be closer to family. Despite this, the discharge care plan was not updated to reflect this change, and there was no documentation of the discharge planning process in the medical record. The resident was discharged with arrangements made for a flight and transportation, but the discharge summary lacked details about the hospital or potential facilities for placement in South Carolina. Interviews with facility staff and external parties involved in the discharge process revealed that the facility did not adequately document or update the discharge plans for these residents. The facility's policy required regular re-evaluation and updates to the discharge plan, which were not followed in these cases. This deficiency was investigated under a specific complaint number, highlighting the facility's non-compliance with discharge planning requirements.
Failure to Follow Mechanical Lift Protocol
Penalty
Summary
The facility failed to ensure that all staff followed the mechanical lift protocol, which resulted in an incident involving Resident #135. The resident, who had diagnoses including diabetes, chronic kidney disease, morbid obesity, spinal stenosis, and osteoarthritis, was dependent on mechanical lift transfers. During a transfer, the Hoyer lift scale detached, causing the resident to drop into her wheelchair, and the scale hit her forehead. Although the resident did not fall, she sustained a cut on her forehead. The incident was reported by the Unit Manager LPN #309, who noted that the transfer was conducted by STNA #312 without the required assistance of a second staff member. Interviews and observations revealed that the mechanical lift malfunction occurred when the weight scale got caught, causing the Hoyer bar to drop suddenly. Maintenance Assistant #311 confirmed that the mechanical lifts were checked monthly, and the issue was reported on the day of the incident. The facility's policy required two employees to assist with mechanical lift transfers, but this protocol was not followed by STNA #312, who received a final written warning for her actions. The incident was self-reported, and a full investigation was conducted.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care for several residents, as observed during a survey. Resident #102, who has Alzheimer's disease and dementia, was found in a wheelchair with wet pants and a puddle of urine on the seat. The assigned STNA was unaware of the resident's need for incontinence care and could not confirm when the resident was last checked or changed. This indicates a lack of communication and accountability among staff regarding resident care assignments. Resident #115, with intellectual disabilities and muscle weakness, was reported by a roommate to have not been changed all night. Upon observation, the resident was found saturated with urine and stool, which had soaked through the incontinence brief and bed sheets onto the mattress. The STNAs responsible for the resident's care were unsure when the resident was last attended to, highlighting a failure in maintaining regular incontinence care schedules. Resident #117, who has cognitive deficits and a tracheostomy, was also found with a large amount of urine that had soaked through the bed sheets to the mattress. The STNA on duty had not provided care since the start of her shift and was unable to state when the resident was last checked. Similarly, Resident #120, with morbid obesity, was found with urine and stool soaked through her incontinence brief and sheets. The STNA responsible did not know when the resident was last changed, indicating a systemic issue in providing timely incontinence care across the facility.
Failure to Honor Resident Rights and Dignity
Penalty
Summary
The facility failed to honor the rights of residents to be treated with respect and dignity, as well as their right to self-determination and communication. This deficiency was highlighted by an incident involving a resident who required assistance with activities of daily living and was dependent on staff for transfers. The resident, who had intact cognition, requested assistance to be transferred back to bed in the evening but was not helped. After several hours without assistance, the resident contacted her son, who then called the police. Upon the police's arrival, the resident was finally assisted back into bed. Interviews with staff and other residents revealed a pattern of complaints about staff being rude and unresponsive to resident needs. The incident was further corroborated by a police report, which indicated that the resident had been left in her wheelchair for an extended period and had soiled herself twice. The facility's policy on resident rights, which includes the right to be treated with respect and to decide when to go to bed, was not adhered to in this case. The facility's administration acknowledged the incident and obtained a copy of the police report, confirming the resident's account of events. This deficiency was investigated under a specific complaint number, indicating a formal recognition of the issue by regulatory authorities.
Failure to Maintain Clean and Sanitary Environment
Penalty
Summary
The facility failed to maintain a clean and sanitary environment, affecting two residents. During an observation, two soiled incontinence briefs were found on a resident's wheelchair, with gnats flying around them. An STNA revealed that she had picked up the briefs from the floor and placed them on the wheelchair. In another instance, a large pile of dirty linens was observed on the floor of a resident's room, emitting a foul odor. The resident confirmed that the linens had been there since the previous night after his bed was changed. This was corroborated by an STNA who acknowledged the situation and indicated she would dispose of the linens.
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Surveyors found that multiple hazardous storage areas, including a closet near medical records, a beauty salon used to store chemical cases, a supply room in one nursing station, a room leading to a smoking area, a housekeeping room near therapy, and a lobby storage room, lacked required self-closing or automatic-closing doors. These conditions did not comply with NFPA 101 requirements for hazardous area enclosure and had the potential to affect all residents and staff in an emergency.
Surveyors found that the facility did not conduct fire drills on every shift each quarter and did not vary drill conditions as required by NFPA 101. Record review showed that one shift lacked a documented drill for an entire quarter, and the pattern of drill times and dates did not demonstrate varied conditions. The Maintenance Director confirmed the incomplete and noncompliant fire drill schedule, which affected all residents and staff emergency preparedness.
Surveyors found that the facility did not maintain clear egress corridors as required by NFPA 101, with a TV/video cart plugged into a corridor outlet and multiple unsecured chairs placed in the hallway near resident rooms and the secured unit dining room, including directly in front of a fire extinguisher. These items projected about 29 inches into an approximately eight-foot-wide corridor and were located in front of the handrail, potentially affecting 28 residents and staff’s ability to assist in an emergency. The Maintenance Director confirmed these corridor obstructions during the survey.
A resident with intact cognition receiving Medicare Part A skilled services for metabolic encephalopathy had services discontinued while benefit days remained, but the facility did not issue the required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN). The Social Services Director later confirmed that no SNF ABN was provided and reported she believed only a Notice of Medicare Non-Coverage (NOMNC) was needed when all skilled services were stopped. This practice conflicted with the facility’s written policy, which required SNF ABNs to be issued when extended care items or services were initiated, reduced, or terminated due to expected non-coverage by Medicare.
Surveyors identified that the facility exceeded the acceptable medication error rate when two residents with type 2 DM received insulin doses that were not administered according to orders or manufacturer instructions. In two separate observations, an LPN administered Novolog and another LPN administered insulin glargine and insulin lispro without priming the insulin pens, and the insulin lispro and Novolog were given after the residents had already consumed a significant portion of their breakfast meals, despite orders for administration before meals. Manufacturer information for both insulin products required priming before each injection to ensure accurate dosing, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and specified time frames.
The facility failed to maintain accurate and complete crash cart audits for multiple full-code residents. Surveyors, accompanied by the DON, found that daily crash cart checks did not include verification of supply expiration dates, and that an extension cord documented as present on several audit dates was not actually in the cart. Audit logs also conflicted with the cart’s contents by indicating that required items such as eye protection, saline, and clear plastic were present when they were not. These findings were inconsistent with the facility’s policy requiring the crash cart to be checked every 24 hours and after each use, with prompt replacement of equipment and supplies.
A resident with chronic respiratory failure on supplemental O2, COPD, and cognitive risk factors was repeatedly documented as non-compliant with the smoking policy, including going out to smoke outside designated times and retaining cigarettes and lighters provided by family. Despite prior assessments identifying this resident as unsafe to smoke without supervision, a later assessment classified the resident as safe to smoke independently without documented rationale or care plan update. The resident subsequently went outside alone with an O2 nasal cannula in place, lit a cigarette, and sustained facial burns when the cannula ignited, as observed by staff and confirmed by EMS and ED records. In a separate case, another cognitively impaired resident with a history of falls had a care-planned intervention for non-skid strips in front of a recliner, but observation and staff confirmation showed the strips were not present, despite remaining on the active fall-risk care plan.
Multiple dependent residents did not receive scheduled showers, bed baths, or shaving as outlined in their care plans and the facility’s routine care policy. One resident recovering from spinal surgery missed numerous scheduled showers over several months. Another resident who relied on staff for self-care repeatedly requested shaving but was not shaved, and visible facial hair was observed after a recent shower. A resident with chronic respiratory failure and a tracheostomy, requiring substantial/maximal assist with personal hygiene, had no documented showers for an extended period and was observed with long facial hair, which staff acknowledged should be removed during bathing or as needed. A cognitively impaired resident with ESRD and CHF, scheduled for twice-weekly showers, had multiple undocumented or missed showers and reported not getting showers despite asking aides who said they lacked time. Another cognitively intact resident with hemiplegia and multiple comorbidities, also scheduled for twice-weekly showers, had several dates where documentation showed no shower/bath/bed bath provided or no entry at all, and she reported feeling unclean and unimportant when her showers were missed.
A resident with an indwelling urinary catheter for urinary retention, and care plan interventions requiring the drainage bag to be properly secured with a dignity cover, was observed seated in a chair with the catheter drainage bag uncovered and containing visible dark yellow urine that could be seen from the hallway. Later, an LPN confirmed the catheter bag was lying directly on the floor without a dignity cover. This situation occurred despite facility policy requiring care to be provided in a manner that respects and enhances each resident’s dignity and personal privacy.
A cognitively intact resident with chronic orthopedic pain had a PRN oxycodone order, but multiple doses were signed out on the narcotic log by an RN without corresponding entries on the MAR or documented pain assessments. A CNA/med tech reported frequent problems with this RN’s narcotic counts and documentation, describing erratic behavior when handling narcotic keys. The resident reported taking oxycodone only once or twice daily and otherwise using Tylenol, which conflicted with the number of oxycodone doses signed out. The facility’s investigation found it was inconclusive whether narcotics were misappropriated or whether there was a failure of documentation, but confirmed there was no evidence that all signed-out doses were administered.
Failure to Maintain Self-Closing Doors for Multiple Hazardous Storage Areas
Penalty
Summary
Surveyors identified a deficiency related to hazardous area protection and door requirements under NFPA 101, 2012 Edition. During facility tours, they observed that multiple hazardous storage areas did not have self-closing or automatic-closing doors as required for hazardous areas such as combustible storage and chemical storage. These areas included a closet next to medical records, a beauty salon being used to store cases of chemicals, a supply room in Station #2, and the room leading to the smoking area in Station #3. On a subsequent tour, surveyors observed additional hazardous areas without self-closing doors. The housekeeping room across from therapy and the lobby storage room were both noted to lack self-closing door mechanisms. The facility census at the time was 59 residents, and the surveyors stated that this deficient practice had the potential to affect all residents and staff's ability to assist in an emergency. The Maintenance Director verified these findings at the time they were observed.
Plan Of Correction
K 0321 This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be admissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as its allegation of substantial compliance as of 06/12/2026 K-0321 Doors with Self-Closing Devices Corrective action for resident/s: 1. The closet door next to medical records was lacking a self-closing door on 5/19/2026. Maintenance director to add self-closing device to closet door next to medical records on or before 06/12/2026 in accordance with applicable code. 2. The beauty salon had chemicals stored in it on 5/19/2026. Maintenance director moved chemicals from beauty salon on 05/20/2026 in accordance with applicable code. 3. The supply room on station 2 was lacking a self-closing door on 5/19/2026. Maintenance director to add self-closing door to supply room on station 2 on or before 06/12/2026 in accordance with applicable code. 4. The room to the smoking area on station 3 was lacking a self-closing door on 5/19/2026. Maintenance director to add a self-closing door to the smoking are on station 3 on or before 06/12/2026 in accordance with applicable code. 4. The housekeeping room across from therapy was lacking a self-closing door on 5/19/2026. Maintenance director to add a self-closing door to the housekeeping room across from therapy gym on or before 06/12/2026 in accordance with applicable code. 5. The lobby storage room was lacking a self-closing door on 5/19/2026. Maintenance director to add a self-closing door to the lobby storage room on or before 06/12/2026 in accordance with applicable code. Identification of other residents who may be affected: LNHA and Maintenance director/designee completed a full facility audit for doors with self-closing devices on 05/26/2026. Any corrective action, including, doors identified as needing self-closures will be added on or before 06/09/2026 in accordance with applicable code. Measures for systemic change: LNHA educated Maintenance Director on 05/26/2026 regarding NFPA 101-2012 sections 19.3.2.1 and 19.3.5.9 specifically regarding doors with self-closing devices. How Corrective Action will be monitored Ongoing "Doors with Self-Closing device audit" to be completed weekly x 2 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 06/12/2026
Failure to Conduct Required Quarterly Fire Drills on All Shifts
Penalty
Summary
The facility failed to conduct fire drills in accordance with NFPA 101, 2012 Edition, sections 19.7.1 through 19.7.1.8, specifically by not holding drills every shift each quarter and not varying drill conditions as required. Record review on 06/09/25 at approximately 10:32 A.M. showed there was no fire drill conducted for the first shift during the third quarter. The documented first-shift fire drills occurred on 01/30/26 at 2:42 P.M., 04/30/26 at 1:51 P.M., and 10/31/25 at 10:58 A.M., indicating a missed quarter. Second-shift fire drills were recorded on 02/26/26 at 5:20 P.M., 06/03/25 at 4:35 P.M., 08/29/25 at 3:46 P.M., and 11/25/25 at 5:09 P.M., and third-shift drills on 02/28/26 at 11:47 P.M., 05/30/25 at 12:18 A.M., 07/22/25 at 11:34 P.M., 09/26/25 at 11:40 P.M., and 12/15/25 at 5:17 A.M. The surveyor determined that drills were not conducted under varied conditions and that the required quarterly drill on each shift was not consistently performed. The Maintenance Director confirmed these findings at the time they were identified, and the deficiency had the potential to affect all 59 residents and staff response in an emergency. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency related to facility-wide emergency preparedness practices and documentation of fire drills.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 05/29/2026 K-0712 Fire Drills Corrective action for resident/s: There were no records of a fire drill for the first shift of the third quarter of 2025. First shift fire drill completed on 5/24/2026 by maintenance director/designee with no findings or corrective action necessary. Identification of other residents who may be affected: On 5/26/2026 Maintenance director/designee completed 100% audit of the scheduled fire drills to ensure a drill is scheduled quarterly each shift with no findings or corrective action necessary. Measures for systemic change: LNHA educated Maintenance Director on 05/26/2026 regarding NFPA 101-2012 section 19.7.1.4 through 19.7.1.7. specifically including fire drill frequency requirements. How Corrective Action will be monitored Ongoing "Fire Drill Audit" to be completed weekly x 2 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 05/29/2026
Obstructed Egress Corridors Due to Equipment and Chairs
Penalty
Summary
The facility failed to maintain required clear egress widths in corridors in accordance with NFPA 101, 2012 Edition, sections 19.2.3.4 through 19.2.3.5 and 7.3.2 through 7.3.2.3, creating projections into the egress corridor that exceeded allowable limits. Surveyors observed that on one day in Station #3, a cart with a television and video equipment was plugged into an outlet in the corridor by room 38, and five activity room chairs were placed in the corridor near the secured unit dining room directly in front of a fire extinguisher. On the following day, surveyors again observed chairs in the Station #3 corridor, with four by room 35 and four by the activities room, and the same television cart still in the corridor; the chairs were not secured. The corridor was approximately eight feet wide, and the projections extended approximately 29 inches into the corridor in front of the handrail. These conditions had the potential to affect 28 residents in the facility and the staff’s ability to assist in an emergency, and the Maintenance Director confirmed the observations at the time of discovery. No specific resident medical histories or conditions were described in the report, only that 28 residents were potentially affected and the facility census was 59.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be subsequent remedial measures and should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 05/29/2026 K-0232 Clear path of egress Corrective action for resident/s: 1. On 05/18/2026 station 3 had a cart with a television parked in the corridor by room 38 that exceeded allowable limits. Maintenance director/designee moved the TV cart into the activity room, out to the corridor on 05/18/2026 in accordance with applicable code. 2. On 5/18/2026 station 3 had 5 chairs in the corridor near the dining room directly in front of the fire extinguisher. Maintenance director/designee moved the chairs into the dining room, out of the corridor on 5/18/2026 in accordance with applicable code. 3. On 5/19/2026 station 3 had 4 chairs by the activity room and 4 by room 35. In addition, the TV cart was in the corridor. The maintenance director/designee moved the chairs and TV cart into the dining room, out of the corridor on 5/19/2026 in accordance with applicable code. Identification of other residents who may be affected: Maintenance director/designee completed a 100% facility audit for clear paths of egress on 5/26/26 with no findings or corrective action necessary. Measures for systemic change: Maintenance Director/designee educated staff on 5/26/2026 regarding NFPA 101-2012 section 19.2.3.4 and 19.2.3.5 specifically including maintaining a clear path of egress. How Corrective Action will be monitored Ongoing "Path of Egress Audit" to be completed weekly x 2 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 05/29/2026
Failure to Issue Required SNF ABN When Discontinuing Medicare Part A Services
Penalty
Summary
The deficiency involves the facility’s failure to issue a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) when Medicare Part A services were discontinued for a resident who still had available benefit days. The resident was admitted with a diagnosis of metabolic encephalopathy and had intact cognition per the Minimum Data Set assessment. The facility’s own SNF Beneficiary Notification Review documented that Medicare Part A skilled services began on 02/11/26 and the last covered day was 03/11/26, and that the facility initiated discharge from Medicare Part A services before the resident’s benefit days were exhausted. Despite this, no SNF ABN was provided to the resident or the resident’s representative. During interviews, the Social Services Director stated that the SNF ABN was issued hours prior to the last covered day but, upon reviewing her files, confirmed that no SNF ABN had actually been issued for this resident. She further explained that she believed an SNF ABN was only required if one skilled service remained and that if all skilled services were being discontinued, only the Notice of Medicare Non-Coverage (NOMNC) needed to be issued. The Administrator, however, stated that a resident should always receive both a SNF ABN and a NOMNC when Medicare Part A services are discontinued and benefit days remain. Review of the facility’s written policy dated 03/28/23 showed that the facility was required to issue SNF ABNs for initiation, reduction, or termination of extended care items or services when Medicare payment was not expected, which did not occur in this case.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as its allegation of substantial compliance as of 05/29/2026 F-0582 Corrective action for resident/s: On 5/14/26 Resident #34 was informed of rights and responsibilities related to Advanced Beneficiary Notice and voiced understanding of information for future reference by administrator. Identification of other residents who may be affected: Any resident receiving skilled services from nursing or therapy services. The Administrator audited all residents who were discharged from skilled services in the past 30 days to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary Notice on 5/29/26. No non-compliance was noted. Measures for systemic change: On 5/14/2026 Business Office Manager, Director of Rehab, Minimum Data Set nurse, Director of Nursing and Social Services Director were educated on proper procedure of issuing of Notice Of Medicare Non Coverage and Advanced Beneficiary Notice by administrator. All upcoming discharges from skilled services will be reviewed weekly at Utilization Review meeting to ensure notices will be delivered timely. How Corrective Action will be monitored: Administrator or designee to complete audits of all residents being discharged from skilled services to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 5/29/26
Insulin Administration Errors and Failure to Prime Insulin Pens
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5%, with surveyors identifying 3 errors out of 28 medication administration opportunities, resulting in a 10.71% error rate. For one resident with type 2 diabetes mellitus and moderate cognitive impairment, the physician’s order directed Novolog insulin 10 units via subcutaneous pen-injector to be given before meals. During an observed medication pass, the LPN administered 10 units of Novolog insulin without priming the pen and did so after the resident had already consumed approximately 50% of the breakfast meal. The LPN later confirmed she did not prime the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer instructions for the Novolog FlexPen specified that an air shot (priming) must be performed before each injection to ensure proper dosing. Another resident, also diagnosed with type 2 diabetes mellitus and with intact cognition, had orders for insulin glargine 35 units subcutaneously twice daily and insulin lispro 20 units subcutaneously before meals, plus 12 units subcutaneously if blood glucose was between 251 mg/dL and 300 mg/dL. During an observed medication administration, an LPN administered 35 units of insulin glargine and 32 units of insulin lispro without priming the insulin pens and after the resident had consumed approximately 90% of the breakfast meal, despite orders for insulin lispro to be given before meals. The LPN later stated she could not remember if she had primed the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer information for insulin lispro stated that the pen must be primed before each injection to confirm insulin delivery and remove air, and that failure to prime could result in too much or too little insulin. The DON confirmed the expectation that insulin be administered as ordered, including priming each pen with two units before dialing the prescribed dose, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and required time frames.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 5/29/2026. F-0759 Corrective action for resident/s: Residents #21 and #22 were assessed and evaluated by nurse and Director of Nursing 5/14/26. Resident #21 and #22 both denied any adverse effects and none were noted upon assessment by the Director of Nursing on 5/14/2026. Notification made to physician on 5/14/2026. LPN # 2 competency Eval on insulin administration with the Director of Nursing completed 5/14/2026. Identification of other residents who may be affected: Diabetic residents on assignment of LPN #2/station 2 have the potential to be affected and were assessed by the DON/Designee on 5/14/26 and found to be within normal limits. Measures for systemic change: All Nurses were educated by the Director of Nursing on the steps for Insulin administration per competency, diabetes clinical protocol policy, Medication and treatment orders policy, administering medications policy, and Obtaining fingerstick Glucose Level policy On 5/14/2026. How Corrective Action will be monitored: Director of Nursing and Assistant Director of Nursing will complete insulin administration audits on 5 nurses. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance: 5/29/2026
Inaccurate Crash Cart Audits and Missing Emergency Equipment
Penalty
Summary
The facility failed to ensure accurate and complete crash cart audits for residents requiring basic life support, affecting eighteen of thirty-five residents who were designated as full code. During an observation of the crash cart with the DON, surveyors found that the daily audit documentation for the month did not include verification of expiration dates for crash cart supplies. Review of the crash cart audit logs showed that an extension cord was documented as being in the cart on multiple dates, but the extension cord was not present in the cart at the time of inspection. Additionally, the audit documentation indicated that required items, including eye protection, saline, and clear plastic, were not present in the crash cart, yet they were documented as being in the cart. The facility’s undated “Emergency Crash Cart” policy stated that the crash cart is to be checked every 24 hours and after every use, and that equipment and supplies are to be noted and replaced promptly, but the observed documentation and contents of the cart did not match these requirements. This deficiency was verified with the DON at the time of the survey and was cited under the requirement that personnel provide basic life support, including CPR, to residents requiring emergency care, subject to physician orders and advance directives, and was investigated under Complaint Number 2687380.
Plan Of Correction
Cridersville Care Center Provider Number:366171 Survey Type: Complaint Survey Survey Date: 04/29/26 This Plan of Correction (PoC) outlines the actions completed by the facility with regards to the deficiency citation. This Plan of correction does not constitute any admission of guilt or liability by the facility and is submitted only in response to the regulatory requirements. Please accept the following as the facility's credible allegation of compliance as of 4/30/26. F678 CPR All Full Code residents #18 have the potential to be affected by the alleged deficiency. On 4/27/26 the DON/ADON re-stocked the crash cart per the inventory sheet for all missing items. Crash cart inventory sheet updated and new one will go into effect on 5/1/26. All licensed nursing staff provided with training related to crash cart inventory being a daily audit review using inventory sheet on 4/27/26 per DON/designee. The DON/designee will conduct clinical rounds and conduct a random audit of crash cart three times per week for 4 (four) weeks to ensure compliance. The results of the audit will be documented. The facility conducted an Ad-Hoc QAPI meeting on 4/27/26 and discussed the alleged deficiency and corrective actions. Date when corrective action will be completed: 4/30/26
Unsafe Smoking Practices with Oxygen and Missed Fall-Prevention Interventions
Penalty
Summary
The deficiency involves the facility’s failure to provide a safe smoking environment, adequate supervision, and appropriate implementation of its smoking policy for a resident who used oxygen and smoked, as well as failure to implement fall-prevention interventions as care planned for another resident. One resident had multiple relevant diagnoses, including chronic respiratory failure with hypoxia, COPD, end-stage renal disease, dependence on supplemental oxygen, diabetes, and necrotizing fasciitis. Her care plans identified impaired visual function, risk for respiratory complications related to a history of smoking, and risk for cognitive decline, with interventions including use of oxygen per order and observation for understanding. A smoking-related care plan created earlier documented that she wished to use smoking products, had been assessed as safe to smoke "with supervision," and was non-compliant with the smoking policy, with family continuing to provide smoking supplies despite education and a verbal warning for non-compliance. Smoking assessments and progress notes showed a pattern of non-compliance and inconsistent classification of this resident’s smoking safety. Multiple smoking observation/assessments completed earlier in March documented that she had no cognitive loss, visual deficits, or dexterity problems but was unsafe to smoke without supervision because she did not return smoking materials and did not follow designated smoke times. Progress notes described her going out to smoke multiple times by herself or with family, including sneaking out next door with a cigarette and going out multiple times in one evening, with staff documenting that she was "reeducated" and that family brought in cigarettes and lighters which she did not return to staff. Despite this history, a smoking assessment completed after a three-day hospital stay assessed her as safe to smoke without supervision, with no documentation explaining how this conclusion was reached or evidence that her care plan was updated accordingly. On the day of the incident, the resident reported she had cigarettes and a lighter on her person after returning from dialysis and stated she "could not find a nurse" and went outside to smoke, saying she "guessed" she forgot she had her oxygen on. A CNA observed her outside and saw a flame coming through the resident’s oxygen nasal cannula tubing, turned off the oxygen tank, removed the tubing, and patted out sparks on the resident’s shirt sleeve. The resident’s face and hands appeared black in color, and EMS documented first-degree burns to the head and face, with the resident stating she lit a cigarette with her nasal cannula on, causing the burn. The hospital record described her face as black from smoke and her lips and mouth as "burnt and charred," with a recommendation for intubation that she refused. The facility’s incident report recorded that she went outside with oxygen on to smoke without notifying staff, that staff witnessed the occurrence as she walked through the dining room door to the courtyard, and that she stated she thought she had turned her oxygen off. The facility’s smoking policy required interdisciplinary evaluation to determine safe versus unsafe smokers, staff maintenance of all smoking paraphernalia for both safe and unsafe smokers, and progressive consequences for policy violations. A separate deficiency involved another resident at risk for falls whose care plan included use of non-skid strips on the floor in front of her recliner as a fall-prevention intervention. This resident had severe cognitive impairment, used a walker and wheelchair, required supervision or touching assistance for transfers and ambulation, and had experienced two or more falls without injury since the prior assessment. The fall-risk care plan, initiated at admission, specified non-skid strips in front of the recliner beginning in November. However, nursing staff interviewed were not familiar with all of the resident’s fall-prevention interventions without checking the record, and observation of the room showed two recliners with no non-skid strips on the floor in front of them. An LPN confirmed that the non-skid strips were not present despite the intervention remaining active in the care plan, and moving the recliners did not reveal any strips. The facility’s fall management policy required identification of hazards and risk factors, implementation of interventions to minimize falls and injuries, and development and implementation of a care plan based on interdisciplinary evaluation, with interventions related to identified risk factors.
Plan Of Correction
Smoking: On 03/21/26 at 3:16 P.M. 911 response was activated for Resident #11 and Medical Director #601 was notified by Registered Nurse (RN) #322. On 03/21/26 at 3:18 P.M. on-call Nurse/Social Services #423 immediately notified the Administrator and Director of Nursing (DON) #304 of the incident involving Resident #11. On 03/21/26 at 3:22 P.M. Emergency Medical Services (EMS) arrived onsite. At 3:30 P.M. Resident #11 was transported to the emergency room. On 03/21/26 at 3:30 P.M. RN #322 completed a smoking re-assessment of Resident #11 assessing the resident to be an unsafe smoker requiring supervision due to failure to remove oxygen prior to entering designated smoking area. On 03/21/26 from 3:38 P.M. through 7:57 P.M. Licensed Practical Nurse (LPN) #337, #336, #335, #338; RN #334, and DON #304 re-assessed residents (who smoke). This included Resident #22, Resident #3, Resident #47, Resident #50, Resident #60, Resident #150, Resident #86, and Resident #10 to determine smoking safety (via smoking assessment). Each resident was re-educated regarding the facility smoking policy and staff verified there were no smoking materials on their person. The residents' smoking materials would be maintained by facility staff and distributed per policy. On 03/21/26 at 4:30 P.M. DON #304 responded to facility and an Ad Hoc (not scheduled) Quality Assurance (QA) meeting was held via telephone with the Administrator, DON #304 and Medical Director #601 to review investigative findings and plan of action. A root cause analysis was completed and determined Resident #11 had smoking materials on her person (believed to be obtained from family without staff knowledge) and failed to remove her oxygen. The QA team discussed a corrective action plan. On 03/21/26 from 5:00 P.M through 03/22/26 at 3:00 P.M. 26 RNs, 13 LPNs, one medical technician (MT), 54 Certified Nursing Assistants (CNA) four activities staff, one central supply staff, 11 dietary staff, 12 housekeeping staff, three laundry staff, one medical records staff, two social designees, two maintenance staff, nine administrative staff, and 19 therapy staff (158 staff at the time of the incident) were provided education regarding the facility smoking policy by DON #304 and the Administrator. This was completed via 1:1, small group in-services or via phone. Newly hired staff would receive education during general orientation regarding the facility's smoking policy. On 03/21/26 at 5:00 P.M. DON #304 completed an audit of all residents who smoke (Resident #22, Resident #3, Resident #47, Resident #50, Resident #60, Resident #150, Resident #86, and Resident #10) to verify smoking evaluations and plans of care accurately reflected the residents' smoking safety needs. The residents were educated on the facility smoking policy, and smoking materials were to be maintained at the nurses' station. An audit was completed which included verification of required safety measures present in designated smoking areas, including an ash can, fire extinguisher, fire blanket, ash trays and no oxygen signs. There were no identified concerns or changes made because of the audits. On 03/21/26 at 8:55 P.M. Resident #11 returned from the ED. LPN #332 verbally educated the resident regarding the facility smoking policy which included the need for supervision, a smoking apron (to be worn) and the facility smoke times. LPN #332 verified no smoking materials were on the resident's person or in her room at this time. On 03/23/26 at 11:00 A.M. the Interdisciplinary Team (IDT) (Administrator, DON #304, Medical Director #601, RN #302, Social Services #427, Social Services #423, DON #300, and Maintenance #436) met in-person to review the plan of action with DON #304/designee to complete weekly monitoring of residents who smoke and designated smoking areas weekly for four weeks with Housekeeping responsible to complete the cleaning. Housekeeping staff were responsible for cleaning ashtrays and the designated smoking area daily. Audits to be reviewed and any further actions required to be directed by the Quality Assurance and Performance Improvement (QAPI) Committee during scheduled meetings. The IDT also reviewed all current smoking assessments and care plans for residents who smoke. Resident #50 required a change in supervision levels with smoking due to cognition levels and her plan of care as well as Resident #11's plan of care was updated to reflect supervision/safety. On 03/23/26 from 3:45 P.M. to 8:55 P.M. Social Services #423 re-educated residents who smoke (Resident #22, Resident #3, Resident #47, Resident #50, Resident #60, Resident #150, Resident #86, Resident #10) and responsible parties, if applicable regarding the facility smoking policy and supervision levels. On 03/23/26 at12:13 P.M. Social Services #427 contacted Resident #11's family member (#602) to schedule a care conference. Family member #602 and Family Member #603 were not available to meet until 03/27/26. On 03/23/26 at 1:00 P.M. staff education related to smoking areas, removal of oxygen prior to entering smoking area and maintaining smoking materials at the nurses' station for residents who smoke was initiated by DON #304 and the Administrator via 1:1, small group in-services or via phone call. Education was completed for all 158 staff by 03/24/26 at 1:00 P.M. Newly hired staff would be educated during general orientation regarding the facility's smoking policy. The facility does not utilize agency staff. On 03/27/26 at 11:00 A.M. a care conference was held with Resident #11 and Family Members #602 and #603, the Administrator, Social Services #423 and Social Services #427. The facility smoking policy was reviewed. The resident and family were informed an involuntary discharge would be initiated should the resident exhibit non-compliance moving forward and supervision would be increased beyond the two-hour standard of care to monitor more closely for non-compliance with the facility smoking policy. Family Member #602 stated he educated his siblings as well. On 04/10/26 at 2:00 P.M. DON #304 initiated education with 26 RNs and 13 LPNs (100% of nurses educated) regarding completion of the smoking evaluation via 1:1, small group in-services, or phone. The education was completed by 6:00 P.M. on 04/10/26. A new resident who smokes must remain supervised until the interdisciplinary team (IDT) reviews and determines smoking safety, at which time the care plan is developed and resident and family education is provided. The communication through the staff would be the care plan. Newly hired staff receive education during general orientation regarding the facility's smoking policy and completion of smoking evaluation via Point Click Care (PCC). On 04/10/26 at 4:29 P.M. DON #304 initiated an order in PCC for the nurse to verify, each shift, that Resident #11's smoking materials were maintained at the nurses' station. On 04/13/26 at 5:30 P.M. DON #304 initiated orders in PCC for nurses to verify, each shift, that all residents who smoke would have smoking materials maintained at the nurses' station. An updated list of smokers included: Resident #60, Resident #50, Resident #11, Resident #86, Resident #113, and Resident #151. On 04/13/26 at 5:45 P.M. DON #304 initiated questionnaires for staff regarding the smoking policy with re-education provided as needed via 1:1 and small group in-services for staff currently in the facility with all staff to be questioned/educated prior to working their next scheduled shift. Falls: On 4/9/26, Maintenance Director placed non-skid strips on the floor in front of Resident #12's recliner. Like Residents are identified as residents who have had a fall within the facility. Utilizing the Fall Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, an audit of falls and appropriate interventions for the past 30 days will be completed by the Director of Nursing or designee to ensure fall interventions are in place per plan of care. This audit along with identified corrections will be completed on or F 0689 before 5/13/26. The Director of Nursing or designee will re-educate licensed nurses and STNA/CNAs on the Fall Management Policy to include fall interventions to be in place per the care plan. This education will be completed on or before 5/13/26. Utilizing the Fall Management Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, the Director of Nursing or designee will complete an audit of new admissions, new readmissions and residents who experience a fall within the last 7 days, weekly for four weeks, beginning 5/14/26 to ensure fall safety interventions are in place per plan of care. Current fall interventions found to not be in place will be corrected with all intervention in place per plan of care. Negative findings to be addressed immediately and negative trends or system wide issues will be reported to the QAPI committee, and the action plan will be adjusted as needed.
Removal Plan
- Activated 911 response for Resident #11 and notified the Medical Director.
- On-call Nurse/Social Services immediately notified the Administrator and DON of the incident.
- EMS arrived onsite and Resident #11 was transported to the emergency room.
- Completed a smoking re-assessment of Resident #11, determining the resident was an unsafe smoker requiring supervision due to failure to remove oxygen prior to entering the designated smoking area.
- Re-assessed all residents who smoke (Residents #22, #3, #47, #50, #60, #150, #86, and #10) to determine smoking safety via smoking assessment.
- Re-educated residents who smoke regarding the facility smoking policy and verified there were no smoking materials on their person.
- Implemented that smoking materials would be maintained by facility staff and distributed per policy.
- Held an ad hoc QA meeting to review investigative findings and plan of action.
- Completed a root cause analysis determining Resident #11 had smoking materials on her person and failed to remove oxygen.
- Developed a corrective action plan.
- Provided facility-wide education to staff on the facility smoking policy.
- Implemented that newly hired staff would receive smoking policy education during orientation.
- Completed an audit of all residents who smoke to verify smoking evaluations and plans of care accurately reflected smoking safety needs.
- Ensured smoking materials were maintained at the nurses’ station.
- Audited designated smoking areas for required safety measures (ash can, fire extinguisher, fire blanket, ash trays, and no-oxygen signs).
- Provided verbal education to Resident #11 on smoking policy (supervision, smoking apron, smoke times).
- Verified no smoking materials were on Resident #11’s person or in her room.
- Conducted an in-person IDT meeting to implement weekly monitoring of residents who smoke and designated smoking areas weekly for four weeks.
- Assigned housekeeping to clean ashtrays and the designated smoking area daily.
- Directed audits to be reviewed by QAPI.
- Reviewed all current smoking assessments and care plans for residents who smoke.
- Updated Resident #50’s supervision level.
- Updated Resident #11’s plan of care to reflect supervision/safety.
- Re-educated residents who smoke and responsible parties (as applicable) regarding the facility smoking policy and supervision levels.
- Contacted Resident #11’s family to schedule a care conference.
- Initiated additional staff education regarding smoking areas, removal of oxygen prior to entering smoking area, and maintaining smoking materials at the nurses’ station.
- Held a care conference with Resident #11 and family to review smoking policy.
- Informed resident/family that involuntary discharge would be initiated for future non-compliance.
- Increased supervision beyond the two-hour standard of care to monitor more closely for non-compliance.
- Provided education to all nurses regarding completion of the smoking evaluation.
- Implemented that new residents who smoke must remain supervised until IDT review determines smoking safety and care plan/education are completed.
- Entered an order in PCC for nursing to verify each shift that Resident #11’s smoking materials were maintained at the nurses’ station.
- Entered orders in PCC for nursing to verify each shift that all residents who smoke have smoking materials maintained at the nurses’ station.
- Initiated staff questionnaires regarding the smoking policy with re-education as needed.
- Required all staff to be questioned/educated prior to working their next scheduled shift.
Failure to Provide Scheduled Bathing and Shaving Assistance for Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide scheduled and needed bathing and shaving assistance to multiple dependent residents in accordance with their care plans, preferences, and the facility’s routine care policy. One resident with spinal stenosis and recent L2–L5 decompression fixation fusion was care planned for substantial/maximal assistance with shower/bath and toileting hygiene and was scheduled for showers on Tuesdays and Fridays. Electronic documentation from early January through early April showed this resident did not receive a shower or bed bath on 11 identified scheduled days, and the DON confirmed these missed bathing events. Another resident with dysphagia and developmental issues, who required assistance with self-care and mobility, reported that she asked staff to shave her but they did not, which bothered her. During an observation following a recent shower, she stated she had not been shaved and that the hair "itched"; small gray hairs were visible on her chin. A CNA confirmed the presence of gray chin hairs and acknowledged the resident needed shaving, stating it would be addressed with the next scheduled shower. A further resident with chronic respiratory failure, tracheostomy status, heart failure, moderate intellectual disabilities, anxiety, depression, and PTSD required substantial/maximal assistance with personal hygiene and had a care plan for assistance with self-care, including personal hygiene. Her shower schedule called for showers on Monday and Thursday nights, with complete shaves for men and women. Review of documentation showed her last recorded shower/bath was nearly a year earlier, with no indication of additional personal hygiene or facial hair removal on that date. Observations on two separate days showed long white hairs on her chin and jaw line, which a CNA later confirmed, stating facial hair removal should occur with baths/showers or as needed. A resident with end stage renal disease, respiratory failure, hyperlipidemia, and congestive heart failure, who had impaired cognition and required partial/moderate assistance with bathing and personal hygiene, was scheduled for showers on Wednesdays and Saturdays. Review of shower documentation from admission through early April revealed no showers provided or refusals documented on at least ten scheduled shower days. In interviews, this resident reported not receiving scheduled showers, was unsure of his shower days, and stated he could use a good scrub down, adding that he had asked aides who told him they did not have time. A CNA explained that shower days appear on shower sheets and in the computer and that CNAs are supposed to document daily, with nurses checking the documentation; the DON verified the resident had not received showers per schedule or preference. Another resident with a fracture of the lower end of the left humerus, hemiplegia and hemiparesis after cerebral infarction, rheumatoid arthritis, hypertensive heart disease, urinary retention, and osteoarthritis was care planned as non–weight bearing to the left upper extremity and requiring substantial/maximal assistance with showering/bathing. Her electronic record showed she was scheduled for showers on Wednesdays and Saturdays. The shower task question "did the resident receive a shower/bath/bed bath?" was documented as "no" on three dates, indicating no shower/bath/bed bath was completed, and left unanswered on three additional dates. The DON confirmed that one missed shower was due to an outside appointment, that on two dates the "no" response meant no bathing of any type occurred, and that on three dates there was no documentation at all. The resident, who was cognitively intact, reported that missing showers made her feel unimportant compared to others and that she did not feel clean when her shower was missed. Facility policy on routine resident care stated that showers, tub baths, and shampoos are to be scheduled according to person-centered care or state guidelines, with additional showers given upon request, but the documented and observed care did not reflect consistent provision of scheduled bathing and shaving for these residents.
Plan Of Correction
1. Resident #5 received a shower by the STNA on 4/13/26. Resident #8 received a shower by the STNA on 4/8/26. Resident #9 received a shower and had their chin shaved by the STNA on 4/14/26. Resident #70 received a shower by the STNA on 4/13/26. Resident #76 received a shower and had their chin shaved by the STNA on 4/15/26. 2. Like residents are identified as residents who need assistance with showering and shaving. Utilizing the Shower Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, an audit of like residents will be completed by the Director of Nursing or designee to ensure that showers and resident shaving are completed. This audit along with identified corrections will be completed on or before 5/13/26. 3. The Director of Nursing or designee will re-educate licensed nurses and STNA's on the Routine Resident Care Policy to include bathing and shaving residents. This education will be completed on or before 5/13/26. 4. Utilizing the Shower Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, the Director of Nursing or designee will complete an audit of 4-6 residents weekly for four weeks, beginning 5/14/26 to ensure that showers and resident shaving are completed. Noncompliance found during audits will be addressed and assistance with showers and/or shaving provided. Negative findings to be addressed immediately and negative trends or system wide issues will be reported to the QAPI committee, and the action plan will be adjusted as needed.
Uncovered Urinary Catheter Drainage Bag Compromises Resident Dignity
Penalty
Summary
The facility failed to maintain a resident’s right to privacy and dignity related to management of an indwelling urinary catheter. A resident admitted with malignant neoplasm of the esophagus and type II diabetes mellitus had a care plan identifying risk for urinary tract infection and catheter-related trauma due to an indwelling catheter for urinary retention. The care plan interventions included ensuring the catheter tubing was secured and the drainage bag was properly secured with a dignity cover in place. Physician orders directed that the resident’s 16 French indwelling urinary catheter be changed every 30 days and as needed, and the comprehensive MDS documented that the resident had an indwelling catheter and was cognitively intact. During observation, the resident was seen seated in a chair with the urinary catheter drainage bag hanging from the chair without a dignity cover, and dark yellow urine was visible in the bag from the hallway. In a later observation and interview, an LPN confirmed that the catheter bag was lying directly on the floor and did not have a dignity cover. Attempts to interview the resident to confirm cognitive status were unsuccessful, as the resident was unable to answer screening questions. Review of the facility’s “Resident Dignity & Personal Privacy” policy stated that the facility should provide care in a manner that respects and enhances each resident’s dignity, individuality, and right to personal property, which was not followed in this instance when the catheter drainage bag was left uncovered and visible.
Plan Of Correction
The Laurels of Athens wishes to have this plan of correction submitted as our written allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission to nor agreement with, either the existence of, or the scope and severity of, any of the cited deficiencies or conclusions set forth in the statement of deficiencies. This plan is prepared and/or executed to ensure continuing compliance with regulatory requirements. Our alleged date of compliance is 5/13/2026. 1. On 4/6/26, Resident #92's catheter bag was removed from the floor, the bag changed and covered for dignity by the licensed nurse. Resident #92 discharged from the facility on 4/11/26. 2. Like Residents are identified as residents who utilize urinary catheters. An audit will be completed by the Director of Nursing or designee for like residents utilizing the Urinary Catheter Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC to ensure catheter bags are covered for dignity and not laying directly on the floor. This audit along with identified corrections will be completed on or before 5/13/26. 3. The Director of Nursing or designee will re-educate licensed nurses on the Indwelling Urinary Catheter Policy as well as Resident Dignity & Personal Privacy Policy to include privacy covers are in place for urinary catheters and that the catheter is not laying on the floor. This education will be completed on or before 5/13/26. 4. Utilizing the Urinary Catheter Audit Tool which was created on 4/20/26 by the Director of Nursing for purpose of this POC, the Director of Nursing or designee will complete an audit of all residents with catheters weekly for four weeks, beginning 5/14/26 to ensure catheter bags are covered for dignity and not laying directly on the floor. Any catheters found to be touching the floor or uncovered will be removed from the floor, the bag changed and covered for dignity. Negative findings to be addressed immediately and negative trends or system wide issues will be reported to the QAPI committee, and the action plan will be adjusted as needed.
Failure to Prevent Possible Misappropriation and Poor Documentation of PRN Narcotics
Penalty
Summary
The deficiency involves failure to prevent potential misappropriation of a resident’s narcotic medication and failure to ensure accurate documentation of controlled substance administration. A cognitively intact resident with chronic pain related to an internal orthopedic device and left knee pain had an order for oxycodone 5 mg PO every four hours PRN for pain and a care plan directing staff to administer medications as ordered and observe for effectiveness and side effects. The resident’s MDS showed she rated her pain as 7/10 and received opioid medication. However, review of the February MAR and the narcotic log revealed multiple discrepancies between narcotic sign-outs and documented administration. On several occasions, oxycodone doses were signed out on the narcotic log by an RN without corresponding documentation on the MAR. Specifically, oxycodone was signed out on one evening at 9:30 p.m. with no MAR entry, and again on a subsequent night at 1:30 a.m. and 5:30 a.m. with no MAR entries for those times. Another dose was signed out at 9:00 p.m. while the MAR reflected administration at 10:16 p.m., and a later dose at 5:30 a.m. was documented on both the narcotic log and MAR. There was also no documentation of pain assessments before or after PRN opioid administration. These documentation gaps meant there was no evidence that all narcotic doses signed out were actually administered to the resident. Staff interviews further highlighted concerns about the handling of narcotics. A CNA/med tech reported frequently taking the narcotic keys from the RN and described the RN’s behavior as erratic, with repeated problems involving incorrect narcotic counts and missing documentation on both the MAR and narcotic log. The resident stated she did not receive oxycodone more than once or twice a day, preferring to take Tylenol the rest of the time, which conflicted with the number of oxycodone doses signed out. When questioned, the RN gave inconsistent explanations about how often she pulled and administered PRN narcotics and acknowledged struggling with the new system, while also suggesting the resident may have received PRN tizanidine instead of remembering oxycodone. The facility’s investigation concluded that evidence was inconclusive as to whether misappropriation occurred or whether the issue was solely lack of documentation, but confirmed there was no evidence the resident received all doses signed out on the narcotic log.
Plan Of Correction
1. Resident #99 had a Self-Reported Incident submitted and investigated via the EIDC on 3/2/26. The investigation was inconclusive as we could not prove that misappropriation occurred. On 2/24/26, Resident #99 was interviewed and pain assessed by Director of Nursing and resident had no ill effects related to the inconsistent documentation in the medical record as it relates to her controlled substance pain medication. 2. Like Residents are identified as residents who utilize controlled substance PRN pain medications. An audit will be completed by the Director of Nursing or designee for like residents utilizing the Controlled Substance Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC to ensure PRN controlled substance pain medications that are signed off the control sheet are documented in the resident medical record as well. This audit along with identified corrections will be completed on or before 5/13/26. 3. The Director of Nursing or designee will re-educate licensed nurses on the Controlled Substances Policy to include appropriate documentation of controlled substances. In addition, the licensed nurses will be re-educated by the Director of Nursing or designee on the Abuse Prohibition Policy to include misappropriation of resident property. This education will be completed on or before 5/13/26. 4. Utilizing the Controlled Substance Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, the Director of Nursing or designee will complete an audit three controlled substance sheets from each of the nine medication carts for a total of twenty-seven sheets weekly for four weeks, beginning 5/14/26 to ensure PRN controlled substance pain medications that are signed off the control sheet are documented in the resident medical record as well. Inconsistencies noted from the audit will be investigated for misappropriation. Negative findings to be addressed immediately and negative trends or system wide issues will be reported to the QAPI committee, and the action plan will be adjusted as needed.
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