Heritage Healthcare Of Lyndhurst
Inspection history, citations, penalties and survey trends for this long-term care facility in Lyndhurst, Ohio.
- Location
- 1575 Brainard Rd, Lyndhurst, Ohio 44124
- CMS Provider Number
- 366114
- Inspections on file
- 48
- Latest survey
- April 7, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Heritage Healthcare Of Lyndhurst during CMS and state inspections, most recent first.
A resident with ALS receiving hospice care was left alone, unable to call for help, and denied hydration and adequate pain management due to staff miscommunication and failure to follow care plans. The resident, fully dependent for care, was observed in severe pain and thirst, with staff incorrectly believing she was NPO despite no such order, and her physician was not notified of her decline or the withholding of fluids.
Surveyors found improper storage of food items, including boxes of frozen food and containers of ingredients placed directly on the floor, as well as unsanitary conditions in the kitchen and nursing unit refrigerators. Food preparation areas and equipment were soiled with food debris and spills, and refrigerators contained unlabelled, undated food and were heavily soiled. Staff confirmed the issues and noted confusion over cleaning responsibilities.
Multiple staff failed to follow infection prevention protocols, including not wearing required PPE during high-contact care for residents with indwelling devices, neglecting hand hygiene before and after resident care and medication administration, and mishandling incontinence and respiratory equipment. These lapses included staff contaminating clean linen carts with soiled gloves, not cleaning or labeling shared wash basins, and leaving respiratory equipment on the floor, all contrary to facility policy and physician orders.
The facility did not provide a complete and accurate facility-wide assessment, omitting key details such as involved personnel, accurate census data, admission and discharge rates, common diagnoses, services offered, and staffing levels for each shift. The Administrator confirmed these omissions, potentially affecting all residents.
Several residents, including those with conditions such as quadriplegia, paraplegia, and dementia, were not offered or documented as having received or refused influenza or pneumococcal vaccines, despite facility policy requiring these immunizations. The DON and cognitively intact residents confirmed that the vaccines were not offered, and medical records lacked documentation of administration, refusal, or contraindication.
Three residents dependent on staff for ADLs did not receive scheduled or as-needed hygiene and grooming care, including missed showers, lack of nail care, and failure to provide timely incontinence care. Observations and interviews revealed that staff, including agency personnel, did not consistently offer or document required care, and residents were left with unmet hygiene needs.
A resident with multiple chronic conditions was served a meal containing a disliked food item, despite documented preferences and care plan interventions. Dietary staff confirmed that the facility lost access to a system tracking food likes and dislikes, resulting in the inability to provide alternate menu items for residents' dislikes. This issue had the potential to affect most residents receiving meals.
A resident dependent on staff for transfers and toileting was left in a wheelchair overnight without timely assistance to bed or incontinence care, despite repeated requests for help. Staff interviews confirmed the resident was found soiled and upset in the morning, and the incident was not documented in the medical record. The resident's right to dignity and self-determination was not honored due to staff inaction and inadequate response.
A resident with multiple complex medical conditions and no support system was left without access to her personal clothing and electric wheelchair for an extended period after admission, as staff did not arrange timely retrieval of her belongings from a previous facility despite her requests.
Two residents who were dependent on staff for ADLs were found unable to access their call lights, with one call light observed on the floor and another wrapped around a bed rail. Both residents confirmed they could not reach their call lights, and staff verified the inaccessibility, contrary to facility policy requiring accessible call systems.
Two residents were not provided with the opportunity to exercise self-determination regarding important aspects of their care. One resident, who was cognitively intact and wheelchair-dependent, was denied timely information about ancillary service schedules despite repeated requests, while another was assigned shower times during the night shift without being consulted about her preferences. The facility did not assess or document resident preferences as required by its own policy.
A resident with multiple serious medical conditions had a physician order for DNRCC-A, but the required code status form was not completed and present in the medical record at the time of review. The deficiency was confirmed by the Administrator during the survey.
The facility did not ensure timely notification to the physician and resident representative regarding significant weight loss for two residents with complex medical conditions, despite facility policy requiring such communication. Documentation was lacking for both physician and family notification, and staff interviews confirmed uncertainty or absence of these notifications.
The facility did not provide accurate NOMNC letters or maintain proper documentation regarding the last covered day for Medicare services and subsequent payor sources for several residents. In multiple cases, medical records lacked evidence of payor transitions or reasons for discharge, and a social worker confirmed these discrepancies.
A resident with significant medical needs was not offered or provided quarterly care plan meetings as required. Documentation showed no evidence of meetings or refusals over a year, and interviews revealed that scheduling conflicts and lack of follow-up led to missed care conferences, despite facility policy supporting flexible scheduling and participation by phone.
The facility failed to obtain ordered lab tests for a UTI and did not provide proper catheter care for a resident with a history of recurrent UTIs, including repeated improper placement of the urinary drainage bag. Additionally, there was a delay in starting prescribed antibiotic therapy for a UTI in another resident due to medication availability issues and lapses in administration. These deficiencies were confirmed through record review, staff interviews, and observation.
Pharmacy recommendations for medication dose reductions and laboratory testing were not timely or properly addressed for two residents, with missing or inadequate documentation of clinical rationale. Additionally, an antibiotic was administered to a resident at a dose outside recommended guidelines without physician review or adjustment, despite facility policy requiring such actions.
Two residents experienced deficiencies in their living environment, including an unaddressed, uncomfortable mattress with a large dip for a resident with quadriplegia, and a soiled floor mat and carpet in another resident's room that had not been cleaned. Staff were aware of the issues, but there was no documentation or timely resolution.
A resident with a history of severe respiratory conditions did not receive their ordered auto-PAP therapy overnight due to an LPN forgetting to apply the device. The missed treatment was not communicated to the day staff, and the resident was later found in respiratory distress, prompting emergency intervention.
Two residents experienced failures in accurate medical record documentation. One resident did not receive a prescribed auto-pap treatment, though an LPN signed off as if it was administered. Another resident's antibiotic was not documented as given, with missing signatures and times for medication pulled from the starter kit. Interviews with the DON and a unit manager confirmed the lack of required documentation.
A resident with dementia smoked in his room, causing a fire hazard, despite the facility's non-smoking policy. The resident, who had a history of smoking and was deemed unfit to live alone, refused to allow staff to inspect his belongings upon admission. This oversight led to the resident retaining smoking materials, which resulted in a smoldering jacket and smoke in the facility.
A resident with chronic pain syndrome and ALS did not receive timely pain medication, leading to severe pain. Despite requests for Morphine Sulfate Concentrate starting at 8:00 P.M., the medication was not administered until after midnight. The LPN on duty did not provide the medication as needed and refused to communicate with the hospice nurse, resulting in a deficiency in pain management.
A resident with severe cognitive impairment fell out of bed during incontinence care due to inadequate assistance from two CNAs, resulting in a head injury and multiple contusions. The resident, who required two staff for bed mobility, was over-rolled and slid to the floor. The facility's procedure for turning patients was not followed, contributing to the fall.
The facility failed to provide dignified feeding assistance to two residents, leaving meal trays out of reach and delaying assistance. Additionally, a resident was transferred using a mechanical lift without proper privacy measures. These incidents highlight a lack of coordination and respect for resident dignity.
The facility did not notify the responsible parties and medical practitioners of two residents involved in a potential sexual abuse incident. Despite facility policy requiring immediate reporting, the family of a resident learned of the incident through informal means, and the Director of Nursing confirmed the lack of formal notification.
A resident with cognitive impairment was allegedly touched inappropriately by another resident, leading to a police investigation. Despite the facility's conclusion of consensual interaction, the resident's mother alleged sexual assault. The incident highlighted a failure to protect the resident from abuse, as per the facility's policy.
A facility failed to report a potential sexual abuse incident involving a cognitively impaired resident who was allegedly touched inappropriately by another resident. Despite the incident being witnessed by a staff member, the facility did not report it to authorities until the resident's mother made a formal allegation. The facility viewed the incident as consensual, overlooking the resident's cognitive impairments and communication deficits.
The facility failed to document an incident involving inappropriate touching between two residents in their medical records. Despite the incident being reported by a staff member, there was no documentation regarding the event or its outcomes in the residents' records, as confirmed by the DON.
The facility failed to maintain a clean and sanitary kitchen environment, including proper labeling and dating of food, discarding expired food, and monitoring the low-temperature dish machine. Observations revealed unlabeled and expired food items, debris in the walk-in freezer, and insufficient sanitizer concentration in the dish machine. The District Dietary Manager confirmed these findings.
The facility failed to properly collect and store trash, including biohazardous waste, potentially affecting all 57 residents. Observations revealed multiple dumpsters with surrounding debris, an overflowing biohazard room, and improperly stored biohazard barrels. Staff confirmed the issues and the need for waste pickup.
The facility failed to ensure washing machines reached the minimum required temperatures for hot water processing, potentially affecting all 57 residents. Observations and interviews revealed uncertainty about the exact temperatures reached during wash cycles, and the facility lacked documentation to confirm compliance with the required 160 degrees Fahrenheit.
The facility failed to serve the appropriate quantities of food as specified in the menu, affecting 49 residents. Cook #141 served only four ounces of macaroni and cheese instead of the required eight ounces, and this discrepancy was confirmed by the Dietary District Manager and Dietetic Technician Registered. Additionally, the facility did not adhere to specific dietary requirements for residents on NPO and NAS diets.
A resident reported that her lockbox containing money, a checkbook, and a bank card went missing from her room. Despite the issue being raised with the facility's management and the Long Term Care Ombudsman, the incident was not reported to the State agency as required by the facility's policy. The resident had mild or no cognitive impairment and diagnoses including major depressive disorder, epilepsy, and hemiplegia.
Failure to Provide Comfort, Hydration, and Pain Management for Dependent Hospice Resident
Penalty
Summary
A resident with amyotrophic lateral sclerosis (ALS), chronic pain syndrome, and total dependence for care was admitted to hospice for end-of-life care. The resident's care plan included interventions for comfort, pain management, and hydration, with specific mention of the need for total assistance with meals, snacks, and fluids, as well as monitoring for dehydration. Despite these documented needs and preferences, the resident was left alone behind a closed door, unable to summon help due to physical limitations and the lack of an accessible call light. The resident was observed to be in severe pain, thirsty, and unable to communicate effectively with staff, repeatedly mouthing requests for help and water. Staff actions and inactions contributed to the deficiency. Certified Nursing Assistant (CNA) staff believed the resident was on nothing by mouth (NPO) status, despite there being no physician or hospice order for NPO, and therefore withheld fluids. The resident reported not having received anything to drink since the previous day and was denied hydration measures, even though she was alert and able to tolerate sips of fluid. Pain management was also inadequate, as all routine pain medications were discontinued, and only one as-needed dose of morphine was administered over a two-day period, with no documentation of its effectiveness. The resident reported pain at the highest level and did not receive timely pain relief due to staff prioritizing other tasks. Communication failures were evident, as staff did not notify the resident's physician of her decline or the withholding of fluids, instead only communicating with the hospice provider. The hospice nurse confirmed there was never an order for NPO status and that the resident required a blow call light, which had not been provided. Facility policies required physician notification for changes in condition and supportive measures for hydration and pain, but these were not followed. The resident remained unable to call for help, was left in discomfort, and her preferences and care needs were not met.
Deficient Food Storage and Unsanitary Kitchen and Refrigerator Conditions
Penalty
Summary
Surveyors observed multiple deficiencies in food storage and kitchen sanitation during their inspection. In the kitchen, several boxes of frozen food were stored directly on the floor of the walk-in freezer, and the dairy walk-in cooler contained an opened and undated bag of hard-boiled eggs, as well as a container of cooked fish with the lid left open. The prep table and surrounding areas were found with dried food splatters, crumbs, and food debris, including on and around equipment such as the Robocoup, steamer, tilt skillet, fryer, grill, and juice machine. The dry storage area also had several boxes and containers of food on the floor, some opened, and a scoop stored inside a container of sugar. The floor under the racks was littered with various debris. The Dietary Manager confirmed these findings and attributed some of the issues to a recent delivery and transition to a new company. Further inspection of nursing unit refrigerators revealed heavy soiling, with dried spills, food containers lacking labels or dates, and the presence of hair on shelves. One refrigerator was filled with unlabelled and undated food items, including lunch bags, pizza, and a grocery bag, with a large spill and utensils left inside. The freezer section contained empty cups, dried food splatter, and a sticky substance. The Diet Technician confirmed that both staff and resident foods were stored together and that there was confusion between nursing and housekeeping regarding responsibility for cleaning the refrigerators. The facility's policy required the food service area to be maintained in a clean and sanitary manner, which was not followed.
Infection Control Lapses in PPE Use, Hand Hygiene, and Equipment Handling
Penalty
Summary
The facility failed to implement an effective infection prevention and control program, as evidenced by multiple observed lapses in the use of personal protective equipment (PPE), hand hygiene, handling of incontinence care supplies, and storage of respiratory equipment. Staff did not consistently don gowns and gloves when providing high-contact care to residents on enhanced barrier precautions (EBP), including those with feeding tubes and other indwelling devices. For example, a certified nursing assistant (CNA) provided hands-on care to a resident with a feeding tube without wearing any PPE, despite clear care plan and physician orders requiring EBP. The CNA was unaware the resident was on EBP, and this was later confirmed by the Director of Nursing (DON). Additional deficiencies were observed in the handling of incontinence care and hand hygiene. One CNA left a resident's room wearing soiled gloves and gown, touched clean linen carts, and returned to the resident's room with soiled gloves in hand, confirming she had contaminated clean supplies. Another CNA failed to wash hands before, during, or after providing incontinence care to two residents, did not properly use PPE, and handled clean and soiled items with contaminated gloves. Shared wash basins were left uncovered and unmarked on the floor, and were not cleaned or labeled as required, creating a risk of cross-contamination between residents. The DON confirmed that staff were required to don PPE for EBP and perform hand hygiene, and that wash basins should be cleaned, labeled, and not shared or stored on the floor. Medication administration practices also failed to meet infection control standards. A registered nurse (RN) did not perform hand hygiene before preparing or administering medications to two residents, and there was no hand sanitizer available on the medication cart. Additionally, a resident's BIPAP mask was found on the floor after being knocked off the nightstand, and a nurse confirmed it was not stored in a sanitary manner. Facility policies reviewed required hand hygiene before and after resident contact, proper use of PPE, and adherence to infection control procedures during medication administration, all of which were not followed in these instances.
Incomplete Facility Assessment Documentation
Penalty
Summary
The facility failed to provide a complete and detailed facility-wide assessment as required. Review of the Enhanced Facility Assessment, last updated by the Administrator, showed that it did not identify all personnel involved in the writing and approval process, did not provide an accurate average census, and did not accurately report the average number of residents admitted and discharged daily. Additionally, the assessment lacked information on common diagnoses admitted to the facility, the types of services or care offered, and details regarding staffing levels for each shift. During an interview, the Administrator acknowledged and agreed with these discrepancies. This deficiency had the potential to affect all 81 residents residing in the facility.
Failure to Offer and Document Flu and Pneumonia Vaccinations
Penalty
Summary
The facility failed to offer influenza and/or pneumococcal vaccines to all residents as required by its own policies. Record reviews and interviews revealed that four out of five residents reviewed for immunizations were neither offered nor refused the flu or pneumonia vaccines for the years 2024 or 2025. For these residents, there was no documentation of vaccine administration, refusal, or contraindication in their medical records. The Director of Nursing (DON) confirmed during interviews that the vaccines were not offered or refused for these residents, and the residents themselves, when cognitively able, also confirmed they had not been offered the vaccines. The affected residents had various diagnoses, including functional quadriplegia, hemiplegia, paraplegia, cerebral infarction, muscle wasting, dysphagia, and vascular dementia. Most were cognitively intact and able to confirm their immunization status. The facility's policies, last revised in 2019 and 2022, require that all residents be offered pneumococcal and influenza vaccines unless medically contraindicated. Despite these policies, the required offers and documentation were not completed for the residents reviewed.
Failure to Provide Scheduled and As-Needed Hygiene and Grooming Care
Penalty
Summary
The facility failed to provide scheduled and as-needed hygiene and grooming care for three residents who were dependent on staff for activities of daily living (ADLs). For one resident with cerebral infarction and muscle weakness, observations over several days revealed long, uneven fingernails embedded with a thick dark substance, and the resident reported not receiving routine showers as scheduled. Certified Nursing Assistants (CNAs) observed the condition of the resident's nails but did not offer assistance. Review of shower and bath records showed multiple missed or undocumented bathing opportunities, and the administrator confirmed the absence of documentation for these dates. Another resident with rhabdomyolysis, osteoarthritis, and upper extremity impairment was scheduled for showers during the night shift. The resident reported that staff would attempt to provide showers in the middle of the night, which she declined due to the timing, but stated she was not refusing showers altogether. Review of shower records indicated several dates with no documentation of showers being offered or completed, and both the administrator and unit manager confirmed that lack of documentation meant the care was not provided. Staff interviews revealed issues with time management, use of agency staff unfamiliar with facility routines, and inconsistent completion of scheduled showers. A third resident, dependent on staff for transfers and toileting due to morbid obesity, lymphedema, and amputation, reported being left in a wheelchair all night without incontinence care due to short staffing and reliance on agency aides. The resident described being left soiled and unattended despite repeated requests for assistance, and this was corroborated by staff interviews. There was no documentation in the medical record regarding the incident, and staff confirmed the resident was found soiled and upset in the morning. The facility's policy required provision of necessary services to maintain hygiene and grooming for residents unable to perform ADLs independently, but this was not followed in these cases.
Failure to Accommodate Resident Food Preferences Due to Loss of Dietary Tracking System
Penalty
Summary
The facility failed to provide meals that accommodated resident food preferences, as evidenced by a cognitively intact resident with chronic kidney disease, gout, and type 2 diabetes mellitus receiving a meal containing corn, which he had repeatedly stated he disliked. The resident's care plan included interventions to provide meals based on his food preferences and physician orders, and his diet order specified a two gram low sodium diet with double protein/meat portions. Despite these documented preferences and orders, the resident was served corn and did not eat it, stating he had informed staff multiple times of his dislike for corn. Interviews with dietary staff revealed that the facility recently lost access to a software system that tracked residents' food likes and dislikes, resulting in the inability to provide alternate food items for residents' documented dislikes. The dietary manager confirmed that since the removal of the previous system, there was no way to retrieve or reference residents' food preferences, and no likes or dislikes were available for any residents in the new system. This failure had the potential to affect the majority of residents receiving food from the kitchen.
Resident Left Without Timely Bed Transfer and Incontinence Care
Penalty
Summary
A resident with morbid obesity, lymphedema, major depressive disorder, generalized anxiety disorder, muscle weakness, and an acquired absence of the right leg below the knee, who was cognitively intact but dependent on staff for transfers and toileting, was not assisted to bed or provided timely incontinence care during a night shift. The resident reported using the call light multiple times and was told by an aide that assistance was delayed due to the need for a second aide for a mechanical lift transfer. The aide later informed the resident that the other aide was on break and he would have to wait. After having a bowel movement, the resident was again told he would have to wait, but no one returned to assist him, and he remained in his wheelchair until the morning shift arrived. Upon arrival of the day shift, staff found the resident still in his wheelchair, soiled, and with a full urinal and cups of urine. The resident expressed that the experience was demeaning and that his requests for care and to go to bed were not honored. Staff interviews confirmed that the resident had been left up all night and that the night shift was short-staffed, with one aide unaccounted for during much of the shift. The incident was not documented in the resident's progress notes, and there was no record of the resident being left in his wheelchair or not receiving incontinence care throughout the night. Further interviews with staff and management revealed inconsistent accounts regarding whether the resident was put to bed as requested. Some staff stated the resident was left in his chair all night, while others claimed he was put to bed. The agency aide assigned to the resident was reported to have left her duties and was subsequently placed on a do-not-return list. The facility's policy states that residents have the right to choose their daily routines, including sleeping and waking times, and to receive care consistent with their needs and preferences. However, in this instance, the resident's autonomy and dignity were not respected, and his care needs were not met in a timely or respectful manner.
Failure to Provide Timely Access to Personal Property
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident had timely access to her personal property, including clothing and an electric wheelchair, after admission. The resident, who had diagnoses including ALS, chronic respiratory failure, COPD, pulmonary hypertension, malnutrition, major depressive disorder, and anxiety disorder, was cognitively intact and dependent on staff for all activities of daily living. Upon admission, the resident had no family or friends to assist with the transfer of her belongings from her previous facility. Documentation from a care conference indicated the resident expressed a need for her personal items, and interviews confirmed she had repeatedly requested them. Despite these requests, the resident remained without her personal items for an extended period, as staff had not arranged for their retrieval. Observations showed the resident lying in bed in a hospital gown with no personal clothing or wheelchair present in her room. Staff interviews revealed that while arrangements were discussed, the items were not picked up due to time constraints and lack of clear responsibility among staff. The facility did not have a specific timeframe for obtaining personal property for residents without family support, resulting in the resident's prolonged lack of access to her belongings.
Failure to Ensure Call Lights Within Reach for Dependent Residents
Penalty
Summary
Surveyors identified that the facility failed to ensure call lights were within reach for two residents who required staff assistance for activities of daily living. For one resident with functional quadriplegia, hemiplegia, and a feeding tube, the call light was observed on the floor, out of reach, while the resident was in bed and requested assistance for repositioning due to discomfort. The resident confirmed inability to access the call light, and a CNA verified its placement on the floor. For another resident with cerebrovascular disease, dementia, and moderate cognitive impairment, the call light was found wrapped around the right-side bed rail, making it inaccessible while the resident was lying in bed with a constricted left arm. The resident stated he could not reach the call light, and a housekeeper confirmed its inaccessibility. Facility policy requires that each resident be provided with a means to call staff directly for assistance from their bed, toileting, bathing facilities, and from the floor.
Failure to Honor Resident Self-Determination and Preferences
Penalty
Summary
The facility failed to respect and promote resident self-determination for two residents reviewed for the ability to choose important aspects of their lives. One resident, who was cognitively intact and used a wheelchair due to paraplegia and other conditions, repeatedly requested to be informed in advance about the schedule of ancillary services such as optometry, podiatry, and dental visits. Despite his requests to the social worker to have this information posted in his room, the social worker refused, stating the information was posted elsewhere. However, observation revealed that the only posted schedules were outdated and located in a secured memory care unit, with no current schedules posted elsewhere in the facility. Another resident, also cognitively intact and dependent on staff for activities and personal care, was scheduled to receive showers during the night shift without being consulted about her preferences. The resident reported that she was never asked when she preferred to have her showers and was simply told they would occur during the 11:00 P.M. to 7:00 A.M. shift. When staff attempted to provide showers during these hours, the resident declined due to the late timing, but this was recorded as a refusal rather than a lack of preference accommodation. Review of the resident's care plan and admission documentation confirmed that her preferences for shower times were not assessed or documented. The facility's policy states that residents have the right to exercise autonomy regarding important facets of their lives, including scheduling healthcare and daily routines such as bathing. However, the facility did not follow its own policy in these cases, as residents' requests and preferences regarding ancillary service schedules and shower times were not honored or accommodated.
Failure to Complete Code Status Form for Resident with DNR Order
Penalty
Summary
The facility failed to ensure that a completed code status form was present for a resident with multiple complex medical diagnoses, including ALS, chronic respiratory failure with hypoxia, COPD, pulmonary hypertension, malnutrition, major depressive disorder, and anxiety disorder. Although a physician order for Do Not Resuscitate Comfort Care Arrest (DNRCC-A) was written and present in the resident's medical record, the required code status form documenting this directive was not completed at the time of review. The resident was noted to have intact cognition, no behaviors, and was dependent on staff for all activities of daily living. This deficiency was confirmed during an interview with the Administrator, who acknowledged that the form had not been completed prior to the surveyor's inquiry.
Failure to Notify Physician and Representative of Significant Weight Loss
Penalty
Summary
The facility failed to ensure timely notification of significant weight loss to the physician and/or resident representative for two residents. For one resident with diagnoses including dementia, failure to thrive, dysphagia, Alzheimer's disease, and moderate protein-calorie malnutrition, weight records showed fluctuations and a notable decrease. Although the nutrition note acknowledged the weight loss and indicated ongoing monitoring, there was no documentation that the physician, nurse practitioner, or resident representative had been notified. The diet technician was unsure if the family had been informed and confirmed that no documentation of such notification existed. The nurse practitioner also stated she was unaware of the weight loss and would have assessed the resident if notified. For another resident with a history of cerebrovascular infarction, traumatic subdural hemorrhage, multiple fractures, gastrostomy, dysphagia, and moderate protein-calorie malnutrition, weight records indicated a significant decrease over several months. Progress notes mentioned a discussion with the resident's mother about the weight loss and plans for weekly monitoring, but there was no documentation of notification to the physician or nurse practitioner. The facility's policy requires prompt notification of the resident, attending physician, and representative regarding changes in condition or status, but this was not followed in these cases.
Failure to Provide Accurate Medicare Coverage Notices and Documentation
Penalty
Summary
The facility failed to provide accurate Notice of Medicare Non-Coverage (NOMNC) letters to residents, specifically regarding the correct last covered day (LCD) for skilled services. In five cases reviewed, the NOMNC letters indicated the end date for Medicare coverage, but the residents' medical records did not contain documentation of the next payor source beginning immediately after the LCD. Additionally, for residents who were discharged, there was no documentation in the medical record explaining the reason for discharge on or before the LCD. Staff interview with a Licensed Social Worker confirmed discrepancies in the documentation of LCDs and the absence of progress notes explaining changes in coverage or payor concerns. This deficiency affected five out of eleven residents reviewed for liability notices, with the facility census at 81. The lack of proper documentation and communication regarding coverage and payor source transitions was directly observed in the medical records and confirmed by staff.
Failure to Offer or Complete Quarterly Care Plan Meetings
Penalty
Summary
The facility failed to ensure that quarterly care plan meetings were offered or completed for a resident with multiple complex medical conditions, including cerebral infarction, neuromuscular dysfunction of the bladder, obstructive and reflux uropathy, and muscle weakness. Record review showed that the resident was cognitively intact but required significant assistance with daily activities and had an indwelling catheter. There was no documentation of care plan meetings or refusals for the resident over a period of twelve months, despite facility policy requiring such meetings and encouraging participation by residents and their representatives. Interviews with the resident, her responsible party, and facility staff revealed that care plan meetings were not scheduled or documented as required. The social worker confirmed that no care plan meeting had been held in the past seven months, citing scheduling conflicts with the resident's daughter and a lack of documentation of attempts to schedule meetings. The responsible party reported only two care plan meetings in five years and described instances where meetings were canceled or not rescheduled due to facility requirements or scheduling difficulties. The administrator confirmed that care conferences could be held by phone or without the resident present if preferred, but there was no evidence that these options were offered or documented for the resident in question.
Failure to Provide Proper Catheter Care and Timely UTI Treatment
Penalty
Summary
The facility failed to obtain ordered laboratory testing to identify a urinary tract infection (UTI) and did not provide proper care and treatment for an indwelling urinary catheter for one resident. This resident had a history of recurrent UTIs, neurogenic bladder, and required an indwelling catheter. Despite orders from the certified nurse practitioner (CNP) on two occasions to obtain a urinalysis with culture and sensitivity, nursing staff did not collect the required urine samples. The resident subsequently developed urinary pain and was sent to the emergency department, where a malpositioned catheter was identified and the resident was treated for cystitis and UTI. Observations revealed repeated improper placement of the urinary drainage bag above the bladder level, both in bed and in a wheelchair, which was confirmed by nursing staff and acknowledged as a recurring issue. Additionally, the facility failed to timely initiate treatment for a UTI for another resident. Laboratory results identified a specific organism and indicated the appropriate antibiotic, but there was a delay between the urine culture result and the administration of the first dose of the prescribed antibiotic. Documentation showed that the medication was not available on the day it was ordered, and the first dose was not given until two days after the culture result. The delay in starting antibiotic therapy was confirmed by the Director of Nursing (DON). Both deficiencies were identified through record review, staff interviews, and direct observation. The failures included not following physician orders for laboratory testing, not maintaining proper catheter care and positioning, and not ensuring timely administration of prescribed medications for UTIs. These actions and inactions directly affected the care and treatment of the residents involved.
Failure to Address Pharmacy Recommendations and Medication Orders in a Timely Manner
Penalty
Summary
The facility failed to ensure that pharmacy recommendations were addressed in a timely and appropriate manner for multiple residents. For one resident with vascular dementia and schizoaffective disorder, pharmacy progress notes indicated recommendations for a gradual dose reduction (GDR) of Cymbalta, as required by federal regulation. The documentation for declining the GDR lacked a patient-specific rationale, and the form was reprinted and signed with inconsistent dates. Additionally, the facility was unable to locate a subsequent pharmacy recommendation for this resident. Another resident with multiple diagnoses, including major depressive disorder and generalized anxiety disorder, also had a pharmacy recommendation for a GDR of Cymbalta. The rationale for declining the GDR was not documented in the medical record, and the form was similarly reprinted and signed with earlier dates. Furthermore, repeated pharmacy recommendations for laboratory testing were not acted upon until several months later, despite being agreed to and signed by the provider. A third resident with sepsis, osteomyelitis, heart failure, and dementia received an antibiotic order for Macrobid that was outside the recommended dose or frequency and required dose adjustment based on renal function. There was no evidence in the progress notes that the dose was reviewed or clarified with the physician, and the medication was administered as ordered. The DON confirmed that the order was not addressed for proper dosing. Facility policies required timely review and documentation of pharmacy recommendations and medication orders, which was not consistently followed.
Failure to Maintain Cleanliness and Provide Comfortable Bedding
Penalty
Summary
The facility failed to provide a clean, sanitary, and comfortable environment for two residents. One resident with quadriplegia, anxiety disorder, contractures, and reduced mobility reported that her mattress was uncomfortable and had a large dip in the middle, which had persisted for about a month. Certified Nurse Aides confirmed the resident's complaints and stated they had informed either the Director of Maintenance or a nurse, but there was no documentation of the concern in the maintenance logs. The mattress issue was only addressed after surveyor observation and staff interviews confirmed the problem. Another resident with cerebrovascular disease, dementia, psychotic and mood disturbances, and dysphagia was observed lying in bed with a floor mat and carpet nearby that were soiled with a dried white substance. The housekeeper verified the dirty condition and stated that the room had not been cleaned that day. These findings demonstrate a failure to maintain a clean, sanitary, and homelike environment for the residents involved.
Failure to Apply Ordered Auto-PAP for Resident with Respiratory Conditions
Penalty
Summary
The facility failed to apply an Automatic Positive Airway Pressure (auto-PAP) machine as ordered for a resident with significant respiratory conditions, including respiratory failure, COPD, obesity, and emphysema. The physician's order required the auto-PAP to be applied every night and as needed for naps. Documentation showed the treatment was not administered on a specific night, and the responsible LPN admitted to forgetting to apply the device, without providing a specific reason. The resident's medical record indicated a history of severe respiratory issues and multiple recent hospitalizations for respiratory failure. On the morning following the missed treatment, the resident was initially alert and eating breakfast but was later found to be in respiratory distress after a call from her daughter. The assigned RN assessed the resident, applied the auto-PAP, and arranged for emergency transfer to the hospital. The night nurse did not communicate the missed treatment to the day staff. The incident was self-reported by the facility, and staff interviews confirmed the lapse in following the treatment order for the auto-PAP application.
Failure to Accurately Document Medical Treatments and Medication Administration
Penalty
Summary
The facility failed to ensure accurate documentation in the medical records for two residents. For one resident with respiratory failure, COPD, obesity, and emphysema, a physician's order required the use of an auto-pap device as needed for naps and every night. The treatment record indicated the device was administered on two specific evenings; however, a self-reported incident and subsequent interviews revealed that the auto-pap was not actually applied on one of those nights. The nurse responsible could not provide a reason for not administering the treatment and had signed off as if it had been completed. For another resident with sepsis, osteomyelitis, heart failure, dementia, and peripheral vascular disease, there was a physician's order for an antibiotic to be administered twice daily. Documentation showed the medication was not available at the time it was needed, and although it was later pulled from the starter kit, there was no record of the time or signature of the nurse who retrieved it. The medication administration record noted the antibiotic was not given and referred to a nurse's note, but there was no documentation confirming administration. Interviews with the DON and a unit manager confirmed the lack of required documentation.
Resident Smokes in Room Despite Non-Smoking Policy
Penalty
Summary
The facility failed to ensure an environment free of accident hazards when smoking materials were not secured, allowing a resident with dementia to smoke in his room. This resident, who had a history of smoking and was deemed unfit to live alone by Adult Protective Services, was admitted to the facility with several medical conditions, including dementia. Upon admission, the resident refused to allow staff to inspect his belongings, and there was no documentation of an inventory of his personal effects. An incident occurred when an alarm sounded in the resident's room, and staff found the room filled with smoke. The smoke was traced to a smoldering jacket in the resident's wardrobe, which was extinguished by a CNA. The resident admitted to having smoked a cigarette butt and placing it in his jacket pocket, which led to the smoldering. Despite the facility's non-smoking policy and the resident's awareness of it, he had an uncontrollable urge to smoke and managed to keep smoking materials in his possession. Interviews with staff revealed inconsistencies in the resident's account of the incident, likely due to his cognitive impairment. The facility's smoking policy required that smoking materials be kept in a designated area and that residents without independent smoking privileges could not have smoking items. However, the resident's refusal to allow an inspection of his belongings upon admission and the lack of a documented inventory contributed to the oversight that led to the incident.
Failure in Pain Management for Resident with Chronic Pain
Penalty
Summary
The facility failed to provide effective pain management for a resident with chronic pain syndrome, ALS, and other conditions, who was admitted to hospice care. The resident was prescribed multiple medications, including Morphine Sulfate Concentrate for breakthrough pain, which was to be administered as needed. On a specific day, the resident's pain levels were documented as high, yet she did not receive her requested breakthrough pain medication in a timely manner, leading to extreme pain. The resident requested her Morphine Sulfate Concentrate starting at 8:00 P.M., but it was not administered until after midnight. The resident was dependent on staff for all personal care and was unable to reposition herself in bed. Despite her requests, the LPN on duty did not provide the medication as needed and refused to communicate with the hospice nurse who was contacted by the resident. The hospice nurse attempted to reach the facility but received no response, and the resident's pain was not addressed until hours later. The facility's failure to administer the medication as ordered and the lack of communication between the LPN and hospice staff contributed to the deficiency. The resident's pain management plan was not followed, and the facility's policy on medication administration was not adhered to, resulting in the resident experiencing severe pain unnecessarily.
Inadequate Assistance During Incontinence Care Leads to Resident Fall
Penalty
Summary
The facility failed to provide adequate assistance to a severely cognitively impaired resident during incontinence care, resulting in a fall with injury. The resident, who required two staff members for bed mobility and was incontinent, fell out of bed while being changed by two CNAs. The incident occurred when the resident was over-rolled and slid to the floor, causing pain and swelling to the left side of the head, cheek, and eye, as well as pain in the left elbow. The resident was transferred to the hospital and diagnosed with a head injury and multiple contusions. The medical record review revealed that the resident had a high risk for falls due to a history of falls, impaired cognition, and dependence on continence care. The care plan indicated the need for total staff assistance with toileting and bed mobility. Despite these requirements, the CNAs involved in the incident did not maintain the resident's safety, leading to the fall. The facility's fall investigation confirmed that the resident was being changed by two CNAs when the fall occurred, and witness statements corroborated the sequence of events leading to the fall. Interviews with the DON and other staff members verified the findings, although there was a discrepancy regarding which CNAs were present during the incident. The facility's procedure for turning patients over in bed was not followed, as the resident was not positioned correctly, increasing the risk of falling. This deficiency was investigated under a specific complaint number, highlighting the failure to provide adequate supervision and assistance during incontinence care.
Failure to Provide Dignified Care and Assistance
Penalty
Summary
The facility failed to provide feeding assistance to two residents, both of whom required help with meals due to their medical conditions. One resident, diagnosed with quadriplegia and anxiety disorder, was observed to have their meal tray placed out of reach, and the staff left without setting up the meal. The resident expressed frustration about the staff's tendency to rush through feeding. Similarly, another resident with amyotrophic lateral sclerosis and anxiety disorder had their meal tray left untouched for an extended period, as no staff member provided the necessary assistance. Despite the presence of staff, the resident was left waiting, and the meal remained untouched. In another incident, the facility failed to maintain the dignity and privacy of a resident during a mechanical lift transfer. The resident, who had severe cognitive impairment and required a mechanical lift for transfers, was being moved without the door closed or privacy curtains drawn. This lack of privacy was only addressed when a staff member noticed the surveyor's presence and closed the door. The staff involved initially provided conflicting accounts of the situation, with one CNA stating that privacy was not necessary, while another later acknowledged that the door should have been closed. These deficiencies highlight the facility's failure to adhere to its policy of providing assistance with meals and maintaining resident dignity during personal care. The observations and interviews conducted during the survey revealed a lack of coordination and communication among staff, resulting in residents not receiving the care and respect they are entitled to.
Failure to Notify Responsible Parties of Potential Abuse Incident
Penalty
Summary
The facility failed to notify the responsible parties and medical practitioners of two residents involved in a potential sexual abuse incident. Resident #100, who was moderately cognitively impaired and required extensive assistance for activities of daily living, was allegedly touched inappropriately by Resident #101, who was cognitively intact and required supervision for daily activities. The incident was reported by a State tested Nursing Assistant to the Registered Nurse Shift Supervisor, who then informed the Director of Nursing. However, there was no evidence that the families or doctors of the involved residents were notified about the incident. The facility's policy mandates immediate reporting of such incidents to various parties, including the resident's representative and attending physician. Despite this, the mother of Resident #100 was not informed by the facility but learned of the incident through a personal phone call from a friend who worked at the facility. The Director of Nursing confirmed the lack of notification to the residents' families and medical practitioners. This deficiency was identified during an investigation under specific complaint numbers.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a resident from sexual abuse, as evidenced by an incident involving inappropriate touching. Resident #100, who was moderately cognitively impaired and required extensive assistance for activities of daily living, was allegedly touched inappropriately by Resident #101. The incident was reported by a State Tested Nursing Assistant (STNA) who witnessed Resident #101 rubbing Resident #100's breast. Despite the facility's conclusion that the interaction was consensual, the resident's mother alleged sexual assault, prompting an investigation. Resident #100 had a history of communication deficits and cognitive impairment, with a mental capacity likened to that of an eight-year-old child due to past brain aneurysms. During interviews, Resident #100 confirmed the touching incident with a childish demeanor, indicating a lack of full comprehension of the situation. The facility's investigation involved interviews with staff and residents, and a police report was filed by Resident #100's mother, leading to further investigation by law enforcement. The facility's policy on abuse prevention was reviewed, highlighting the residents' right to be free from abuse and neglect. Despite the policy, the facility's interpretation of the incident as consensual was challenged by the resident's mother and the police report, which considered the possibility of gross sexual imposition. The deficiency was noted under a master complaint number, indicating non-compliance with regulations designed to protect residents from abuse.
Failure to Report Potential Sexual Abuse Incident
Penalty
Summary
The facility failed to implement its abuse policy in response to an incident involving potential sexual abuse of a resident. Resident #100, who was moderately cognitively impaired and required extensive assistance for daily activities, was allegedly touched inappropriately by another resident, Resident #101. The incident was initially reported by a State tested Nursing Assistant (STNA) who witnessed the event. However, the facility did not take immediate protective actions or report the incident to local law enforcement or the state agency until the resident's mother made a formal allegation of sexual abuse. The facility viewed the incident as consensual due to both residents being their own responsible parties. Resident #100's medical history included epilepsy, major depressive disorder, anxiety disorder, and communication deficits, with a mental capacity likened to that of an eight-year-old child. Despite these factors, the facility did not follow its policy, which required immediate reporting of such incidents to various authorities, including law enforcement and the state agency. The deficiency was identified during an investigation under Master Complaint Number OH00156168 and Complaint Number OH00156099.
Failure to Document Incident in Medical Records
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents, which is a deficiency in safeguarding resident-identifiable information and maintaining medical records according to accepted professional standards. Resident #100, who was moderately cognitively impaired and required extensive assistance for activities of daily living, was involved in an incident where Resident #101, who was cognitively intact and required supervision for activities of daily living, allegedly engaged in inappropriate touching. This incident was reported by a State tested Nursing Assistant to the Registered Nurse Shift Supervisor, who then notified the Director of Nursing. Despite the incident being reported, a review of the medical records for both residents revealed no documentation regarding the incident or its outcomes. An interview with the Director of Nursing confirmed the absence of documentation in the medical records concerning the alleged sexual abuse incident. This lack of documentation indicates a failure to ensure a complete and accurate medical record for the residents involved.
Failure to Maintain Sanitary Kitchen Environment and Proper Food Management
Penalty
Summary
The facility failed to ensure a clean and sanitary kitchen environment, which included proper labeling and dating of food, discarding expired food, and appropriate monitoring of the low-temperature dish machine. During an observation of the kitchen, several issues were noted: packs of sliced cheese and turkey in the walk-in cooler lacked labels and dates, a loosely wrapped package of hard-boiled eggs was not labeled or dated, and various other food items had illegible or missing dates. Additionally, the walk-in freezer had debris and ice build-up, and the slicer had unidentifiable debris on it. In the dishroom, the temperature and sanitizer log was incomplete, and test strips for the chlorine sanitizer were unavailable. The dry stock room contained moldy and expired bread, further indicating a lack of proper food management practices. Interviews with the District Dietary Manager (DDM) confirmed these findings and the failure to adhere to the facility's food storage policies. Further inspection of the dish machine revealed that the facility had obtained chlorine test strips, but the sanitizer concentration was insufficient, as indicated by the faint purple color on the test strips. The DDM confirmed that the sanitizer was not meeting the required parts per million (ppm) for effective sanitation. The facility's policy on warewashing, which required maintaining dish machine water temperatures and completing temperature and sanitizer concentration logs, was not followed. This deficiency was investigated under Complaint Number OH00152455.
Improper Trash and Biohazardous Waste Management
Penalty
Summary
The facility failed to ensure that trash, including biohazardous waste, was collected and stored appropriately, potentially affecting all 57 residents. During an observation with the District Dietary Manager (DDM), multiple dumpsters were found in the parking lot area behind the facility. The designated dietary dumpster was open and surrounded by debris, including cut-up onions, leaves, Christmas lights, a broken dresser, chair, and couch. Additional trash, such as snow plow markers, a box, and takeout containers, were found outside another dumpster. A red biohazard barrel and a bookshelf were also improperly stored in a wooden open gated area near the dumpster. The DDM confirmed that the dumpster area was not reasonably clean and that the biohazardous waste should not have been in the parking lot. Further observation with the Director of Maintenance (DOM) revealed additional debris, including a large pile of mattresses and chairs, near the dietary dumpster. The biohazard barrel remained in the wooden open gated area. The DOM also showed the surveyor the first-floor biohazard room on the Critical Recovery Unit (CRU), which was overflowing with at least five red bags and a large box with a red bag. The DOM confirmed that the biohazardous waste barrel should not have been outside and that the biohazard room was overly full, indicating the need for waste pickup. Facility policies reviewed indicated that the area surrounding the exterior dumpster should be free of rubbish and that medical waste should be stored in designated biohazard rooms, protected from animals, and not providing a food source for insects and rodents.
Failure to Ensure Washing Machines Reach Required Temperatures
Penalty
Summary
The facility failed to ensure that washing machines reached the minimum required temperatures for hot water processing, potentially affecting all 57 residents. Observations revealed that the soiled linen laundry room contained three washers without temperature gauges or logs. The laundry cycles listed on the wall lacked temperature information. During an observation, a laundry aide used a yellow plate thermometer to measure the wash cycle temperature, which read a maximum of 150.6 degrees Fahrenheit. Interviews with the Housekeeping and Laundry Supervisor, Director of Maintenance, and other staff indicated uncertainty about the exact temperatures reached during wash cycles. The facility did not have documentation to confirm that the washing machines met the required 160 degrees Fahrenheit for hot water processing. The Director of Nursing, who also served as the facility's infection preventionist, and the Regional Clinical Director were unable to provide adequate evidence that the washing machines met the required temperature. Review of the User's Guide for the washers and a letter from Ecolab recommended washing with detergent in water at or above 160 degrees Fahrenheit for 25 or more minutes. The deficiency was investigated under Complaint Number OH00152455 and represented continued non-compliance from a previous survey dated 03/05/24.
Failure to Serve Appropriate Food Quantities
Penalty
Summary
The facility failed to ensure foods were served in appropriate quantities, affecting 49 residents receiving food from the kitchen. Specifically, the menu for Week 1, Tuesday lunch indicated that residents were to receive one cup (eight ounces) of baked macaroni and cheese. However, during lunch service, Cook #141 was observed using a gray #8-scoop, serving only four ounces of both regular and pureed macaroni and cheese, which is half the amount specified in the menu. This discrepancy was confirmed during an interview with the Dietary District Manager and Dietetic Technician Registered, who acknowledged that the serving size did not follow the menu as written. Additionally, the review of the diet list revealed that four residents were ordered nothing-by-mouth (NPO) and four other residents were scheduled to receive a different entree due to their regular No Added Salt (NAS) diet. Despite these specific dietary requirements, the facility did not adhere to the prescribed menu and serving sizes, leading to non-compliance. This deficiency was investigated under Complaint Numbers OH00152484 and OH00152455.
Failure to Report Misappropriation of Resident Property
Penalty
Summary
The facility failed to ensure an allegation of misappropriation of property was reported to the State agency. This affected one resident who reported that her lockbox containing between twenty and fifty dollars, a checkbook, and a bank card went missing from her room. The items were noted missing on 03/31/24 and reported to a facility nurse on 04/01/24. Despite the resident and the Long Term Care Ombudsman raising the issue with the facility's management, the incident was not reported to the State agency as required by the facility's policy. The resident's progress notes also lacked documentation of the missing lockbox. The resident, who had diagnoses including major depressive disorder, epilepsy, and hemiplegia, was admitted to the facility on an unspecified date and had mild or no cognitive impairment according to her Minimum Data Set assessment. The facility's Administrator confirmed that the alleged theft was not reported to the State agency and that the situation had been ongoing since before she began working at the facility. The facility's Abuse and Misappropriation policy required that any allegations be investigated and reported within required timeframes, which was not adhered to in this case.
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Surveyors found that multiple hazardous storage areas, including a closet near medical records, a beauty salon used to store chemical cases, a supply room in one nursing station, a room leading to a smoking area, a housekeeping room near therapy, and a lobby storage room, lacked required self-closing or automatic-closing doors. These conditions did not comply with NFPA 101 requirements for hazardous area enclosure and had the potential to affect all residents and staff in an emergency.
Surveyors found that the facility did not conduct fire drills on every shift each quarter and did not vary drill conditions as required by NFPA 101. Record review showed that one shift lacked a documented drill for an entire quarter, and the pattern of drill times and dates did not demonstrate varied conditions. The Maintenance Director confirmed the incomplete and noncompliant fire drill schedule, which affected all residents and staff emergency preparedness.
Surveyors found that the facility did not maintain clear egress corridors as required by NFPA 101, with a TV/video cart plugged into a corridor outlet and multiple unsecured chairs placed in the hallway near resident rooms and the secured unit dining room, including directly in front of a fire extinguisher. These items projected about 29 inches into an approximately eight-foot-wide corridor and were located in front of the handrail, potentially affecting 28 residents and staff’s ability to assist in an emergency. The Maintenance Director confirmed these corridor obstructions during the survey.
A resident with intact cognition receiving Medicare Part A skilled services for metabolic encephalopathy had services discontinued while benefit days remained, but the facility did not issue the required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN). The Social Services Director later confirmed that no SNF ABN was provided and reported she believed only a Notice of Medicare Non-Coverage (NOMNC) was needed when all skilled services were stopped. This practice conflicted with the facility’s written policy, which required SNF ABNs to be issued when extended care items or services were initiated, reduced, or terminated due to expected non-coverage by Medicare.
Surveyors identified that the facility exceeded the acceptable medication error rate when two residents with type 2 DM received insulin doses that were not administered according to orders or manufacturer instructions. In two separate observations, an LPN administered Novolog and another LPN administered insulin glargine and insulin lispro without priming the insulin pens, and the insulin lispro and Novolog were given after the residents had already consumed a significant portion of their breakfast meals, despite orders for administration before meals. Manufacturer information for both insulin products required priming before each injection to ensure accurate dosing, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and specified time frames.
The facility failed to maintain accurate and complete crash cart audits for multiple full-code residents. Surveyors, accompanied by the DON, found that daily crash cart checks did not include verification of supply expiration dates, and that an extension cord documented as present on several audit dates was not actually in the cart. Audit logs also conflicted with the cart’s contents by indicating that required items such as eye protection, saline, and clear plastic were present when they were not. These findings were inconsistent with the facility’s policy requiring the crash cart to be checked every 24 hours and after each use, with prompt replacement of equipment and supplies.
A resident with chronic respiratory failure on supplemental O2, COPD, and cognitive risk factors was repeatedly documented as non-compliant with the smoking policy, including going out to smoke outside designated times and retaining cigarettes and lighters provided by family. Despite prior assessments identifying this resident as unsafe to smoke without supervision, a later assessment classified the resident as safe to smoke independently without documented rationale or care plan update. The resident subsequently went outside alone with an O2 nasal cannula in place, lit a cigarette, and sustained facial burns when the cannula ignited, as observed by staff and confirmed by EMS and ED records. In a separate case, another cognitively impaired resident with a history of falls had a care-planned intervention for non-skid strips in front of a recliner, but observation and staff confirmation showed the strips were not present, despite remaining on the active fall-risk care plan.
Multiple dependent residents did not receive scheduled showers, bed baths, or shaving as outlined in their care plans and the facility’s routine care policy. One resident recovering from spinal surgery missed numerous scheduled showers over several months. Another resident who relied on staff for self-care repeatedly requested shaving but was not shaved, and visible facial hair was observed after a recent shower. A resident with chronic respiratory failure and a tracheostomy, requiring substantial/maximal assist with personal hygiene, had no documented showers for an extended period and was observed with long facial hair, which staff acknowledged should be removed during bathing or as needed. A cognitively impaired resident with ESRD and CHF, scheduled for twice-weekly showers, had multiple undocumented or missed showers and reported not getting showers despite asking aides who said they lacked time. Another cognitively intact resident with hemiplegia and multiple comorbidities, also scheduled for twice-weekly showers, had several dates where documentation showed no shower/bath/bed bath provided or no entry at all, and she reported feeling unclean and unimportant when her showers were missed.
A resident with an indwelling urinary catheter for urinary retention, and care plan interventions requiring the drainage bag to be properly secured with a dignity cover, was observed seated in a chair with the catheter drainage bag uncovered and containing visible dark yellow urine that could be seen from the hallway. Later, an LPN confirmed the catheter bag was lying directly on the floor without a dignity cover. This situation occurred despite facility policy requiring care to be provided in a manner that respects and enhances each resident’s dignity and personal privacy.
A cognitively intact resident with chronic orthopedic pain had a PRN oxycodone order, but multiple doses were signed out on the narcotic log by an RN without corresponding entries on the MAR or documented pain assessments. A CNA/med tech reported frequent problems with this RN’s narcotic counts and documentation, describing erratic behavior when handling narcotic keys. The resident reported taking oxycodone only once or twice daily and otherwise using Tylenol, which conflicted with the number of oxycodone doses signed out. The facility’s investigation found it was inconclusive whether narcotics were misappropriated or whether there was a failure of documentation, but confirmed there was no evidence that all signed-out doses were administered.
Failure to Maintain Self-Closing Doors for Multiple Hazardous Storage Areas
Penalty
Summary
Surveyors identified a deficiency related to hazardous area protection and door requirements under NFPA 101, 2012 Edition. During facility tours, they observed that multiple hazardous storage areas did not have self-closing or automatic-closing doors as required for hazardous areas such as combustible storage and chemical storage. These areas included a closet next to medical records, a beauty salon being used to store cases of chemicals, a supply room in Station #2, and the room leading to the smoking area in Station #3. On a subsequent tour, surveyors observed additional hazardous areas without self-closing doors. The housekeeping room across from therapy and the lobby storage room were both noted to lack self-closing door mechanisms. The facility census at the time was 59 residents, and the surveyors stated that this deficient practice had the potential to affect all residents and staff's ability to assist in an emergency. The Maintenance Director verified these findings at the time they were observed.
Plan Of Correction
K 0321 This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be admissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as its allegation of substantial compliance as of 06/12/2026 K-0321 Doors with Self-Closing Devices Corrective action for resident/s: 1. The closet door next to medical records was lacking a self-closing door on 5/19/2026. Maintenance director to add self-closing device to closet door next to medical records on or before 06/12/2026 in accordance with applicable code. 2. The beauty salon had chemicals stored in it on 5/19/2026. Maintenance director moved chemicals from beauty salon on 05/20/2026 in accordance with applicable code. 3. The supply room on station 2 was lacking a self-closing door on 5/19/2026. Maintenance director to add self-closing door to supply room on station 2 on or before 06/12/2026 in accordance with applicable code. 4. The room to the smoking area on station 3 was lacking a self-closing door on 5/19/2026. Maintenance director to add a self-closing door to the smoking are on station 3 on or before 06/12/2026 in accordance with applicable code. 4. The housekeeping room across from therapy was lacking a self-closing door on 5/19/2026. Maintenance director to add a self-closing door to the housekeeping room across from therapy gym on or before 06/12/2026 in accordance with applicable code. 5. The lobby storage room was lacking a self-closing door on 5/19/2026. Maintenance director to add a self-closing door to the lobby storage room on or before 06/12/2026 in accordance with applicable code. Identification of other residents who may be affected: LNHA and Maintenance director/designee completed a full facility audit for doors with self-closing devices on 05/26/2026. Any corrective action, including, doors identified as needing self-closures will be added on or before 06/09/2026 in accordance with applicable code. Measures for systemic change: LNHA educated Maintenance Director on 05/26/2026 regarding NFPA 101-2012 sections 19.3.2.1 and 19.3.5.9 specifically regarding doors with self-closing devices. How Corrective Action will be monitored Ongoing "Doors with Self-Closing device audit" to be completed weekly x 2 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 06/12/2026
Failure to Conduct Required Quarterly Fire Drills on All Shifts
Penalty
Summary
The facility failed to conduct fire drills in accordance with NFPA 101, 2012 Edition, sections 19.7.1 through 19.7.1.8, specifically by not holding drills every shift each quarter and not varying drill conditions as required. Record review on 06/09/25 at approximately 10:32 A.M. showed there was no fire drill conducted for the first shift during the third quarter. The documented first-shift fire drills occurred on 01/30/26 at 2:42 P.M., 04/30/26 at 1:51 P.M., and 10/31/25 at 10:58 A.M., indicating a missed quarter. Second-shift fire drills were recorded on 02/26/26 at 5:20 P.M., 06/03/25 at 4:35 P.M., 08/29/25 at 3:46 P.M., and 11/25/25 at 5:09 P.M., and third-shift drills on 02/28/26 at 11:47 P.M., 05/30/25 at 12:18 A.M., 07/22/25 at 11:34 P.M., 09/26/25 at 11:40 P.M., and 12/15/25 at 5:17 A.M. The surveyor determined that drills were not conducted under varied conditions and that the required quarterly drill on each shift was not consistently performed. The Maintenance Director confirmed these findings at the time they were identified, and the deficiency had the potential to affect all 59 residents and staff response in an emergency. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency related to facility-wide emergency preparedness practices and documentation of fire drills.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 05/29/2026 K-0712 Fire Drills Corrective action for resident/s: There were no records of a fire drill for the first shift of the third quarter of 2025. First shift fire drill completed on 5/24/2026 by maintenance director/designee with no findings or corrective action necessary. Identification of other residents who may be affected: On 5/26/2026 Maintenance director/designee completed 100% audit of the scheduled fire drills to ensure a drill is scheduled quarterly each shift with no findings or corrective action necessary. Measures for systemic change: LNHA educated Maintenance Director on 05/26/2026 regarding NFPA 101-2012 section 19.7.1.4 through 19.7.1.7. specifically including fire drill frequency requirements. How Corrective Action will be monitored Ongoing "Fire Drill Audit" to be completed weekly x 2 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 05/29/2026
Obstructed Egress Corridors Due to Equipment and Chairs
Penalty
Summary
The facility failed to maintain required clear egress widths in corridors in accordance with NFPA 101, 2012 Edition, sections 19.2.3.4 through 19.2.3.5 and 7.3.2 through 7.3.2.3, creating projections into the egress corridor that exceeded allowable limits. Surveyors observed that on one day in Station #3, a cart with a television and video equipment was plugged into an outlet in the corridor by room 38, and five activity room chairs were placed in the corridor near the secured unit dining room directly in front of a fire extinguisher. On the following day, surveyors again observed chairs in the Station #3 corridor, with four by room 35 and four by the activities room, and the same television cart still in the corridor; the chairs were not secured. The corridor was approximately eight feet wide, and the projections extended approximately 29 inches into the corridor in front of the handrail. These conditions had the potential to affect 28 residents in the facility and the staff’s ability to assist in an emergency, and the Maintenance Director confirmed the observations at the time of discovery. No specific resident medical histories or conditions were described in the report, only that 28 residents were potentially affected and the facility census was 59.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be subsequent remedial measures and should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 05/29/2026 K-0232 Clear path of egress Corrective action for resident/s: 1. On 05/18/2026 station 3 had a cart with a television parked in the corridor by room 38 that exceeded allowable limits. Maintenance director/designee moved the TV cart into the activity room, out to the corridor on 05/18/2026 in accordance with applicable code. 2. On 5/18/2026 station 3 had 5 chairs in the corridor near the dining room directly in front of the fire extinguisher. Maintenance director/designee moved the chairs into the dining room, out of the corridor on 5/18/2026 in accordance with applicable code. 3. On 5/19/2026 station 3 had 4 chairs by the activity room and 4 by room 35. In addition, the TV cart was in the corridor. The maintenance director/designee moved the chairs and TV cart into the dining room, out of the corridor on 5/19/2026 in accordance with applicable code. Identification of other residents who may be affected: Maintenance director/designee completed a 100% facility audit for clear paths of egress on 5/26/26 with no findings or corrective action necessary. Measures for systemic change: Maintenance Director/designee educated staff on 5/26/2026 regarding NFPA 101-2012 section 19.2.3.4 and 19.2.3.5 specifically including maintaining a clear path of egress. How Corrective Action will be monitored Ongoing "Path of Egress Audit" to be completed weekly x 2 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 05/29/2026
Failure to Issue Required SNF ABN When Discontinuing Medicare Part A Services
Penalty
Summary
The deficiency involves the facility’s failure to issue a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) when Medicare Part A services were discontinued for a resident who still had available benefit days. The resident was admitted with a diagnosis of metabolic encephalopathy and had intact cognition per the Minimum Data Set assessment. The facility’s own SNF Beneficiary Notification Review documented that Medicare Part A skilled services began on 02/11/26 and the last covered day was 03/11/26, and that the facility initiated discharge from Medicare Part A services before the resident’s benefit days were exhausted. Despite this, no SNF ABN was provided to the resident or the resident’s representative. During interviews, the Social Services Director stated that the SNF ABN was issued hours prior to the last covered day but, upon reviewing her files, confirmed that no SNF ABN had actually been issued for this resident. She further explained that she believed an SNF ABN was only required if one skilled service remained and that if all skilled services were being discontinued, only the Notice of Medicare Non-Coverage (NOMNC) needed to be issued. The Administrator, however, stated that a resident should always receive both a SNF ABN and a NOMNC when Medicare Part A services are discontinued and benefit days remain. Review of the facility’s written policy dated 03/28/23 showed that the facility was required to issue SNF ABNs for initiation, reduction, or termination of extended care items or services when Medicare payment was not expected, which did not occur in this case.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as its allegation of substantial compliance as of 05/29/2026 F-0582 Corrective action for resident/s: On 5/14/26 Resident #34 was informed of rights and responsibilities related to Advanced Beneficiary Notice and voiced understanding of information for future reference by administrator. Identification of other residents who may be affected: Any resident receiving skilled services from nursing or therapy services. The Administrator audited all residents who were discharged from skilled services in the past 30 days to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary Notice on 5/29/26. No non-compliance was noted. Measures for systemic change: On 5/14/2026 Business Office Manager, Director of Rehab, Minimum Data Set nurse, Director of Nursing and Social Services Director were educated on proper procedure of issuing of Notice Of Medicare Non Coverage and Advanced Beneficiary Notice by administrator. All upcoming discharges from skilled services will be reviewed weekly at Utilization Review meeting to ensure notices will be delivered timely. How Corrective Action will be monitored: Administrator or designee to complete audits of all residents being discharged from skilled services to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 5/29/26
Insulin Administration Errors and Failure to Prime Insulin Pens
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5%, with surveyors identifying 3 errors out of 28 medication administration opportunities, resulting in a 10.71% error rate. For one resident with type 2 diabetes mellitus and moderate cognitive impairment, the physician’s order directed Novolog insulin 10 units via subcutaneous pen-injector to be given before meals. During an observed medication pass, the LPN administered 10 units of Novolog insulin without priming the pen and did so after the resident had already consumed approximately 50% of the breakfast meal. The LPN later confirmed she did not prime the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer instructions for the Novolog FlexPen specified that an air shot (priming) must be performed before each injection to ensure proper dosing. Another resident, also diagnosed with type 2 diabetes mellitus and with intact cognition, had orders for insulin glargine 35 units subcutaneously twice daily and insulin lispro 20 units subcutaneously before meals, plus 12 units subcutaneously if blood glucose was between 251 mg/dL and 300 mg/dL. During an observed medication administration, an LPN administered 35 units of insulin glargine and 32 units of insulin lispro without priming the insulin pens and after the resident had consumed approximately 90% of the breakfast meal, despite orders for insulin lispro to be given before meals. The LPN later stated she could not remember if she had primed the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer information for insulin lispro stated that the pen must be primed before each injection to confirm insulin delivery and remove air, and that failure to prime could result in too much or too little insulin. The DON confirmed the expectation that insulin be administered as ordered, including priming each pen with two units before dialing the prescribed dose, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and required time frames.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 5/29/2026. F-0759 Corrective action for resident/s: Residents #21 and #22 were assessed and evaluated by nurse and Director of Nursing 5/14/26. Resident #21 and #22 both denied any adverse effects and none were noted upon assessment by the Director of Nursing on 5/14/2026. Notification made to physician on 5/14/2026. LPN # 2 competency Eval on insulin administration with the Director of Nursing completed 5/14/2026. Identification of other residents who may be affected: Diabetic residents on assignment of LPN #2/station 2 have the potential to be affected and were assessed by the DON/Designee on 5/14/26 and found to be within normal limits. Measures for systemic change: All Nurses were educated by the Director of Nursing on the steps for Insulin administration per competency, diabetes clinical protocol policy, Medication and treatment orders policy, administering medications policy, and Obtaining fingerstick Glucose Level policy On 5/14/2026. How Corrective Action will be monitored: Director of Nursing and Assistant Director of Nursing will complete insulin administration audits on 5 nurses. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance: 5/29/2026
Inaccurate Crash Cart Audits and Missing Emergency Equipment
Penalty
Summary
The facility failed to ensure accurate and complete crash cart audits for residents requiring basic life support, affecting eighteen of thirty-five residents who were designated as full code. During an observation of the crash cart with the DON, surveyors found that the daily audit documentation for the month did not include verification of expiration dates for crash cart supplies. Review of the crash cart audit logs showed that an extension cord was documented as being in the cart on multiple dates, but the extension cord was not present in the cart at the time of inspection. Additionally, the audit documentation indicated that required items, including eye protection, saline, and clear plastic, were not present in the crash cart, yet they were documented as being in the cart. The facility’s undated “Emergency Crash Cart” policy stated that the crash cart is to be checked every 24 hours and after every use, and that equipment and supplies are to be noted and replaced promptly, but the observed documentation and contents of the cart did not match these requirements. This deficiency was verified with the DON at the time of the survey and was cited under the requirement that personnel provide basic life support, including CPR, to residents requiring emergency care, subject to physician orders and advance directives, and was investigated under Complaint Number 2687380.
Plan Of Correction
Cridersville Care Center Provider Number:366171 Survey Type: Complaint Survey Survey Date: 04/29/26 This Plan of Correction (PoC) outlines the actions completed by the facility with regards to the deficiency citation. This Plan of correction does not constitute any admission of guilt or liability by the facility and is submitted only in response to the regulatory requirements. Please accept the following as the facility's credible allegation of compliance as of 4/30/26. F678 CPR All Full Code residents #18 have the potential to be affected by the alleged deficiency. On 4/27/26 the DON/ADON re-stocked the crash cart per the inventory sheet for all missing items. Crash cart inventory sheet updated and new one will go into effect on 5/1/26. All licensed nursing staff provided with training related to crash cart inventory being a daily audit review using inventory sheet on 4/27/26 per DON/designee. The DON/designee will conduct clinical rounds and conduct a random audit of crash cart three times per week for 4 (four) weeks to ensure compliance. The results of the audit will be documented. The facility conducted an Ad-Hoc QAPI meeting on 4/27/26 and discussed the alleged deficiency and corrective actions. Date when corrective action will be completed: 4/30/26
Unsafe Smoking Practices with Oxygen and Missed Fall-Prevention Interventions
Penalty
Summary
The deficiency involves the facility’s failure to provide a safe smoking environment, adequate supervision, and appropriate implementation of its smoking policy for a resident who used oxygen and smoked, as well as failure to implement fall-prevention interventions as care planned for another resident. One resident had multiple relevant diagnoses, including chronic respiratory failure with hypoxia, COPD, end-stage renal disease, dependence on supplemental oxygen, diabetes, and necrotizing fasciitis. Her care plans identified impaired visual function, risk for respiratory complications related to a history of smoking, and risk for cognitive decline, with interventions including use of oxygen per order and observation for understanding. A smoking-related care plan created earlier documented that she wished to use smoking products, had been assessed as safe to smoke "with supervision," and was non-compliant with the smoking policy, with family continuing to provide smoking supplies despite education and a verbal warning for non-compliance. Smoking assessments and progress notes showed a pattern of non-compliance and inconsistent classification of this resident’s smoking safety. Multiple smoking observation/assessments completed earlier in March documented that she had no cognitive loss, visual deficits, or dexterity problems but was unsafe to smoke without supervision because she did not return smoking materials and did not follow designated smoke times. Progress notes described her going out to smoke multiple times by herself or with family, including sneaking out next door with a cigarette and going out multiple times in one evening, with staff documenting that she was "reeducated" and that family brought in cigarettes and lighters which she did not return to staff. Despite this history, a smoking assessment completed after a three-day hospital stay assessed her as safe to smoke without supervision, with no documentation explaining how this conclusion was reached or evidence that her care plan was updated accordingly. On the day of the incident, the resident reported she had cigarettes and a lighter on her person after returning from dialysis and stated she "could not find a nurse" and went outside to smoke, saying she "guessed" she forgot she had her oxygen on. A CNA observed her outside and saw a flame coming through the resident’s oxygen nasal cannula tubing, turned off the oxygen tank, removed the tubing, and patted out sparks on the resident’s shirt sleeve. The resident’s face and hands appeared black in color, and EMS documented first-degree burns to the head and face, with the resident stating she lit a cigarette with her nasal cannula on, causing the burn. The hospital record described her face as black from smoke and her lips and mouth as "burnt and charred," with a recommendation for intubation that she refused. The facility’s incident report recorded that she went outside with oxygen on to smoke without notifying staff, that staff witnessed the occurrence as she walked through the dining room door to the courtyard, and that she stated she thought she had turned her oxygen off. The facility’s smoking policy required interdisciplinary evaluation to determine safe versus unsafe smokers, staff maintenance of all smoking paraphernalia for both safe and unsafe smokers, and progressive consequences for policy violations. A separate deficiency involved another resident at risk for falls whose care plan included use of non-skid strips on the floor in front of her recliner as a fall-prevention intervention. This resident had severe cognitive impairment, used a walker and wheelchair, required supervision or touching assistance for transfers and ambulation, and had experienced two or more falls without injury since the prior assessment. The fall-risk care plan, initiated at admission, specified non-skid strips in front of the recliner beginning in November. However, nursing staff interviewed were not familiar with all of the resident’s fall-prevention interventions without checking the record, and observation of the room showed two recliners with no non-skid strips on the floor in front of them. An LPN confirmed that the non-skid strips were not present despite the intervention remaining active in the care plan, and moving the recliners did not reveal any strips. The facility’s fall management policy required identification of hazards and risk factors, implementation of interventions to minimize falls and injuries, and development and implementation of a care plan based on interdisciplinary evaluation, with interventions related to identified risk factors.
Plan Of Correction
Smoking: On 03/21/26 at 3:16 P.M. 911 response was activated for Resident #11 and Medical Director #601 was notified by Registered Nurse (RN) #322. On 03/21/26 at 3:18 P.M. on-call Nurse/Social Services #423 immediately notified the Administrator and Director of Nursing (DON) #304 of the incident involving Resident #11. On 03/21/26 at 3:22 P.M. Emergency Medical Services (EMS) arrived onsite. At 3:30 P.M. Resident #11 was transported to the emergency room. On 03/21/26 at 3:30 P.M. RN #322 completed a smoking re-assessment of Resident #11 assessing the resident to be an unsafe smoker requiring supervision due to failure to remove oxygen prior to entering designated smoking area. On 03/21/26 from 3:38 P.M. through 7:57 P.M. Licensed Practical Nurse (LPN) #337, #336, #335, #338; RN #334, and DON #304 re-assessed residents (who smoke). This included Resident #22, Resident #3, Resident #47, Resident #50, Resident #60, Resident #150, Resident #86, and Resident #10 to determine smoking safety (via smoking assessment). Each resident was re-educated regarding the facility smoking policy and staff verified there were no smoking materials on their person. The residents' smoking materials would be maintained by facility staff and distributed per policy. On 03/21/26 at 4:30 P.M. DON #304 responded to facility and an Ad Hoc (not scheduled) Quality Assurance (QA) meeting was held via telephone with the Administrator, DON #304 and Medical Director #601 to review investigative findings and plan of action. A root cause analysis was completed and determined Resident #11 had smoking materials on her person (believed to be obtained from family without staff knowledge) and failed to remove her oxygen. The QA team discussed a corrective action plan. On 03/21/26 from 5:00 P.M through 03/22/26 at 3:00 P.M. 26 RNs, 13 LPNs, one medical technician (MT), 54 Certified Nursing Assistants (CNA) four activities staff, one central supply staff, 11 dietary staff, 12 housekeeping staff, three laundry staff, one medical records staff, two social designees, two maintenance staff, nine administrative staff, and 19 therapy staff (158 staff at the time of the incident) were provided education regarding the facility smoking policy by DON #304 and the Administrator. This was completed via 1:1, small group in-services or via phone. Newly hired staff would receive education during general orientation regarding the facility's smoking policy. On 03/21/26 at 5:00 P.M. DON #304 completed an audit of all residents who smoke (Resident #22, Resident #3, Resident #47, Resident #50, Resident #60, Resident #150, Resident #86, and Resident #10) to verify smoking evaluations and plans of care accurately reflected the residents' smoking safety needs. The residents were educated on the facility smoking policy, and smoking materials were to be maintained at the nurses' station. An audit was completed which included verification of required safety measures present in designated smoking areas, including an ash can, fire extinguisher, fire blanket, ash trays and no oxygen signs. There were no identified concerns or changes made because of the audits. On 03/21/26 at 8:55 P.M. Resident #11 returned from the ED. LPN #332 verbally educated the resident regarding the facility smoking policy which included the need for supervision, a smoking apron (to be worn) and the facility smoke times. LPN #332 verified no smoking materials were on the resident's person or in her room at this time. On 03/23/26 at 11:00 A.M. the Interdisciplinary Team (IDT) (Administrator, DON #304, Medical Director #601, RN #302, Social Services #427, Social Services #423, DON #300, and Maintenance #436) met in-person to review the plan of action with DON #304/designee to complete weekly monitoring of residents who smoke and designated smoking areas weekly for four weeks with Housekeeping responsible to complete the cleaning. Housekeeping staff were responsible for cleaning ashtrays and the designated smoking area daily. Audits to be reviewed and any further actions required to be directed by the Quality Assurance and Performance Improvement (QAPI) Committee during scheduled meetings. The IDT also reviewed all current smoking assessments and care plans for residents who smoke. Resident #50 required a change in supervision levels with smoking due to cognition levels and her plan of care as well as Resident #11's plan of care was updated to reflect supervision/safety. On 03/23/26 from 3:45 P.M. to 8:55 P.M. Social Services #423 re-educated residents who smoke (Resident #22, Resident #3, Resident #47, Resident #50, Resident #60, Resident #150, Resident #86, Resident #10) and responsible parties, if applicable regarding the facility smoking policy and supervision levels. On 03/23/26 at12:13 P.M. Social Services #427 contacted Resident #11's family member (#602) to schedule a care conference. Family member #602 and Family Member #603 were not available to meet until 03/27/26. On 03/23/26 at 1:00 P.M. staff education related to smoking areas, removal of oxygen prior to entering smoking area and maintaining smoking materials at the nurses' station for residents who smoke was initiated by DON #304 and the Administrator via 1:1, small group in-services or via phone call. Education was completed for all 158 staff by 03/24/26 at 1:00 P.M. Newly hired staff would be educated during general orientation regarding the facility's smoking policy. The facility does not utilize agency staff. On 03/27/26 at 11:00 A.M. a care conference was held with Resident #11 and Family Members #602 and #603, the Administrator, Social Services #423 and Social Services #427. The facility smoking policy was reviewed. The resident and family were informed an involuntary discharge would be initiated should the resident exhibit non-compliance moving forward and supervision would be increased beyond the two-hour standard of care to monitor more closely for non-compliance with the facility smoking policy. Family Member #602 stated he educated his siblings as well. On 04/10/26 at 2:00 P.M. DON #304 initiated education with 26 RNs and 13 LPNs (100% of nurses educated) regarding completion of the smoking evaluation via 1:1, small group in-services, or phone. The education was completed by 6:00 P.M. on 04/10/26. A new resident who smokes must remain supervised until the interdisciplinary team (IDT) reviews and determines smoking safety, at which time the care plan is developed and resident and family education is provided. The communication through the staff would be the care plan. Newly hired staff receive education during general orientation regarding the facility's smoking policy and completion of smoking evaluation via Point Click Care (PCC). On 04/10/26 at 4:29 P.M. DON #304 initiated an order in PCC for the nurse to verify, each shift, that Resident #11's smoking materials were maintained at the nurses' station. On 04/13/26 at 5:30 P.M. DON #304 initiated orders in PCC for nurses to verify, each shift, that all residents who smoke would have smoking materials maintained at the nurses' station. An updated list of smokers included: Resident #60, Resident #50, Resident #11, Resident #86, Resident #113, and Resident #151. On 04/13/26 at 5:45 P.M. DON #304 initiated questionnaires for staff regarding the smoking policy with re-education provided as needed via 1:1 and small group in-services for staff currently in the facility with all staff to be questioned/educated prior to working their next scheduled shift. Falls: On 4/9/26, Maintenance Director placed non-skid strips on the floor in front of Resident #12's recliner. Like Residents are identified as residents who have had a fall within the facility. Utilizing the Fall Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, an audit of falls and appropriate interventions for the past 30 days will be completed by the Director of Nursing or designee to ensure fall interventions are in place per plan of care. This audit along with identified corrections will be completed on or F 0689 before 5/13/26. The Director of Nursing or designee will re-educate licensed nurses and STNA/CNAs on the Fall Management Policy to include fall interventions to be in place per the care plan. This education will be completed on or before 5/13/26. Utilizing the Fall Management Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, the Director of Nursing or designee will complete an audit of new admissions, new readmissions and residents who experience a fall within the last 7 days, weekly for four weeks, beginning 5/14/26 to ensure fall safety interventions are in place per plan of care. Current fall interventions found to not be in place will be corrected with all intervention in place per plan of care. Negative findings to be addressed immediately and negative trends or system wide issues will be reported to the QAPI committee, and the action plan will be adjusted as needed.
Removal Plan
- Activated 911 response for Resident #11 and notified the Medical Director.
- On-call Nurse/Social Services immediately notified the Administrator and DON of the incident.
- EMS arrived onsite and Resident #11 was transported to the emergency room.
- Completed a smoking re-assessment of Resident #11, determining the resident was an unsafe smoker requiring supervision due to failure to remove oxygen prior to entering the designated smoking area.
- Re-assessed all residents who smoke (Residents #22, #3, #47, #50, #60, #150, #86, and #10) to determine smoking safety via smoking assessment.
- Re-educated residents who smoke regarding the facility smoking policy and verified there were no smoking materials on their person.
- Implemented that smoking materials would be maintained by facility staff and distributed per policy.
- Held an ad hoc QA meeting to review investigative findings and plan of action.
- Completed a root cause analysis determining Resident #11 had smoking materials on her person and failed to remove oxygen.
- Developed a corrective action plan.
- Provided facility-wide education to staff on the facility smoking policy.
- Implemented that newly hired staff would receive smoking policy education during orientation.
- Completed an audit of all residents who smoke to verify smoking evaluations and plans of care accurately reflected smoking safety needs.
- Ensured smoking materials were maintained at the nurses’ station.
- Audited designated smoking areas for required safety measures (ash can, fire extinguisher, fire blanket, ash trays, and no-oxygen signs).
- Provided verbal education to Resident #11 on smoking policy (supervision, smoking apron, smoke times).
- Verified no smoking materials were on Resident #11’s person or in her room.
- Conducted an in-person IDT meeting to implement weekly monitoring of residents who smoke and designated smoking areas weekly for four weeks.
- Assigned housekeeping to clean ashtrays and the designated smoking area daily.
- Directed audits to be reviewed by QAPI.
- Reviewed all current smoking assessments and care plans for residents who smoke.
- Updated Resident #50’s supervision level.
- Updated Resident #11’s plan of care to reflect supervision/safety.
- Re-educated residents who smoke and responsible parties (as applicable) regarding the facility smoking policy and supervision levels.
- Contacted Resident #11’s family to schedule a care conference.
- Initiated additional staff education regarding smoking areas, removal of oxygen prior to entering smoking area, and maintaining smoking materials at the nurses’ station.
- Held a care conference with Resident #11 and family to review smoking policy.
- Informed resident/family that involuntary discharge would be initiated for future non-compliance.
- Increased supervision beyond the two-hour standard of care to monitor more closely for non-compliance.
- Provided education to all nurses regarding completion of the smoking evaluation.
- Implemented that new residents who smoke must remain supervised until IDT review determines smoking safety and care plan/education are completed.
- Entered an order in PCC for nursing to verify each shift that Resident #11’s smoking materials were maintained at the nurses’ station.
- Entered orders in PCC for nursing to verify each shift that all residents who smoke have smoking materials maintained at the nurses’ station.
- Initiated staff questionnaires regarding the smoking policy with re-education as needed.
- Required all staff to be questioned/educated prior to working their next scheduled shift.
Failure to Provide Scheduled Bathing and Shaving Assistance for Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide scheduled and needed bathing and shaving assistance to multiple dependent residents in accordance with their care plans, preferences, and the facility’s routine care policy. One resident with spinal stenosis and recent L2–L5 decompression fixation fusion was care planned for substantial/maximal assistance with shower/bath and toileting hygiene and was scheduled for showers on Tuesdays and Fridays. Electronic documentation from early January through early April showed this resident did not receive a shower or bed bath on 11 identified scheduled days, and the DON confirmed these missed bathing events. Another resident with dysphagia and developmental issues, who required assistance with self-care and mobility, reported that she asked staff to shave her but they did not, which bothered her. During an observation following a recent shower, she stated she had not been shaved and that the hair "itched"; small gray hairs were visible on her chin. A CNA confirmed the presence of gray chin hairs and acknowledged the resident needed shaving, stating it would be addressed with the next scheduled shower. A further resident with chronic respiratory failure, tracheostomy status, heart failure, moderate intellectual disabilities, anxiety, depression, and PTSD required substantial/maximal assistance with personal hygiene and had a care plan for assistance with self-care, including personal hygiene. Her shower schedule called for showers on Monday and Thursday nights, with complete shaves for men and women. Review of documentation showed her last recorded shower/bath was nearly a year earlier, with no indication of additional personal hygiene or facial hair removal on that date. Observations on two separate days showed long white hairs on her chin and jaw line, which a CNA later confirmed, stating facial hair removal should occur with baths/showers or as needed. A resident with end stage renal disease, respiratory failure, hyperlipidemia, and congestive heart failure, who had impaired cognition and required partial/moderate assistance with bathing and personal hygiene, was scheduled for showers on Wednesdays and Saturdays. Review of shower documentation from admission through early April revealed no showers provided or refusals documented on at least ten scheduled shower days. In interviews, this resident reported not receiving scheduled showers, was unsure of his shower days, and stated he could use a good scrub down, adding that he had asked aides who told him they did not have time. A CNA explained that shower days appear on shower sheets and in the computer and that CNAs are supposed to document daily, with nurses checking the documentation; the DON verified the resident had not received showers per schedule or preference. Another resident with a fracture of the lower end of the left humerus, hemiplegia and hemiparesis after cerebral infarction, rheumatoid arthritis, hypertensive heart disease, urinary retention, and osteoarthritis was care planned as non–weight bearing to the left upper extremity and requiring substantial/maximal assistance with showering/bathing. Her electronic record showed she was scheduled for showers on Wednesdays and Saturdays. The shower task question "did the resident receive a shower/bath/bed bath?" was documented as "no" on three dates, indicating no shower/bath/bed bath was completed, and left unanswered on three additional dates. The DON confirmed that one missed shower was due to an outside appointment, that on two dates the "no" response meant no bathing of any type occurred, and that on three dates there was no documentation at all. The resident, who was cognitively intact, reported that missing showers made her feel unimportant compared to others and that she did not feel clean when her shower was missed. Facility policy on routine resident care stated that showers, tub baths, and shampoos are to be scheduled according to person-centered care or state guidelines, with additional showers given upon request, but the documented and observed care did not reflect consistent provision of scheduled bathing and shaving for these residents.
Plan Of Correction
1. Resident #5 received a shower by the STNA on 4/13/26. Resident #8 received a shower by the STNA on 4/8/26. Resident #9 received a shower and had their chin shaved by the STNA on 4/14/26. Resident #70 received a shower by the STNA on 4/13/26. Resident #76 received a shower and had their chin shaved by the STNA on 4/15/26. 2. Like residents are identified as residents who need assistance with showering and shaving. Utilizing the Shower Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, an audit of like residents will be completed by the Director of Nursing or designee to ensure that showers and resident shaving are completed. This audit along with identified corrections will be completed on or before 5/13/26. 3. The Director of Nursing or designee will re-educate licensed nurses and STNA's on the Routine Resident Care Policy to include bathing and shaving residents. This education will be completed on or before 5/13/26. 4. Utilizing the Shower Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, the Director of Nursing or designee will complete an audit of 4-6 residents weekly for four weeks, beginning 5/14/26 to ensure that showers and resident shaving are completed. Noncompliance found during audits will be addressed and assistance with showers and/or shaving provided. Negative findings to be addressed immediately and negative trends or system wide issues will be reported to the QAPI committee, and the action plan will be adjusted as needed.
Uncovered Urinary Catheter Drainage Bag Compromises Resident Dignity
Penalty
Summary
The facility failed to maintain a resident’s right to privacy and dignity related to management of an indwelling urinary catheter. A resident admitted with malignant neoplasm of the esophagus and type II diabetes mellitus had a care plan identifying risk for urinary tract infection and catheter-related trauma due to an indwelling catheter for urinary retention. The care plan interventions included ensuring the catheter tubing was secured and the drainage bag was properly secured with a dignity cover in place. Physician orders directed that the resident’s 16 French indwelling urinary catheter be changed every 30 days and as needed, and the comprehensive MDS documented that the resident had an indwelling catheter and was cognitively intact. During observation, the resident was seen seated in a chair with the urinary catheter drainage bag hanging from the chair without a dignity cover, and dark yellow urine was visible in the bag from the hallway. In a later observation and interview, an LPN confirmed that the catheter bag was lying directly on the floor and did not have a dignity cover. Attempts to interview the resident to confirm cognitive status were unsuccessful, as the resident was unable to answer screening questions. Review of the facility’s “Resident Dignity & Personal Privacy” policy stated that the facility should provide care in a manner that respects and enhances each resident’s dignity, individuality, and right to personal property, which was not followed in this instance when the catheter drainage bag was left uncovered and visible.
Plan Of Correction
The Laurels of Athens wishes to have this plan of correction submitted as our written allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission to nor agreement with, either the existence of, or the scope and severity of, any of the cited deficiencies or conclusions set forth in the statement of deficiencies. This plan is prepared and/or executed to ensure continuing compliance with regulatory requirements. Our alleged date of compliance is 5/13/2026. 1. On 4/6/26, Resident #92's catheter bag was removed from the floor, the bag changed and covered for dignity by the licensed nurse. Resident #92 discharged from the facility on 4/11/26. 2. Like Residents are identified as residents who utilize urinary catheters. An audit will be completed by the Director of Nursing or designee for like residents utilizing the Urinary Catheter Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC to ensure catheter bags are covered for dignity and not laying directly on the floor. This audit along with identified corrections will be completed on or before 5/13/26. 3. The Director of Nursing or designee will re-educate licensed nurses on the Indwelling Urinary Catheter Policy as well as Resident Dignity & Personal Privacy Policy to include privacy covers are in place for urinary catheters and that the catheter is not laying on the floor. This education will be completed on or before 5/13/26. 4. Utilizing the Urinary Catheter Audit Tool which was created on 4/20/26 by the Director of Nursing for purpose of this POC, the Director of Nursing or designee will complete an audit of all residents with catheters weekly for four weeks, beginning 5/14/26 to ensure catheter bags are covered for dignity and not laying directly on the floor. Any catheters found to be touching the floor or uncovered will be removed from the floor, the bag changed and covered for dignity. Negative findings to be addressed immediately and negative trends or system wide issues will be reported to the QAPI committee, and the action plan will be adjusted as needed.
Failure to Prevent Possible Misappropriation and Poor Documentation of PRN Narcotics
Penalty
Summary
The deficiency involves failure to prevent potential misappropriation of a resident’s narcotic medication and failure to ensure accurate documentation of controlled substance administration. A cognitively intact resident with chronic pain related to an internal orthopedic device and left knee pain had an order for oxycodone 5 mg PO every four hours PRN for pain and a care plan directing staff to administer medications as ordered and observe for effectiveness and side effects. The resident’s MDS showed she rated her pain as 7/10 and received opioid medication. However, review of the February MAR and the narcotic log revealed multiple discrepancies between narcotic sign-outs and documented administration. On several occasions, oxycodone doses were signed out on the narcotic log by an RN without corresponding documentation on the MAR. Specifically, oxycodone was signed out on one evening at 9:30 p.m. with no MAR entry, and again on a subsequent night at 1:30 a.m. and 5:30 a.m. with no MAR entries for those times. Another dose was signed out at 9:00 p.m. while the MAR reflected administration at 10:16 p.m., and a later dose at 5:30 a.m. was documented on both the narcotic log and MAR. There was also no documentation of pain assessments before or after PRN opioid administration. These documentation gaps meant there was no evidence that all narcotic doses signed out were actually administered to the resident. Staff interviews further highlighted concerns about the handling of narcotics. A CNA/med tech reported frequently taking the narcotic keys from the RN and described the RN’s behavior as erratic, with repeated problems involving incorrect narcotic counts and missing documentation on both the MAR and narcotic log. The resident stated she did not receive oxycodone more than once or twice a day, preferring to take Tylenol the rest of the time, which conflicted with the number of oxycodone doses signed out. When questioned, the RN gave inconsistent explanations about how often she pulled and administered PRN narcotics and acknowledged struggling with the new system, while also suggesting the resident may have received PRN tizanidine instead of remembering oxycodone. The facility’s investigation concluded that evidence was inconclusive as to whether misappropriation occurred or whether the issue was solely lack of documentation, but confirmed there was no evidence the resident received all doses signed out on the narcotic log.
Plan Of Correction
1. Resident #99 had a Self-Reported Incident submitted and investigated via the EIDC on 3/2/26. The investigation was inconclusive as we could not prove that misappropriation occurred. On 2/24/26, Resident #99 was interviewed and pain assessed by Director of Nursing and resident had no ill effects related to the inconsistent documentation in the medical record as it relates to her controlled substance pain medication. 2. Like Residents are identified as residents who utilize controlled substance PRN pain medications. An audit will be completed by the Director of Nursing or designee for like residents utilizing the Controlled Substance Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC to ensure PRN controlled substance pain medications that are signed off the control sheet are documented in the resident medical record as well. This audit along with identified corrections will be completed on or before 5/13/26. 3. The Director of Nursing or designee will re-educate licensed nurses on the Controlled Substances Policy to include appropriate documentation of controlled substances. In addition, the licensed nurses will be re-educated by the Director of Nursing or designee on the Abuse Prohibition Policy to include misappropriation of resident property. This education will be completed on or before 5/13/26. 4. Utilizing the Controlled Substance Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, the Director of Nursing or designee will complete an audit three controlled substance sheets from each of the nine medication carts for a total of twenty-seven sheets weekly for four weeks, beginning 5/14/26 to ensure PRN controlled substance pain medications that are signed off the control sheet are documented in the resident medical record as well. Inconsistencies noted from the audit will be investigated for misappropriation. Negative findings to be addressed immediately and negative trends or system wide issues will be reported to the QAPI committee, and the action plan will be adjusted as needed.
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