Highland Square Nursing And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Akron, Ohio.
- Location
- 1211 W Market St, Akron, Ohio 44313
- CMS Provider Number
- 365316
- Inspections on file
- 50
- Latest survey
- September 18, 2025
- Citations (last 12 mo.)
- 5 (1 serious)
Citation history
Health deficiencies cited at Highland Square Nursing And Rehabilitation during CMS and state inspections, most recent first.
A resident with moderate cognitive impairment was sexually abused by a housekeeper, who sent inappropriate messages and engaged in sexual acts with the resident. The facility failed to recognize the abuse, did not prohibit staff-resident intimate relationships in its policy, and did not properly follow up with police or implement further interventions after the incident. Leadership and staff believed the relationship was consensual, despite evidence of fear and cognitive impairment.
Surveyors observed multiple instances of unclean and poorly maintained areas, including damaged ceilings, soiled carpets, peeling wallpaper, water stains, holes in walls, and dirty elevators. These deficiencies were confirmed by staff and affected several residents, with the potential to impact all individuals in the facility.
A resident with significant cardiac history did not have documentation of a scheduled or attended follow-up cardiology appointment after hospital discharge, despite a physician order. Another resident receiving wound care for a surgical wound on the left shin had no corresponding treatment order or care plan entry, even though wound care was performed by nursing staff as recommended by a wound care service. Both deficiencies involved lapses in ensuring physician orders were properly documented and followed.
A resident with significant cardiac conditions received glasses from the facility's optometry service but was later unable to see out of them. The Social Services Director was informed of the issue and added the resident to the list for the next optometry visit but did not follow up or document the concern in the medical record, and had not received any optometry visit reports since starting at the facility.
A CNA failed to follow infection control protocols during incontinence care for a resident with a G-tube and multiple medical conditions. The CNA did not wear a gown as required, placed soiled linens on the floor, and touched clean surfaces with contaminated gloves without performing hand hygiene, contrary to facility policy.
A resident with a full code status was found unresponsive on the toilet. CNAs alerted an LPN, who, instead of starting CPR, sought guidance from another LPN and the Unit Manager due to difficulty accessing the resident's advance directives. No CPR was performed before EMS arrived and pronounced the resident deceased, despite the resident's documented wishes for full life-saving measures.
Staff failed to remain awake and alert during overnight shifts, as evidenced by photos and videos provided by a resident, showing CNAs sleeping in resident care areas while call lights went unanswered. The concern was reported to the Administrator but not properly investigated, and LPNs on duty were unaware of the sleeping staff. Facility policy prohibits sleeping on duty except during designated breaks, and this failure resulted in potential neglect of all residents on the affected floors.
A staff member failed to wear a beard net properly and used hands instead of tongs to handle food, violating the facility's sanitation policies. This had the potential to affect 56 residents, as three were NPO and not directly impacted.
A facility failed to provide comprehensive care for a resident's leg braces. The resident, with mild cognitive impairment and multiple diagnoses, wanted to wear leg braces but lacked a care plan or physician's order. Staff were unaware of the need for braces, and there was no documentation in therapy notes. Interviews revealed communication and documentation issues, with the facility's policies on assistive devices and care plans not followed.
A resident with multiple diagnoses, including diabetes and asthma, did not receive pantoprazole as ordered by the physician for about two weeks after it was brought to the facility. Additionally, despite complaints of nausea and vomiting, the resident was not ordered or administered Zofran as needed. The facility's policy required timely medication administration, but the facility failed to adhere to this, as confirmed by interviews with staff and family members.
A resident with multiple diagnoses, including muscle weakness, was not provided with additional therapy services after winning an appeal for more therapy days. Despite being approved for therapy from August 6 to August 10, the facility did not resume therapy, citing the resident's independent mobility. Interviews revealed a lack of documentation and communication regarding the continuation of therapy services.
The facility failed to maintain a clean and sanitary kitchen, impacting meal service for all residents. Observations revealed gnats, dirty trash cans, and food debris on equipment and floors. The Dietary Manager confirmed these issues, which violated the facility's policy on maintaining sanitary conditions.
The facility did not adhere to its smoking policy, leading to cigarette butts being discarded improperly in the resident smoking area and side guest entrance. The administrator confirmed the issue, which was identified during a complaint investigation.
A resident with chronic pain due to conditions like osteoarthritis and spinal stenosis did not receive a palliative care consultation despite expressing interest and having a physician's order for it. The resident reported ongoing pain and lack of follow-up on the palliative care option, which was confirmed by the facility administrator. This issue was a repeat deficiency from a prior survey.
A resident with chronic pain did not receive Methadone as ordered due to unavailability on multiple occasions. The nursing staff failed to update the physician about missed doses or reduced dosage, and the facility's medication administration policy was not followed.
The facility failed to identify risks and provide adequate supervision for residents with substance use disorders, leading to multiple drug overdoses. The facility did not enforce its visitation policy, allowing residents to obtain and use drugs during unsupervised visits. This resulted in Immediate Jeopardy and actual harm to the residents involved.
Failure to Protect Resident from Sexual Abuse by Staff Member
Penalty
Summary
A facility failed to protect a resident with moderate cognitive impairment from sexual abuse by a housekeeper. The housekeeper sent inappropriate text messages and photos to the resident, soliciting sexual favors, and subsequently engaged in sexual acts with the resident on two occasions. The resident reported performing these acts out of fear, and text message evidence corroborated the inappropriate communications initiated by the staff member. The resident's medical record indicated a history of traumatic brain injury, impaired cognition, and the presence of a legal guardian. The facility did not recognize the staff-to-resident sexual contact as abuse, despite the resident's cognitive impairment and the power imbalance between staff and resident. Interviews with facility leadership and staff revealed a belief that the relationship was consensual, and the facility's abuse policy at the time did not explicitly prohibit staff-resident intimate relationships or address the issue of consent in cognitively impaired residents. The facility's investigation concluded that the resident had willingly participated, and there was no intent to cause harm, despite statements from the resident and her guardian indicating fear and lack of true consent. The facility also failed to properly follow up with law enforcement regarding the incident. When the police were initially contacted, staff were unable to identify the perpetrator, and there was no subsequent update to the police once the staff member was identified. The facility did not implement additional interventions or follow-up in the resident's medical record after the incidents of sexual abuse were disclosed. The deficiency affected one resident out of three reviewed for abuse, in a facility with a census of 63.
Removal Plan
- Resident #50's friend updated facility staff that HK #208 came into Resident #50's room on two separate occasions in the previous week and made her perform oral sex on him.
- HK #208 was suspended pending further investigation.
- The facility opened a self-reported incident (SRI) tracking number 264268.
- HK #208's employment ended with the facility when the employee resigned.
- Resident #50 was signed up for psychological services with consent from her guardian and assistance from Social Services Designee (SSD) #212.
- Resident #50 was referred to follow-up with psychological services by Social Service Designee (SSD) #212 to evaluate mood status related to the incidents with HK #208.
- The social services designee completed a depression test, Patient Health Questionnaire-9 (PHQ-9), to evaluate the resident's mood status related to the incidents with the staff member.
- The President of Operations and President of Clinical Services educated the RDO #201 on BIMs assessment and scoring, staff to resident relations (as included in updated facility abuse policy deeming this act abuse), police follow-up, and thorough investigations.
- The President of Clinical Services updated the facility Abuse Policy to include staff to resident relations, specifically in the policy training section.
- The facility re-opened the SRI related to Resident #50. The police were updated that Resident #50 wanted to re-speak with them again.
- The RDO #201 and Regional Director of Clinical Services educated the Administrator and DON on BIMs assessment and scoring, staff to resident relations, police follow-up, and thorough investigations.
- The Administrator and DON educated the following staff members: Activities Director, Human Resources Director, Unit Manager, Wound Nurse, Maintenance Director, Social Services Director, Central Supply Clerk and Housekeeping Supervisor on BIMs assessment and scoring, staff to resident relations, police follow-up, and thorough investigations.
- The facility held an Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting to review the incident, the investigation, and the facility abuse policy not outlining physical and emotional contact between staff and resident.
- The facility completed a Brief Interview for Mental Status (BIMs) Assessment on all residents.
- All care plans were reviewed regarding cognitive status after the BIMS assessments were updated.
- The facility wound nurse completed skin assessments on all residents who had a BIMS of 12 or below.
- The facility Social Services Designee, Activity Director and the clinical management staff completed resident abuse questionnaires for residents with a BIMs score of 13 or above.
- All staff were educated on BIMs assessment and scoring, staff to resident relations, police follow-up, and thorough investigations.
- The facility notified the police department regarding the abuse allegation, re-opening of the facility investigation for sexual abuse and provided the alleged perpetrator's information.
- The facility implemented a plan to complete head-to-toe assessments on five random residents who had a BIMs score of 12 or less to assess for signs and symptoms of abuse, five times a week for four weeks then five residents weekly for four weeks.
- The facility would interview five random residents five times for four weeks and then five random residents weekly for four weeks with abuse questionnaires for residents with a BIMs of 13 or higher.
- The facility would complete five random staff questionnaires on new abuse policy five times a week for four weeks and then five random staff weekly for four weeks.
- RDO #201 and the Regional Director of Clinical Services would audit facility SRIs for a thorough and proper investigation.
- RDO #201 and the Regional Director of Clinical Services would audit SRIs for police notification.
- All discrepancies would be submitted to the QAPI Committee and revised as needed for three months.
Failure to Maintain Clean and Well-Maintained Environment
Penalty
Summary
The facility failed to maintain a clean, sanitary, and well-maintained environment, as evidenced by multiple observations of damaged and soiled areas throughout the building. Specific findings included a large, broken bubble of plaster/paint on a resident's ceiling, moderately soiled carpets, dried paint and stains on doors and floors, peeling and torn wallpaper, water stains, bulging and damaged baseboards, and holes in walls in several resident rooms. The elevator interiors were found to be scratched and dirty, with missing flooring and heavily soiled entryways. Hallways and walk-through areas near nurses' stations were observed to have heavy scuff marks, scratches, and dirt. These conditions were verified by both the Assistant Director of Nursing and the Administrator during facility tours and interviews. The deficiency affected eight identified residents but had the potential to impact all residents in the facility, which had a census of 64 at the time. The facility's policy required regular cleaning and prompt attention to visibly soiled or contaminated surfaces, but observations indicated that these standards were not met. The findings were confirmed through interviews with facility staff, including the Administrator and a CNA, who acknowledged the presence of the damage and lack of cleanliness in the affected areas.
Failure to Ensure Physician-Ordered Appointments and Wound Care Orders
Penalty
Summary
The facility failed to ensure that a resident with a history of congestive heart failure, ischemic cardiomyopathy, and other cardiac conditions attended a physician-ordered follow-up cardiology appointment after returning from a hospital stay for shortness of breath and CHF exacerbation. Although the LPN entered the order for the follow-up appointment into the medical record, there was no documentation that the appointment was scheduled or attended. Both the LPN and the DON were unable to verify whether the appointment was arranged or completed, indicating a lapse in following through with physician orders for post-hospitalization care. Additionally, the facility did not ensure that wound care treatment orders were written and included in the care plan for a resident with a traumatic brain injury and multiple fractures who was receiving wound care for an open area on the left shin. The wound care was being performed as recommended by a visiting wound care service, but there was no corresponding order in the medical record, nor was the treatment addressed in the resident's comprehensive care plan. The wound nurse confirmed that the order for wound care had not been entered into the system, despite performing the treatment as directed by the wound care service.
Failure to Ensure Follow-Up and Documentation for Optometry Services
Penalty
Summary
The facility failed to ensure adequate follow-up regarding optometry services for a resident with multiple cardiac diagnoses, including CHF, ischemic cardiomyopathy, and a history of sudden cardiac arrest. The resident was provided glasses by the facility's contracted optometry service, but later reported, through family, an inability to see out of the glasses. The Social Services Director (SSD) added the resident to the list for the next optometry visit but did not follow up to confirm if the resident was seen or if the issue was resolved. There was no documentation in the resident's medical record regarding vision or optometry services, and the SSD had not received any visit reports from the contracted optometry service since starting at the facility. These actions and omissions resulted in a lack of documented follow-up and unresolved vision concerns for the resident.
Failure to Follow Infection Control Guidelines During Incontinence Care
Penalty
Summary
A deficiency was identified when a certified nursing assistant (CNA) failed to follow infection control guidelines during incontinence care for a resident with multiple medical conditions, including left side hemiplegia, cognitive communication deficit, atrial fibrillation, and hypertension. The resident was dependent on staff for all activities of daily living and required enhanced barrier precautions due to a gastrostomy tube. Physician orders and the resident's care plan specified that staff were to use personal protective equipment (PPE), including gloves and a gown, during personal care. However, during an observed episode of incontinence care, the CNA donned gloves but did not wear a gown as required. During the care, the CNA removed soiled linens and a brief contaminated with fecal matter and placed them on the floor next to the resident's bed. After cleansing the resident's perineal area, the CNA, still wearing the same soiled gloves, touched clean linens and various surfaces in the room, including the over bed table and bed controls, without removing the gloves or performing hand hygiene. The CNA confirmed awareness of the enhanced barrier precautions but acknowledged not following them, including failing to don a gown and not performing hand hygiene before handling clean items. Facility policies required the use of both gown and gloves for high-contact care and specified hand hygiene after glove removal, but did not provide instructions for handling soiled linens and briefs after removal.
Failure to Initiate CPR for Full Code Resident Due to Delayed Access to Advance Directives
Penalty
Summary
A deficiency occurred when staff failed to provide basic life support (BLS), including cardiopulmonary resuscitation (CPR), to a resident who was found unresponsive on the toilet, despite the resident's advance directive indicating full code status. Certified Nursing Assistants (CNAs) discovered the resident in distress and alerted an LPN, who assessed the resident and found no pulse. Instead of initiating immediate CPR, the LPN sought guidance from another LPN on a different floor, who then contacted the Unit Manager at home for advice on locating the resident's advance directives. During this time, the LPN was unable to quickly access the resident's code status due to difficulties finding the medical chart and lack of immediate computer access. The delay in action resulted in no CPR being performed while staff attempted to confirm the resident's code status. EMS was contacted and arrived to find the resident deceased, with rigor mortis and other signs of irreversible death present. EMS staff indicated it was too late for resuscitation efforts. The resident was left slumped over on the toilet until EMS arrived, and staff did not attempt to move the resident or initiate life-saving measures as required by the facility's policy and the resident's documented wishes. The resident involved had a history of cognitive, social, and emotional deficits following cerebrovascular disease, mild vascular dementia, chronic obstructive pulmonary disease, atrial fibrillation, congestive heart failure, polyosteoarthritis, and a previous myocardial infarction. The resident's physician orders and care plan clearly indicated a full code status, meaning all life-saving measures were to be used in a medical emergency. Despite this, the staff's failure to promptly initiate CPR and their inability to access the resident's advance directives in a timely manner directly contributed to the deficiency.
Removal Plan
- The Director of Nursing (DON) provided education on Advance Directives, location of advanced directives, change of condition, and immediate response of CPR to all staff.
- Training was verified by review of sign in sheets.
- The DON and Administrator interviewed and/or collected statements from all staff working at the time of the incident involving Resident #61.
- A whole house audit of all residents was completed by the Regional Director of Clinical Services (RDCS) verifying code status, care plans and signed Do Not Resuscitate (DNR) forms.
- The Human Resource Director reviewed all nursing staff files to verify cardiopulmonary resuscitation (CPR) certifications were valid.
- The RDCS verified all laptops on the units were accounted for and available for nursing access.
- The DON audited crash carts to ensure all equipment was in place.
- An ADHOC Quality Assurance and Performance Improvement (QAPI) meeting was completed to discuss Advance Directives for all residents and develop education pertaining to Advance Directives, location of advanced directives, change in condition, and immediate response of CPR.
- A second ADHOC QAPI meeting was held to discuss code status levels, staff response expectations, and implementation/adjustment of the corrective action plan.
- Staff received education on advanced directives, location of the advanced directives, immediate response of CPR and change in condition by the RDCS and DON, with completion verified via sign-in sheets and random staff interviews.
- The facility implemented a plan for the DON/Designee to conduct Code Blue drills and location of advance directives on alternating shifts.
- The facility implemented a plan for the Administrator/Designee to audit all deaths to ensure resident's advanced directives were honored per preference.
- The facility implemented a plan for the DON/Designee to conduct audits to ensure that residents' change in conditions were addressed.
- The facility implemented a plan for the DON/Designee to conduct audits to ensure each unit had a laptop for nursing access.
Staff Sleeping on Duty Leads to Potential Resident Neglect
Penalty
Summary
Facility staff failed to remain awake and alert while on duty, resulting in the potential for resident neglect on the second and third floors, affecting all 39 residents residing on those units. A resident with intact cognition reported that staff on the midnight shift were sleeping while call lights were going off, and provided videos and photos as evidence. The resident had reported this concern to the Administrator, who refused to review the videos, and the concern was marked as resolved without evidence of an investigation into the specific staff involved. Review of staffing schedules confirmed that on the nights in question, only one CNA was assigned to each floor, with LPNs splitting coverage. Video and photographic evidence showed CNAs sleeping at the nurse's station and in resident care areas while call lights remained activated and unanswered. Interviews with LPNs assigned to those shifts revealed they were unaware of staff sleeping and had not been asked to cover for CNAs during those times. Facility policy prohibits staff from sleeping while on duty, except during designated breaks in specific areas. The facility's abuse and neglect policy defines neglect as the failure to provide necessary goods and services to avoid harm or distress. The evidence provided by the resident, corroborated by the Regional Director of Operations, confirmed that staff were sleeping in resident care areas during their shifts, in violation of facility policy and resulting in a failure to protect residents from potential neglect.
Improper Food Handling and Hygiene Practices
Penalty
Summary
The facility failed to ensure proper food handling and hygiene practices, as observed during a meal service. A staff member, identified as [NAME] #462, did not wear a beard net correctly, allowing his beard to be exposed during meal preparation and service. This was confirmed during an observation with the Regional Dietary Manager. Additionally, the same staff member used his hands to remove hamburger and hotdog buns from their bags instead of using appropriate utensils like tongs, as required by the facility's sanitation and infection control policy. The deficiency had the potential to affect 56 of the 59 residents, as three residents were noted to be NPO (nothing by mouth) and thus not directly impacted by the food handling practices. The facility's policies on hair covering and sanitation/infection control were reviewed and indicated that all exposed body hair should be effectively restrained and that appropriate utensils should be used for serving food.
Failure to Provide Comprehensive Care for Leg Braces
Penalty
Summary
The facility failed to ensure that a resident received appropriate treatment and comprehensive care regarding the use of leg braces. The resident, who has diagnoses including schizoaffective disorder, borderline personality disorder, and polyosteoarthritis, was admitted with mild cognitive impairment and required extensive assistance for all activities of daily living. Despite the resident's desire to wear leg braces, there was no care plan or physician's order for the braces, and the facility staff were unaware of the need for them. The resident had refused therapy treatments on several occasions, and there was no documentation regarding the leg braces in the therapy notes. Interviews with facility staff revealed a lack of communication and documentation regarding the leg braces. The LPN was unaware of the braces, and the Infection Preventionist confirmed there was no order or care plan for them. The Occupational Therapist reported that the braces were delivered without notice, and the resident could not tolerate them, with no documentation of physician notification. The facility's policies on assistive devices and comprehensive care plans were not followed, leading to the deficiency in care for the resident.
Failure to Administer Medication as Prescribed
Penalty
Summary
The facility failed to ensure that Resident #5 received his medication as ordered by the physician, which affected one resident out of three reviewed for medication administration. Resident #5, who had diagnoses including diabetes, pain in the leg, psychoactive substance abuse, asthma, and muscle weakness, was admitted to the facility and had intact cognition. On 07/22/24, the physician ordered pantoprazole 40 mg once daily for epigastric pain, but the order was not entered until 08/08/24, and the resident received his first dose on that date. The delay in medication administration was confirmed by interviews with the Regional Director of Clinical Services and the resident's family member, who reported that the medication was not administered for about two weeks after it was brought to the facility. Additionally, on 09/14/24, Resident #5 complained of nausea and vomiting, and the physician was notified, resulting in new orders for laboratory tests and Zofran 4 mg every six hours as needed. However, the September 2024 physician's order and Medication Administration Record revealed that Zofran was neither ordered nor administered. The Director of Nursing confirmed that no order for Zofran was written on 09/14/24, and the issue was acknowledged by the Ombudsman Supervisor, who noted that the resident and his mother had reached out to the Ombudsman due to the delay in receiving the medication. The facility's policy titled 'Administering Medications' dated 12/12 stated that medication should be administered in a safe and timely manner as prescribed. However, the facility did not adhere to this policy, as evidenced by the delay in administering pantoprazole and the lack of an order for Zofran. The Regional Director of Clinical Services confirmed that the facility was aware of the resident's physician appointments but did not follow up with the physician's office for new orders, contributing to the deficiency.
Failure to Provide Approved Therapy Services After Appeal
Penalty
Summary
The facility failed to provide therapy services to a resident after he won an appeal for additional therapy days. The resident, who had diagnoses including diabetes, leg pain, psychoactive substance abuse, asthma, and muscle weakness, was initially admitted with orders for physical and occupational therapy four times a week for four weeks. Despite being approved for additional therapy from August 6 to August 10, the resident did not receive these services. The therapy department did not resume therapy, citing that the resident did not need more therapy as he was independently walking with a walker. Interviews with facility staff revealed a lack of communication and documentation regarding the continuation of therapy services after the appeal was won. The Director of Therapy acknowledged that typically, therapy would continue for the certification period after a successful appeal, but this did not occur for the resident. The Regional Director of Operations confirmed there was no documentation indicating that the additional therapy days were solely for discharge planning, and the resident did not receive the approved therapy during this period. This deficiency was investigated under Complaint Number OH00157525.
Unsanitary Kitchen Conditions Affect Meal Service
Penalty
Summary
The facility failed to maintain the kitchen in a clean and sanitary manner, affecting 57 of 57 residents who received meals from the kitchen. During a kitchen tour, several unsanitary conditions were observed, including gnats flying around, a trash can with red and brown substances splashed on it, and a three-tiered silver cart with mixers that had dried food debris. Additionally, a trash can in the middle of the kitchen was dirty and lacked a lid, the steam table was dirty with dried food, and the shelf underneath it was dusty and dirty with food debris. The plate warmer and several three-tiered carts were also dirty with food buildup, and there was dirt and food debris on the floor of the freezer. Dietary Manager #635 confirmed these concerns during an interview, acknowledging that the steam table should be cleaned after every meal, trash cans should be cleaned and have lids, and freezers should be cleaned daily. The facility's policy, titled 'Cleaning and Sanitizing Dietary Areas and Equipment,' stated that all kitchen areas and equipment should be maintained in a sanitary manner and be free of food, grease, and other soil buildup. This deficiency was identified as an incidental finding during the investigation of a complaint.
Failure to Implement Smoking Policy
Penalty
Summary
The facility failed to implement its smoking policy, resulting in a failure to maintain a safe and clean environment. Observations were made of the resident smoking area and the side guest entrance, where numerous cigarette butts were found discarded in the mulch and on a window ledge. The administrator confirmed the presence of cigarette butts in these areas. The facility's smoking policy requires that cigarette butts and other smoking debris be discarded in designated receptacles and that staff keep the area free of debris at the end of each smoke break. This deficiency was identified during the investigation of a master complaint.
Failure to Arrange Palliative Care Consultation for Resident with Chronic Pain
Penalty
Summary
The facility failed to ensure a palliative care consultation was arranged for a resident with chronic pain, identified as Resident #24. The resident was admitted with multiple diagnoses, including osteoarthritis, spinal stenosis, and chronic pain. On May 2, 2024, a nurse discussed pain management options with the resident, who expressed interest in palliative care. A request for a palliative care referral was sent to the nurse practitioner, and a physician's order for the referral was documented on May 4, 2024. However, there was no evidence that the resident had been seen for palliative care by the time of the survey. Interviews conducted during the survey revealed that the resident continued to experience pain related to spinal stenosis and had not received any follow-up regarding the palliative care consultation. The resident mentioned that the Director of Nursing had previously discussed the possibility of palliative care, but no further action had been taken. The facility administrator confirmed that no palliative care consultation had been completed for the resident as of the survey date. This deficiency was a repeat issue from a previous complaint survey conducted on June 27, 2024.
Failure to Administer Pain Medication as Ordered
Penalty
Summary
The facility failed to ensure that pain medications were available and administered as ordered by the physician for a resident with chronic pain. The resident had a physician's order for Methadone HCl 80 mg to be taken twice daily for pain management. However, the Medication Administration Record (MAR) indicated that the resident did not receive the prescribed Methadone on several occasions in May and June 2024. Specifically, the medication was unavailable on multiple dates, and the nursing staff did not update the physician about the missed doses or the reduced dosage provided on one occasion. Interviews with the nursing staff and the resident confirmed the lapses in medication administration. The resident reported experiencing periods without her pain medication due to the nursing staff's failure to order the medications in a timely manner, although other as-needed pain medications were available. The facility's policy on administering medications, which requires medications to be administered according to the orders, was not followed. The nursing progress notes further documented the unavailability of Methadone and the lack of communication with the physician regarding these issues.
Failure to Supervise Residents with Substance Use Disorders
Penalty
Summary
The facility failed to properly identify potential risks and hazards for residents with a substance use disorder and provide adequate supervision to prevent drug overdoses. This deficiency resulted in Immediate Jeopardy and actual harm when a resident with a known substance abuse history was found unresponsive and required cardiopulmonary resuscitation (CPR) and hospitalization after a Fentanyl and Methadone overdose. Another resident with a known substance abuse history was also found unresponsive and required CPR after a drug overdose. The facility had identified 15 residents with active or current substance use disorders, ten residents with behavioral health needs, and 14 residents who participated in the facility's substance abuse program. The incidents occurred because the facility did not enforce its visitation policy, which required supervised visits for residents in the substance abuse program. On multiple occasions, residents were found unresponsive due to drug overdoses after unsupervised visits. The facility's failure to supervise these visits allowed residents to obtain and use drugs, leading to life-threatening situations. Interviews with staff revealed that the facility's substance use disorder program was not adequately enforced, and visits were not supervised as required by the facility's policy. The facility's assessment and care plans for the residents involved indicated that they had mood and behavior problems related to substance abuse and required specific interventions, including supervised visits and participation in a third-party substance abuse program. However, these interventions were not consistently implemented, leading to the overdoses. The facility's failure to conduct adequate room searches and monitor residents' conditions further contributed to the incidents. The deficiency was identified and corrected after the survey, but the lack of proper supervision and enforcement of the facility's policies led to significant harm to the residents involved.
Removal Plan
- Licensed Practical Nurse (LPN) #223 called 911 related to Resident #44.
- The Director of Nursing (DON) was notified by LPN #216 of a possible overdose of Resident #44.
- Akron City Emergency Medical Services (EMS) arrived at the facility, administered Resident #44 Narcan. MD #800 was notified, orders to monitor resident and complete tox screen. LPN #223 was asked by LPN #216 to witness an interview with Resident #61 about an incident that occurred with Resident #44. When both nurses approached Resident #61's room, they observed the resident lying face down on his floor and unresponsive. LPN #223 initiated CPR and LPN #216 went to the third floor to alert the paramedics that were already in the building.
- DON was notified by LPN #223 that Resident #61 was found unresponsive of possibly an overdose.
- The DON advised charge nurses LPN #223 and LPN #216 to complete a head count of residents and check the status of all residents. All other residents were accounted for with no concerns.
- Charge nurses LPN #223 and LPN #216 were directed to obtain statements from all staff in the building regarding the incident.
- The DON notified the Administrator two residents (#44 and #61) were found unresponsive from a possible drug overdose.
- LPN #223 notified MD #800 of Resident #61 being unresponsive.
- The DON arrived at the facility. A whole house audit was completed to ensure no other residents had been affected. The DON went to Resident #61's room to check his status. Then, DON went to the third floor to check the status of Resident #44.
- Resident #44 and Resident #61 were placed on Q 15-minute safety checks.
- The Administrator arrived at the facility.
- LPN #223 received an order from MD #800 to complete urinalysis from both residents (#44 and #61).
- The Administrator reviewed and made a copy of the visitor log with the findings of a visitor for Resident #44.
- The DON received a call from nurse LPN #223 for a change in condition for Resident #44. MD #800 was notified and 911 was called and Resident #44 was transferred to the hospital.
- RDCS #700, the Administrator and the DON reviewed staff statements, and staffing list for current day. It was determined the root cause of the drug overdose incident was a facility failure to supervise visitation per the facility substance abuse program policy.
- Education on the facility substance abuse program interventions and monitoring was initiated by the Administrator and DON for all facility staff.
- The third-party program residents were provided with their signed contracts in order to review the expectations of the contract by SS #276, the counselor from the program.
- A Quality Assessment Performance Improvement (QAPI) meeting was held with RDO #710 and MD #800 via telephone, RDCS #700, the Administrator, DON, Unit Manager/LPN #201, Medical Records (MR) #204, Admissions Director (AD) #205, Business Office Manager (BOM) #202, Human Resources (HR) #203, and Therapy Director (DOR) #720, to discuss the incidents.
- Resident #44 returned to the facility and agreed to participate in individual and case management services through the third-party program. Resident #44 had participated in the third-party program and then again began participation.
- LPN #216 notified the DON of concern for Resident #61 appearing under the influence due to resident being difficult to arouse and not acting like self. The nurse then called MD #800 and EMS to transport the resident to the hospital. EMS arrived at the facility with police due to concern of possible overdose. Staff at the facility searched Resident #61's room with police officers. Inside his notebook a folded-up bus pass was located with a black substance in it. Officers tested the substance which was positive for Fentanyl.
- Resident #61 returned to the facility after testing positive for Fentanyl in hospital.
- The facility clinical team met with SS #276 to discuss the incident that occurred involving Resident #61.
- The Administrator held a QAPI meeting to discuss the root cause of the incident and determined facility failure to conduct adequate room searches. Staff in attendance at the QAPI meeting included RDO #710 and MD #800 via telephone, RDCS #700, the Administrator, the DON, Unit Managers LPN #201 and LPN #200, MR #204, AD #205, BOM #202, HR #203, and DOR #720.
- The Administrator and RDO #710 completed room searches for all residents in the substance use disorder program with no additional negative findings. Residents were observed at this time for any changes in behaviors such as slurring of words, change in cognition, increase in agitation and avoidance of eye contact or conversation. No concerns noted at this time.
- Resident #61 discharged from the facility. The resident was given discharge instructions and summary. MD #800 was in agreement with the resident's discharge.
- RDO #710 educated the department head team which included the Administrator, the DON, Unit Managers LPN #200 and LPN #201, MR #204, AD #205, BOM #202, HR #203 and DOR #720 on the facility's substance abuse disorder program policy with emphasis on random room searches, random search of any delivered packages and supervised visitation.
- Department head (BOM #202, DON, the Administrator, HR #203, AD #205, Unit Manager/LPN #201, MR #204, Activities Director (AD) #208, and Minimum Data Set nurse (MDS) #207) education was provided regarding the substance abuse contract completed by RDO #710.
- All staff education was completed regarding the substance abuse contract by the department heads BOM #202, DON, the Administrator, HR #203, AD #205, Unit Manager/LPN #201, MR #204, AD #208 and MDS #207.
- Front desk staff receptionist (RCP) #265, RCP #266 and RCP #267 were re-educated on the process of supervised visitation by the Administrator: 1. Visitation would be conducted in the main lobby and would be supervised by the receptionist or designee. 2. In the event the phone rings during a visit, the phones would not be answered by the receptionist and would roll over to the floors. 3. If assistance was needed, notify another staff member. 4. In the event of needing to leave the desk notify another staff member to cover.
- At least once a week the administrator and clinical team meet with SS #276, the third-party counselor, on Wednesdays and as needed. During this meeting a discussion of all residents who were active with attending groups through third-party program. Discussion of the residents, discharge plans, meeting goals, progress, or any concerns such as decreased participation, changes in behaviors or at risk. The bed board was present to discuss any residents who were not active in the program for reassessment and encouragement to participate. At the time of this meeting, it would be discussed for room searches and random tox screens to be completed with the third-party program and at the facility level. Communication between the Administrator and the third-party program/counselor would be continuous and as needed if any concerns arise.
- The facility implemented a plan for the Administrator/designee to audit the visitation log, to include monitoring of the sign in book for completion and to ensure visitations five times per week for four weeks and then randomly thereafter. Discrepancies would be reviewed in QAPI and revised as needed.
- The facility implemented a plan for the Administrator/designee to audit to ensure random room searches of residents participating in the substance use disorder program were completed for three residents weekly for four weeks and then randomly thereafter. All audit findings would be submitted to QAPI for recommendations and review.
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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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