Hillside Plaza
Inspection history, citations, penalties and survey trends for this long-term care facility in Cleveland, Ohio.
- Location
- 18220 Euclid Ave, Cleveland, Ohio 44112
- CMS Provider Number
- 365006
- Inspections on file
- 27
- Latest survey
- September 8, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Hillside Plaza during CMS and state inspections, most recent first.
A resident with multiple complex conditions did not have medication administration consistently documented in the MAR, with numerous blank entries for various medications over two months. Nursing staff later confirmed they had administered the medications but failed to sign off at the time, only completing documentation after being prompted by facility leadership. Facility policy requires immediate documentation after administration, which was not followed in these instances.
Surveyors found the kitchen unsanitary, with an empty soap dispenser at the hand washing station, dried food bits and spills on the floor, and grubby surfaces on equipment and counters. Dietary staff confirmed that cleaning had not been done as required, and the facility's policy called for regular cleaning and sanitizing of kitchen areas. All residents receiving meals from the kitchen were potentially affected.
A resident with severe cognitive impairment and immobility developed an open area on the right inner heel that was not identified or treated promptly due to missed weekly skin assessments and lack of communication among staff. The wound was only discovered during incontinence care, and documentation of required skin assessments was absent, despite records indicating they were completed. The facility's policy for daily skin visualization and risk assessment was not followed, leading to delayed recognition and treatment of the wound.
A resident with ESRD and multiple comorbidities did not receive immediate assessment or documentation of her dialysis access site for bleeding or complications upon return from dialysis. Despite physician orders and facility policy requiring post-dialysis evaluation, staff only checked the site later in the shift, and the required documentation was missing.
A resident with a history of atrial fibrillation and heart failure did not receive a scheduled dose of Flecainide Acetate because the medication could not be found in the med cart. An LPN was unable to administer the medication or recall if the cardiology service was contacted. The medication was later found in an inconspicuous location, but not in time for the scheduled administration. The resident was cognitively intact and required some assistance with daily activities.
A deficiency was found when an LPN failed to perform hand hygiene after picking up dropped medications from the floor and before administering replacement medications to a resident with multiple health conditions. Additionally, a CNA providing incontinence care to another resident placed soiled linens and briefs directly on the floor instead of in a proper container, leaving them there during care. Both actions were contrary to facility policy on infection prevention and control.
The facility failed to update care plans for two residents with new fall prevention interventions. A resident with kidney failure and CHF fell from bed, but recommended interventions like a floor mattress and safety checks were not added to the care plan. Another resident with breast cancer and diabetes fell, and despite refusing non-skid socks and call light use, the care plan was not updated with these refusals or a new tab alarm intervention. The facility's policy required care plan updates, but this was not followed.
The facility failed to implement fall prevention interventions for two residents, leading to deficiencies in their care. A resident experienced an unwitnessed fall due to missing interventions like a floor mattress and safety checks. Another resident lacked non-skid strips and had a walker out of reach, despite physician orders and care plan interventions. Staff confirmed these oversights, indicating a lapse in following the facility's fall prevention policy.
A facility failed to change a resident's oxygen tubing weekly as ordered by the physician. The resident, with a history of kidney failure, CHF, and stroke, required oxygen due to ineffective breathing patterns. Despite the care plan and physician's orders, the tubing was not changed for three weeks. A nurse confirmed the oversight, which was against the facility's policy.
A resident reported discomfort with incontinence care provided by a CNA, but the LTC facility failed to promptly report, investigate, and remove the CNA from duty as per their abuse policy. The facility did not notify the Ohio Department of Health or law enforcement immediately, and the investigation was delayed, leading to a deficiency.
A resident reported improper incontinence care by a male CNA, describing it as degrading. Despite the report, the facility delayed investigating and did not immediately remove the CNA from providing care, contrary to its abuse policy. The investigation was initiated weeks later after corporate involvement, revealing inconsistencies in handling the incident.
The facility's QAPI committee failed to meet quarterly with the required members, including the medical director or designee. A review of sign-in sheets showed that while the medical director attended a meeting in March, they or a designee were absent in June, and a nurse practitioner attended as a designee in August. The facility's policy did not specify required members, and the absence of documentation was confirmed by the Administrator. This deficiency was found during a complaint investigation.
A resident with multiple health conditions experienced a significant drop in blood pressure, but the LPN administered morning medications without notifying the physician or nurse practitioner. The nurse practitioner indicated that the low blood pressure required physician notification and potential medication adjustments. The facility's policy lacked specific guidelines on when to notify physicians, contributing to the oversight.
A facility failed to promptly report an allegation of staff-to-resident sexual abuse involving a resident with COPD, diabetes, and spinal stenosis. The incident occurred during incontinence care, and despite the resident's discomfort, the facility did not report the incident to the Ohio Department of Health, local police, or the resident's physician until weeks later. Interviews revealed discrepancies in handling the incident, with concerns about thoroughness due to the CNA's relation to the Administrator.
The facility failed to ensure call lights were within reach for two residents, both at risk for falls and dependent on staff for assistance. Observations revealed that one resident's call light was ten feet away on another bed, while another's was on a nightstand out of reach. Interviews confirmed these findings, violating the facility's policy.
A facility failed to administer oxygen per physician orders and lacked appropriate signage for oxygen use. A resident with COPD and CHF received 4.5 liters of oxygen instead of the ordered three liters. Additionally, there was no signage indicating oxygen use in the resident's room or the central supply room where oxygen cylinders were stored. The DON confirmed these discrepancies, which violated the facility's policy.
A facility failed to implement proper infection control measures, including the use of Enhanced Barrier Precautions (EBP) for a resident with a pressure wound. An LPN did not wear a gown during high-contact care and carried medications against her chest, risking cross-contamination. Additionally, a blood pressure monitor was not cleaned between uses on two residents, and a bedpan was stored unsanitarily on the floor. The facility lacked specific policies addressing these issues.
Failure to Timely Document Medication Administration
Penalty
Summary
The facility failed to ensure timely and accurate documentation of medication administration for one resident out of three reviewed. The resident in question had multiple complex diagnoses, including osteomyelitis, spinal cord injury, sepsis, and paraplegia, and was cognitively intact. Review of the resident's electronic Medication Administration Record (MAR) for July and August revealed numerous instances where medications were not signed as administered, leaving blank spaces for several medications across multiple dates. Further investigation showed that the corresponding printed MARs for July had manual initials added after the fact, and the electronic MARs for August were signed off electronically at a much later date. Interviews with nursing staff and facility leadership confirmed that medications had been administered but were not documented at the time of administration. Staff reported forgetting to sign off on the MARs and later completed the documentation after being approached by facility management. Facility policy requires that the individual administering medications must record the administration directly after giving the medication and review the MAR at the end of each pass to ensure all doses are documented. The policy also states that no staff should leave duty without recording all medication administrations. The failure to document medication administration as required by policy and professional standards led to the identified deficiency.
Unsanitary Kitchen Conditions and Inadequate Cleaning Practices
Penalty
Summary
Surveyors observed that the facility failed to maintain a sanitary kitchen environment, as required by professional standards and facility policy. During an inspection, the soap dispenser above the hand washing station was found to be empty, and a dietary aide indicated that housekeeping would need to refill it. Further observation of the kitchen revealed dried food bits and multiple dried, dark brown and clear, sticky fluid spills on the floor. Metal counters, meal carts, shelves, and the doors and sides of the freezer, cooler, and oven were covered with whitish drip marks and what appeared to be dried food and liquid smudges, making all surfaces appear grubby. Interviews with dietary staff confirmed the unsanitary conditions, with one aide stating she had just arrived for work and could tell that no cleaning had been done the previous day. The dietary manager, who had only recently started working at the facility, also confirmed the kitchen was not clean and acknowledged the need for improvement. Review of the facility's undated policy on food preparation and storage indicated that the kitchen was to be kept neat and orderly, with surfaces and equipment cleaned and sanitized as appropriate. All 43 residents who received meals from the kitchen had the potential to be affected by these unsanitary conditions.
Failure to Timely Identify and Treat Resident's Open Heel Wound
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, hemiplegia, and total dependence for mobility and personal care developed an open area on the right inner heel that was not identified or treated in a timely manner. The resident's care plan included risk factors for skin breakdown and interventions such as regular Braden scoring and assistance with turning and repositioning, but did not specify weekly skin assessments or prompt reporting of skin abnormalities to a physician. Physician orders required weekly skin assessments, but documentation of these assessments was missing, despite the Treatment Administration Record indicating they were completed. Direct observation revealed the open area on the resident's right inner foot, which had a dark reddish-brown wound bed and clear tissue covering it. The CNA providing care was aware of the wound but did not report it, assuming nurses already knew. The LPN who observed the wound did not notify the assigned nurse. Further interviews with nursing staff and the DON confirmed that the assigned nurse and DON were unaware of the wound, and no one had communicated its presence. The wound was later assessed by the wound nurse practitioner, who described it as an abrasion with granulation tissue and mild maceration, and a treatment was subsequently initiated. Review of the resident's medical record, progress notes, and shower sheets showed no documentation of the wound or evidence that the required weekly skin assessments were performed. The facility's skin care policy required daily visualization of residents' skin and risk assessment using the Braden Scale, but these procedures were not followed for this resident, resulting in a failure to identify and treat the wound in a timely manner.
Failure to Immediately Assess Dialysis Access Site Post-Treatment
Penalty
Summary
The facility failed to ensure that a resident who was dependent on hemodialysis received comprehensive assessments of her dialysis access site immediately after returning from dialysis treatments. Review of the resident's medical record and dialysis communication forms over a period of several months showed no evidence of immediate monitoring or documentation of the access site for bleeding or other complications upon return from the dialysis center. Although physician orders required completion of dialysis assessment forms before and after dialysis, as well as shunt assessments every shift, there was no documentation that the access site was evaluated right after the resident's return to the facility. Interviews with the Director of Nursing and Clinical Service Manager confirmed that while nurses were checking the resident's shunt during the shift, there was no evidence of an immediate post-dialysis assessment as required. The facility's policy stated that the Dialysis Communication Form should be completed each time the resident had dialysis, but the form lacked documentation of the resident's status immediately after returning from treatment. The resident involved had multiple diagnoses, including end-stage renal disease, diabetes, and cardiac conditions, and required assistance with activities of daily living.
Missed Dose of Cardiac Medication Due to Medication Unavailability
Penalty
Summary
A deficiency occurred when a resident with a history of paroxysmal atrial fibrillation, pneumonia, and chronic diastolic heart failure did not receive a scheduled dose of Flecainide Acetate 50 mg, an antiarrhythmic medication ordered to be administered twice daily. The medication was not given as ordered on the evening of 03/11/25 because it could not be located in the medication cart. The nurse on duty was unable to find the medication, did not administer it, and could not recall if the resident's cardiology service was contacted. The nurse stated the medication was eventually found in an inconspicuous place in the cart, but not in time for the scheduled dose. Documentation indicated that the pharmacy was contacted after the missed dose, and the supervisor was notified, but the medication could not be reordered by the nurse at that time. The resident's care plan identified her as being at risk for decreased cardiac output and abnormal lab values related to her cardiac conditions, with interventions including medication administration as ordered and monitoring for cardiac symptoms. The resident was cognitively intact and required some assistance with activities of daily living. Interviews with staff confirmed the missed dose and the importance of the medication, although the nurse practitioner felt that missing a single dose would not likely cause immediate harm. The facility's review determined that only one dose was missed, and the medication was subsequently located.
Failure to Follow Infection Control Practices During Medication Administration and Incontinence Care
Penalty
Summary
A deficiency was identified when a Licensed Practical Nurse (LPN) failed to follow proper infection control practices during medication administration for a resident with organ-limited amyloidosis, vascular dementia, and acute kidney failure. The LPN prepared the resident's medications, and when two pills were dropped on the floor, she picked them up with her bare hands and discarded them. Without performing hand hygiene, she proceeded to open the medication cart, prepare replacement medications, and administer them to the resident, all without washing her hands or using hand sanitizer at any point during the process. The LPN confirmed in an interview that she did not perform hand hygiene after handling the dropped pills or before handling the medication cart and administering the medications. Another deficiency was observed during incontinence care for a resident with anoxic brain damage, benign intracranial hypertension, hemiplegia, and hemiparesis, who was dependent on staff for all activities of daily living and was always incontinent. A Certified Nursing Assistant (CNA) providing care threw the resident's soiled bed linens, towels, and urine-saturated incontinence brief directly onto the floor instead of placing them in a plastic bag or appropriate container. The soiled items remained on the floor during care, and the CNA acknowledged in an interview that this action could cause cross contamination. Facility policy requires hand hygiene before and after direct resident contact, before handling medications, and after handling soiled linens, but these procedures were not followed.
Failure to Update Care Plans for Fall Interventions
Penalty
Summary
The facility failed to update care plans with new interventions for falls for two residents. Resident #1, who was admitted with conditions such as kidney failure and congestive heart failure, experienced an unwitnessed fall from bed. Although new interventions like placing a mattress on the floor and conducting 30-minute safety checks were recommended, these were not added to the resident's care plan. An observation confirmed the absence of the mattress in the resident's room, and the Director of Nursing acknowledged the oversight. Resident #29, with a history of breast cancer and diabetes, also experienced an unwitnessed fall. Despite multiple refusals to wear non-skid socks or use the call light, the care plan was not updated to reflect these refusals or the new intervention of adding a tab alarm while in bed. The facility's policy required care plans to be updated as needed, but this was not adhered to, as confirmed by the Administrator.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to implement fall prevention interventions for two residents, leading to deficiencies in their care. Resident #1, who was at risk for falls due to an unstable health condition, experienced an unwitnessed fall from bed. Despite recommendations from a fall review to place a mattress on the floor and conduct 30-minute safety checks, these interventions were not added to the resident's care plan, nor were they observed in practice. The Director of Nursing confirmed the absence of these interventions, indicating a lapse in updating the care plan and implementing necessary safety measures. Similarly, Resident #29, who had a history of falls and was at high risk, did not have non-skid strips on the floor as ordered by the physician. Additionally, the resident's walker was not within reach, contrary to the care plan's interventions. These oversights were confirmed by staff interviews, highlighting a failure to adhere to physician orders and care plan interventions designed to prevent falls. The facility's policy on falls emphasized the need to evaluate, document, and revise care plans to prevent further incidents, which was not adequately followed in these cases.
Failure to Change Oxygen Tubing as Ordered
Penalty
Summary
The facility failed to ensure that oxygen tubing was changed as ordered for a resident, which was identified during a survey. The medical record review for a resident revealed an admission with diagnoses including kidney failure, congestive heart failure, and a history of stroke. The resident was moderately cognitively impaired and required assistance with daily activities. The care plan indicated the resident had ineffective breathing patterns and required oxygen administration per physician's orders. However, the physician's order to change the oxygen tubing weekly was not followed, as the tubing in use was dated three weeks prior to the observation. A registered nurse confirmed the tubing should have been changed weekly, as per the facility's policy on oxygen administration.
Failure to Enforce Abuse Policy and Investigate Allegation
Penalty
Summary
The facility failed to enforce its abuse policy by not promptly reporting an allegation of abuse, not immediately investigating the allegation of staff-to-resident abuse, and not ensuring the alleged perpetrator was removed from providing direct care to residents. This incident involved a resident who reported improper incontinence care by a CNA. The resident, who had diagnoses including COPD, diabetes, and spinal stenosis, expressed discomfort with the way the CNA provided care, but did not initially describe the incident as abusive. The facility's investigation was delayed, and the CNA continued to work with residents after the allegation was made. Witness statements and interviews revealed inconsistencies in the accounts of the incident, with some staff members unaware of any allegations and others reporting that the resident felt uncomfortable with the care provided. The facility did not report the incident to the Ohio Department of Health or local law enforcement immediately, as required by their policy. The facility's abuse policy mandates immediate reporting of all allegations to the administrator and the Ohio Department of Health, as well as the removal of the accused staff member from the facility pending investigation. However, the facility did not adhere to these procedures, resulting in a deficiency. The investigation was not completed within the required timeframe, and key witness statements were not obtained, contributing to the non-compliance finding.
Failure to Investigate and Protect Resident from Alleged Abuse
Penalty
Summary
The facility failed to immediately investigate and implement protective measures upon receiving an allegation of staff-to-resident abuse. This involved a resident who had reported improper incontinence care by a male Certified Nursing Assistant (CNA). The resident, who had intact cognition and was dependent on staff assistance, expressed discomfort with the way the CNA provided care, describing it as degrading. Despite the resident's report, the facility did not document the allegation in the nursing notes, and the CNA continued to work in the facility for several weeks before being suspended. The facility's investigation into the incident was delayed, and the alleged perpetrator was not removed from providing direct care immediately, as required by the facility's abuse policy. The Director of Nursing (DON) and the Administrator were informed of the incident, but the investigation was not initiated until several weeks later, after the allegation was reported to corporate. During this time, the CNA continued to work on both the men's and women's units, potentially affecting all residents in the facility. Interviews with staff and the resident revealed inconsistencies in the reporting and handling of the incident. The resident's daughter and other staff members corroborated the resident's account of feeling uncomfortable with the care provided. However, the facility's administration did not perceive the incident as abuse initially, and the investigation was not thorough. The facility's policy required immediate removal of the accused staff member and a comprehensive investigation, which was not adhered to, leading to a deficiency in handling the abuse allegation.
QAPI Committee Lacks Required Members
Penalty
Summary
The facility failed to ensure that the Quality Assurance Performance Improvement (QAPI) committee met at least quarterly with the required members, including the medical director or their designee. The review of QAPI sign-in sheets from October 2023 to August 2024 revealed that while a meeting was held in March 2024 with the medical director present, a subsequent meeting in June 2024 did not have the medical director or a designee in attendance. Another meeting in August 2024 was attended by a nurse practitioner as the medical director's designee. There was no documented evidence of a QAPI meeting with the medical director or designee from March to August 2024, a period exceeding five months. An interview with the Administrator confirmed the absence of such documentation. Additionally, the facility's policy on Quality Assurance Performance Improvement, dated July 2024, did not specify the required members for these meetings, including the medical director or designee. This deficiency was identified during a complaint investigation.
Failure to Notify Physician of Change in Resident's Condition
Penalty
Summary
The facility failed to notify the physician or designee regarding a change in condition for Resident #13, who was admitted with diagnoses including chronic obstructive pulmonary disease, hypertension, congestive heart failure, and oxygen dependence. The resident's blood pressure readings from 10/24/24 to 11/07/24 showed a significant drop on 11/07/24 to 72/55, which was later rechecked and found to be 96/56 with a heart rate of 56. Despite this low blood pressure, LPN #604 administered the resident's morning medications, which included several that could further affect blood pressure and heart rate, without consulting the physician or nurse practitioner. The nurse practitioner, who was familiar with the resident, indicated that the low blood pressure warranted physician notification and potential adjustments to the medication regimen, such as holding certain medications and conducting further assessments. The Director of Nursing confirmed that the LPN should have contacted the physician before administering the medications. The facility's policy on notifying physicians of changes in a resident's condition lacked specific guidelines on when to notify, contributing to the oversight. This deficiency was identified during an investigation under Master Complaint Number OH00159487.
Failure to Report Alleged Abuse in a Timely Manner
Penalty
Summary
The facility failed to promptly report an allegation of staff-to-resident sexual abuse involving a resident with chronic obstructive pulmonary disease, diabetes, and spinal stenosis. The incident occurred when a CNA was providing incontinence care, and the resident expressed discomfort with the manner in which the care was provided. Despite the resident's report of discomfort and the involvement of multiple staff members, the facility did not report the incident to the Ohio Department of Health, local police, or the resident's physician until several weeks later. The incident was initially reported by a CNA who witnessed the resident's discomfort and reported it to the Director of Nursing (DON) and the Administrator. However, the facility did not take immediate action to report the incident as required by their abuse policy. The resident later described the incident as uncomfortable but did not label it as sexual abuse. Despite this, the facility's policy required all allegations of abuse to be reported immediately, which was not done in this case. Interviews with staff revealed discrepancies in the handling of the incident, with some staff members feeling that the incident was not thoroughly investigated due to the CNA involved being related to the Administrator. The facility's failure to report the incident promptly and conduct a thorough investigation led to a deficiency being cited under Complaint Number OH00159263.
Failure to Ensure Call Lights Within Reach
Penalty
Summary
The facility failed to ensure that call lights were within reach for two residents, which was identified during a survey. Resident #36, who had diagnoses including chronic obstructive pulmonary disease, diabetes, and paranoid schizophrenia, was observed lying in bed without a call light within reach. Her care plan indicated she was at risk for falls due to impaired mobility and required the call light to be accessible. Despite having intact cognition and being dependent on staff for most care activities, her call light was found on the other bed in her room, approximately ten feet away, making it inaccessible. Similarly, Resident #33, with diagnoses of arthritis and hypertension, was also found without her call light within reach. Her care plan noted she was at risk for falls and required assistance with daily activities. During observation, her call light was placed on her nightstand, out of her reach. Interviews with the residents and staff confirmed these findings. The facility's policy required call lights to be within reach, but this was not adhered to, leading to the deficiency being noted.
Oxygen Administration Deficiency
Penalty
Summary
The facility failed to administer oxygen according to physician orders and did not provide appropriate signage indicating oxygen use for a resident. Resident #13, who had diagnoses including chronic obstructive pulmonary disease (COPD) and congestive heart failure (CHF), was observed receiving 4.5 liters per minute of oxygen via nasal cannula, contrary to the physician's order of three liters per minute. Additionally, there was no signage outside the resident's room indicating oxygen was in use, which is a requirement according to the facility's policy. Further observations revealed that an LPN removed an oxygen e-cylinder from the resident's room and stored it in a central supply room without appropriate signage indicating the presence of oxygen. The Director of Nursing confirmed the discrepancy in the oxygen administration and the lack of signage, acknowledging that the central supply room was being used for oxygen storage without her knowledge. The facility's policy mandates checking physician orders for oxygen administration and placing signs where oxygen is in use, which was not adhered to in this instance.
Infection Control and Equipment Sanitation Deficiencies
Penalty
Summary
The facility failed to implement proper infection control measures, particularly in the use of Enhanced Barrier Precautions (EBP) for Resident #13, who had a coccyx pressure wound. Despite a care plan indicating the need for EBP, a Licensed Practical Nurse (LPN) did not wear a gown during high-contact care activities, such as repositioning and transferring the resident. The LPN also carried medications against her chest, potentially causing cross-contamination, and admitted to not being informed of any contagious disease in Resident #13, despite the presence of a sign indicating EBP was required. Additionally, the facility did not ensure proper cleaning of medical equipment between resident uses. An LPN used an electric blood pressure monitor on two residents without cleaning the cuff and monitor between uses, which was confirmed by the LPN and the Director of Nursing (DON). The facility's policy did not specifically address the cleaning of blood pressure cuffs and monitors between residents, contributing to this oversight. The facility also failed to store a bedpan in a sanitary manner for Resident #35, who was dependent on staff for toileting hygiene. The bedpan was observed lying uncovered on the bathroom floor, which was verified by a Certified Nursing Assistant (CNA) and the DON. The facility lacked a policy on bedpan storage, and the DON acknowledged that bedpans should be stored in a bag, not directly on the floor.
Latest citations in Ohio
Surveyors found that multiple hazardous storage areas, including a closet near medical records, a beauty salon used to store chemical cases, a supply room in one nursing station, a room leading to a smoking area, a housekeeping room near therapy, and a lobby storage room, lacked required self-closing or automatic-closing doors. These conditions did not comply with NFPA 101 requirements for hazardous area enclosure and had the potential to affect all residents and staff in an emergency.
Surveyors found that the facility did not conduct fire drills on every shift each quarter and did not vary drill conditions as required by NFPA 101. Record review showed that one shift lacked a documented drill for an entire quarter, and the pattern of drill times and dates did not demonstrate varied conditions. The Maintenance Director confirmed the incomplete and noncompliant fire drill schedule, which affected all residents and staff emergency preparedness.
Surveyors found that the facility did not maintain clear egress corridors as required by NFPA 101, with a TV/video cart plugged into a corridor outlet and multiple unsecured chairs placed in the hallway near resident rooms and the secured unit dining room, including directly in front of a fire extinguisher. These items projected about 29 inches into an approximately eight-foot-wide corridor and were located in front of the handrail, potentially affecting 28 residents and staff’s ability to assist in an emergency. The Maintenance Director confirmed these corridor obstructions during the survey.
A resident with intact cognition receiving Medicare Part A skilled services for metabolic encephalopathy had services discontinued while benefit days remained, but the facility did not issue the required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN). The Social Services Director later confirmed that no SNF ABN was provided and reported she believed only a Notice of Medicare Non-Coverage (NOMNC) was needed when all skilled services were stopped. This practice conflicted with the facility’s written policy, which required SNF ABNs to be issued when extended care items or services were initiated, reduced, or terminated due to expected non-coverage by Medicare.
Surveyors identified that the facility exceeded the acceptable medication error rate when two residents with type 2 DM received insulin doses that were not administered according to orders or manufacturer instructions. In two separate observations, an LPN administered Novolog and another LPN administered insulin glargine and insulin lispro without priming the insulin pens, and the insulin lispro and Novolog were given after the residents had already consumed a significant portion of their breakfast meals, despite orders for administration before meals. Manufacturer information for both insulin products required priming before each injection to ensure accurate dosing, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and specified time frames.
The facility failed to maintain accurate and complete crash cart audits for multiple full-code residents. Surveyors, accompanied by the DON, found that daily crash cart checks did not include verification of supply expiration dates, and that an extension cord documented as present on several audit dates was not actually in the cart. Audit logs also conflicted with the cart’s contents by indicating that required items such as eye protection, saline, and clear plastic were present when they were not. These findings were inconsistent with the facility’s policy requiring the crash cart to be checked every 24 hours and after each use, with prompt replacement of equipment and supplies.
A resident with chronic respiratory failure on supplemental O2, COPD, and cognitive risk factors was repeatedly documented as non-compliant with the smoking policy, including going out to smoke outside designated times and retaining cigarettes and lighters provided by family. Despite prior assessments identifying this resident as unsafe to smoke without supervision, a later assessment classified the resident as safe to smoke independently without documented rationale or care plan update. The resident subsequently went outside alone with an O2 nasal cannula in place, lit a cigarette, and sustained facial burns when the cannula ignited, as observed by staff and confirmed by EMS and ED records. In a separate case, another cognitively impaired resident with a history of falls had a care-planned intervention for non-skid strips in front of a recliner, but observation and staff confirmation showed the strips were not present, despite remaining on the active fall-risk care plan.
Multiple dependent residents did not receive scheduled showers, bed baths, or shaving as outlined in their care plans and the facility’s routine care policy. One resident recovering from spinal surgery missed numerous scheduled showers over several months. Another resident who relied on staff for self-care repeatedly requested shaving but was not shaved, and visible facial hair was observed after a recent shower. A resident with chronic respiratory failure and a tracheostomy, requiring substantial/maximal assist with personal hygiene, had no documented showers for an extended period and was observed with long facial hair, which staff acknowledged should be removed during bathing or as needed. A cognitively impaired resident with ESRD and CHF, scheduled for twice-weekly showers, had multiple undocumented or missed showers and reported not getting showers despite asking aides who said they lacked time. Another cognitively intact resident with hemiplegia and multiple comorbidities, also scheduled for twice-weekly showers, had several dates where documentation showed no shower/bath/bed bath provided or no entry at all, and she reported feeling unclean and unimportant when her showers were missed.
A resident with an indwelling urinary catheter for urinary retention, and care plan interventions requiring the drainage bag to be properly secured with a dignity cover, was observed seated in a chair with the catheter drainage bag uncovered and containing visible dark yellow urine that could be seen from the hallway. Later, an LPN confirmed the catheter bag was lying directly on the floor without a dignity cover. This situation occurred despite facility policy requiring care to be provided in a manner that respects and enhances each resident’s dignity and personal privacy.
A cognitively intact resident with chronic orthopedic pain had a PRN oxycodone order, but multiple doses were signed out on the narcotic log by an RN without corresponding entries on the MAR or documented pain assessments. A CNA/med tech reported frequent problems with this RN’s narcotic counts and documentation, describing erratic behavior when handling narcotic keys. The resident reported taking oxycodone only once or twice daily and otherwise using Tylenol, which conflicted with the number of oxycodone doses signed out. The facility’s investigation found it was inconclusive whether narcotics were misappropriated or whether there was a failure of documentation, but confirmed there was no evidence that all signed-out doses were administered.
Failure to Maintain Self-Closing Doors for Multiple Hazardous Storage Areas
Penalty
Summary
Surveyors identified a deficiency related to hazardous area protection and door requirements under NFPA 101, 2012 Edition. During facility tours, they observed that multiple hazardous storage areas did not have self-closing or automatic-closing doors as required for hazardous areas such as combustible storage and chemical storage. These areas included a closet next to medical records, a beauty salon being used to store cases of chemicals, a supply room in Station #2, and the room leading to the smoking area in Station #3. On a subsequent tour, surveyors observed additional hazardous areas without self-closing doors. The housekeeping room across from therapy and the lobby storage room were both noted to lack self-closing door mechanisms. The facility census at the time was 59 residents, and the surveyors stated that this deficient practice had the potential to affect all residents and staff's ability to assist in an emergency. The Maintenance Director verified these findings at the time they were observed.
Plan Of Correction
K 0321 This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be admissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as its allegation of substantial compliance as of 06/12/2026 K-0321 Doors with Self-Closing Devices Corrective action for resident/s: 1. The closet door next to medical records was lacking a self-closing door on 5/19/2026. Maintenance director to add self-closing device to closet door next to medical records on or before 06/12/2026 in accordance with applicable code. 2. The beauty salon had chemicals stored in it on 5/19/2026. Maintenance director moved chemicals from beauty salon on 05/20/2026 in accordance with applicable code. 3. The supply room on station 2 was lacking a self-closing door on 5/19/2026. Maintenance director to add self-closing door to supply room on station 2 on or before 06/12/2026 in accordance with applicable code. 4. The room to the smoking area on station 3 was lacking a self-closing door on 5/19/2026. Maintenance director to add a self-closing door to the smoking are on station 3 on or before 06/12/2026 in accordance with applicable code. 4. The housekeeping room across from therapy was lacking a self-closing door on 5/19/2026. Maintenance director to add a self-closing door to the housekeeping room across from therapy gym on or before 06/12/2026 in accordance with applicable code. 5. The lobby storage room was lacking a self-closing door on 5/19/2026. Maintenance director to add a self-closing door to the lobby storage room on or before 06/12/2026 in accordance with applicable code. Identification of other residents who may be affected: LNHA and Maintenance director/designee completed a full facility audit for doors with self-closing devices on 05/26/2026. Any corrective action, including, doors identified as needing self-closures will be added on or before 06/09/2026 in accordance with applicable code. Measures for systemic change: LNHA educated Maintenance Director on 05/26/2026 regarding NFPA 101-2012 sections 19.3.2.1 and 19.3.5.9 specifically regarding doors with self-closing devices. How Corrective Action will be monitored Ongoing "Doors with Self-Closing device audit" to be completed weekly x 2 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 06/12/2026
Failure to Conduct Required Quarterly Fire Drills on All Shifts
Penalty
Summary
The facility failed to conduct fire drills in accordance with NFPA 101, 2012 Edition, sections 19.7.1 through 19.7.1.8, specifically by not holding drills every shift each quarter and not varying drill conditions as required. Record review on 06/09/25 at approximately 10:32 A.M. showed there was no fire drill conducted for the first shift during the third quarter. The documented first-shift fire drills occurred on 01/30/26 at 2:42 P.M., 04/30/26 at 1:51 P.M., and 10/31/25 at 10:58 A.M., indicating a missed quarter. Second-shift fire drills were recorded on 02/26/26 at 5:20 P.M., 06/03/25 at 4:35 P.M., 08/29/25 at 3:46 P.M., and 11/25/25 at 5:09 P.M., and third-shift drills on 02/28/26 at 11:47 P.M., 05/30/25 at 12:18 A.M., 07/22/25 at 11:34 P.M., 09/26/25 at 11:40 P.M., and 12/15/25 at 5:17 A.M. The surveyor determined that drills were not conducted under varied conditions and that the required quarterly drill on each shift was not consistently performed. The Maintenance Director confirmed these findings at the time they were identified, and the deficiency had the potential to affect all 59 residents and staff response in an emergency. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency related to facility-wide emergency preparedness practices and documentation of fire drills.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 05/29/2026 K-0712 Fire Drills Corrective action for resident/s: There were no records of a fire drill for the first shift of the third quarter of 2025. First shift fire drill completed on 5/24/2026 by maintenance director/designee with no findings or corrective action necessary. Identification of other residents who may be affected: On 5/26/2026 Maintenance director/designee completed 100% audit of the scheduled fire drills to ensure a drill is scheduled quarterly each shift with no findings or corrective action necessary. Measures for systemic change: LNHA educated Maintenance Director on 05/26/2026 regarding NFPA 101-2012 section 19.7.1.4 through 19.7.1.7. specifically including fire drill frequency requirements. How Corrective Action will be monitored Ongoing "Fire Drill Audit" to be completed weekly x 2 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 05/29/2026
Obstructed Egress Corridors Due to Equipment and Chairs
Penalty
Summary
The facility failed to maintain required clear egress widths in corridors in accordance with NFPA 101, 2012 Edition, sections 19.2.3.4 through 19.2.3.5 and 7.3.2 through 7.3.2.3, creating projections into the egress corridor that exceeded allowable limits. Surveyors observed that on one day in Station #3, a cart with a television and video equipment was plugged into an outlet in the corridor by room 38, and five activity room chairs were placed in the corridor near the secured unit dining room directly in front of a fire extinguisher. On the following day, surveyors again observed chairs in the Station #3 corridor, with four by room 35 and four by the activities room, and the same television cart still in the corridor; the chairs were not secured. The corridor was approximately eight feet wide, and the projections extended approximately 29 inches into the corridor in front of the handrail. These conditions had the potential to affect 28 residents in the facility and the staff’s ability to assist in an emergency, and the Maintenance Director confirmed the observations at the time of discovery. No specific resident medical histories or conditions were described in the report, only that 28 residents were potentially affected and the facility census was 59.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be subsequent remedial measures and should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 05/29/2026 K-0232 Clear path of egress Corrective action for resident/s: 1. On 05/18/2026 station 3 had a cart with a television parked in the corridor by room 38 that exceeded allowable limits. Maintenance director/designee moved the TV cart into the activity room, out to the corridor on 05/18/2026 in accordance with applicable code. 2. On 5/18/2026 station 3 had 5 chairs in the corridor near the dining room directly in front of the fire extinguisher. Maintenance director/designee moved the chairs into the dining room, out of the corridor on 5/18/2026 in accordance with applicable code. 3. On 5/19/2026 station 3 had 4 chairs by the activity room and 4 by room 35. In addition, the TV cart was in the corridor. The maintenance director/designee moved the chairs and TV cart into the dining room, out of the corridor on 5/19/2026 in accordance with applicable code. Identification of other residents who may be affected: Maintenance director/designee completed a 100% facility audit for clear paths of egress on 5/26/26 with no findings or corrective action necessary. Measures for systemic change: Maintenance Director/designee educated staff on 5/26/2026 regarding NFPA 101-2012 section 19.2.3.4 and 19.2.3.5 specifically including maintaining a clear path of egress. How Corrective Action will be monitored Ongoing "Path of Egress Audit" to be completed weekly x 2 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 05/29/2026
Failure to Issue Required SNF ABN When Discontinuing Medicare Part A Services
Penalty
Summary
The deficiency involves the facility’s failure to issue a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) when Medicare Part A services were discontinued for a resident who still had available benefit days. The resident was admitted with a diagnosis of metabolic encephalopathy and had intact cognition per the Minimum Data Set assessment. The facility’s own SNF Beneficiary Notification Review documented that Medicare Part A skilled services began on 02/11/26 and the last covered day was 03/11/26, and that the facility initiated discharge from Medicare Part A services before the resident’s benefit days were exhausted. Despite this, no SNF ABN was provided to the resident or the resident’s representative. During interviews, the Social Services Director stated that the SNF ABN was issued hours prior to the last covered day but, upon reviewing her files, confirmed that no SNF ABN had actually been issued for this resident. She further explained that she believed an SNF ABN was only required if one skilled service remained and that if all skilled services were being discontinued, only the Notice of Medicare Non-Coverage (NOMNC) needed to be issued. The Administrator, however, stated that a resident should always receive both a SNF ABN and a NOMNC when Medicare Part A services are discontinued and benefit days remain. Review of the facility’s written policy dated 03/28/23 showed that the facility was required to issue SNF ABNs for initiation, reduction, or termination of extended care items or services when Medicare payment was not expected, which did not occur in this case.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as its allegation of substantial compliance as of 05/29/2026 F-0582 Corrective action for resident/s: On 5/14/26 Resident #34 was informed of rights and responsibilities related to Advanced Beneficiary Notice and voiced understanding of information for future reference by administrator. Identification of other residents who may be affected: Any resident receiving skilled services from nursing or therapy services. The Administrator audited all residents who were discharged from skilled services in the past 30 days to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary Notice on 5/29/26. No non-compliance was noted. Measures for systemic change: On 5/14/2026 Business Office Manager, Director of Rehab, Minimum Data Set nurse, Director of Nursing and Social Services Director were educated on proper procedure of issuing of Notice Of Medicare Non Coverage and Advanced Beneficiary Notice by administrator. All upcoming discharges from skilled services will be reviewed weekly at Utilization Review meeting to ensure notices will be delivered timely. How Corrective Action will be monitored: Administrator or designee to complete audits of all residents being discharged from skilled services to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 5/29/26
Insulin Administration Errors and Failure to Prime Insulin Pens
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5%, with surveyors identifying 3 errors out of 28 medication administration opportunities, resulting in a 10.71% error rate. For one resident with type 2 diabetes mellitus and moderate cognitive impairment, the physician’s order directed Novolog insulin 10 units via subcutaneous pen-injector to be given before meals. During an observed medication pass, the LPN administered 10 units of Novolog insulin without priming the pen and did so after the resident had already consumed approximately 50% of the breakfast meal. The LPN later confirmed she did not prime the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer instructions for the Novolog FlexPen specified that an air shot (priming) must be performed before each injection to ensure proper dosing. Another resident, also diagnosed with type 2 diabetes mellitus and with intact cognition, had orders for insulin glargine 35 units subcutaneously twice daily and insulin lispro 20 units subcutaneously before meals, plus 12 units subcutaneously if blood glucose was between 251 mg/dL and 300 mg/dL. During an observed medication administration, an LPN administered 35 units of insulin glargine and 32 units of insulin lispro without priming the insulin pens and after the resident had consumed approximately 90% of the breakfast meal, despite orders for insulin lispro to be given before meals. The LPN later stated she could not remember if she had primed the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer information for insulin lispro stated that the pen must be primed before each injection to confirm insulin delivery and remove air, and that failure to prime could result in too much or too little insulin. The DON confirmed the expectation that insulin be administered as ordered, including priming each pen with two units before dialing the prescribed dose, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and required time frames.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 5/29/2026. F-0759 Corrective action for resident/s: Residents #21 and #22 were assessed and evaluated by nurse and Director of Nursing 5/14/26. Resident #21 and #22 both denied any adverse effects and none were noted upon assessment by the Director of Nursing on 5/14/2026. Notification made to physician on 5/14/2026. LPN # 2 competency Eval on insulin administration with the Director of Nursing completed 5/14/2026. Identification of other residents who may be affected: Diabetic residents on assignment of LPN #2/station 2 have the potential to be affected and were assessed by the DON/Designee on 5/14/26 and found to be within normal limits. Measures for systemic change: All Nurses were educated by the Director of Nursing on the steps for Insulin administration per competency, diabetes clinical protocol policy, Medication and treatment orders policy, administering medications policy, and Obtaining fingerstick Glucose Level policy On 5/14/2026. How Corrective Action will be monitored: Director of Nursing and Assistant Director of Nursing will complete insulin administration audits on 5 nurses. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance: 5/29/2026
Inaccurate Crash Cart Audits and Missing Emergency Equipment
Penalty
Summary
The facility failed to ensure accurate and complete crash cart audits for residents requiring basic life support, affecting eighteen of thirty-five residents who were designated as full code. During an observation of the crash cart with the DON, surveyors found that the daily audit documentation for the month did not include verification of expiration dates for crash cart supplies. Review of the crash cart audit logs showed that an extension cord was documented as being in the cart on multiple dates, but the extension cord was not present in the cart at the time of inspection. Additionally, the audit documentation indicated that required items, including eye protection, saline, and clear plastic, were not present in the crash cart, yet they were documented as being in the cart. The facility’s undated “Emergency Crash Cart” policy stated that the crash cart is to be checked every 24 hours and after every use, and that equipment and supplies are to be noted and replaced promptly, but the observed documentation and contents of the cart did not match these requirements. This deficiency was verified with the DON at the time of the survey and was cited under the requirement that personnel provide basic life support, including CPR, to residents requiring emergency care, subject to physician orders and advance directives, and was investigated under Complaint Number 2687380.
Plan Of Correction
Cridersville Care Center Provider Number:366171 Survey Type: Complaint Survey Survey Date: 04/29/26 This Plan of Correction (PoC) outlines the actions completed by the facility with regards to the deficiency citation. This Plan of correction does not constitute any admission of guilt or liability by the facility and is submitted only in response to the regulatory requirements. Please accept the following as the facility's credible allegation of compliance as of 4/30/26. F678 CPR All Full Code residents #18 have the potential to be affected by the alleged deficiency. On 4/27/26 the DON/ADON re-stocked the crash cart per the inventory sheet for all missing items. Crash cart inventory sheet updated and new one will go into effect on 5/1/26. All licensed nursing staff provided with training related to crash cart inventory being a daily audit review using inventory sheet on 4/27/26 per DON/designee. The DON/designee will conduct clinical rounds and conduct a random audit of crash cart three times per week for 4 (four) weeks to ensure compliance. The results of the audit will be documented. The facility conducted an Ad-Hoc QAPI meeting on 4/27/26 and discussed the alleged deficiency and corrective actions. Date when corrective action will be completed: 4/30/26
Unsafe Smoking Practices with Oxygen and Missed Fall-Prevention Interventions
Penalty
Summary
The deficiency involves the facility’s failure to provide a safe smoking environment, adequate supervision, and appropriate implementation of its smoking policy for a resident who used oxygen and smoked, as well as failure to implement fall-prevention interventions as care planned for another resident. One resident had multiple relevant diagnoses, including chronic respiratory failure with hypoxia, COPD, end-stage renal disease, dependence on supplemental oxygen, diabetes, and necrotizing fasciitis. Her care plans identified impaired visual function, risk for respiratory complications related to a history of smoking, and risk for cognitive decline, with interventions including use of oxygen per order and observation for understanding. A smoking-related care plan created earlier documented that she wished to use smoking products, had been assessed as safe to smoke "with supervision," and was non-compliant with the smoking policy, with family continuing to provide smoking supplies despite education and a verbal warning for non-compliance. Smoking assessments and progress notes showed a pattern of non-compliance and inconsistent classification of this resident’s smoking safety. Multiple smoking observation/assessments completed earlier in March documented that she had no cognitive loss, visual deficits, or dexterity problems but was unsafe to smoke without supervision because she did not return smoking materials and did not follow designated smoke times. Progress notes described her going out to smoke multiple times by herself or with family, including sneaking out next door with a cigarette and going out multiple times in one evening, with staff documenting that she was "reeducated" and that family brought in cigarettes and lighters which she did not return to staff. Despite this history, a smoking assessment completed after a three-day hospital stay assessed her as safe to smoke without supervision, with no documentation explaining how this conclusion was reached or evidence that her care plan was updated accordingly. On the day of the incident, the resident reported she had cigarettes and a lighter on her person after returning from dialysis and stated she "could not find a nurse" and went outside to smoke, saying she "guessed" she forgot she had her oxygen on. A CNA observed her outside and saw a flame coming through the resident’s oxygen nasal cannula tubing, turned off the oxygen tank, removed the tubing, and patted out sparks on the resident’s shirt sleeve. The resident’s face and hands appeared black in color, and EMS documented first-degree burns to the head and face, with the resident stating she lit a cigarette with her nasal cannula on, causing the burn. The hospital record described her face as black from smoke and her lips and mouth as "burnt and charred," with a recommendation for intubation that she refused. The facility’s incident report recorded that she went outside with oxygen on to smoke without notifying staff, that staff witnessed the occurrence as she walked through the dining room door to the courtyard, and that she stated she thought she had turned her oxygen off. The facility’s smoking policy required interdisciplinary evaluation to determine safe versus unsafe smokers, staff maintenance of all smoking paraphernalia for both safe and unsafe smokers, and progressive consequences for policy violations. A separate deficiency involved another resident at risk for falls whose care plan included use of non-skid strips on the floor in front of her recliner as a fall-prevention intervention. This resident had severe cognitive impairment, used a walker and wheelchair, required supervision or touching assistance for transfers and ambulation, and had experienced two or more falls without injury since the prior assessment. The fall-risk care plan, initiated at admission, specified non-skid strips in front of the recliner beginning in November. However, nursing staff interviewed were not familiar with all of the resident’s fall-prevention interventions without checking the record, and observation of the room showed two recliners with no non-skid strips on the floor in front of them. An LPN confirmed that the non-skid strips were not present despite the intervention remaining active in the care plan, and moving the recliners did not reveal any strips. The facility’s fall management policy required identification of hazards and risk factors, implementation of interventions to minimize falls and injuries, and development and implementation of a care plan based on interdisciplinary evaluation, with interventions related to identified risk factors.
Plan Of Correction
Smoking: On 03/21/26 at 3:16 P.M. 911 response was activated for Resident #11 and Medical Director #601 was notified by Registered Nurse (RN) #322. On 03/21/26 at 3:18 P.M. on-call Nurse/Social Services #423 immediately notified the Administrator and Director of Nursing (DON) #304 of the incident involving Resident #11. On 03/21/26 at 3:22 P.M. Emergency Medical Services (EMS) arrived onsite. At 3:30 P.M. Resident #11 was transported to the emergency room. On 03/21/26 at 3:30 P.M. RN #322 completed a smoking re-assessment of Resident #11 assessing the resident to be an unsafe smoker requiring supervision due to failure to remove oxygen prior to entering designated smoking area. On 03/21/26 from 3:38 P.M. through 7:57 P.M. Licensed Practical Nurse (LPN) #337, #336, #335, #338; RN #334, and DON #304 re-assessed residents (who smoke). This included Resident #22, Resident #3, Resident #47, Resident #50, Resident #60, Resident #150, Resident #86, and Resident #10 to determine smoking safety (via smoking assessment). Each resident was re-educated regarding the facility smoking policy and staff verified there were no smoking materials on their person. The residents' smoking materials would be maintained by facility staff and distributed per policy. On 03/21/26 at 4:30 P.M. DON #304 responded to facility and an Ad Hoc (not scheduled) Quality Assurance (QA) meeting was held via telephone with the Administrator, DON #304 and Medical Director #601 to review investigative findings and plan of action. A root cause analysis was completed and determined Resident #11 had smoking materials on her person (believed to be obtained from family without staff knowledge) and failed to remove her oxygen. The QA team discussed a corrective action plan. On 03/21/26 from 5:00 P.M through 03/22/26 at 3:00 P.M. 26 RNs, 13 LPNs, one medical technician (MT), 54 Certified Nursing Assistants (CNA) four activities staff, one central supply staff, 11 dietary staff, 12 housekeeping staff, three laundry staff, one medical records staff, two social designees, two maintenance staff, nine administrative staff, and 19 therapy staff (158 staff at the time of the incident) were provided education regarding the facility smoking policy by DON #304 and the Administrator. This was completed via 1:1, small group in-services or via phone. Newly hired staff would receive education during general orientation regarding the facility's smoking policy. On 03/21/26 at 5:00 P.M. DON #304 completed an audit of all residents who smoke (Resident #22, Resident #3, Resident #47, Resident #50, Resident #60, Resident #150, Resident #86, and Resident #10) to verify smoking evaluations and plans of care accurately reflected the residents' smoking safety needs. The residents were educated on the facility smoking policy, and smoking materials were to be maintained at the nurses' station. An audit was completed which included verification of required safety measures present in designated smoking areas, including an ash can, fire extinguisher, fire blanket, ash trays and no oxygen signs. There were no identified concerns or changes made because of the audits. On 03/21/26 at 8:55 P.M. Resident #11 returned from the ED. LPN #332 verbally educated the resident regarding the facility smoking policy which included the need for supervision, a smoking apron (to be worn) and the facility smoke times. LPN #332 verified no smoking materials were on the resident's person or in her room at this time. On 03/23/26 at 11:00 A.M. the Interdisciplinary Team (IDT) (Administrator, DON #304, Medical Director #601, RN #302, Social Services #427, Social Services #423, DON #300, and Maintenance #436) met in-person to review the plan of action with DON #304/designee to complete weekly monitoring of residents who smoke and designated smoking areas weekly for four weeks with Housekeeping responsible to complete the cleaning. Housekeeping staff were responsible for cleaning ashtrays and the designated smoking area daily. Audits to be reviewed and any further actions required to be directed by the Quality Assurance and Performance Improvement (QAPI) Committee during scheduled meetings. The IDT also reviewed all current smoking assessments and care plans for residents who smoke. Resident #50 required a change in supervision levels with smoking due to cognition levels and her plan of care as well as Resident #11's plan of care was updated to reflect supervision/safety. On 03/23/26 from 3:45 P.M. to 8:55 P.M. Social Services #423 re-educated residents who smoke (Resident #22, Resident #3, Resident #47, Resident #50, Resident #60, Resident #150, Resident #86, Resident #10) and responsible parties, if applicable regarding the facility smoking policy and supervision levels. On 03/23/26 at12:13 P.M. Social Services #427 contacted Resident #11's family member (#602) to schedule a care conference. Family member #602 and Family Member #603 were not available to meet until 03/27/26. On 03/23/26 at 1:00 P.M. staff education related to smoking areas, removal of oxygen prior to entering smoking area and maintaining smoking materials at the nurses' station for residents who smoke was initiated by DON #304 and the Administrator via 1:1, small group in-services or via phone call. Education was completed for all 158 staff by 03/24/26 at 1:00 P.M. Newly hired staff would be educated during general orientation regarding the facility's smoking policy. The facility does not utilize agency staff. On 03/27/26 at 11:00 A.M. a care conference was held with Resident #11 and Family Members #602 and #603, the Administrator, Social Services #423 and Social Services #427. The facility smoking policy was reviewed. The resident and family were informed an involuntary discharge would be initiated should the resident exhibit non-compliance moving forward and supervision would be increased beyond the two-hour standard of care to monitor more closely for non-compliance with the facility smoking policy. Family Member #602 stated he educated his siblings as well. On 04/10/26 at 2:00 P.M. DON #304 initiated education with 26 RNs and 13 LPNs (100% of nurses educated) regarding completion of the smoking evaluation via 1:1, small group in-services, or phone. The education was completed by 6:00 P.M. on 04/10/26. A new resident who smokes must remain supervised until the interdisciplinary team (IDT) reviews and determines smoking safety, at which time the care plan is developed and resident and family education is provided. The communication through the staff would be the care plan. Newly hired staff receive education during general orientation regarding the facility's smoking policy and completion of smoking evaluation via Point Click Care (PCC). On 04/10/26 at 4:29 P.M. DON #304 initiated an order in PCC for the nurse to verify, each shift, that Resident #11's smoking materials were maintained at the nurses' station. On 04/13/26 at 5:30 P.M. DON #304 initiated orders in PCC for nurses to verify, each shift, that all residents who smoke would have smoking materials maintained at the nurses' station. An updated list of smokers included: Resident #60, Resident #50, Resident #11, Resident #86, Resident #113, and Resident #151. On 04/13/26 at 5:45 P.M. DON #304 initiated questionnaires for staff regarding the smoking policy with re-education provided as needed via 1:1 and small group in-services for staff currently in the facility with all staff to be questioned/educated prior to working their next scheduled shift. Falls: On 4/9/26, Maintenance Director placed non-skid strips on the floor in front of Resident #12's recliner. Like Residents are identified as residents who have had a fall within the facility. Utilizing the Fall Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, an audit of falls and appropriate interventions for the past 30 days will be completed by the Director of Nursing or designee to ensure fall interventions are in place per plan of care. This audit along with identified corrections will be completed on or F 0689 before 5/13/26. The Director of Nursing or designee will re-educate licensed nurses and STNA/CNAs on the Fall Management Policy to include fall interventions to be in place per the care plan. This education will be completed on or before 5/13/26. Utilizing the Fall Management Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, the Director of Nursing or designee will complete an audit of new admissions, new readmissions and residents who experience a fall within the last 7 days, weekly for four weeks, beginning 5/14/26 to ensure fall safety interventions are in place per plan of care. Current fall interventions found to not be in place will be corrected with all intervention in place per plan of care. Negative findings to be addressed immediately and negative trends or system wide issues will be reported to the QAPI committee, and the action plan will be adjusted as needed.
Removal Plan
- Activated 911 response for Resident #11 and notified the Medical Director.
- On-call Nurse/Social Services immediately notified the Administrator and DON of the incident.
- EMS arrived onsite and Resident #11 was transported to the emergency room.
- Completed a smoking re-assessment of Resident #11, determining the resident was an unsafe smoker requiring supervision due to failure to remove oxygen prior to entering the designated smoking area.
- Re-assessed all residents who smoke (Residents #22, #3, #47, #50, #60, #150, #86, and #10) to determine smoking safety via smoking assessment.
- Re-educated residents who smoke regarding the facility smoking policy and verified there were no smoking materials on their person.
- Implemented that smoking materials would be maintained by facility staff and distributed per policy.
- Held an ad hoc QA meeting to review investigative findings and plan of action.
- Completed a root cause analysis determining Resident #11 had smoking materials on her person and failed to remove oxygen.
- Developed a corrective action plan.
- Provided facility-wide education to staff on the facility smoking policy.
- Implemented that newly hired staff would receive smoking policy education during orientation.
- Completed an audit of all residents who smoke to verify smoking evaluations and plans of care accurately reflected smoking safety needs.
- Ensured smoking materials were maintained at the nurses’ station.
- Audited designated smoking areas for required safety measures (ash can, fire extinguisher, fire blanket, ash trays, and no-oxygen signs).
- Provided verbal education to Resident #11 on smoking policy (supervision, smoking apron, smoke times).
- Verified no smoking materials were on Resident #11’s person or in her room.
- Conducted an in-person IDT meeting to implement weekly monitoring of residents who smoke and designated smoking areas weekly for four weeks.
- Assigned housekeeping to clean ashtrays and the designated smoking area daily.
- Directed audits to be reviewed by QAPI.
- Reviewed all current smoking assessments and care plans for residents who smoke.
- Updated Resident #50’s supervision level.
- Updated Resident #11’s plan of care to reflect supervision/safety.
- Re-educated residents who smoke and responsible parties (as applicable) regarding the facility smoking policy and supervision levels.
- Contacted Resident #11’s family to schedule a care conference.
- Initiated additional staff education regarding smoking areas, removal of oxygen prior to entering smoking area, and maintaining smoking materials at the nurses’ station.
- Held a care conference with Resident #11 and family to review smoking policy.
- Informed resident/family that involuntary discharge would be initiated for future non-compliance.
- Increased supervision beyond the two-hour standard of care to monitor more closely for non-compliance.
- Provided education to all nurses regarding completion of the smoking evaluation.
- Implemented that new residents who smoke must remain supervised until IDT review determines smoking safety and care plan/education are completed.
- Entered an order in PCC for nursing to verify each shift that Resident #11’s smoking materials were maintained at the nurses’ station.
- Entered orders in PCC for nursing to verify each shift that all residents who smoke have smoking materials maintained at the nurses’ station.
- Initiated staff questionnaires regarding the smoking policy with re-education as needed.
- Required all staff to be questioned/educated prior to working their next scheduled shift.
Failure to Provide Scheduled Bathing and Shaving Assistance for Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide scheduled and needed bathing and shaving assistance to multiple dependent residents in accordance with their care plans, preferences, and the facility’s routine care policy. One resident with spinal stenosis and recent L2–L5 decompression fixation fusion was care planned for substantial/maximal assistance with shower/bath and toileting hygiene and was scheduled for showers on Tuesdays and Fridays. Electronic documentation from early January through early April showed this resident did not receive a shower or bed bath on 11 identified scheduled days, and the DON confirmed these missed bathing events. Another resident with dysphagia and developmental issues, who required assistance with self-care and mobility, reported that she asked staff to shave her but they did not, which bothered her. During an observation following a recent shower, she stated she had not been shaved and that the hair "itched"; small gray hairs were visible on her chin. A CNA confirmed the presence of gray chin hairs and acknowledged the resident needed shaving, stating it would be addressed with the next scheduled shower. A further resident with chronic respiratory failure, tracheostomy status, heart failure, moderate intellectual disabilities, anxiety, depression, and PTSD required substantial/maximal assistance with personal hygiene and had a care plan for assistance with self-care, including personal hygiene. Her shower schedule called for showers on Monday and Thursday nights, with complete shaves for men and women. Review of documentation showed her last recorded shower/bath was nearly a year earlier, with no indication of additional personal hygiene or facial hair removal on that date. Observations on two separate days showed long white hairs on her chin and jaw line, which a CNA later confirmed, stating facial hair removal should occur with baths/showers or as needed. A resident with end stage renal disease, respiratory failure, hyperlipidemia, and congestive heart failure, who had impaired cognition and required partial/moderate assistance with bathing and personal hygiene, was scheduled for showers on Wednesdays and Saturdays. Review of shower documentation from admission through early April revealed no showers provided or refusals documented on at least ten scheduled shower days. In interviews, this resident reported not receiving scheduled showers, was unsure of his shower days, and stated he could use a good scrub down, adding that he had asked aides who told him they did not have time. A CNA explained that shower days appear on shower sheets and in the computer and that CNAs are supposed to document daily, with nurses checking the documentation; the DON verified the resident had not received showers per schedule or preference. Another resident with a fracture of the lower end of the left humerus, hemiplegia and hemiparesis after cerebral infarction, rheumatoid arthritis, hypertensive heart disease, urinary retention, and osteoarthritis was care planned as non–weight bearing to the left upper extremity and requiring substantial/maximal assistance with showering/bathing. Her electronic record showed she was scheduled for showers on Wednesdays and Saturdays. The shower task question "did the resident receive a shower/bath/bed bath?" was documented as "no" on three dates, indicating no shower/bath/bed bath was completed, and left unanswered on three additional dates. The DON confirmed that one missed shower was due to an outside appointment, that on two dates the "no" response meant no bathing of any type occurred, and that on three dates there was no documentation at all. The resident, who was cognitively intact, reported that missing showers made her feel unimportant compared to others and that she did not feel clean when her shower was missed. Facility policy on routine resident care stated that showers, tub baths, and shampoos are to be scheduled according to person-centered care or state guidelines, with additional showers given upon request, but the documented and observed care did not reflect consistent provision of scheduled bathing and shaving for these residents.
Plan Of Correction
1. Resident #5 received a shower by the STNA on 4/13/26. Resident #8 received a shower by the STNA on 4/8/26. Resident #9 received a shower and had their chin shaved by the STNA on 4/14/26. Resident #70 received a shower by the STNA on 4/13/26. Resident #76 received a shower and had their chin shaved by the STNA on 4/15/26. 2. Like residents are identified as residents who need assistance with showering and shaving. Utilizing the Shower Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, an audit of like residents will be completed by the Director of Nursing or designee to ensure that showers and resident shaving are completed. This audit along with identified corrections will be completed on or before 5/13/26. 3. The Director of Nursing or designee will re-educate licensed nurses and STNA's on the Routine Resident Care Policy to include bathing and shaving residents. This education will be completed on or before 5/13/26. 4. Utilizing the Shower Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, the Director of Nursing or designee will complete an audit of 4-6 residents weekly for four weeks, beginning 5/14/26 to ensure that showers and resident shaving are completed. Noncompliance found during audits will be addressed and assistance with showers and/or shaving provided. Negative findings to be addressed immediately and negative trends or system wide issues will be reported to the QAPI committee, and the action plan will be adjusted as needed.
Uncovered Urinary Catheter Drainage Bag Compromises Resident Dignity
Penalty
Summary
The facility failed to maintain a resident’s right to privacy and dignity related to management of an indwelling urinary catheter. A resident admitted with malignant neoplasm of the esophagus and type II diabetes mellitus had a care plan identifying risk for urinary tract infection and catheter-related trauma due to an indwelling catheter for urinary retention. The care plan interventions included ensuring the catheter tubing was secured and the drainage bag was properly secured with a dignity cover in place. Physician orders directed that the resident’s 16 French indwelling urinary catheter be changed every 30 days and as needed, and the comprehensive MDS documented that the resident had an indwelling catheter and was cognitively intact. During observation, the resident was seen seated in a chair with the urinary catheter drainage bag hanging from the chair without a dignity cover, and dark yellow urine was visible in the bag from the hallway. In a later observation and interview, an LPN confirmed that the catheter bag was lying directly on the floor and did not have a dignity cover. Attempts to interview the resident to confirm cognitive status were unsuccessful, as the resident was unable to answer screening questions. Review of the facility’s “Resident Dignity & Personal Privacy” policy stated that the facility should provide care in a manner that respects and enhances each resident’s dignity, individuality, and right to personal property, which was not followed in this instance when the catheter drainage bag was left uncovered and visible.
Plan Of Correction
The Laurels of Athens wishes to have this plan of correction submitted as our written allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission to nor agreement with, either the existence of, or the scope and severity of, any of the cited deficiencies or conclusions set forth in the statement of deficiencies. This plan is prepared and/or executed to ensure continuing compliance with regulatory requirements. Our alleged date of compliance is 5/13/2026. 1. On 4/6/26, Resident #92's catheter bag was removed from the floor, the bag changed and covered for dignity by the licensed nurse. Resident #92 discharged from the facility on 4/11/26. 2. Like Residents are identified as residents who utilize urinary catheters. An audit will be completed by the Director of Nursing or designee for like residents utilizing the Urinary Catheter Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC to ensure catheter bags are covered for dignity and not laying directly on the floor. This audit along with identified corrections will be completed on or before 5/13/26. 3. The Director of Nursing or designee will re-educate licensed nurses on the Indwelling Urinary Catheter Policy as well as Resident Dignity & Personal Privacy Policy to include privacy covers are in place for urinary catheters and that the catheter is not laying on the floor. This education will be completed on or before 5/13/26. 4. Utilizing the Urinary Catheter Audit Tool which was created on 4/20/26 by the Director of Nursing for purpose of this POC, the Director of Nursing or designee will complete an audit of all residents with catheters weekly for four weeks, beginning 5/14/26 to ensure catheter bags are covered for dignity and not laying directly on the floor. Any catheters found to be touching the floor or uncovered will be removed from the floor, the bag changed and covered for dignity. Negative findings to be addressed immediately and negative trends or system wide issues will be reported to the QAPI committee, and the action plan will be adjusted as needed.
Failure to Prevent Possible Misappropriation and Poor Documentation of PRN Narcotics
Penalty
Summary
The deficiency involves failure to prevent potential misappropriation of a resident’s narcotic medication and failure to ensure accurate documentation of controlled substance administration. A cognitively intact resident with chronic pain related to an internal orthopedic device and left knee pain had an order for oxycodone 5 mg PO every four hours PRN for pain and a care plan directing staff to administer medications as ordered and observe for effectiveness and side effects. The resident’s MDS showed she rated her pain as 7/10 and received opioid medication. However, review of the February MAR and the narcotic log revealed multiple discrepancies between narcotic sign-outs and documented administration. On several occasions, oxycodone doses were signed out on the narcotic log by an RN without corresponding documentation on the MAR. Specifically, oxycodone was signed out on one evening at 9:30 p.m. with no MAR entry, and again on a subsequent night at 1:30 a.m. and 5:30 a.m. with no MAR entries for those times. Another dose was signed out at 9:00 p.m. while the MAR reflected administration at 10:16 p.m., and a later dose at 5:30 a.m. was documented on both the narcotic log and MAR. There was also no documentation of pain assessments before or after PRN opioid administration. These documentation gaps meant there was no evidence that all narcotic doses signed out were actually administered to the resident. Staff interviews further highlighted concerns about the handling of narcotics. A CNA/med tech reported frequently taking the narcotic keys from the RN and described the RN’s behavior as erratic, with repeated problems involving incorrect narcotic counts and missing documentation on both the MAR and narcotic log. The resident stated she did not receive oxycodone more than once or twice a day, preferring to take Tylenol the rest of the time, which conflicted with the number of oxycodone doses signed out. When questioned, the RN gave inconsistent explanations about how often she pulled and administered PRN narcotics and acknowledged struggling with the new system, while also suggesting the resident may have received PRN tizanidine instead of remembering oxycodone. The facility’s investigation concluded that evidence was inconclusive as to whether misappropriation occurred or whether the issue was solely lack of documentation, but confirmed there was no evidence the resident received all doses signed out on the narcotic log.
Plan Of Correction
1. Resident #99 had a Self-Reported Incident submitted and investigated via the EIDC on 3/2/26. The investigation was inconclusive as we could not prove that misappropriation occurred. On 2/24/26, Resident #99 was interviewed and pain assessed by Director of Nursing and resident had no ill effects related to the inconsistent documentation in the medical record as it relates to her controlled substance pain medication. 2. Like Residents are identified as residents who utilize controlled substance PRN pain medications. An audit will be completed by the Director of Nursing or designee for like residents utilizing the Controlled Substance Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC to ensure PRN controlled substance pain medications that are signed off the control sheet are documented in the resident medical record as well. This audit along with identified corrections will be completed on or before 5/13/26. 3. The Director of Nursing or designee will re-educate licensed nurses on the Controlled Substances Policy to include appropriate documentation of controlled substances. In addition, the licensed nurses will be re-educated by the Director of Nursing or designee on the Abuse Prohibition Policy to include misappropriation of resident property. This education will be completed on or before 5/13/26. 4. Utilizing the Controlled Substance Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, the Director of Nursing or designee will complete an audit three controlled substance sheets from each of the nine medication carts for a total of twenty-seven sheets weekly for four weeks, beginning 5/14/26 to ensure PRN controlled substance pain medications that are signed off the control sheet are documented in the resident medical record as well. Inconsistencies noted from the audit will be investigated for misappropriation. Negative findings to be addressed immediately and negative trends or system wide issues will be reported to the QAPI committee, and the action plan will be adjusted as needed.
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