Kimes Nursing And Rehab Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Athens, Ohio.
- Location
- 75 Kimes Lane, Athens, Ohio 45701
- CMS Provider Number
- 366250
- Inspections on file
- 23
- Latest survey
- March 9, 2026
- Citations (last 12 mo.)
- 11 (1 serious)
Citation history
Health deficiencies cited at Kimes Nursing And Rehab Llc during CMS and state inspections, most recent first.
An agency LPN prepared and administered evening medications for two roommates at the same time in a dark room, placing both sets of pills into labeled cups and later admitting this practice. As a result, a resident who had no orders for benzodiazepines or opioids was erroneously given his roommate’s Xanax, Percocet, and Gabapentin, while his own ordered medications were documented as given. Shortly after administration, the roommate reported to a CNA that his pain medications did not feel like they had worked, and later stated that he believed the medications had been mixed up. The affected resident became increasingly lethargic over the evening, but despite abnormal presentation and staff concern, the LPN did not promptly notify a physician or report a suspected med error, and only contacted the on-call provider and EMS after the resident became unresponsive, hypotensive, and bradycardic. EMS and hospital records documented unresponsiveness, pinpoint pupils, hypotension, bradycardia, treatment with Narcan and Atropine, ICU admission, and a urine drug screen positive for benzodiazepines and oxycodone, confirming a significant medication error and associated deterioration in the resident’s condition.
The facility did not update the state survey agency regarding changes in its administrative leadership, including an interim Administrator who served for several months and the current Administrator. A review of the EIDC website showed that these administrators were not listed as required, and the current Administrator acknowledged that the facility had failed to report these changes. This non-compliance affected all residents and was identified during a complaint investigation.
The facility did not maintain an effective training program for new CNAs, as evidenced by two CNAs lacking required education in compliance and ethics, the QA program, behavioral health, and effective communication. Review of personnel files showed missing training modules for these staff members, and HR confirmed that the required training had not been completed. This issue was identified as an incidental finding during a complaint investigation affecting all residents.
A cognitively intact resident with multiple chronic conditions, who was not ordered any benzodiazepines or opioids, became progressively lethargic and then unresponsive after an agency LPN prepared and administered bedtime medications for him and his roommate at the same time. The roommate later reported he believed their medications had been switched, noting his usual gabapentin and oxycodone were missing and that he did not experience his typical pain relief, while his roommate quickly became "out of it" and difficult to arouse. Staff initially attributed the affected resident’s lethargy to fatigue from a room change, did not promptly notify the physician when the change in condition was first observed, and allowed his condition to worsen over several hours before calling EMS, who found him hypotensive, bradycardic, unresponsive with pinpoint pupils, and later documented a urine drug screen positive for benzodiazepines and oxycodone—drugs ordered for the roommate but not for the affected resident. Despite these findings and consistent reports from the roommate and family, facility leadership did not substantiate a medication error or clearly correlate the resident’s change in condition to a suspected medication mix-up.
A resident with intact cognition reported to staff, through her son and in her own interview, that one of several lottery tickets she had received, which she believed to be a $250 winner, was missing while the other non-winning tickets remained in her room. The resident and her son searched the room without finding the ticket, and multiple staff, including CNAs, RNs, and the ADON, later confirmed seeing lottery tickets on the bedside table but could not account for the missing winning ticket. The situation was recognized by the social worker, Administrator, and DON as a potential misappropriation that should be reported to the state under facility policy, yet neither the Administrator nor the DON submitted the required state report within the mandated timeframe, resulting in a failure to report an allegation of misappropriation.
The facility failed to provide scheduled showers to three dependent residents who required staff assistance with ADLs due to conditions such as dementia, muscle weakness, hypertension, cancer, osteoarthritis, cognitive deficits, and pain. Care plans and MDS assessments documented that each resident needed staff help with bathing/showering, and the facility’s shower schedules specified twice-weekly showers on designated shifts. However, shower records showed multiple missed shower dates for each resident, and the ADON confirmed that these residents did not receive their scheduled showers and that no additional documentation existed to show the care was provided.
A resident with type II DM, hidradenitis suppurativa, and MASD had a care plan and physician orders for daily non-pressure wound care, including cleansing with chlorhexidine, application of clindamycin gel, calcium alginate or ABD pads, and nystatin powder to the peri-wound area. Review of treatment administration records showed multiple days on which the ordered daily wound treatments were not documented as completed. The ADON confirmed that these wound care treatments were not performed as ordered and that there was no documented reason for the missed treatments or additional supporting documentation.
Surveyors found that the facility did not implement care-planned fall-prevention interventions for two high-risk residents. One resident with severe cognitive impairment, gait abnormalities, and a history of multiple falls had a care plan requiring her walker to be kept within reach in her room, but during observation only her wheelchair was at bedside and no walker was accessible; a CNA familiar with her care needs was unaware she had a walker and confirmed it was not in reach. Another resident with hemiplegia, muscle weakness, and dependence for transfers had a care plan requiring provision of a reacher/grabber and encouragement to use it when items fell, yet she was observed in bed without the device in reach, later found stored on a distant nightstand; the resident confirmed it was not accessible, and an LPN verified that the reacher/grabber was a planned fall-prevention intervention that was not in place.
Surveyors observed an RN enter the room of a resident on transmission-based precautions for Covid-19 to administer morning medications wearing only an N-95 respirator and gloves, without a required gown, despite the facility’s Covid-19 policy mandating a respirator, gown, gloves, and eye protection for confirmed Covid-19 cases. The resident, who had multiple comorbidities including CHF, CKD, hypertensive heart disease, and morbid obesity, reported it was the tenth and final day of isolation following a positive Covid-19 test. A PPE cart was present outside the room, but the RN stated there were no gowns in it and admitted she did not check other carts, even though she knew a gown was required. The Droplet Precautions sign identifying the resident’s status was not prominently displayed, resting diagonally on a handrail and partially obscured by hallway equipment, and the medical record lacked a specific physician order detailing the need for and duration of Covid-19 TBP.
The facility failed to enforce its COVID-19 infection prevention and control policy during an outbreak affecting all residents. Despite posted instructions requiring N95 masks at all times, multiple night-shift staff, including LPNs and CNAs, were observed working without any masks, even while caring for residents with confirmed COVID-19. Some staff stated they were unsure of mask requirements or did not believe masks were effective. In addition, a CNA entered the room of a resident on droplet/contact precautions for COVID-19 wearing a gown, gloves, and an N95 mask but no eye protection, later stating she did not know eye protection was required, while an RN confirmed it was. Facility records showed numerous residents had recently tested positive for COVID-19, and the written policy required source control and full PPE (N95, gown, gloves, eye protection) for staff entering rooms of residents with suspected or confirmed infection, which was not consistently followed.
Three residents with severe cognitive impairment and dependent on staff for bathing did not receive scheduled showers on multiple occasions, as confirmed by care records and staff interviews. Staff reported that showers were missed during periods of inadequate staffing, with priority given to other essential care tasks. The DON confirmed that residents' shower preferences were documented and that the missed showers occurred as indicated in the records.
Two residents with significant medical conditions did not receive timely or accurate pressure ulcer care, including a nurse treating the wrong site and delays in initiating ordered treatments. Nursing staff also failed to document wound assessments on the correct dates, and treatments were not started promptly after physician orders, contrary to facility policy.
A resident with dementia and chronic respiratory failure was allegedly physically abused by a CNA during care. The incident was witnessed by another CNA, who delayed reporting it. The facility failed to notify law enforcement or the resident's family, and the Administrator did not substantiate the allegation due to insufficient evidence. This represents non-compliance with the facility's abuse prevention policy.
The facility failed to offer pneumococcal vaccinations to several residents, as revealed by a review of medical records and consent forms. The affected residents, who had various medical conditions, either did not have a record of receiving the vaccine or had no physician orders for it. The facility's consent process relied on residents or their families to request the vaccine, and there was no specific consent form for pneumococcal vaccination. The DON acknowledged the lack of proof that residents were asked about receiving the vaccine.
A resident was transferred to the hospital due to an elevated sodium level, but the facility failed to provide the resident's representative with a bed-hold notice as required. The facility's policy requires informing residents or their representatives of the bed-hold policy upon admission and prior to transfers, but documentation was missing in this case, as confirmed by the Social Service Director.
A facility failed to ensure accurate PASARR documentation for a resident, omitting an anxiety disorder diagnosis despite it being documented since the previous year. This discrepancy was confirmed through record review and staff interviews.
The facility failed to develop comprehensive care plans for two residents, one requiring management for anticoagulant therapy and the other for anxiety disorder. A resident with complex medical conditions, including end-stage renal disease and heart disease, was prescribed Eliquis without a corresponding care plan. Another resident with anxiety disorder lacked a specific and patient-centered care plan. These deficiencies were confirmed by the DON.
The facility failed to ensure hospice records were available for a resident receiving hospice care, impacting continuity of care. Additionally, another resident with chronic edema did not have compression stockings applied as ordered by the physician. Observations showed the resident without stockings, and staff interviews revealed a lack of awareness and adherence to the physician's orders.
The facility failed to implement fall prevention interventions for two residents at risk for falls. One resident, with a history of falls and fractures, did not have a visual reminder to use the call light, leading to a fall and hip fracture. Another resident, with severe cognitive impairment, fell due to the absence of dycem in the wheelchair, as required by the care plan. The DON confirmed these deficiencies.
A facility failed to assess and create a care plan for a resident with PTSD, despite the resident having multiple diagnoses including chronic PTSD, heart failure, and Alzheimer's disease. The resident's medical record lacked a PTSD assessment or care plan, and staff interviews revealed a lack of awareness regarding the resident's PTSD triggers or history.
A facility failed to follow infection prevention guidelines when a STNA did not wear a gown during wound care for a resident on enhanced barrier precautions. The resident had a pressure ulcer and required specific precautions to prevent the spread of multi-drug resistant organisms. Despite clear signage and policy requirements, the STNA only wore gloves, leading to a breach in infection control protocols.
A resident with a complex medical history was treated with antibiotics for a suspected UTI before culture and sensitivity results were available. The resident exhibited symptoms such as lethargy and unformed speech, leading to a physician's order for urinalysis and Rocephin. The UA/C&S results suggested contamination, but the resident had already completed the antibiotic course. The DON confirmed the premature antibiotic treatment.
The facility failed to implement physician-ordered pressure reduction devices for two residents, leading to deficiencies in pressure ulcer care. A resident with a stage I pressure ulcer was observed without the required off-loading boot and air mattress. Another resident with pressure ulcers was found on an alternating air mattress set incorrectly to a weight of 450 pounds, despite weighing only 133 pounds. These deficiencies were identified during a complaint investigation.
Significant Medication Error and Delayed Response After Wrong Medications Given
Penalty
Summary
The deficiency involves a failure to ensure that a resident was free from significant medication errors when an agency LPN did not follow proper medication administration procedures. The LPN prepared and administered evening/bedtime medications for two roommates at the same time, in a dark room, by popping both residents’ pills into separate cups labeled with their names. The LPN later admitted that she prepared both residents’ medications together and that the room was dark when she administered the medications. One resident, who was not ordered any benzodiazepines or opioid pain medications, was instead given medications that were ordered for his roommate, including Xanax 2 mg PO, Percocet (Oxycodone/Acetaminophen) 10–325 mg PO, and Gabapentin 800 mg PO. The resident who received the wrong medications had a history that included dementia with Lewy Bodies, neurocognitive disorder, mood disorder, major depressive disorder, anxiety disorder, CHF, hypertension, cirrhosis, muscle weakness, difficulty walking, and insomnia. His active orders included medications such as Abilify, Aspirin, Atorvastatin, Vitamin D, Plavix, Aricept, Fluoxetine, Lactulose, Magnesium Oxide, Melatonin, Remeron, Potassium Chloride, Sennosides, and Tamsulosin, with PRN orders for Acetaminophen, artificial tears, Mucinex, and Zofran. He had no orders for benzodiazepines or opioids. On the evening in question, the LPN documented administering his scheduled evening/bedtime medications around 8:44 P.M. and noted that he complained of being tired after a room change earlier that day. Shortly thereafter, his roommate complained to a CNA that his pain medications did not feel like they had worked, stating he could usually tell within 10 minutes when they took effect, suggesting concern that he had not received his usual medications. The facility also failed to timely identify and correlate the reported medication mix-up with the resident’s subsequent change in condition. Around 8:53 P.M., the LPN found the resident lethargic but responsive to touch and able to follow simple commands, with vital signs within acceptable ranges. The resident’s wife reported that he had not awakened during her visit. Despite the roommate’s report that he believed the medications had been mixed up and the LPN’s own acknowledgment that both residents’ medications had been prepared together, the LPN did not notify a physician of a possible medication error or seek medical guidance at that time. Throughout the night, the resident remained lethargic, and staff noted that something seemed “off,” but no provider was contacted until approximately 1:15 A.M., when the resident was found unresponsive, hypotensive, and bradycardic. EMS was then called, and the resident was transferred to the hospital with an altered mental status and unresponsiveness. Hospital evaluation, including a urine drug screen, showed the presence of benzodiazepines and oxycodone, which matched medications ordered for the roommate and not for the resident, confirming that a significant medication error had occurred and contributed to the resident’s serious deterioration in condition. Additional documentation from EMS and the hospital further described the resident’s condition following the error. EMS records indicated that the resident was unresponsive with pinpoint pupils, hypotension, bradycardia, and a Glasgow Coma Scale score of seven, and he received multiple doses of Narcan and Atropine en route. The ED provider note documented hypotension, bradycardia, poor responsiveness, and initial miotic pupils with partial response to Narcan, and the clinical impression included acute encephalopathy and unresponsiveness. The hospital history and physical described acute hypoxic respiratory failure and multifocal pneumonia, with progressive respiratory decline requiring endotracheal intubation and ICU admission. These findings, together with the positive urine drug screen for benzodiazepines and oxycodone in a resident without orders for those medications, were included in the facility’s investigation file as evidence of the significant medication error and its impact on the resident’s condition. The facility’s internal investigation gathered statements from the involved LPN, another LPN who assessed the resident, and a CNA. The agency LPN confirmed that she had prepared both roommates’ medications at the same time, in the dark, and that the roommate later complained that his medications did not feel effective. The second LPN reported that the resident’s condition appeared abnormal and that she eventually insisted he be sent out when he no longer responded as before. The CNA reported that the resident initially seemed at his baseline but later became more lethargic and took a “drastic turn” after his wife left. The DON acknowledged that the incident was possibly medication-related and that the resident’s transfer to the hospital for unresponsiveness was logged as an incident. Collectively, these actions and inactions—improper preparation and administration of medications, failure to promptly recognize and act on the reported medication mix-up, and delayed notification of a physician despite progressive lethargy—constituted the deficiency in ensuring the resident was free from significant medication errors.
Removal Plan
- The Vice President of Clinical Services created a performance improvement plan (PIP), presented it to the Director of Nursing (DON), and the DON assigned the Assistant Director of Nursing (ADON) to assist with medication audits designed to address medication pass performance criteria.
- The DON began an investigation for a possible medication error requiring a resident to be sent to the hospital.
- The DON interviewed the nurse involved and obtained the nurse’s statement of the incident.
- The DON interviewed the nurse working the night of the event and obtained the nurse’s statement.
- The DON interviewed the CNA who worked with the resident the night of the event.
- The DON interviewed the resident’s roommate to obtain a statement.
- The facility provided education on proper medication administration and the five rights of medication administration.
- The DON initiated an in-service on safe medication administration techniques and change of condition with nurses currently on shift regarding the possible medication error.
- The facility implemented a plan for the DON/designee to educate nurses on changes of condition and the five rights of medication administration followed by medication administration audits.
- The facility completed education for all current full-time licensed nurses and implemented a plan for new and agency nurses to be educated upon hire/scheduling by unit managers.
- The facility continued the process for an agency nurse resource guide binder to be available for agency staff to review.
- The DON/ADON began auditing changes in condition per the established schedule, with results reviewed through QAPI and issues addressed as needed.
- The DON/ADON began medication audits per the established schedule, including audits of resident identification/picture identification availability, with results reviewed through QAPI and issues addressed as needed.
- The DON conducted interviews with nurses who had worked prior to the incident/event.
- The ADON completed skin checks and health assessments on residents with low BIMS scores to identify changes in condition or possible medication adverse effects.
- The Vice President of Clinical Services and DON reviewed current policies and procedures for medication administration and change in condition.
- The physician assessed the roommate resident for possible medication adverse effects and reviewed medications for the affected resident.
- The DON reviewed the agency staff process and provided report forms to nursing staff at the beginning of shift to inform nurses how residents take their medication, and identified additions needed to the process including five rights and change in condition policy/education.
- Social Services conducted resident interviews regarding life satisfaction, abuse/neglect, and comfort reporting concerns.
- The DON completed a one-on-one in-service with the nurse involved on safe medication administration and change in resident conditions.
- The DON initiated an in-service for nursing staff on when to notify the DON regarding accidents/incidents, significant changes, medication errors, and emergencies, and implemented education upon hire for new nurses.
- The facility placed the nurse involved on the Do Not Return list.
- The facility implemented a requirement for all residents to have a picture in their chart and completed an immediate audit to verify compliance.
- The physician reviewed medications for the affected resident upon return from the hospital.
- The provider reviewed and approved all medications and documents for the affected resident.
- Social Services interviewed residents to identify concerns about receiving other residents’ medications.
- The facility implemented a plan to discuss the incident at the next QAPI meeting and to review audit results through QAPI with issues addressed as needed.
Failure to Notify State Agency of Administrator Changes
Penalty
Summary
The facility failed to notify the state survey agency of changes in administrative personnel, specifically changes in the Administrator position, affecting all 59 residents in the facility. Review of the Enhanced Information Dissemination and Collection (EIDC) website showed that neither the current Administrator nor the interim Administrator who served from November 2025 through January 2026 were listed as required. In an interview, the current Administrator confirmed that the facility had not informed the state survey agency of these changes in administrators, including the current Administrator. This deficiency was identified as an incidental finding of non-compliance during the investigation of Complaint Number 2735791. No additional resident-specific clinical information, medical history, or condition at the time of the deficiency was provided in the report.
Failure to Ensure Required Training for CNAs
Penalty
Summary
The facility failed to maintain an effective training program for staff, affecting all 59 residents in the facility. Record review of personnel files showed that one CNA hired on 12/19/25 did not have documented training in compliance and ethics, the quality assurance program, effective communication, or behavioral health. Another CNA hired on 10/08/25 did not have documented training in compliance and ethics, the quality assurance program, or behavioral health. During an interview on 03/04/26 at 3:04 P.M., the HR staff member confirmed that the required training had not been completed for these CNAs. This deficiency was identified as an incidental finding of non-compliance during the investigation of Complaint Number 2735791.
Failure to Recognize and Report Change in Condition Related to Suspected Medication Error
Penalty
Summary
The deficiency involves the facility’s failure to timely identify and report a significant change in condition for a cognitively intact resident, and to properly correlate that change to a suspected medication error. The resident had multiple diagnoses including dementia with Lewy Bodies, mood and anxiety disorders, CHF, hypertension, cirrhosis, and insomnia, but his MDS showed he was cognitively intact, had no communication issues, and was not ordered any benzodiazepines or opioids. His active orders included antidepressants, antipsychotic adjunct therapy, dementia medication, cardiac and GI medications, sleep aids, and bowel regimen, with PRN orders limited to acetaminophen, artificial tears, Mucinex, and Zofran. He did not have any orders for Xanax, oxycodone, or other narcotic pain medications. On the evening in question, an agency LPN prepared bedtime medications for the resident and his roommate at the same time, popping both residents’ pills into separate labeled cups at the medication cart. She crushed the cognitively intact resident’s pills in pudding and later gave the roommate’s pills whole, acknowledging that the room was dark when she administered the roommate’s medications. The roommate later reported that he believed he had received his roommate’s medications and that his own usual large gabapentin pill and the bitter-tasting oxycodone were missing from what he was given. He stated he did not experience his usual pain relief within 10–15 minutes and complained to staff that he had not received his correct medications. He also reported telling staff that his roommate had been given his medications and that this was why the roommate became unresponsive, and he stated that no one from the facility assessed him or investigated his report of a medication mix-up. After the agency LPN administered the bedtime medications, the resident complained of being tired following a room change and was assisted to bed. Around 8:53 p.m., the resident’s wife arrived and reported that he had not awakened during her visit. The LPN found him lethargic but able to follow commands, with vital signs within normal limits, and attributed his condition to fatigue from the move. Throughout the night, the LPN and another LPN noted that “something seemed off,” but they continued to attribute his lethargy to the room change and sleepiness. The resident’s condition progressively worsened; by approximately 1:15 a.m. he was more lethargic, then unresponsive to verbal and painful stimuli, with hypotension and borderline oxygen saturation. Only at that point was the on-call physician notified and EMS summoned. EMS and hospital records documented hypotension, bradycardia, unresponsiveness, pinpoint pupils, administration of Narcan and Atropine, and a urine drug screen positive for benzodiazepines and oxycodone—medications not ordered for the resident but ordered for his roommate. Despite these findings and the roommate’s contemporaneous statements, the DON reported she did not substantiate a medication error and did not clearly link the resident’s change in condition to a medication mix-up, reflecting a failure to promptly recognize, correlate, and report the suspected medication error and associated change in condition to the physician. Hospital documentation further described the resident as presenting with acute encephalopathy, acute hypoxic respiratory failure, shock, and unresponsiveness with pinpoint pupils and low blood pressure and heart rate. The ED and ICU notes referenced multiple doses of Narcan, a positive urine drug screen for benzodiazepines and oxycodone, and family and roommate concerns that the resident had received his roommate’s medications, including opioids and gabapentin. Subsequent hospital records from a tertiary facility noted that the encephalopathy was likely multifactorial on a background of Lewy Body dementia, with possible contributions from polypharmacy and anoxic brain injury in the setting of prolonged downtime and suspected receipt of the roommate’s opioids and gabapentin, though this could not be definitively confirmed. Within the facility, however, the change in condition was initially attributed to fatigue from a room move, the resident was allowed to remain in a progressively worsening state for several hours before EMS was called, and the facility did not substantiate or clearly document a medication error despite objective toxicology findings and consistent reports from the roommate and family. The facility’s internal investigation collected staff statements, MARs for both residents, controlled drug records, and hospital records. The agency LPN acknowledged that she prepared both residents’ medications at the same time and that it was possible she could have popped pills into the wrong cup or grabbed the wrong cup when crushing medications, though she denied intentionally giving the wrong medications. Another LPN recalled the roommate saying that the agency nurse had given the lethargic resident his pills, and that EMS administered Narcan due to pinpoint pupils. The DON confirmed that the resident’s urine drug screen was positive for benzodiazepines and oxycodone, and that the roommate was ordered Xanax and oxycodone at bedtime, but she stated she could not be certain the resident did not receive these drugs from another source and therefore did not substantiate a medication error. This sequence of events demonstrates that the resident’s significant change in condition was not promptly recognized as potentially medication-related, was not timely reported to the physician when first observed, and was not adequately correlated with the suspected medication error despite contemporaneous reports and objective toxicology findings.
Failure to Report Allegation of Misappropriation of Resident Property
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of misappropriation of resident property to the state as required by regulation and facility policy. Resident #10 was admitted with diagnoses including muscle weakness and hypertension, and her care plan and MDS documented intact cognition with no behaviors or history of making false allegations. A grievance report documented that the resident’s son had brought five lottery tickets to the resident; when he returned, the resident reported that one ticket, which she stated was a $250 winner, was missing while the other four tickets remained present but were not winners. According to the grievance documentation and interviews, the resident’s son searched the room, including dressers, drawers, and the trashcan, but could not locate the winning ticket. The social worker then assisted in searching the room without success. Resident #10 confirmed that her son had brought her four or five scratch-off tickets, that one was a $250 winner, and that she later noticed the winning ticket was missing after leaving the room for an activity and returning. She stated she did not throw the ticket away, did not see anyone else throw it away, and did not witness another resident or staff member take it, but believed someone must have taken it. Multiple staff members, including CNAs, RNs, agency nurses, and the ADON, were interviewed; several recalled seeing lottery tickets on the resident’s bedside table on various days, but none could confirm the number of tickets or what happened to the winning ticket. Interviews with facility leadership established that the situation was recognized as a potential misappropriation. The social worker stated that allegations of abuse or misappropriation would be reported to the state by the Administrator or DON. The Administrator acknowledged that a missing lottery ticket worth $250 constituted an allegation of misappropriation that should have been reported to the state and stated that such allegations should be reported immediately, but confirmed he did not report it and was unsure of his responsibility. The DON stated that allegations of misappropriation are to be reported to the state immediately upon suspicion or discovery, but confirmed she had not reported the allegation and had not been informed of the situation until later in the week. Review of the facility’s Abuse Investigation and Reporting policy showed that all reports of misappropriation must be promptly reported to appropriate agencies, with allegations reported within two hours, which did not occur in this case.
Failure to Provide Scheduled Showers and ADL Assistance
Penalty
Summary
The deficiency involves the facility’s failure to provide scheduled showers and personal care to dependent residents who required assistance with activities of daily living (ADLs). One resident with dementia, muscle weakness, diabetes, and impaired mobility had a care plan dated 08/27/25 indicating a need for assistance with self-care, ADLs, and mobility, with a goal to remain clean, dry, dressed, groomed, and free of odors. Interventions included dependent shower assistance by one helper, and an MDS dated 11/18/25 showed the resident required maximum assistance for bathing. The shower schedule showed this resident was to receive showers on Mondays and Fridays on dayshift, but shower records revealed missed showers on 02/20/26 and 02/27/26. Another resident with hypertension and cancer had a care plan dated 08/15/25 indicating dependence on staff for bathing/showering due to pain, limited mobility, limited range of motion, and weakness, with a goal to maintain current ADL function. An MDS showed this resident was dependent on staff for bathing and had refused care on four to six days during the review period. The shower schedule indicated showers on Tuesday and Friday dayshift, but shower records showed missed showers on 12/26/25 and 12/30/25. A third resident with hypertension, osteoarthritis, impaired mobility, weakness, cognitive deficits, and pain had a care plan dated 10/13/25 requiring assistance with self-care, ADLs, and mobility, including assistance as needed with showers twice weekly or per preference and partial assist with showers. The MDS indicated moderate assistance was needed for bathing/showering, and the shower schedule listed Tuesday and Friday nightshift. Shower records showed this resident did not receive showers on 10/21/25, 11/06/25, 11/13/25, 11/25/25, and 11/28/25. In an interview on 03/04/26 at 1:10 P.M., the ADON confirmed these residents were not provided scheduled showers and that there was no other documentation to show the showers were given.
Failure to Complete Ordered Daily Wound Care Treatments
Penalty
Summary
The facility failed to ensure that ordered non-pressure wound care treatments were completed as prescribed for one resident. The resident was admitted with type II diabetes and hidradenitis suppurativa, and an MDS assessment documented moisture associated skin damage (MASD). A care plan identified the resident as being at risk for skin impairment due to weakness, cognitive deficit, incontinence, impaired mobility, thin and fragile skin, falls, and autoimmune disease, with goals and interventions that included keeping the skin clean and dry, using lotion on dry but not broken skin, monitoring and documenting skin injuries, and following facility protocols for treatment. An order dated 11/18/25 directed daily wound care including cleansing with chlorhexidine wash, applying clindamycin gel to the wound, covering with an ABD pad, and applying nystatin powder to the peri-wound area; this order remained in effect until 12/19/25. Record review of the treatment administration record for 12/2025 showed that this daily wound care was not completed on 12/11/25, 12/12/25, 12/16/25, and 12/18/25. A subsequent order dated 12/19/25 revised the daily treatment to include cleansing with chlorhexidine wash, applying clindamycin gel, applying calcium alginate, covering with an ABD pad, and applying nystatin powder to the peri-wound. The treatment administration record for 12/2025 showed missed treatments on 12/21/25, 12/25/25, 12/30/25, and 12/31/25, and the record for 01/2026 showed missed treatments on 01/03/26, 01/04/26, and 01/05/26. In an interview, the ADON confirmed that these treatments were not completed as ordered and stated there was no reason they should not have been completed and no additional documentation explaining the omissions. This deficiency was investigated under Complaint Number 2722441.
Failure to Implement Care-Planned Fall-Prevention Interventions for High-Risk Residents
Penalty
Summary
The deficiency involves the facility’s failure to implement fall-prevention interventions as outlined in residents’ care plans for residents identified as high fall risks. For one resident with multiple diagnoses including osteoporosis, gait abnormalities, cognitive impairment, and a history of multiple falls, the fall risk assessment identified her as high risk and her care plan required that her walker be kept within reach when she was in her room. During observation, the resident was lying in bed with her wheelchair at the bedside, but no walker was within reach as required by her fall-prevention care plan. A CNA who had been working at the facility for about four months reported being familiar with this resident, acknowledged that the resident was a fall risk with a history of falls, and stated that the resident was supposed to wear non-skid socks or shoes when ambulating and primarily used a wheelchair. However, the CNA was not aware that the resident had a walker and confirmed, upon returning to the room, that no walker was kept within the resident’s reach despite this being an active intervention in the resident’s fall-risk care plan. For a second resident with multiple conditions including hemiplegia, muscle weakness, reduced mobility, and total incontinence, the fall risk assessment also identified her as high risk for falls, and her care plan required that she be provided with a reacher/grabber and encouraged to use it, particularly if she dropped items on the floor. Observation found this resident in bed with an air mattress, perimeter overlay, assist bars, and call light within reach, but without a reacher/grabber in reach as specified in her care plan. The resident stated she had a reacher/grabber “around there somewhere” but confirmed it was not within reach, and a reacher/grabber was later observed stored on a nightstand in an area of the room not accessible to her. An LPN, new to the facility, confirmed that the reacher/grabber was part of the resident’s fall-prevention interventions and that it was not within the resident’s reach at the time of observation. The facility’s fall policies required identification and implementation of interventions based on resident-specific risks, but the required interventions were not in place for these residents at the time of surveyor observations.
Failure to Ensure Appropriate PPE Use for Resident on Covid-19 Transmission-Based Precautions
Penalty
Summary
The deficiency involves the facility’s failure to ensure appropriate use of personal protective equipment (PPE) for a resident on transmission-based precautions (TBP) for Covid-19. During a medication pass on the North hall, an RN entered the room of Resident #30, who verbally reported it was her tenth and final day of isolation for a positive Covid-19 test, wearing only an N-95 particulate respirator and gloves. The RN did not don a gown before entering, despite the facility’s Covid-19 policy requiring a NIOSH-approved N-95 or higher respirator, gown, gloves, and eye protection for healthcare providers entering the room of a patient with suspected or confirmed Covid-19 infection. Observation after the medication pass showed a PPE cart outside the resident’s room and a Droplet Precautions sign that was not prominently displayed, as it was resting diagonally on the handrail, partially obscured by equipment stored in the hallway. Record review showed Resident #30 was admitted on an earlier date with diagnoses including congestive heart failure, chronic kidney disease, hypertensive heart disease, and morbid obesity. Nursing progress notes documented that on a prior date the resident was tested for Covid-19 due to headache, chills without fever, and sore throat, and the test was positive. However, the active physician’s orders did not include a specific order for TBP for Covid-19 or the duration of isolation, only an open-ended order allowing Covid-19 testing as needed. In an interview, the RN confirmed she knew the resident was in isolation for Covid-19, acknowledged that a gown was required PPE for entering the room, and stated she did not wear a gown because none were available in the PPE cart and she did not check other carts. She also acknowledged that the Droplet Precautions sign was not clearly visible or posted on the door where it would be easily seen when the door was closed.
Failure to Enforce COVID-19 Source Control and PPE Requirements During Outbreak
Penalty
Summary
The deficiency involves the facility’s failure to maintain and implement its infection prevention and control program, including required COVID-19 precautions, during an active outbreak that affected all residents. Surveyors observed a sign at the facility entrance stating that staff and visitors were required to wear N95 masks at all times due to a current COVID-19 outbreak. Despite this, four of five night-shift staff members, including two LPNs and two CNAs, were observed inside the facility without any masks. One LPN acknowledged she had a resident on her unit with COVID-19 and confirmed staff were supposed to wear masks at all times. Another CNA stated she was unsure whether staff were required to wear masks at all times and reported working on the LTC unit. A second LPN, who also had a resident with COVID-19 on his unit, stated he did not believe masks worked, was not aware staff were to wear masks, and said he would only wear a regular mask, not an N95, when entering a COVID-positive resident’s room. Another CNA reported being unclear about mask use outside resident rooms and stated that staff had become more relaxed about mask use at night after several residents had COVID-19. Further observations showed improper use of personal protective equipment (PPE) for residents on isolation for COVID-19. A CNA delivering a breakfast tray to a resident on droplet/contact precautions for COVID-19 donned a gown, gloves, and an N95 mask but did not wear eye protection while providing care and handling items in the room. Upon exiting, she removed her gown and gloves, performed hand hygiene, and applied a new N95 mask, later stating she was new and did not know eye protection was required for entering the room of a resident with COVID-19. An RN confirmed that staff were required to wear eye protection when entering such rooms. Record review showed that one resident had tested positive for COVID-19 and was placed on isolation, and another resident later tested positive and was placed on droplet/contact isolation. Facility infection tracking logs documented that 18 residents had tested positive for COVID-19 over a defined period, with all but one remaining in the facility. The facility’s written COVID-19 policy required source control (mask use) for individuals in areas experiencing a SARS-CoV-2 outbreak and specified that staff entering rooms of residents with suspected or confirmed COVID-19 must use an N95 mask, gown, gloves, and eye protection, which was not consistently followed in practice.
Failure to Provide Showers per Resident Preferences Due to Staffing Shortages
Penalty
Summary
The facility failed to ensure that residents received showers according to their preferred schedules, as documented in their care plans. Three residents with severe cognitive impairment and dependent on staff for bathing did not receive showers on multiple scheduled days. Medical records and care plans indicated that these residents were to receive showers twice a week, with specific days assigned for each individual. Shower records revealed that the scheduled showers were missed on several occasions for each resident. Interviews with CNAs, LPNs, and RNs confirmed that showers were not completed when there were staffing challenges. Staff reported that, during periods of inadequate staffing, priority was given to other essential care tasks such as turning, changing, and assisting residents with eating, resulting in showers being omitted. The Acting DON confirmed that residents' shower preferences were obtained on admission and that the missed showers were accurately reflected in the records. Family members of one resident expressed concern about the resident's hygiene, noting a decline in cleanliness and the importance of showering to the resident. The deficiency was identified during an investigation under specific complaint numbers.
Failure to Provide Timely and Accurate Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate and timely pressure ulcer care for two residents, resulting in deficiencies in wound management and prevention. For one resident with a history of congestive heart failure, respiratory failure, diabetes, and stage four kidney disease, a physician's order was in place to treat a pressure ulcer on the left heel. However, during wound care, a registered nurse mistakenly treated the right heel, which no longer had a pressure ulcer, instead of the left heel as ordered. The nurse confirmed the error after it was pointed out, and the facility's policy required adherence to physician orders for wound treatment. Another resident, admitted after hip replacement surgery and with stage three kidney disease and hypertension, was identified as being at risk for skin breakdown. Initial skin assessments were inaccurately dated, and the resident developed pressure ulcers on the right upper buttock and coccyx, which later merged into a larger wound. Treatment for these ulcers was not initiated until several days after the wounds were first noted, despite physician orders being obtained. Additionally, deep tissue pressure injuries were identified on both heels, but treatment was delayed by a day after the injuries were discovered and orders were received. Interviews with nursing staff and the Director of Nursing confirmed that documentation was not completed on the correct dates and that treatments were not started promptly as required by facility policy. The facility's Skin Integrity Management Policy specified that treatment plans should be established and implemented for residents with pressure ulcers, but these procedures were not consistently followed for the affected residents.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to ensure timely and appropriate reporting of an allegation of physical abuse involving a resident with chronic respiratory failure, dementia with psychotic disturbance, and psychosis. The incident occurred when two CNAs were providing care to the resident, who became combative. One CNA reportedly responded to the resident's attempt to bite by pushing and smacking the resident's head. This incident was witnessed by the other CNA, who did not report it immediately. The abuse was not reported to the local law enforcement agency or the resident's family, and the facility's Administrator unsubstantiated the allegation due to a lack of evidence. The facility's policy requires immediate reporting of abuse allegations to a supervisor, with subsequent notifications to the physician, resident's family, Ombudsman, and local law enforcement. However, the report indicates a delay in reporting the incident, as the witnessing CNA did not report it until several hours later, and the Administrator did not notify the necessary parties. The deficiency was identified during the investigation of a complaint, highlighting non-compliance with the facility's abuse prevention policy.
Failure to Offer Pneumococcal Vaccinations
Penalty
Summary
The facility failed to offer pneumococcal immunizations to residents, as evidenced by the review of medical records, vaccination consent forms, and staff interviews. This deficiency affected four out of five residents sampled for immunization review. The residents involved had various medical conditions, including heart disease, diabetes, dementia, renal disease, and respiratory failure. The immunization records for these residents showed either no record of receiving a pneumococcal vaccine or an unknown type of vaccine administered years prior. Additionally, there were no physician orders for the pneumococcal vaccine for these residents. The facility's Vaccine Administration Record (VAR)/Informed Consent form allowed residents or their responsible parties to indicate their wish to receive vaccinations, including COVID-19, influenza, and others. However, the forms for the affected residents did not indicate a request for the pneumococcal vaccine. An interview with the Director of Nursing (DON) revealed that there was no specific consent form for the pneumococcal vaccine, and the facility relied on residents or their families to write in their request for this vaccine. The DON acknowledged that there was no proof that the affected residents were asked about receiving the pneumococcal vaccine, highlighting a gap in the facility's vaccination consent process.
Failure to Provide Bed-Hold Notice During Hospital Transfer
Penalty
Summary
The facility failed to provide a bed-hold notice to a resident's representative when the resident was transferred to the hospital. This deficiency was identified during a review of the medical records of a resident who was admitted to the facility with diagnoses including dementia with behavioral disturbances, unspecified intellectual disability, generalized anxiety disorder, restlessness and agitation, and hypernatremia. The resident was transferred to the hospital due to an elevated sodium level, and although the resident's sister was informed of the transfer, there was no documentation that she was provided with a bed-hold notice as required by the facility's policy. The facility's policy mandates that residents or their representatives be informed of the bed-hold policy upon admission and prior to any transfer for hospitalization or therapeutic leave. In this case, the resident's medical record lacked evidence of compliance with this policy, as confirmed by the Social Service Director. The director was unable to find any documentation indicating that the resident's representative received the necessary bed-hold notice within the required timeframe, highlighting a lapse in the facility's adherence to its own procedures.
Inaccurate PASARR Documentation for Resident
Penalty
Summary
The facility failed to ensure that the Pre-Admission Screening and Resident Review (PASARR) documents were accurate regarding a resident's current conditions and diagnoses. This deficiency was identified during a review of records and staff interviews, affecting one resident. The resident in question had a range of diagnoses, including anxiety disorder, schizoaffective disorder, dementia, and several other medical conditions. Despite having a documented diagnosis of anxiety disorder since July 2021, the PASARR completed in January 2022 did not list this diagnosis. This discrepancy was confirmed during an interview with the Marketing Director, who acknowledged the absence of the anxiety diagnosis on the PASARR document.
Deficiencies in Care Planning for Anticoagulant and Anxiety Management
Penalty
Summary
The facility failed to develop comprehensive care plans for two residents, leading to deficiencies in their care. Resident #36, who has a complex medical history including end-stage renal disease, diabetes, heart disease, and other serious conditions, was prescribed the anticoagulant medication Eliquis for acute deep venous thrombosis. Despite the critical nature of this medication, the facility did not create a care plan to manage the resident's anticoagulant therapy. This oversight was confirmed during an interview with the Director of Nursing, who acknowledged the absence of a care plan for the resident's Eliquis use. Similarly, Resident #10, who has diagnoses including heart disease, diabetes, dementia, and anxiety disorder, did not have a specific and patient-centered care plan for managing anxiety. The resident's most recent assessment indicated a need for partial assistance with certain activities, yet the care plan failed to address the anxiety disorder and its specific symptoms. This lack of a tailored care plan was also verified by the Director of Nursing, highlighting a gap in the facility's approach to individualized resident care.
Deficiencies in Hospice Documentation and Compression Stocking Application
Penalty
Summary
The facility failed to ensure the availability of hospice records for Resident #109, which is crucial for continuity of care. The resident, who was admitted with multiple diagnoses including dementia and heart failure, was receiving hospice services with a prognosis of less than six months. Despite the care plan indicating the need for hospice services and documentation, the facility did not have the necessary hospice certification, care plan, or assessment in the resident's medical record. Interviews with the LPN confirmed that the required hospice documentation was not present. Additionally, the facility did not apply compression stockings as ordered by the physician for Resident #32, who was experiencing chronic left lower extremity edema. The resident, who had dementia and other mobility issues, was ordered to have compression stockings applied daily. However, observations revealed that the resident was not wearing the stockings, and the care plans did not address the edema or the use of compression stockings. Interviews with the CNA and LPN indicated a lack of awareness and adherence to the physician's orders, with the LPN acknowledging that the treatment administration record was inaccurately initialed to reflect compliance. These deficiencies highlight lapses in the facility's adherence to care plans and physician orders, impacting the quality of care provided to residents. The absence of hospice documentation and the failure to apply prescribed compression stockings demonstrate a lack of coordination and communication among the facility's staff, affecting the residents' care and well-being.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to implement fall prevention interventions as per the care plans for two residents at risk for falls. Resident #33, who had a history of falls and fractures, was admitted with a care plan that included using a visual reminder to prompt the use of a call light for assistance. Despite this, the resident experienced a fall resulting in a right hip fracture, as the visual reminder was not present in the room. The Director of Nursing confirmed the absence of the visual reminder, which was supposed to be in place following an interdisciplinary team review after the resident's previous fall. Resident #38, diagnosed with severe cognitive impairment and requiring substantial assistance, was also affected by the facility's failure to adhere to fall prevention measures. The care plan for this resident included the use of dycem in the wheelchair to prevent falls. However, during an incident, the dycem was not in place, leading to the resident being found on the floor. The Director of Nursing verified that the dycem was not in the wheelchair at the time of the fall, contrary to the care plan requirements.
Failure to Assess and Plan for PTSD in Resident
Penalty
Summary
The facility failed to ensure that a resident with Post Traumatic Stress Disorder (PTSD) was appropriately assessed to identify the cause of the PTSD and to minimize triggers and/or re-traumatization. This deficiency affected one resident, identified as having PTSD/trauma, within a facility census of 51. The resident had a range of pertinent diagnoses, including chronic PTSD, heart failure, morbid obesity, Alzheimer's disease, and other mental health disorders. Despite being cognitively intact and using a walker for mobility, the resident's medical record lacked an assessment or care plan for PTSD. Interviews with the Registered Social Worker and the Director of Nursing confirmed the absence of a PTSD care plan or assessment, with the staff unaware of the resident's PTSD triggers or history.
Infection Control Breach During Wound Care
Penalty
Summary
The facility failed to adhere to infection prevention guidelines by not wearing appropriate personal protective equipment during wound care for a resident. The resident, who was cognitively intact and used a wheelchair, had a right lateral heel unstageable pressure ulcer and was on enhanced barrier precautions due to their medical condition. The precautions required staff to wear gloves and gowns during high-contact activities such as wound care. However, during an observation, a State Tested Nurse Aide (STNA) assisted with the resident's wound care by only wearing gloves and not a gown, despite the clear signage on the resident's door indicating the need for enhanced barrier precautions. The STNA was observed holding the resident's leg in the air for at least two minutes without wearing a gown, and her clothing was in contact with the side of the bed. This action was in direct violation of the facility's Enhanced Barrier Precautions policy, which mandates the use of gloves and gowns for high-contact resident care activities to prevent the spread of multi-drug resistant organisms. The STNA confirmed in an interview that she did not wear a gown, acknowledging the resident was on enhanced barrier precautions.
Antibiotic Administered Before Culture Results
Penalty
Summary
The facility failed to ensure that a resident was not treated with an antibiotic prior to the return of culture and sensitivity (C&S) results. This deficiency affected a resident who was being reviewed for a urinary tract infection (UTI). The resident had a complex medical history, including neurocognitive disorder with Lewy bodies, dementia, Alzheimer's disease, and other conditions. The resident's care plan included monitoring for signs and symptoms of UTI and ensuring proper toileting and pericare. On a specific date, the resident exhibited increased lethargy, unformed speech, and had not voided in 12 hours, prompting the physician to order a straight catheterization, urinalysis (UA) with C&S, and Rocephin, an antibiotic, for three days. The UA/C&S results, collected the day after the antibiotic was started, suggested probable contamination and recommended a repeat test if clinically indicated. Despite this, the resident had already completed the three-day course of Rocephin by the time the results were received. The Director of Nursing confirmed that the resident was treated with antibiotics before the UA/C&S results were available. The physician decided not to repeat the UA, as the resident's behavior had returned to baseline.
Failure to Implement Physician-Ordered Pressure Reduction Devices
Penalty
Summary
The facility failed to implement physician-ordered pressure reduction devices for two residents, leading to deficiencies in pressure ulcer care. Resident #109, who was admitted with multiple diagnoses including a stage I pressure ulcer, was observed without the physician-ordered off-loading boot and air mattress. Despite orders to use these devices to prevent further skin breakdown, they were not in place during multiple observations on the same day. The resident's care plan included interventions such as an air mattress and off-loading boot, but these were not executed as required. Similarly, Resident #45, who had a history of pressure ulcers and required substantial assistance with mobility, was found on an alternating air mattress set incorrectly to a weight of 450 pounds, despite weighing only 133 pounds. The care plan and physician orders specified the use of an alternating air mattress, but the incorrect setting was confirmed by an LPN who was unsure of the correct weight setting. This oversight was later corrected by a Registered Nurse Clinical Compliance Specialist. These deficiencies were identified during a complaint investigation.
Self-audit
Pick a level of detail and, optionally, what to focus on — then generate a survey-ready checklist distilled from the most recent citations.
Beta · AI-generated — for reference only, not professional advice. Verify against current CMS guidance before relying on it. Assisto accepts no responsibility for how this checklist is used.
Citations used to create this checklist
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.
Self-audit
Pick a level of detail and, optionally, what to focus on — then generate a survey-ready checklist distilled from the most recent citations.
Beta · AI-generated — for reference only, not professional advice. Verify against current CMS guidance before relying on it. Assisto accepts no responsibility for how this checklist is used.
Citations used to create this checklist
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
