Laurels Of Athens, The
Inspection history, citations, penalties and survey trends for this long-term care facility in Athens, Ohio.
- Location
- 70 Columbus Circle, Athens, Ohio 45701
- CMS Provider Number
- 366396
- Inspections on file
- 23
- Latest survey
- December 16, 2024
- Citations (last 12 mo.)
- 16 (1 serious)
Citation history
Health deficiencies cited at Laurels Of Athens, The during CMS and state inspections, most recent first.
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.
A resident with a documented history of depression was prescribed Buspirone and Vistaril for anxiety, and the MDS reflected use of anti-anxiety medications, yet the Active Diagnoses section did not list an anxiety disorder. Review of the resident's care plans showed they addressed only depression and antidepressant use, and the psychotropic medication care plan referenced only antidepressants, omitting the anti-anxiety drugs. The MAR confirmed ongoing administration of both anti-anxiety medications, and the DON acknowledged that the resident's anxiety and related medications were not included in the active care plans.
A resident with osteomyelitis, type II DM, and dementia had an existing care plan identifying fall risk and a goal to remain free from fall-related injury. After the resident experienced a fall that led to hospital transfer, staff implemented new fall interventions such as bedside reorientation and visual cues to use the call light, but these interventions were not added to the written care plan until weeks later. The DON confirmed the care plan did not reflect the current fall interventions during this period, contrary to the facility’s care planning policy.
The deficiency involves two residents for whom the facility did not follow established care expectations. A resident with multiple risk factors for impaired skin integrity reported a blister on the back of the thigh that later tore during a mechanical lift transfer; despite the resident’s report and a staff-taken photo days earlier, the skin alteration was not formally identified or assessed until it was observed by surveyors, revealing a MASD area on the posterior thigh. In a separate case, a resident receiving prn Oxycodone and care-planned as at risk for constipation went multiple times more than three days without a documented BM, including one eight-day interval, with no documented nursing interventions, no laxatives given, and no evidence of physician notification, even as prn opioid doses continued.
The facility failed to consistently document meal intake for two residents who had significant weight loss or were at nutritional/dehydration risk, despite care plans and physician orders identifying the need for monitoring. One resident with dementia, diabetes, and a history of significant weight loss had only about one‑third of meals documented over a month, with many days lacking any recorded intake, even though she was ordered a regular diet and supplements and was identified as at risk for malnutrition. Another resident with ESRD, respiratory failure, CHF, and on dialysis had multiple missing meal percentage entries across two months, including entire days without any documented intake, despite being care planned for nutritional risk. Staff interviews confirmed that meal intakes were expected to be documented in the EMR and that trays for residents away at appointments should be saved and offered later, but the Administrator and DON acknowledged that required intake documentation was missing.
Surveyors found that a resident with chronic respiratory failure and a tracheostomy did not have an Ambu (resuscitation) bag readily available at the bedside, despite facility policy requiring a handheld resuscitation bag with oxygen source to be easily accessible for emergencies; the RN confirmed the bag was missing and would have to be obtained from a crash cart if needed. In addition, another resident receiving continuous oxygen therapy at 3 L/min via nasal cannula had no corresponding physician order, which was confirmed on record review and by an LPN in social services.
Surveyors found that the facility failed to identify and document trauma triggers in the care plans of two residents with PTSD. One resident with dementia and severe cognitive impairment had a trauma history noted but no triggers listed on the trauma care plan, and no social services re-evaluation was completed after a prior assessment despite the MDS continuing to show PTSD as an active diagnosis. Another resident with depression and PTSD related to Vietnam War service had a trauma evaluation and social services assessment documenting nightmares, difficulty sleeping, and specific triggers of loud noises and enclosed spaces, yet the active trauma care plan only contained vague language and an incomplete intervention to "avoid (specify)" without listing those triggers.
A resident with chronic pain and an order for PRN oxycodone 5 mg had doses signed out on the narcotic log by an LPN on two occasions, but these doses were not documented as administered on the MAR. The DON acknowledged the discrepancy between the narcotic log and MAR and referenced a prior resident interview from another misappropriation investigation, though no documentation showed the resident was interviewed about these specific undocumented administrations. The resident reported receiving medications as requested and having no concerns with other nurses, while the facility’s controlled substances policy addressed receipt and logging of medications but did not prevent the identified documentation inconsistencies.
Surveyors found that two residents did not receive medications in accordance with physician orders and drug administration guidelines. One resident on Metoprolol for hypertension and heart disease had the drug given nightly with blood pressure documented, but staff did not obtain or document the ordered apical pulse with hold parameters for HR <60 bpm. Another resident receiving weekly Fosamax for osteoporosis had the medication administered in the morning around the same time as breakfast service, despite orders to give it with a full glass of water on an empty stomach and drug information specifying administration at least 30 minutes before any food or other medications.
A resident with overactive bladder and complaints of dysuria had an order for a one-time UA C&S, along with care plan interventions for labs per orders and monitoring for UTI. Staff did not attempt to obtain the urine specimen until five days after the order, when an LPN’s initial straight cath attempt was unsuccessful due to positioning and a subsequent attempt was refused by the resident, who requested a bedpan instead. There was no documentation of earlier collection attempts, no evidence that the provider was notified of the refusal, and no record that the ordered UA C&S was ever completed, despite facility policy requiring timely completion of ordered lab services.
The facility failed to maintain complete and accurate medical records for multiple residents, including missing and delayed documentation of a fall and hospital transfer, incomplete shower and meal intake records, undocumented bowel movements despite a PRN laxative order, and missing treatment administration entries for ordered tracheostomy care and inner cannula changes. Staff, including LPNs, an RN, and the DON, confirmed that assessments, investigations, and routine care were either not documented, left blank, or not signed in the EMR or on treatment records, contrary to the facility’s own documentation policy.
Surveyors identified multiple infection control failures involving three residents. During tracheostomy care for a resident with chronic respiratory failure and a trach, an RN removed soiled gloves after handling the inner cannula and dressing and then donned sterile gloves without performing required hand hygiene between glove changes before cleaning the stoma and applying a new dressing. In a separate incident, an RN performed a finger-stick blood glucose test on a diabetic resident using a shared glucometer and returned the device to the medication cart without disinfecting it, despite facility policy requiring decontamination of shared glucometers. Additionally, a resident with an indwelling urinary catheter was observed seated with the catheter drainage bag lying directly on the floor, contrary to facility policy that catheter bags and tubing be kept off the floor.
A resident with dementia and other chronic conditions, who was severely cognitively impaired per MDS, received a COVID-19 vaccine dose based on a consent form signed by a former guardian. After guardianship was transferred to the resident's nephew, no new consent was obtained before a subsequent COVID-19 vaccination was administered by a contracted vaccination company, which relied on the outdated consent and did not verify current guardianship status with facility staff. The current guardian reported he had not been informed about the vaccination and would not have consented due to the resident's prior reaction to a shingles vaccine.
A resident with dementia and other medical conditions experienced a fall and was found in pain. Despite having pain medication orders, the resident did not receive timely medication or an x-ray, which revealed a displaced hip fracture requiring surgery. Staff reported the resident's significant pain, but the nurse did not act promptly, leading to a delay in care and actual harm.
The facility did not follow the prescribed CCHO diet menu for several residents during a lunch meal service. Residents on CCHO diets received incorrect desserts, with some receiving chocolate chip cookies instead of the required seasonal fresh fruit. The dietary staff did not prepare the correct items, and the nursing staff did not verify the tray contents before delivery.
A resident with multiple medical conditions did not receive scheduled showers on two occasions, as documented evidence was lacking. The resident, who required assistance for personal care, reported inconsistencies in receiving showers and preferred morning showers. The DON acknowledged the documentation gap, but there was no evidence of the resident refusing showers, contrary to initial claims.
A resident with chronic respiratory conditions was found to be using supplemental oxygen without a physician's order, and their nebulizer equipment was improperly cleaned and stored. The resident's medical history included acute on chronic respiratory failure, COPD, and CHF. Observations showed the nebulizer was not stored correctly, and the oxygen use lacked a valid order, as confirmed by an RN.
A resident with dementia was repeatedly observed seated in her room, visible from the hallway, wearing only a t-shirt and incontinence brief. Despite her habit of dressing minimally and refusing to have her door closed, the care plan lacked interventions to address this behavior. Staff interviews revealed a lack of awareness and documentation, resulting in a dignity-related deficiency.
A resident's Ativan medication went missing from a locked medication cart in an LTC facility. Despite thorough searches and interviews, the missing medication was not found. The nurse responsible for the cart speculated it might have been accidentally disposed of, but the investigation could not confirm this. Facility policies on narcotic counts and medication cart use were reviewed, but the exact cause of the missing medication remains undetermined.
A facility failed to thoroughly investigate the misappropriation of Ativan prescribed to a resident with dementia and anxiety. The medication went missing during a shift change, and despite a search, it was not found. Interviews with staff, including the responsible RN, did not reveal any clear evidence of misconduct, but the investigation was incomplete as it did not include interviews with other residents or a comprehensive review of the RN's practices. Anonymous staff raised concerns about the RN's medication administration, which were not fully explored.
The facility failed to ensure proper labeling and record-keeping of medications. Observations revealed discrepancies in the control drug record for Methadone and multiple instances of loose, unpackaged pills in medication carts across different halls. Staff confirmed these findings, indicating non-compliance with facility policies on medication management.
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.
Failure to Care Plan for Anxiety Disorder and Anti-Anxiety Medications
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan addressing a resident's anxiety disorder and related anti-anxiety medications, as required by §483.21(b). The resident was admitted with a diagnosis of depression and later received new physician orders for Buspirone 5 mg twice daily and Vistaril 25 mg three times daily, both prescribed for anxiety. The quarterly MDS assessment documented that the resident received anti-anxiety medication during the assessment period, but the Active Diagnoses section did not list an anxiety disorder diagnosis despite the ongoing use of two medications for that condition. Review of the resident's active care plans showed no care plan specifically addressing anxiety or the use of anti-anxiety medications. Existing care plans addressed potential mood fluctuations and depression, focusing only on antidepressant use, and a separate care plan for risk of adverse reactions to psychotropic medications referenced only antidepressant therapy for depression. The MAR confirmed that the resident was receiving Buspirone and Vistaril as ordered for anxiety. In an interview, the DON confirmed that the resident's active care plans did not address her anxiety or the use of anti-anxiety medications and acknowledged that a care plan for anxiety should have been in place.
Plan Of Correction
1. Resident #100 had their order for Buspar and Vistaril orders clarified on 4/22/26 by the Unit Manager to clarify the indication for use of the ordered medications and validated care plan for accuracy. The Buspar order was clarified by the physician to be used for diagnosis of Depression and the Vistaril order was clarified by the physician to be used for a diagnosis of itching. The care plan was updated to include the use of the antianxiety/anxiolytic medications for diagnoses of Depression and Itching on 5/7/26 by Social Service Designee. The resident does not have an active diagnosis of Anxiety as clarified by the physician. 2. Like Residents are identified as residents who utilize medication for anxiety. An audit will be completed by the Director of Nursing or designee for like residents utilizing the Medication Review Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC to ensure residents who utilize medication for anxiety have an active diagnosis and care plan in place to address anxiety. 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 Care Planning and Physicians Orders Policies to ensure orders include an accurate and appropriate diagnosis and a care plan is initiated or revised to indicate use of antianxiety/anxiolytic medications. This education will be completed on or before 5/13/26. 4. Utilizing the Medication Review 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 F 0656 complete an audit 4-6 residents weekly for four weeks, beginning 5/14/26 to ensure residents who utilize medication for anxiety have an active diagnosis and care plan in place to address anxiety. Discrepancies noted from audits will be corrected to include clarification of orders and revision of care plans. 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 Timely Update Care Plan After Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s comprehensive care plan was revised in a timely manner to reflect current fall interventions after a fall event. The resident was admitted with diagnoses including acute osteomyelitis of the right ankle and foot, type II diabetes, and dementia. A care plan dated 03/10/26 identified the resident as being at risk for fall-related injury and falls due to history and fear of falling, with a goal to remain free from injury related to falls. A nursing note dated 03/25/26 documented that the resident went to the hospital, without additional information. In an interview, the resident reported having a fall that required hospital transfer, though he did not specify the date. Further review of the care plan showed that specific fall interventions, including reorienting the resident at bedside and providing a visual cue to use the call light for assistance, were created on 04/09/26 and were related to the fall that occurred on 03/25/26. In an interview, the DON confirmed that these interventions, which were implemented immediately after the fall, were not added to the written care plan until 04/09/26, leaving the care plan not up to date until that date. The facility’s “Care Planning” policy required that every resident have a person-centered care plan developed and implemented based on the comprehensive assessment, with measurable objectives and time frames to meet identified needs, but the resident’s care plan was not revised promptly after the fall as required.
Plan Of Correction
1. Resident #86 had their fall care plan updated on 4/9/26 by the Director of Nursing to reflect current fall interventions. 2. 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 for the past 30 days will be completed by the Director of Nursing or designee to ensure fall care plans reflect current fall interventions. 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 Fall Management Policy to include updating the care plan with new interventions as appropriate. This education will be completed on or before 5/13/26. 4. 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 audit new admissions, readmissions and residents who experience a fall weekly for four weeks, beginning 5/14/26 to ensure fall care plans reflect current fall interventions. Discrepancies noted during audits will be corrected with care plans updated to reflect current fall interventions. 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 Address New Skin Breakdown and Constipation in Residents at Risk
Penalty
Summary
The deficiency involves the facility’s failure to identify and treat a new skin condition for a resident at high risk for impaired skin integrity. The resident had diagnoses including spinal stenosis, radiculopathy, type II diabetes, hypertension, a current surgical wound, a history of MASD, anemia, and morbid obesity, and a care plan requiring weekly head-to-toe skin assessments and prompt reporting of abnormal findings. A weekly skin assessment documented on 03/30/25 indicated no skin issues. However, the resident later reported having what she believed to be a blister on the back of her left thigh that tore during a mechanical lift transfer, resulting in a wound that she stated was not addressed by staff despite her request for a nurse assessment. A nurse recalled the resident mentioning a blister weeks earlier but reported not seeing any area at that time. On 04/08/26, observation revealed an area on the back of the resident’s left thigh that appeared dry, peeling, and healing, approximately two by three inches, which an LPN confirmed. Subsequent documentation that same day described a new MASD area on the left posterior thigh measuring eight by 12 centimeters. The resident reported that a CNA had taken a picture of the back of her thigh on 04/03/26 using the resident’s phone, showing the area existed several days before the facility formally identified and documented it. A supervising RN confirmed that if a wound had been found and photographed on 04/03/26, it should have been identified and treated before 04/08/26, when the facility became aware of the skin alteration through the surveyor. This sequence shows a gap between the resident’s report of a skin issue, staff awareness via a photograph, and the formal recognition and assessment of the skin impairment. A second deficiency concerns the facility’s failure to implement interventions when a resident went more than three days without a bowel movement despite being at risk for constipation related to opioid use. The resident had diagnoses including adult-onset diabetes mellitus, generalized osteoarthritis, hypokalemia, depression, and anxiety disorder, and had an order for prn Oxycodone 5 mg by mouth every four hours for pain since admission. Her care plan identified her as at risk for constipation due to opioid use, with a goal of having a bowel movement at least every three days and interventions to observe for signs and symptoms of constipation. Bowel records over a 30-day period showed three episodes where no bowel movement was documented for more than three days: one four-day interval, one eight-day interval, and another four-day interval. During these periods, there was no documentation of any nursing interventions to promote a bowel movement, no laxatives administered, and no evidence of physician contact for constipation management, even though the resident continued to receive prn Oxycodone. The DON acknowledged the extended intervals without recorded bowel movements and the lack of documented interventions, and stated there was no bowel protocol in place, although it was an expectation that nurses contact the physician if no bowel movement occurred within three to four days.
Plan Of Correction
Formatted text (without <text> tags or quotes): 1. Resident #8 had their skin alteration evaluated by the wound nurse and appropriate treatment orders implemented on 4/8/26. Resident #99 had a medium bowel movement documented on 4/17/26 by the STNA and was assessed by the RN Unit Manager on 5/7/26 with no ill effects of going greater than 3 days without a bowel movement. Licensed Nurse obtained physician's order on 5/7/26 for stool softener. 2. Like Residents are identified as residents who have a skin alteration. A full-house skin sweep was completed by the Wound Nurse on 4/23/26 to identify any unreported skin alterations. Utilizing the Skin Alteration 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 skin alterations are evaluated and have appropriate treatment orders in place. This audit along with identified corrections will be completed on or before 5/13/26. Like Residents are identified as residents who have greater than 3 days with no bowel movement documented as indicated on the clinical alerts via PCC. Utilizing the Change in Condition 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 residents who do not have a bowel movement documented within three days have documentation in place for appropriate intervention/follow up. This audit will look back to 5/2/26. 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 STNAs, including CNA #373 and RN #330 on the Skin Management and Notification of Change Policy to include reporting of skin alterations and notifying the physician of a resident change in status. This education will be completed on or before 5/13/26. The Director of Nursing or designee will re-educate licensed nurses utilize PCC to identify and address clinical alerts related to no bowel movements greater than three days and to follow the Notification of Change Policy regarding physician notification. This education will be completed on or before 5/13/26. 4. Utilizing the Skin Alteration 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 skin alterations are evaluated and have appropriate treatment orders in place. Noncompliance noted during the audits will be corrected with appropriate treatment orders in place. Audits will be reviewed by Quality Assurance/Performance Improvement Committee for additional recommendations. Utilizing the Change in Condition 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 residents who do not have a bowel movement documented within three days have documentation in place for appropriate intervention/follow up. Noncompliance noted during the audits will be corrected with documentation in place for appropriate intervention/follow up. 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 Consistently Document Meal Intake for Residents at Nutritional Risk
Penalty
Summary
The deficiency involves the facility’s failure to consistently document meal consumption for residents with significant weight loss or identified nutritional risk, preventing adequate monitoring of their nutritional status. One resident with dementia, diabetes, depression, anxiety, and vitamin deficiencies was admitted at 154.4 pounds and had a documented downward weight trend to 140 pounds after three months and then to 130 pounds. Her care plan identified her as at risk for nutrition with a history of significant weight loss at one, three, and six months, with goals to avoid unplanned significant weight changes and interventions including a regular diet, offering substitutes, providing ordered supplements, and documenting consumption. Physician orders noted she was at risk for malnutrition and prescribed a regular diet and house supplements twice daily. However, review of her meal intake records over a 30‑day period showed that only 29 of 90 meals had documented intake, with no documentation at all for any of the three meals on 16 separate days and incomplete documentation on several other days. Staff interviews further confirmed the lack of consistent documentation for this resident. A CNA reported that the resident ate breakfast in the dining room and usually had lunch and supper with family in her room or while out on drives, and that her appetite varied by day. The CNA stated that if the resident ate less than 50% of a meal, staff would offer alternatives, but she was not aware of the resident receiving supplements or having weight loss, and there were no supplements available for the resident in the container at the nurses’ station that day. An LPN verified that the resident’s meal percentages were not being consistently recorded in the EMR, acknowledging that only about one‑third of the resident’s meals were documented and that this information was important for the dietitian when determining nutritional interventions related to weight loss. A second resident, admitted with end stage renal disease, respiratory failure, hyperlipidemia, and congestive heart failure, had impaired cognition and required set‑up/clean‑up assistance with meals and was care planned as being at nutritional and/or dehydration risk due to recent surgery, CHF, dialysis, increased needs, and skin alteration. Interventions included assisting with meals and providing the ordered diet. This resident had multiple missing meal intake entries over March and April, including entire days with no documented breakfast, lunch, or dinner, and numerous individual meals without recorded percentages. Interviews with dietary and CNA staff indicated that trays for residents away at dialysis should be returned to the kitchen, stored in the fridge, or placed in the server room until the resident returned, and that meal intakes should be documented in the computer. The Administrator and DON confirmed the missing meal percentage documentation, and facility policy required accurate records of residents’ food intake to be completed by assigned personnel.
Plan Of Correction
1. On 5/6/26 the Director of Nursing reviewed Resident # 5 and determined there was no ill effect related to the missing meal documentation and the resident's weight remains stable. On 5/6/26 the Director of Nursing reviewed Resident # 12 and determined there was no ill effect related to the missing meal documentation and the resident's weight remains stable. 2. Like Residents are identified as residents who receive meals from the facility. Utilizing the Meal Intake Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, an audit of identified residents will be completed by the Director of Nursing or designee to ensure they have diet orders in PCC and meal intake is being documented in PCC. This audit along with identified corrections will be completed on or before 5/13/26. 3. The Director of Nursing designee will re-educate licensed nurses and STNA's on the Food Acceptance Policy to include documenting meal intake in POC. This education will be completed on or before 5/13/26. 4. Utilizing the Meal Intake 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 4-6 residents weekly for four weeks, beginning 5/14/26 to ensure they have diet orders in PCC and meal intake is being documented in PCC. Noncompliance noted during audits will be corrected to ensure diet orders are in PCC and meal intake is being documented in PCC. 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 Maintain Tracheostomy Emergency Equipment and Oxygen Orders
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate respiratory and tracheostomy-related care and equipment for two residents. One resident, admitted with chronic respiratory failure with hypoxia, tracheostomy status, COPD, heart failure, and chronic pulmonary edema, had active orders for 28% humidified oxygen via tracheostomy collar to maintain oxygen saturation above 90%, with tracheostomy care every shift and a full code status. Her care plan identified risk for respiratory distress, decannulation, and infection, with interventions including humidified oxygen and tracheostomy care per orders and protocol. During an observation of tracheostomy care performed by an RN, the resident’s room was checked for emergency medical supplies related to her tracheostomy. All necessary emergency equipment was present except for an Ambu (resuscitation) bag, which could not be located despite the nurse searching the room. The RN acknowledged that an Ambu bag should be readily accessible in the room for emergencies and stated she would need to leave the room or have someone obtain one from the crash cart if needed. The facility’s tracheostomy care policy specified that a handheld resuscitation bag with attached oxygen source must be readily available for easy access in an emergency. The deficiency also includes the facility’s failure to ensure a physician’s order was in place for oxygen administration for another resident prior to its use. This resident was admitted with diagnoses including major depression and hypertension. An MDS assessment documented that the resident received continuous oxygen therapy. During an observation, the resident was noted to have oxygen in place at 3 L/min via nasal cannula. Review of current orders showed there was no physician’s order for the resident to receive oxygen. In a subsequent observation and interview, the resident was again seen resting in bed with oxygen in place, and a social services staff member, who is also an LPN, confirmed that there was no order in place for the oxygen therapy being administered.
Plan Of Correction
1. On 5/6/26, Director of Nursing verified an ambu bag at Resident #9's bedside. On 4/13/26 the Licensed Nurse contacted the physician and obtained an order for oxygen use for Resident #39. 2. Like Residents are identified as residents who utilize a tracheostomy within in the facility. Utilizing the Tracheostomy Care Audit tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, an audit of identified residents will be completed by the Director of Nursing or designee to ensure they have an Ambu bag at bedside. This audit along with identified corrections will be completed on or before 5/13/26. Like Residents are identified as residents who utilize oxygen within the facility. Utilizing the Respiratory Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, an audit of identified residents will be completed by the Director of Nursing or designee to ensure residents utilizing oxygen have physician orders for oxygen use in place. 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 Physician Orders, the emergency equipment to be at bedside for residents with a tracheostomy and the Use of Oxygen Policies to include obtaining physician orders for use of oxygen. This education will be completed on or before 5/13/26. 4. Utilizing the Tracheostomy Care 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 all residents with a tracheostomy weekly for four weeks, beginning 5/14/26 to ensure they have an Ambu bag at bedside. Noncompliance noted from audits will be corrected with emergency equipment at bedside for residents with a tracheostomy. Audits will be reviewed by Quality Assurance/Performance Improvement Committee for additional recommendations. Utilizing the Respiratory 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 4-6 residents weekly for four weeks, beginning 5/14/26 to ensure residents utilizing oxygen have physician orders for oxygen use in place. Noncompliance noted from audits will be corrected with physician orders obtained for resident with oxygen use in place. 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 Identify and Document PTSD Trauma Triggers in Care Plans
Penalty
Summary
The deficiency involves the facility’s failure to provide trauma-informed care by identifying and documenting trauma triggers on care plans for residents with PTSD, as required by regulation and facility policy. For one resident with Alzheimer’s disease, dementia, major depressive disorder, PTSD, and severe cognitive impairment, the trauma care plan initiated in mid-2023 noted a past abusive relationship as a trauma history but did not identify any specific trauma triggers. Social services re-evaluations completed in 2025 repeatedly documented that the resident had not suffered from PTSD since the last assessment, but there was no subsequent social services re-evaluation after November 2025 despite the quarterly MDS in January 2026 listing PTSD as an active diagnosis. The social services worker confirmed that no triggers were identified on the care plan and there was no documentation that the resident denied having triggers, and also confirmed the absence of a required re-evaluation after November 2025. For a second resident admitted in early 2026 with major depressive disorder and later-documented PTSD, the facility completed a trauma evaluation that recorded affirmative responses to questions about experiencing a frightening or traumatic event and having unwanted thoughts or nightmares about it, but the form did not explain what the resulting score meant and contained no additional comments. The resident was hospitalized for pneumonia and, during that hospitalization, PTSD was listed as an active diagnosis treated with Effexor. Upon readmission, the attending physician and a subsequent social services re-evaluation both documented PTSD as an active diagnosis, with the social services assessment specifying that the PTSD was related to Vietnam War service, that the resident had difficulty sleeping almost every night, and that loud noises and closed spaces were identified as triggers. Despite this information, the resident’s active trauma care plan only generally stated that he had experienced trauma in the past, that his PTSD was from the Vietnam War, and that he was followed by VA psychiatric services. The care plan described possible trauma expressions such as hypervigilance, social isolation, and flashbacks, and included goals related to feeling safe and not being re-traumatized, but the interventions section merely stated to avoid “(specify)” without listing the known triggers. During an interview, the resident confirmed that loud or sudden noises and enclosed spaces were triggers and described his reaction when triggered, yet these specific triggers were not incorporated into the trauma-informed care plan until the day of the survey, contrary to the facility’s policy requiring that identified trauma and triggers be addressed in the care plan and that social services re-evaluations be completed with each MDS or at least every 90 days.
Plan Of Correction
1. On 4/14/26 the Social Service Designee reviewed resident #78's Trauma Care Plan and updated it to indicate no identified triggers for PTSD. A social service re-evaluation was completed on 4/24/26 by the Social Service Director at which time the resident denied any trauma. On 4/28/26 the Social Service Designee reviewed resident #109's Trauma Care Plan and updated it to include identified triggers for PTSD. 2. Like Residents are identified as residents who have a history of trauma. Utilizing the Trauma Informed Care Audit Tool, which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, an audit of identified residents will be completed by the Social Services Designee to ensure the SS evaluation accurately identifies PTSD and they have identified trauma triggers listed on their trauma care plan. This audit along with identified corrections will be completed on or before 5/13/26. 3. The Administrator or designee will re-educate the Social Services department on the Social Services Documentation Policy to include evaluating trauma and care planning triggers for residents with a history of trauma. This education will be completed on or before 5/13/26. 4. Utilizing the Trauma Informed Care 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 admissions, readmissions and residents due for quarterly assessments weekly for four weeks beginning 5/14/26 to ensure the SS evaluation identifies those with PTSD diagnosis and that trauma triggers are listed on their trauma care plan. Noncompliance noted from audits will be corrected with residents reassessed and care plans revised as indicated. 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.
Inaccurate Documentation of PRN Controlled Substance Administration
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate documentation of controlled substances in the medical record for a resident receiving PRN opioid pain medication. The resident was admitted with hypertension and anemia and had an order for oxycodone 5 mg by mouth every four hours as needed for pain, with a care plan identifying chronic pain related to an internal orthopedic device and left knee pain. The care plan interventions included administering medications as ordered and observing for effectiveness and side effects. The resident’s MDS indicated intact cognition and that the resident had pain and received opioid medication. Record review showed that on two separate dates in February, an LPN signed out oxycodone 5 mg on the narcotic log at specific morning times, but there were no corresponding entries on the MAR indicating that the medication was administered at those times. The DON acknowledged that the LPN had signed out the medication on the narcotic log without signing it as administered on the MAR and stated they did not believe there was a concern for diversion or misappropriation, referencing an interview with the resident in another investigation. However, there was no statement in the misappropriation investigation documentation indicating that the resident had been interviewed about these specific instances of medications being signed out without MAR documentation. The resident later reported receiving medications as requested and having no concerns with other nurses. The facility’s written controlled substances policy addressed receipt, verification, and logging of controlled medications but did not prevent the discrepancy between the narcotic log and MAR documentation identified in this case.
Plan Of Correction
1. Resident #99 was interviewed by Director of Nursing on 2/25/26 and 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. 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 3 residents per med cart for a total of 27 residents who utilize controlled substance PRN pain medication 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. Discrepancies noted during the audits will be investigated and documentation corrected to accurately reflect medicine administered. 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 Follow Medication Parameters and Fasting Requirements for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure that residents’ drug regimens were free from unnecessary drugs by not following specific physician orders and administration parameters. For one resident with hypertensive heart disease with heart failure, atrial fibrillation, and hypertension, the physician ordered Metoprolol Succinate ER 25 mg to be given nightly at bedtime with parameters to hold the medication if the systolic blood pressure was less than 100 mmHg or the heart rate was less than 60 bpm. Review of the MARs for March and April showed the medication was administered at 9:00 P.M. with blood pressures documented prior to administration, but there was no documentation that an apical pulse was checked before giving the medication, despite the order including heart rate parameters. Further review of the resident’s EMR, including the vital signs tab, revealed no evidence that an apical pulse was obtained and recorded at times corresponding to the administration of Metoprolol. This lack of documentation was confirmed by the DON, who was unable to locate any record of apical pulse checks prior to the nightly doses. The DON acknowledged that the resident’s heart rate should have been checked because Metoprolol is known to slow the heart rate. The deficiency also includes the facility’s failure to administer an osteoporosis medication in accordance with physician orders and recommended administration guidelines. Another resident, diagnosed with age-related osteoporosis, had an order for alendronate sodium (Fosamax) 70 mg once weekly on Fridays, to be given with a full glass of water and on an empty stomach. The MAR and a 30-day medication administration audit showed that the Fosamax was administered between 8:25 A.M. and 8:53 A.M., while breakfast on that hall was served at 8:30 A.M. in the dining room or at 8:50 A.M. in the resident’s room. An LPN confirmed that the resident typically ate breakfast at those times and acknowledged that, based on the administration times, the medication was not being given on an empty stomach, which would result in poor absorption according to the drug information cited from Medscape.
Plan Of Correction
1. Resident #12 had their order for Fosamax clarified with the physician on 4/8/26 by a licensed nurse to administer the medication on an empty stomach. Resident #12 was assessed by the Director of Nursing on 5/7/26 with no ill effects noted. Resident's Fosamax was discontinued by the physician on 4/30/26. Resident #100 had their order for Metoprolol updated to include monitoring of their pulse on 4/14/26 by the Director of Nursing. Resident #100 was assessed by the Director of Nursing on 5/7/26 with no ill effects noted. 2. Like Residents are identified as residents who utilize bisphosphonate medications for the treatment of osteoporosis. An audit will be completed by the Director of Nursing or designee for like residents utilizing the Medication Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, to ensure residents who utilize medication for osteoporosis receive them on an empty stomach and/or according to physician orders. This audit along with identified corrections will be completed on or before 5/13/26. Like Residents are identified as residents who utilize betablocker medications with specific orders to monitor their pulse for the treatment of hypertension. An audit will be completed by the Director of Nursing or designee for like residents utilizing the Medication Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, to ensure residents who utilize beta blocker medication for hypertension have their pulse monitored when the physician indicates specific parameters within the order. 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 Physicians Order Policy to ensure orders include and are transcribed with the information that is necessary and accurate to carry out the order correctly. This education will be completed on or before 5/13/26. 4. Utilizing the Medication 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 4-6 residents weekly for four weeks, beginning 5/14/26 to ensure residents who utilize medication for osteoporosis receive them on an empty stomach and/or according to physician orders and to ensure residents who utilize beta blocker medication for hypertension have their pulse monitored when the physician indicates specific parameters within the order. Discrepancies noted during the audits will be corrected with physician orders clarified. 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 Obtain Ordered UA C&S for Resident with Dysuria
Penalty
Summary
The facility failed to ensure that a urinalysis with culture and sensitivity (UA C&S) was obtained as ordered for a resident with risk factors for urinary tract infection (UTI). The resident was admitted with diagnoses including spinal stenosis and radiculopathy and had a care plan indicating risk for bladder incontinence, skin breakdown, and UTI due to overactive bladder, with goals to minimize risk of septicemia through prompt recognition and treatment of UTI symptoms. An order dated 10/17/25 directed that a UA C&S be obtained one time for dysuria. A subsequent care plan dated 10/20/25 documented that the resident was at risk for UTI due to complaints of dysuria, with interventions including encouraging fluids, obtaining labs per orders, and taking vitals as ordered or per facility protocol. Nursing documentation showed that on 10/22/25 at 10:00 A.M., an LPN attempted to obtain a urine specimen via straight catheterization but was unable to do so due to the resident’s positioning, and planned to attempt again after repositioning. At 10:30 A.M. the same day, after repositioning, the resident yelled that she did not want to be straight cathed and requested to use a bedpan for the sample, then refused. There was no evidence in the medical record of any attempts to collect the urine sample prior to 10/22/25, no documentation that the provider was notified of the resident’s refusal, and no evidence that the ordered urine test was ever obtained. The PA who ordered the UA C&S confirmed there were no results in the record and stated he would have expected the sample to be collected as quickly as possible. The DON confirmed that the order was given on 10/17/25 and that collection was not attempted until five days later, contrary to the facility’s laboratory services policy requiring labs to be completed and results provided within normal timeframes for appropriate intervention.
Plan Of Correction
1. Resident #8 had a urinalysis collected on 10/23/26 by Ohio Health Hospital and received treatment as ordered by the physician. 2. Like Residents are identified as residents who have received orders for a urinalysis. An audit will be completed by the Director of Nursing or designee for residents who have received an order for a urinalysis in the past 30 days utilizing the Laboratory Services Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, to ensure residents had their urine obtained, physician was notified of results and physician orders were carried out as appropriate. 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 Laboratory Services Policy to ensure urinalysis tests are obtained and results are provided within timeframes normal for appropriate intervention. This education will be completed on or before 5/13/26. 4. Utilizing the Laboratory Services 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 all urinalysis ordered within the last 7 days, weekly for four weeks beginning 5/14/26 to ensure residents had their urine obtained, physician was notified of results and physician orders were carried out as appropriate. Noncompliance noted during the audits will be corrected with urinalysis obtained, physician notified of results and physician orders were carried out as appropriate. Negative findings to be addressed immediately and negative trends or system wide issues will be reported to the
Incomplete and Inaccurate Medical Record Documentation for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete, accurate, and timely medical records for multiple residents, as required by regulation. For one resident with acute osteomyelitis of the right ankle and foot, type II diabetes, and dementia, the care plan identified a risk for fall-related injury. A nursing note documented that the resident went to the hospital on a specific evening but did not include any additional information. An electronic change-in-condition assessment for that date was opened but left blank, and the fall investigation was opened but not signed until weeks later. The DON stated that the paper fall investigation used for QAPI was not considered part of the medical record. Another resident, admitted with dysphagia and developmental issues, had multiple missing entries in shower documentation over several weeks. The DON confirmed that shower documentation was missing on numerous identified dates. The same resident’s meal intake records also contained multiple gaps for specific meals and days, which the DON likewise confirmed as missing. The resident reported that she did receive her showers but that staff did not assist her with shaving, while the record did not consistently reflect the provision of showers or meal intake. A third resident with dementia, difficulty walking, and low back pain had bowel movement (BM) records showing no documented BM for a seven-day period and a separate five-day period. The resident had an active PRN order for Bisacodyl 10 mg suppository for constipation, in place since admission, but the MARs for the relevant months showed no administration of the medication during those intervals. An LPN confirmed the absence of documented BMs and the lack of recorded Bisacodyl administration, and later acknowledged that some BMs were not entered into the EMR. The resident’s daughter reported that the resident’s bowels moved regularly and that the family monitored this closely, expressing confidence that BMs occurred during the periods where none were documented. A fourth resident with chronic respiratory failure with hypoxia, COPD, asthma, chronic pulmonary edema, and a tracheostomy had physician orders for tracheostomy care and inner cannula cleaning every shift. Review of the treatment administration records for a given month revealed multiple shifts with missing nurse initials where tracheostomy care should have been documented. An RN confirmed that the TAR did not provide documented evidence that tracheostomy care was completed on those dates and explained that on those shifts a medication technician was assigned to the hall, and a nurse from another hall would have performed the care but failed to sign it. The facility’s “Documentation Expectations” policy required healthcare personnel to complete documentation in the medical record using accepted principles and for licensed nurses to audit documentation for completeness and accuracy, which was not met in these instances.
Plan Of Correction
1. On 5/6/26 Resident #9 was assessed by Director of Nursing and shows no ill effect related to the lack of documentation for tracheostomy care. On 5/6/26 Resident #12 was assessed by Director of Nursing and shows no ill effect related to going greater than 3 days with no bowel movement documented. On 4/15/26 Resident #76 received a shower by the STNA. On 5/6/26 the Director of Nursing reviewed Resident #76 and determined there was no ill effect related to the missing meal documentation and the resident's weight remains stable. Resident #86's fall investigation was completed on 4/28/26 the Interdisciplinary Team. A new intervention of a reaching device was implemented and placed on the resident's care plan. The reaching device was implemented on 3/25/26 by the licensed nurse. The care plan was updated on 4/9/26 by the Director of Nursing to include intervention of a reaching device. 2. Like Residents are identified as residents who utilize a tracheostomy. An audit will be completed by the Director of Nursing or designee utilizing the Tracheostomy Care Audit tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC to ensure tracheostomy care is documented in the medical record. This audit will look back to 5/1/26. This audit along with identified corrections will be completed on or before 5/13/26. Like Residents are identified as residents who go greater than 3 days with no bowel movement documented in the medical record. An audit will be completed by the Director of Nursing or designee utilizing the Change in Condition Audit tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, to ensure appropriate documentation is completed when a resident goes greater than 3 days with no bowel movement. This audit will look back to 5/1/26. This audit along with identified corrections will be completed on or before 5/13/26. Like Residents are identified as residents who need assistance with showering. 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 completed and documented in the medical record. This audit will look back to 5/1/26. This audit along with identified corrections will be completed on or before 5/13/26. 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 for the past 30 days will be completed by the Director of Nursing or designee to ensure fall documentation is entered into the residents' medical record post fall. 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 Tracheostomy tube cannula and stoma care policy to include documenting the procedure. This education will be completed on or before 5/13/26. The Director of Nursing or designee will re-educate licensed nurses on Notification of Change Policy to include follow up documentation related to a resident with no bowel movement documented within 3 days. This education will be completed on or before 5/13/26. The Director of Nursing or designee will re-educate licensed nurses and STNA's on the Routine Resident Care Policy to include documentation of bathing. This education will be completed on or before 5/13/26. The Director of Nursing or designee will re-educate licensed nurses and STNA's on the Food Acceptance Policy to include documenting meal intake in POC. This education will be completed on or before 5/13/26. The Director of Nursing or designee will re-educate licensed nurses on the Fall Management Policy to include fall documentation entered into the residents' medical record post fall. This education will be completed on or before 5/13/26. 4. Utilizing the Tracheostomy Care 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 residents with tracheostomies to ensure tracheostomy care is documented in the medical record. This audit will be completed for all residents who have a tracheostomy weekly for 4 weeks, beginning 5/14/26 to ensure tracheostomy care is documented in the medical record. Noncompliance noted during audits will be corrected with tracheostomy care documented in the medical record. Audits will be reviewed by Quality Assurance/Performance Improvement Committee for additional recommendations. Utilizing the Change in Condition 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 residents with no bowel movement documented for greater than 3 days to ensure appropriate documentation is completed. This audit will be completed for 4-6 residents weekly for 4 weeks, beginning 5/14/26 to ensure appropriate documentation is completed when a resident goes greater than 3 days with no bowel movement. Noncompliance noted during the audits will be corrected with appropriate documentation completed. Audits will be reviewed by Quality Assurance/Performance Improvement Committee for additional recommendations. 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 resident showers to ensure that showers are completed and documented in the medical record. This audit will be completed for 4-6 residents weekly for 4 weeks, beginning 5/14/26 to ensure that showers completed and documented in the medical record. Noncompliance noted during audits will be corrected with showers completed and documented in the medical record. Audits will be reviewed by Quality Assurance/Performance Improvement Committee for additional recommendations. Utilizing the Fall 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 residents experiencing a fall within the last 7 days ensure fall documentation is entered into the residents' medical record post fall. This will be completed weekly for 4 weeks, beginning 5/14/26 to ensure fall documentation is entered into the residents' medical record post fall. Noncompliance noted from the audits will be corrected with documentation entered into the residents' medical record post fall. 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.
Infection Control Failures in Tracheostomy Care, Glucometer Disinfection, and Catheter Management
Penalty
Summary
The deficiency involves multiple failures in the facility’s infection prevention and control practices related to respiratory care, blood glucose monitoring, and indwelling urinary catheter management. One resident with chronic respiratory failure, COPD, asthma, chronic pulmonary edema, and a tracheostomy had physician orders for tracheostomy care every shift and a daily inner cannula change. During an observed tracheostomy care procedure, the RN donned PPE, washed her hands, and set up supplies, then removed the old inner cannula and dressing with gloved hands and disposed of them. After this, she removed her gloves and immediately donned a new pair of sterile gloves from the tracheostomy care kit without performing hand hygiene in between glove changes, then proceeded to clean around the tracheostomy stoma and apply a new split gauze dressing. The RN later confirmed she had not performed hand hygiene between glove removal and donning new gloves, despite the facility’s tracheostomy care policy requiring hand hygiene at that point. Another deficiency occurred during blood glucose monitoring for a resident with intact cognition, diabetes, morbid obesity, chronic kidney disease stage 5, and atherosclerotic heart disease, who used a walker and received insulin. An RN entered the resident’s room to check blood sugar, initially using the resident’s Dexcom G7 receiver, then obtained consent to perform a finger-stick blood glucose test. After completing the finger stick with a shared glucometer, the RN returned to the cart, placed the glucometer on the cart, unlocked the cart, and stored the glucometer inside without disinfecting it. The RN later confirmed that the glucometer was not cleaned after use and acknowledged that it should have been disinfected after use on this resident, as it was a shared device used for multiple residents on the same hall. Facility policy required the glucometer to be disinfected on all external parts following the disinfectant’s directions. A further deficiency was identified in the management of an indwelling urinary catheter for a resident admitted with malignant neoplasm of the esophagus and type II diabetes mellitus. The resident had a care plan indicating risk for urinary tract infection and catheter-related trauma due to an indwelling catheter for urinary retention, with goals that the resident show no signs or symptoms of urinary infection and that the catheter remain patent and without complications. Interventions included ensuring the catheter tubing and drainage bag were secured properly with a dignity cover in place. Physician orders directed that the #16 French indwelling catheter be changed every 30 days and as needed, and the MDS confirmed the catheter was in place. During observation, the resident was seated in a chair with the catheter bag lying directly on the floor, with no barrier in place. An LPN confirmed that the catheter bag was on the floor. The facility’s catheter-associated urinary tract infection prevention policy specified that catheter bags and tubing should be kept off the floor.
Plan Of Correction
Formatted text (without <text> tags or quotes): 1. On 5/6/26 Resident #9 was assessed by Director of Nursing and shows no ill effect related to the lack of hand hygiene after removing the inner cannula and split gauze dressing. 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. Resident #19 was assessed by 5/6/26 on Director of Nursing and revealed no signs of infection or ill effects related to not disinfecting the glucometer after use. Resident #28 was assessed by 5/6/26 on Director of Nursing and revealed no signs of infection or ill effects related to not disinfecting the glucometer after use. Resident #79 was assessed by 5/6/26 on Director of Nursing and revealed no signs of infection or ill effects related to not disinfecting the glucometer after use. 2. Like Residents are identified as residents who utilize a tracheostomy and no other like resident were identified. An audit will be completed by the Director of Nursing or designee utilizing the Trach Tube Cannula and Stoma Care Skills check off which were created on 4/20/26 by the Director of Nursing for the purpose of this POC to ensure licensed nurses are preforming tracheostomy care according to the facility policy. This audit along with identified corrections will be completed on or before 5/13/26. 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 located below the bladder but not laying on the floor. This audit along with identified corrections will be completed on or before 5/13/26. Like Residents are identified as residents who utilize a facility glucometer. An audit will be completed by the Director of Nursing or designee utilizing the Glucometer Decontamination Skills check-off which was created on 4/20/26 by the Director of Nursing for the purpose of this POC to ensure licensed nurses are disinfecting glucometers after use according to the facility policy. 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 tracheostomy tube cannula and stoma care policy to include hand hygiene during the procedure and hand hygiene with glove changes. This education will be completed on or before 5/13/26. The Director of Nursing or designee will re-educate licensed nurses on the Indwelling Urinary Catheter Policy to include placement of urinary catheter bags. This education will be completed on or before 5/13/26. The Director of Nursing or designee will re-educate licensed nurses on the Glucometer and PT/INR Decontamination Policy to include disinfecting the glucometer after use. This education will be completed on or before 5/13/26. 4. Utilizing the Tracheostomy Care 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 all residents with tracheostomies to ensure licensed nurses are performing tracheostomy care according to the facility policy. This audit will be completed weekly for 4 weeks, beginning 5/14/26 to ensure licensed nurses are performing tracheostomy care according to the facility policy. Noncompliance noted during the audits will be corrected with licensed nurse re-educated with return demonstration. Audits will be reviewed by Quality Assurance/Performance Improvement Committee for additional recommendations. Utilizing the Urinary Catheter Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, Director of Nursing or designee will complete an audit of all residents who utilize urinary catheters to ensure catheter bags are located below the bladder but not laying on the floor. This audit will be completed weekly for 4 weeks, beginning 5/14/26 to ensure catheter bags are located below the bladder but not laying on the floor. Noncompliance noted during audits will be corrected with catheter bags changed and relocated to below the bladder but not laying on the floor. Audits will be reviewed by Quality Assurance/Performance Improvement Committee for additional recommendations. Utilizing the Glucometer Decontamination Skills check-off 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 5 observations of licensed nurses weekly for 4 weeks, beginning 5/14/26 to ensure the glucometer is disinfected appropriately after use. Noncompliance noted during audits will be corrected with the glucometer disinfected appropriately after use. 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.
COVID-19 Vaccine Given Without Consent From Current Guardian
Penalty
Summary
Surveyors identified a deficiency related to COVID-19 immunization consent when a resident received a COVID-19 vaccine dose without consent from the current legal guardian. The resident, who had diagnoses including late-onset Alzheimer's disease, dementia, atherosclerotic heart disease, hypertensive heart disease without heart failure, and a history of falls, was admitted in March 2021 and re-entered in November 2025. The medical record showed a COVID-19 vaccine consent form signed by the resident's former guardian in April 2025, and the resident received a COVID-19 vaccination on that same date. Guardianship paperwork indicated that the resident's nephew became the legal guardian in July 2025. The resident's quarterly MDS from April 2026 documented a Brief Interview for Mental Status (BIMS) score of three, indicating severe cognitive impairment, although the resident was independent with ADLs, always continent, and had no pain or skin issues during the review period. Record review further showed that the resident received another COVID-19 vaccination in November 2025, but there was no consent form signed by the current guardian for that dose. In an interview, the current guardian stated he had not been informed that the resident was eligible for a COVID-19 vaccine prior to administration and reported he would not have consented due to the resident's prior reaction to a shingles vaccine. The DON confirmed that the resident's guardian had changed in July 2025 and that no consent from the current guardian was obtained before the November 2025 vaccination. The DON also stated that a contracted vaccination company administered the vaccine and used the prior consent from April 2025 without checking with the facility before giving the later dose.
Plan Of Correction
F 0887 1. Resident #44 was assessed by Director of Nursing on 4/29/26 and suffered no ill effects from receiving the covid vaccine. 2. Like Residents are identified as residents who received the covid vaccine within the facility. An audit will be completed by the Director of Nursing or designee for like residents utilizing the Immunization Documentation Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC to ensure consents are accurate, including guardian signatures, as applicable. 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 Resident Covid – 19 Vaccination Policy to include obtaining consent prior from the resident or designated healthcare representative to administering the covid 19 vaccine. This education will be completed on or before 5/13/26. 4. Utilizing the Immunization Documentation 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 residents who receive the covid 19 vaccine during the last 7 days weekly for four weeks, beginning 5/14/26 to ensure consent is obtained from the resident or the residents designated healthcare representative prior to administering the covid 19 vaccine. Noncompliance noted during the audits will be corrected with consents obtained prior to administering the covid 19 vaccine. 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 Provide Timely Care After Resident Fall
Penalty
Summary
The facility failed to provide timely, comprehensive, and individualized care to a resident following an unwitnessed fall with injury. The resident, who had a history of dementia, chronic kidney disease, and other medical conditions, experienced a fall and was found in the hallway complaining of pain. Despite having orders for pain medication, the resident did not receive as-needed pain medication until several hours after the fall, and an x-ray was not conducted until the following day. The x-ray revealed a displaced fracture of the left femoral head, necessitating surgical intervention. Interviews with staff and review of records indicated that the resident was in significant pain following the fall, as evidenced by her vocalizations and physical reactions during range of motion assessments. Multiple staff members reported that the resident was screaming in pain when her leg was moved, yet the nurse on duty did not take immediate action to address the pain or send the resident to the hospital. The facility's policy on pain management, which includes comprehensive evaluation and timely intervention, was not followed, leading to a delay in appropriate care. The Director of Nursing acknowledged the delay in ordering the x-ray and the lack of documentation in the nurse's notes. The facility's failure to act promptly and effectively in response to the resident's fall and subsequent pain resulted in actual harm to the resident, as she required surgical intervention for a hip fracture that was not promptly diagnosed or treated.
Failure to Follow CCHO Diet Menu
Penalty
Summary
The facility failed to adhere to the prescribed menus for residents on consistent carbohydrate (CCHO) diets during a lunch meal service. Specifically, four residents on CCHO diets were observed receiving incorrect meal components. Three of these residents were given two chocolate chip cookies instead of the seasonal fresh fruit specified in their diet plan, while one resident did not receive any dessert. The meal tickets clearly indicated the CCHO diet requirements, yet the dietary staff did not follow these instructions, leading to the incorrect meal preparation. The issue was further compounded when the trays were delivered to the residents without verification by the nursing staff. Both a nurse and a CNA passed the trays without questioning the contents, despite the meal tickets indicating the dietary restrictions. The Food Service Director confirmed the oversight, acknowledging that the dietary staff did not prepare the seasonal fresh fruit required for the CCHO diet, resulting in the incorrect dessert being served. This lapse in following the dietician-approved menu was verified by both the RN and CNA involved in the tray delivery.
Failure to Provide Scheduled Showers to Resident
Penalty
Summary
The facility failed to ensure that a resident, who was dependent on staff for personal care, received the necessary assistance for scheduled showers. The resident, who had multiple medical conditions including dementia, diabetes, and heart failure, was scheduled to receive showers three times a week. However, there was no documented evidence of the resident receiving showers on two scheduled days. The resident reported inconsistencies in receiving showers and expressed a preference for morning showers, which was not always accommodated. The Director of Nursing (DON) acknowledged the lack of documentation for the missed showers and initially suggested that the resident might have refused them. However, the resident denied refusing showers on the specified dates, and there was no documentation to support the DON's claim. The facility's policy required residents to receive necessary assistance for personal hygiene, but the documentation and interviews revealed a failure to adhere to this policy, resulting in the resident not receiving scheduled showers.
Deficiency in Respiratory Care for a Resident
Penalty
Summary
The facility failed to ensure that a resident using supplemental oxygen had a physician's order for its use, and that nebulizer equipment was properly cleaned and stored when not in use. The resident, who was admitted with diagnoses including acute on chronic respiratory failure with hypoxia, COPD, CHF, and sleep apnea, was dependent on supplemental oxygen. Despite these conditions, the resident's physician's orders did not include an order for the use of supplemental oxygen, although the resident was observed using it. Additionally, the resident's nebulizer equipment was not properly maintained. Observations revealed that the nebulizer was not stored in a bag when not in use, and the reservoir still contained condensation, indicating it had not been rinsed or dried after its last use. The equipment was found lying on top of the dresser next to the resident's bed. An RN confirmed the absence of a valid order for supplemental oxygen and acknowledged the improper cleaning and storage of the nebulizer equipment.
Failure to Ensure Dignity for Resident with Dementia
Penalty
Summary
The facility failed to provide a comprehensive and individualized treatment plan for a resident diagnosed with dementia, which resulted in a dignity-related deficiency. The resident, who was moderately impaired with a BIMS score of nine, was observed multiple times seated in her room in a wheelchair, dressed only in a t-shirt and incontinence brief, and visible from the hallway. Despite the resident's habit of dressing minimally in the morning and refusing to have her door closed, the care plan did not include interventions to address this behavior. Interviews with facility staff, including a CNA, LPN, and RN Unit Manager, revealed a lack of awareness and documentation regarding the resident's behavior of sitting in view from the hallway without proper clothing. The LPN social services designee confirmed that the situation was not dignified for the resident or others in the facility. The absence of a care plan intervention to address the resident's behavior indicates a failure to ensure the resident's dignity and independence.
Misappropriation of Resident's Ativan
Penalty
Summary
The facility failed to prevent the misappropriation of narcotics, specifically Ativan, prescribed to a resident diagnosed with Alzheimer's, dementia, anxiety, and other conditions. The resident was prescribed Ativan 1 mg three times daily for anxiety, and the medication was administered as ordered until a discrepancy was noted. During a shift change, it was discovered that a card containing 30 Ativan pills was missing from the narcotic box in the medication cart, which was supposed to be under double lock and accessible only to the assigned nurse. Despite a thorough search of the medication carts, medication room, shred bins, and trash, the missing medication was not located. The investigation revealed that the nurse responsible for the medication cart, RN #186, had verified the correct count at the beginning of her shift and maintained that she did not give her keys to anyone else. She speculated that the missing medication might have been accidentally disposed of with empty non-narcotic medication cards. However, the trash was searched without success, and the nurse was unable to locate the trash bag that had been taken to the dumpster. Interviews with other staff members did not yield any observations of the medication cart being left unlocked or medications being left on top of the cart. The facility's policies on narcotic counts and medication cart use were reviewed, highlighting the requirement for narcotics to be counted at the beginning and end of each shift with two nurses present, and for medication carts to remain locked when not in use. Despite these policies, the investigation could not determine the exact cause of the missing Ativan, and the nurse involved was suspended pending the outcome of the investigation. The police were notified, and a report was filed, but the medication was not recovered, and no further discrepancies were noted in the narcotic count.
Failure to Investigate Misappropriation of Medication
Penalty
Summary
The facility failed to thoroughly investigate an allegation of misappropriation of controlled medication affecting a resident diagnosed with Alzheimer's, dementia, anxiety, and other conditions. The resident was prescribed Ativan for anxiety, and a discrepancy was noted when a card of 30 Ativan pills went missing during a shift change. The investigation revealed that the medication was last accounted for at the beginning of the shift, but was missing by the end of the day. Despite a search of the medication carts, medication room, shred bins, and trash, the missing medication was not located. Interviews with staff, including the RN responsible for the medication, indicated that the RN did not recall leaving the cart unlocked or giving her keys to anyone else. The RN speculated that the medication might have been accidentally disposed of with empty non-narcotic cards. However, the investigation did not include interviews with other residents or a thorough assessment to ensure they received their medications as ordered. Additionally, there were no signs of impairment in the RN, and her personnel file showed no previous concerns related to medication administration. The facility's investigation was incomplete, as it did not adequately address concerns raised by anonymous staff members about the RN's medication administration practices. These staff members reported that residents had complained about not receiving medications timely or as ordered when the RN was on duty. Furthermore, the investigation did not include a comprehensive review of the RN's interactions with other residents or an assessment of their medication administration records. The facility's policy on abuse prohibition and misappropriation was not fully adhered to, as the investigation lacked thoroughness and failed to interview all relevant parties.
Medication Labeling and Record-Keeping Deficiencies
Penalty
Summary
The facility failed to ensure that controlled medications were properly signed out when administered and that medications were properly labeled and packaged. During an observation of the 300 medication cart, it was found that a resident had 25 Methadone 5 mg tablets in the blister packet, while the control drug record sheet indicated there should be 26 tablets. The LPN confirmed that she had administered a Methadone tablet to the resident earlier that morning but had not signed it out on the control drug record sheet. Additionally, there were loose and unpackaged pills found in the medication cart, which the LPN confirmed and stated she would dispose of. Further observations revealed similar issues across other medication carts. On the 400 medication cart, two loose unpacked pills were found, and the LPN confirmed they were not labeled. On the 100 medication cart, three loose unpacked pills were observed, and the RN confirmed they were not labeled. Lastly, the 200 medication cart had four loose unpacked pills, which the LPN confirmed were not labeled. The facility's policies on narcotic count and medication management were reviewed, indicating that medications must be signed out on the narcotic count sheet and stored in compliance with state and federal regulations, which was not adhered to in these instances.
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Surveyors found that multiple hazardous storage areas, including a closet near medical records, a beauty salon used to store chemical cases, a supply room in one nursing station, a room leading to a smoking area, a housekeeping room near therapy, and a lobby storage room, lacked required self-closing or automatic-closing doors. These conditions did not comply with NFPA 101 requirements for hazardous area enclosure and had the potential to affect all residents and staff in an emergency.
Surveyors found that the facility did not conduct fire drills on every shift each quarter and did not vary drill conditions as required by NFPA 101. Record review showed that one shift lacked a documented drill for an entire quarter, and the pattern of drill times and dates did not demonstrate varied conditions. The Maintenance Director confirmed the incomplete and noncompliant fire drill schedule, which affected all residents and staff emergency preparedness.
Surveyors found that the facility did not maintain clear egress corridors as required by NFPA 101, with a TV/video cart plugged into a corridor outlet and multiple unsecured chairs placed in the hallway near resident rooms and the secured unit dining room, including directly in front of a fire extinguisher. These items projected about 29 inches into an approximately eight-foot-wide corridor and were located in front of the handrail, potentially affecting 28 residents and staff’s ability to assist in an emergency. The Maintenance Director confirmed these corridor obstructions during the survey.
A resident with intact cognition receiving Medicare Part A skilled services for metabolic encephalopathy had services discontinued while benefit days remained, but the facility did not issue the required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN). The Social Services Director later confirmed that no SNF ABN was provided and reported she believed only a Notice of Medicare Non-Coverage (NOMNC) was needed when all skilled services were stopped. This practice conflicted with the facility’s written policy, which required SNF ABNs to be issued when extended care items or services were initiated, reduced, or terminated due to expected non-coverage by Medicare.
Surveyors identified that the facility exceeded the acceptable medication error rate when two residents with type 2 DM received insulin doses that were not administered according to orders or manufacturer instructions. In two separate observations, an LPN administered Novolog and another LPN administered insulin glargine and insulin lispro without priming the insulin pens, and the insulin lispro and Novolog were given after the residents had already consumed a significant portion of their breakfast meals, despite orders for administration before meals. Manufacturer information for both insulin products required priming before each injection to ensure accurate dosing, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and specified time frames.
The facility failed to maintain accurate and complete crash cart audits for multiple full-code residents. Surveyors, accompanied by the DON, found that daily crash cart checks did not include verification of supply expiration dates, and that an extension cord documented as present on several audit dates was not actually in the cart. Audit logs also conflicted with the cart’s contents by indicating that required items such as eye protection, saline, and clear plastic were present when they were not. These findings were inconsistent with the facility’s policy requiring the crash cart to be checked every 24 hours and after each use, with prompt replacement of equipment and supplies.
A resident with chronic respiratory failure on supplemental O2, COPD, and cognitive risk factors was repeatedly documented as non-compliant with the smoking policy, including going out to smoke outside designated times and retaining cigarettes and lighters provided by family. Despite prior assessments identifying this resident as unsafe to smoke without supervision, a later assessment classified the resident as safe to smoke independently without documented rationale or care plan update. The resident subsequently went outside alone with an O2 nasal cannula in place, lit a cigarette, and sustained facial burns when the cannula ignited, as observed by staff and confirmed by EMS and ED records. In a separate case, another cognitively impaired resident with a history of falls had a care-planned intervention for non-skid strips in front of a recliner, but observation and staff confirmation showed the strips were not present, despite remaining on the active fall-risk care plan.
Multiple dependent residents did not receive scheduled showers, bed baths, or shaving as outlined in their care plans and the facility’s routine care policy. One resident recovering from spinal surgery missed numerous scheduled showers over several months. Another resident who relied on staff for self-care repeatedly requested shaving but was not shaved, and visible facial hair was observed after a recent shower. A resident with chronic respiratory failure and a tracheostomy, requiring substantial/maximal assist with personal hygiene, had no documented showers for an extended period and was observed with long facial hair, which staff acknowledged should be removed during bathing or as needed. A cognitively impaired resident with ESRD and CHF, scheduled for twice-weekly showers, had multiple undocumented or missed showers and reported not getting showers despite asking aides who said they lacked time. Another cognitively intact resident with hemiplegia and multiple comorbidities, also scheduled for twice-weekly showers, had several dates where documentation showed no shower/bath/bed bath provided or no entry at all, and she reported feeling unclean and unimportant when her showers were missed.
A resident with an indwelling urinary catheter for urinary retention, and care plan interventions requiring the drainage bag to be properly secured with a dignity cover, was observed seated in a chair with the catheter drainage bag uncovered and containing visible dark yellow urine that could be seen from the hallway. Later, an LPN confirmed the catheter bag was lying directly on the floor without a dignity cover. This situation occurred despite facility policy requiring care to be provided in a manner that respects and enhances each resident’s dignity and personal privacy.
A cognitively intact resident with chronic orthopedic pain had a PRN oxycodone order, but multiple doses were signed out on the narcotic log by an RN without corresponding entries on the MAR or documented pain assessments. A CNA/med tech reported frequent problems with this RN’s narcotic counts and documentation, describing erratic behavior when handling narcotic keys. The resident reported taking oxycodone only once or twice daily and otherwise using Tylenol, which conflicted with the number of oxycodone doses signed out. The facility’s investigation found it was inconclusive whether narcotics were misappropriated or whether there was a failure of documentation, but confirmed there was no evidence that all signed-out doses were administered.
Failure to Maintain Self-Closing Doors for Multiple Hazardous Storage Areas
Penalty
Summary
Surveyors identified a deficiency related to hazardous area protection and door requirements under NFPA 101, 2012 Edition. During facility tours, they observed that multiple hazardous storage areas did not have self-closing or automatic-closing doors as required for hazardous areas such as combustible storage and chemical storage. These areas included a closet next to medical records, a beauty salon being used to store cases of chemicals, a supply room in Station #2, and the room leading to the smoking area in Station #3. On a subsequent tour, surveyors observed additional hazardous areas without self-closing doors. The housekeeping room across from therapy and the lobby storage room were both noted to lack self-closing door mechanisms. The facility census at the time was 59 residents, and the surveyors stated that this deficient practice had the potential to affect all residents and staff's ability to assist in an emergency. The Maintenance Director verified these findings at the time they were observed.
Plan Of Correction
K 0321 This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be admissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as its allegation of substantial compliance as of 06/12/2026 K-0321 Doors with Self-Closing Devices Corrective action for resident/s: 1. The closet door next to medical records was lacking a self-closing door on 5/19/2026. Maintenance director to add self-closing device to closet door next to medical records on or before 06/12/2026 in accordance with applicable code. 2. The beauty salon had chemicals stored in it on 5/19/2026. Maintenance director moved chemicals from beauty salon on 05/20/2026 in accordance with applicable code. 3. The supply room on station 2 was lacking a self-closing door on 5/19/2026. Maintenance director to add self-closing door to supply room on station 2 on or before 06/12/2026 in accordance with applicable code. 4. The room to the smoking area on station 3 was lacking a self-closing door on 5/19/2026. Maintenance director to add a self-closing door to the smoking are on station 3 on or before 06/12/2026 in accordance with applicable code. 4. The housekeeping room across from therapy was lacking a self-closing door on 5/19/2026. Maintenance director to add a self-closing door to the housekeeping room across from therapy gym on or before 06/12/2026 in accordance with applicable code. 5. The lobby storage room was lacking a self-closing door on 5/19/2026. Maintenance director to add a self-closing door to the lobby storage room on or before 06/12/2026 in accordance with applicable code. Identification of other residents who may be affected: LNHA and Maintenance director/designee completed a full facility audit for doors with self-closing devices on 05/26/2026. Any corrective action, including, doors identified as needing self-closures will be added on or before 06/09/2026 in accordance with applicable code. Measures for systemic change: LNHA educated Maintenance Director on 05/26/2026 regarding NFPA 101-2012 sections 19.3.2.1 and 19.3.5.9 specifically regarding doors with self-closing devices. How Corrective Action will be monitored Ongoing "Doors with Self-Closing device audit" to be completed weekly x 2 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 06/12/2026
Failure to Conduct Required Quarterly Fire Drills on All Shifts
Penalty
Summary
The facility failed to conduct fire drills in accordance with NFPA 101, 2012 Edition, sections 19.7.1 through 19.7.1.8, specifically by not holding drills every shift each quarter and not varying drill conditions as required. Record review on 06/09/25 at approximately 10:32 A.M. showed there was no fire drill conducted for the first shift during the third quarter. The documented first-shift fire drills occurred on 01/30/26 at 2:42 P.M., 04/30/26 at 1:51 P.M., and 10/31/25 at 10:58 A.M., indicating a missed quarter. Second-shift fire drills were recorded on 02/26/26 at 5:20 P.M., 06/03/25 at 4:35 P.M., 08/29/25 at 3:46 P.M., and 11/25/25 at 5:09 P.M., and third-shift drills on 02/28/26 at 11:47 P.M., 05/30/25 at 12:18 A.M., 07/22/25 at 11:34 P.M., 09/26/25 at 11:40 P.M., and 12/15/25 at 5:17 A.M. The surveyor determined that drills were not conducted under varied conditions and that the required quarterly drill on each shift was not consistently performed. The Maintenance Director confirmed these findings at the time they were identified, and the deficiency had the potential to affect all 59 residents and staff response in an emergency. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency related to facility-wide emergency preparedness practices and documentation of fire drills.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 05/29/2026 K-0712 Fire Drills Corrective action for resident/s: There were no records of a fire drill for the first shift of the third quarter of 2025. First shift fire drill completed on 5/24/2026 by maintenance director/designee with no findings or corrective action necessary. Identification of other residents who may be affected: On 5/26/2026 Maintenance director/designee completed 100% audit of the scheduled fire drills to ensure a drill is scheduled quarterly each shift with no findings or corrective action necessary. Measures for systemic change: LNHA educated Maintenance Director on 05/26/2026 regarding NFPA 101-2012 section 19.7.1.4 through 19.7.1.7. specifically including fire drill frequency requirements. How Corrective Action will be monitored Ongoing "Fire Drill Audit" to be completed weekly x 2 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 05/29/2026
Obstructed Egress Corridors Due to Equipment and Chairs
Penalty
Summary
The facility failed to maintain required clear egress widths in corridors in accordance with NFPA 101, 2012 Edition, sections 19.2.3.4 through 19.2.3.5 and 7.3.2 through 7.3.2.3, creating projections into the egress corridor that exceeded allowable limits. Surveyors observed that on one day in Station #3, a cart with a television and video equipment was plugged into an outlet in the corridor by room 38, and five activity room chairs were placed in the corridor near the secured unit dining room directly in front of a fire extinguisher. On the following day, surveyors again observed chairs in the Station #3 corridor, with four by room 35 and four by the activities room, and the same television cart still in the corridor; the chairs were not secured. The corridor was approximately eight feet wide, and the projections extended approximately 29 inches into the corridor in front of the handrail. These conditions had the potential to affect 28 residents in the facility and the staff’s ability to assist in an emergency, and the Maintenance Director confirmed the observations at the time of discovery. No specific resident medical histories or conditions were described in the report, only that 28 residents were potentially affected and the facility census was 59.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be subsequent remedial measures and should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 05/29/2026 K-0232 Clear path of egress Corrective action for resident/s: 1. On 05/18/2026 station 3 had a cart with a television parked in the corridor by room 38 that exceeded allowable limits. Maintenance director/designee moved the TV cart into the activity room, out to the corridor on 05/18/2026 in accordance with applicable code. 2. On 5/18/2026 station 3 had 5 chairs in the corridor near the dining room directly in front of the fire extinguisher. Maintenance director/designee moved the chairs into the dining room, out of the corridor on 5/18/2026 in accordance with applicable code. 3. On 5/19/2026 station 3 had 4 chairs by the activity room and 4 by room 35. In addition, the TV cart was in the corridor. The maintenance director/designee moved the chairs and TV cart into the dining room, out of the corridor on 5/19/2026 in accordance with applicable code. Identification of other residents who may be affected: Maintenance director/designee completed a 100% facility audit for clear paths of egress on 5/26/26 with no findings or corrective action necessary. Measures for systemic change: Maintenance Director/designee educated staff on 5/26/2026 regarding NFPA 101-2012 section 19.2.3.4 and 19.2.3.5 specifically including maintaining a clear path of egress. How Corrective Action will be monitored Ongoing "Path of Egress Audit" to be completed weekly x 2 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 05/29/2026
Failure to Issue Required SNF ABN When Discontinuing Medicare Part A Services
Penalty
Summary
The deficiency involves the facility’s failure to issue a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) when Medicare Part A services were discontinued for a resident who still had available benefit days. The resident was admitted with a diagnosis of metabolic encephalopathy and had intact cognition per the Minimum Data Set assessment. The facility’s own SNF Beneficiary Notification Review documented that Medicare Part A skilled services began on 02/11/26 and the last covered day was 03/11/26, and that the facility initiated discharge from Medicare Part A services before the resident’s benefit days were exhausted. Despite this, no SNF ABN was provided to the resident or the resident’s representative. During interviews, the Social Services Director stated that the SNF ABN was issued hours prior to the last covered day but, upon reviewing her files, confirmed that no SNF ABN had actually been issued for this resident. She further explained that she believed an SNF ABN was only required if one skilled service remained and that if all skilled services were being discontinued, only the Notice of Medicare Non-Coverage (NOMNC) needed to be issued. The Administrator, however, stated that a resident should always receive both a SNF ABN and a NOMNC when Medicare Part A services are discontinued and benefit days remain. Review of the facility’s written policy dated 03/28/23 showed that the facility was required to issue SNF ABNs for initiation, reduction, or termination of extended care items or services when Medicare payment was not expected, which did not occur in this case.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as its allegation of substantial compliance as of 05/29/2026 F-0582 Corrective action for resident/s: On 5/14/26 Resident #34 was informed of rights and responsibilities related to Advanced Beneficiary Notice and voiced understanding of information for future reference by administrator. Identification of other residents who may be affected: Any resident receiving skilled services from nursing or therapy services. The Administrator audited all residents who were discharged from skilled services in the past 30 days to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary Notice on 5/29/26. No non-compliance was noted. Measures for systemic change: On 5/14/2026 Business Office Manager, Director of Rehab, Minimum Data Set nurse, Director of Nursing and Social Services Director were educated on proper procedure of issuing of Notice Of Medicare Non Coverage and Advanced Beneficiary Notice by administrator. All upcoming discharges from skilled services will be reviewed weekly at Utilization Review meeting to ensure notices will be delivered timely. How Corrective Action will be monitored: Administrator or designee to complete audits of all residents being discharged from skilled services to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 5/29/26
Insulin Administration Errors and Failure to Prime Insulin Pens
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5%, with surveyors identifying 3 errors out of 28 medication administration opportunities, resulting in a 10.71% error rate. For one resident with type 2 diabetes mellitus and moderate cognitive impairment, the physician’s order directed Novolog insulin 10 units via subcutaneous pen-injector to be given before meals. During an observed medication pass, the LPN administered 10 units of Novolog insulin without priming the pen and did so after the resident had already consumed approximately 50% of the breakfast meal. The LPN later confirmed she did not prime the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer instructions for the Novolog FlexPen specified that an air shot (priming) must be performed before each injection to ensure proper dosing. Another resident, also diagnosed with type 2 diabetes mellitus and with intact cognition, had orders for insulin glargine 35 units subcutaneously twice daily and insulin lispro 20 units subcutaneously before meals, plus 12 units subcutaneously if blood glucose was between 251 mg/dL and 300 mg/dL. During an observed medication administration, an LPN administered 35 units of insulin glargine and 32 units of insulin lispro without priming the insulin pens and after the resident had consumed approximately 90% of the breakfast meal, despite orders for insulin lispro to be given before meals. The LPN later stated she could not remember if she had primed the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer information for insulin lispro stated that the pen must be primed before each injection to confirm insulin delivery and remove air, and that failure to prime could result in too much or too little insulin. The DON confirmed the expectation that insulin be administered as ordered, including priming each pen with two units before dialing the prescribed dose, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and required time frames.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 5/29/2026. F-0759 Corrective action for resident/s: Residents #21 and #22 were assessed and evaluated by nurse and Director of Nursing 5/14/26. Resident #21 and #22 both denied any adverse effects and none were noted upon assessment by the Director of Nursing on 5/14/2026. Notification made to physician on 5/14/2026. LPN # 2 competency Eval on insulin administration with the Director of Nursing completed 5/14/2026. Identification of other residents who may be affected: Diabetic residents on assignment of LPN #2/station 2 have the potential to be affected and were assessed by the DON/Designee on 5/14/26 and found to be within normal limits. Measures for systemic change: All Nurses were educated by the Director of Nursing on the steps for Insulin administration per competency, diabetes clinical protocol policy, Medication and treatment orders policy, administering medications policy, and Obtaining fingerstick Glucose Level policy On 5/14/2026. How Corrective Action will be monitored: Director of Nursing and Assistant Director of Nursing will complete insulin administration audits on 5 nurses. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance: 5/29/2026
Inaccurate Crash Cart Audits and Missing Emergency Equipment
Penalty
Summary
The facility failed to ensure accurate and complete crash cart audits for residents requiring basic life support, affecting eighteen of thirty-five residents who were designated as full code. During an observation of the crash cart with the DON, surveyors found that the daily audit documentation for the month did not include verification of expiration dates for crash cart supplies. Review of the crash cart audit logs showed that an extension cord was documented as being in the cart on multiple dates, but the extension cord was not present in the cart at the time of inspection. Additionally, the audit documentation indicated that required items, including eye protection, saline, and clear plastic, were not present in the crash cart, yet they were documented as being in the cart. The facility’s undated “Emergency Crash Cart” policy stated that the crash cart is to be checked every 24 hours and after every use, and that equipment and supplies are to be noted and replaced promptly, but the observed documentation and contents of the cart did not match these requirements. This deficiency was verified with the DON at the time of the survey and was cited under the requirement that personnel provide basic life support, including CPR, to residents requiring emergency care, subject to physician orders and advance directives, and was investigated under Complaint Number 2687380.
Plan Of Correction
Cridersville Care Center Provider Number:366171 Survey Type: Complaint Survey Survey Date: 04/29/26 This Plan of Correction (PoC) outlines the actions completed by the facility with regards to the deficiency citation. This Plan of correction does not constitute any admission of guilt or liability by the facility and is submitted only in response to the regulatory requirements. Please accept the following as the facility's credible allegation of compliance as of 4/30/26. F678 CPR All Full Code residents #18 have the potential to be affected by the alleged deficiency. On 4/27/26 the DON/ADON re-stocked the crash cart per the inventory sheet for all missing items. Crash cart inventory sheet updated and new one will go into effect on 5/1/26. All licensed nursing staff provided with training related to crash cart inventory being a daily audit review using inventory sheet on 4/27/26 per DON/designee. The DON/designee will conduct clinical rounds and conduct a random audit of crash cart three times per week for 4 (four) weeks to ensure compliance. The results of the audit will be documented. The facility conducted an Ad-Hoc QAPI meeting on 4/27/26 and discussed the alleged deficiency and corrective actions. Date when corrective action will be completed: 4/30/26
Unsafe Smoking Practices with Oxygen and Missed Fall-Prevention Interventions
Penalty
Summary
The deficiency involves the facility’s failure to provide a safe smoking environment, adequate supervision, and appropriate implementation of its smoking policy for a resident who used oxygen and smoked, as well as failure to implement fall-prevention interventions as care planned for another resident. One resident had multiple relevant diagnoses, including chronic respiratory failure with hypoxia, COPD, end-stage renal disease, dependence on supplemental oxygen, diabetes, and necrotizing fasciitis. Her care plans identified impaired visual function, risk for respiratory complications related to a history of smoking, and risk for cognitive decline, with interventions including use of oxygen per order and observation for understanding. A smoking-related care plan created earlier documented that she wished to use smoking products, had been assessed as safe to smoke "with supervision," and was non-compliant with the smoking policy, with family continuing to provide smoking supplies despite education and a verbal warning for non-compliance. Smoking assessments and progress notes showed a pattern of non-compliance and inconsistent classification of this resident’s smoking safety. Multiple smoking observation/assessments completed earlier in March documented that she had no cognitive loss, visual deficits, or dexterity problems but was unsafe to smoke without supervision because she did not return smoking materials and did not follow designated smoke times. Progress notes described her going out to smoke multiple times by herself or with family, including sneaking out next door with a cigarette and going out multiple times in one evening, with staff documenting that she was "reeducated" and that family brought in cigarettes and lighters which she did not return to staff. Despite this history, a smoking assessment completed after a three-day hospital stay assessed her as safe to smoke without supervision, with no documentation explaining how this conclusion was reached or evidence that her care plan was updated accordingly. On the day of the incident, the resident reported she had cigarettes and a lighter on her person after returning from dialysis and stated she "could not find a nurse" and went outside to smoke, saying she "guessed" she forgot she had her oxygen on. A CNA observed her outside and saw a flame coming through the resident’s oxygen nasal cannula tubing, turned off the oxygen tank, removed the tubing, and patted out sparks on the resident’s shirt sleeve. The resident’s face and hands appeared black in color, and EMS documented first-degree burns to the head and face, with the resident stating she lit a cigarette with her nasal cannula on, causing the burn. The hospital record described her face as black from smoke and her lips and mouth as "burnt and charred," with a recommendation for intubation that she refused. The facility’s incident report recorded that she went outside with oxygen on to smoke without notifying staff, that staff witnessed the occurrence as she walked through the dining room door to the courtyard, and that she stated she thought she had turned her oxygen off. The facility’s smoking policy required interdisciplinary evaluation to determine safe versus unsafe smokers, staff maintenance of all smoking paraphernalia for both safe and unsafe smokers, and progressive consequences for policy violations. A separate deficiency involved another resident at risk for falls whose care plan included use of non-skid strips on the floor in front of her recliner as a fall-prevention intervention. This resident had severe cognitive impairment, used a walker and wheelchair, required supervision or touching assistance for transfers and ambulation, and had experienced two or more falls without injury since the prior assessment. The fall-risk care plan, initiated at admission, specified non-skid strips in front of the recliner beginning in November. However, nursing staff interviewed were not familiar with all of the resident’s fall-prevention interventions without checking the record, and observation of the room showed two recliners with no non-skid strips on the floor in front of them. An LPN confirmed that the non-skid strips were not present despite the intervention remaining active in the care plan, and moving the recliners did not reveal any strips. The facility’s fall management policy required identification of hazards and risk factors, implementation of interventions to minimize falls and injuries, and development and implementation of a care plan based on interdisciplinary evaluation, with interventions related to identified risk factors.
Plan Of Correction
Smoking: On 03/21/26 at 3:16 P.M. 911 response was activated for Resident #11 and Medical Director #601 was notified by Registered Nurse (RN) #322. On 03/21/26 at 3:18 P.M. on-call Nurse/Social Services #423 immediately notified the Administrator and Director of Nursing (DON) #304 of the incident involving Resident #11. On 03/21/26 at 3:22 P.M. Emergency Medical Services (EMS) arrived onsite. At 3:30 P.M. Resident #11 was transported to the emergency room. On 03/21/26 at 3:30 P.M. RN #322 completed a smoking re-assessment of Resident #11 assessing the resident to be an unsafe smoker requiring supervision due to failure to remove oxygen prior to entering designated smoking area. On 03/21/26 from 3:38 P.M. through 7:57 P.M. Licensed Practical Nurse (LPN) #337, #336, #335, #338; RN #334, and DON #304 re-assessed residents (who smoke). This included Resident #22, Resident #3, Resident #47, Resident #50, Resident #60, Resident #150, Resident #86, and Resident #10 to determine smoking safety (via smoking assessment). Each resident was re-educated regarding the facility smoking policy and staff verified there were no smoking materials on their person. The residents' smoking materials would be maintained by facility staff and distributed per policy. On 03/21/26 at 4:30 P.M. DON #304 responded to facility and an Ad Hoc (not scheduled) Quality Assurance (QA) meeting was held via telephone with the Administrator, DON #304 and Medical Director #601 to review investigative findings and plan of action. A root cause analysis was completed and determined Resident #11 had smoking materials on her person (believed to be obtained from family without staff knowledge) and failed to remove her oxygen. The QA team discussed a corrective action plan. On 03/21/26 from 5:00 P.M through 03/22/26 at 3:00 P.M. 26 RNs, 13 LPNs, one medical technician (MT), 54 Certified Nursing Assistants (CNA) four activities staff, one central supply staff, 11 dietary staff, 12 housekeeping staff, three laundry staff, one medical records staff, two social designees, two maintenance staff, nine administrative staff, and 19 therapy staff (158 staff at the time of the incident) were provided education regarding the facility smoking policy by DON #304 and the Administrator. This was completed via 1:1, small group in-services or via phone. Newly hired staff would receive education during general orientation regarding the facility's smoking policy. On 03/21/26 at 5:00 P.M. DON #304 completed an audit of all residents who smoke (Resident #22, Resident #3, Resident #47, Resident #50, Resident #60, Resident #150, Resident #86, and Resident #10) to verify smoking evaluations and plans of care accurately reflected the residents' smoking safety needs. The residents were educated on the facility smoking policy, and smoking materials were to be maintained at the nurses' station. An audit was completed which included verification of required safety measures present in designated smoking areas, including an ash can, fire extinguisher, fire blanket, ash trays and no oxygen signs. There were no identified concerns or changes made because of the audits. On 03/21/26 at 8:55 P.M. Resident #11 returned from the ED. LPN #332 verbally educated the resident regarding the facility smoking policy which included the need for supervision, a smoking apron (to be worn) and the facility smoke times. LPN #332 verified no smoking materials were on the resident's person or in her room at this time. On 03/23/26 at 11:00 A.M. the Interdisciplinary Team (IDT) (Administrator, DON #304, Medical Director #601, RN #302, Social Services #427, Social Services #423, DON #300, and Maintenance #436) met in-person to review the plan of action with DON #304/designee to complete weekly monitoring of residents who smoke and designated smoking areas weekly for four weeks with Housekeeping responsible to complete the cleaning. Housekeeping staff were responsible for cleaning ashtrays and the designated smoking area daily. Audits to be reviewed and any further actions required to be directed by the Quality Assurance and Performance Improvement (QAPI) Committee during scheduled meetings. The IDT also reviewed all current smoking assessments and care plans for residents who smoke. Resident #50 required a change in supervision levels with smoking due to cognition levels and her plan of care as well as Resident #11's plan of care was updated to reflect supervision/safety. On 03/23/26 from 3:45 P.M. to 8:55 P.M. Social Services #423 re-educated residents who smoke (Resident #22, Resident #3, Resident #47, Resident #50, Resident #60, Resident #150, Resident #86, Resident #10) and responsible parties, if applicable regarding the facility smoking policy and supervision levels. On 03/23/26 at12:13 P.M. Social Services #427 contacted Resident #11's family member (#602) to schedule a care conference. Family member #602 and Family Member #603 were not available to meet until 03/27/26. On 03/23/26 at 1:00 P.M. staff education related to smoking areas, removal of oxygen prior to entering smoking area and maintaining smoking materials at the nurses' station for residents who smoke was initiated by DON #304 and the Administrator via 1:1, small group in-services or via phone call. Education was completed for all 158 staff by 03/24/26 at 1:00 P.M. Newly hired staff would be educated during general orientation regarding the facility's smoking policy. The facility does not utilize agency staff. On 03/27/26 at 11:00 A.M. a care conference was held with Resident #11 and Family Members #602 and #603, the Administrator, Social Services #423 and Social Services #427. The facility smoking policy was reviewed. The resident and family were informed an involuntary discharge would be initiated should the resident exhibit non-compliance moving forward and supervision would be increased beyond the two-hour standard of care to monitor more closely for non-compliance with the facility smoking policy. Family Member #602 stated he educated his siblings as well. On 04/10/26 at 2:00 P.M. DON #304 initiated education with 26 RNs and 13 LPNs (100% of nurses educated) regarding completion of the smoking evaluation via 1:1, small group in-services, or phone. The education was completed by 6:00 P.M. on 04/10/26. A new resident who smokes must remain supervised until the interdisciplinary team (IDT) reviews and determines smoking safety, at which time the care plan is developed and resident and family education is provided. The communication through the staff would be the care plan. Newly hired staff receive education during general orientation regarding the facility's smoking policy and completion of smoking evaluation via Point Click Care (PCC). On 04/10/26 at 4:29 P.M. DON #304 initiated an order in PCC for the nurse to verify, each shift, that Resident #11's smoking materials were maintained at the nurses' station. On 04/13/26 at 5:30 P.M. DON #304 initiated orders in PCC for nurses to verify, each shift, that all residents who smoke would have smoking materials maintained at the nurses' station. An updated list of smokers included: Resident #60, Resident #50, Resident #11, Resident #86, Resident #113, and Resident #151. On 04/13/26 at 5:45 P.M. DON #304 initiated questionnaires for staff regarding the smoking policy with re-education provided as needed via 1:1 and small group in-services for staff currently in the facility with all staff to be questioned/educated prior to working their next scheduled shift. Falls: On 4/9/26, Maintenance Director placed non-skid strips on the floor in front of Resident #12's recliner. Like Residents are identified as residents who have had a fall within the facility. Utilizing the Fall Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, an audit of falls and appropriate interventions for the past 30 days will be completed by the Director of Nursing or designee to ensure fall interventions are in place per plan of care. This audit along with identified corrections will be completed on or F 0689 before 5/13/26. The Director of Nursing or designee will re-educate licensed nurses and STNA/CNAs on the Fall Management Policy to include fall interventions to be in place per the care plan. This education will be completed on or before 5/13/26. Utilizing the Fall Management Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, the Director of Nursing or designee will complete an audit of new admissions, new readmissions and residents who experience a fall within the last 7 days, weekly for four weeks, beginning 5/14/26 to ensure fall safety interventions are in place per plan of care. Current fall interventions found to not be in place will be corrected with all intervention in place per plan of care. Negative findings to be addressed immediately and negative trends or system wide issues will be reported to the QAPI committee, and the action plan will be adjusted as needed.
Removal Plan
- Activated 911 response for Resident #11 and notified the Medical Director.
- On-call Nurse/Social Services immediately notified the Administrator and DON of the incident.
- EMS arrived onsite and Resident #11 was transported to the emergency room.
- Completed a smoking re-assessment of Resident #11, determining the resident was an unsafe smoker requiring supervision due to failure to remove oxygen prior to entering the designated smoking area.
- Re-assessed all residents who smoke (Residents #22, #3, #47, #50, #60, #150, #86, and #10) to determine smoking safety via smoking assessment.
- Re-educated residents who smoke regarding the facility smoking policy and verified there were no smoking materials on their person.
- Implemented that smoking materials would be maintained by facility staff and distributed per policy.
- Held an ad hoc QA meeting to review investigative findings and plan of action.
- Completed a root cause analysis determining Resident #11 had smoking materials on her person and failed to remove oxygen.
- Developed a corrective action plan.
- Provided facility-wide education to staff on the facility smoking policy.
- Implemented that newly hired staff would receive smoking policy education during orientation.
- Completed an audit of all residents who smoke to verify smoking evaluations and plans of care accurately reflected smoking safety needs.
- Ensured smoking materials were maintained at the nurses’ station.
- Audited designated smoking areas for required safety measures (ash can, fire extinguisher, fire blanket, ash trays, and no-oxygen signs).
- Provided verbal education to Resident #11 on smoking policy (supervision, smoking apron, smoke times).
- Verified no smoking materials were on Resident #11’s person or in her room.
- Conducted an in-person IDT meeting to implement weekly monitoring of residents who smoke and designated smoking areas weekly for four weeks.
- Assigned housekeeping to clean ashtrays and the designated smoking area daily.
- Directed audits to be reviewed by QAPI.
- Reviewed all current smoking assessments and care plans for residents who smoke.
- Updated Resident #50’s supervision level.
- Updated Resident #11’s plan of care to reflect supervision/safety.
- Re-educated residents who smoke and responsible parties (as applicable) regarding the facility smoking policy and supervision levels.
- Contacted Resident #11’s family to schedule a care conference.
- Initiated additional staff education regarding smoking areas, removal of oxygen prior to entering smoking area, and maintaining smoking materials at the nurses’ station.
- Held a care conference with Resident #11 and family to review smoking policy.
- Informed resident/family that involuntary discharge would be initiated for future non-compliance.
- Increased supervision beyond the two-hour standard of care to monitor more closely for non-compliance.
- Provided education to all nurses regarding completion of the smoking evaluation.
- Implemented that new residents who smoke must remain supervised until IDT review determines smoking safety and care plan/education are completed.
- Entered an order in PCC for nursing to verify each shift that Resident #11’s smoking materials were maintained at the nurses’ station.
- Entered orders in PCC for nursing to verify each shift that all residents who smoke have smoking materials maintained at the nurses’ station.
- Initiated staff questionnaires regarding the smoking policy with re-education as needed.
- Required all staff to be questioned/educated prior to working their next scheduled shift.
Failure to Provide Scheduled Bathing and Shaving Assistance for Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide scheduled and needed bathing and shaving assistance to multiple dependent residents in accordance with their care plans, preferences, and the facility’s routine care policy. One resident with spinal stenosis and recent L2–L5 decompression fixation fusion was care planned for substantial/maximal assistance with shower/bath and toileting hygiene and was scheduled for showers on Tuesdays and Fridays. Electronic documentation from early January through early April showed this resident did not receive a shower or bed bath on 11 identified scheduled days, and the DON confirmed these missed bathing events. Another resident with dysphagia and developmental issues, who required assistance with self-care and mobility, reported that she asked staff to shave her but they did not, which bothered her. During an observation following a recent shower, she stated she had not been shaved and that the hair "itched"; small gray hairs were visible on her chin. A CNA confirmed the presence of gray chin hairs and acknowledged the resident needed shaving, stating it would be addressed with the next scheduled shower. A further resident with chronic respiratory failure, tracheostomy status, heart failure, moderate intellectual disabilities, anxiety, depression, and PTSD required substantial/maximal assistance with personal hygiene and had a care plan for assistance with self-care, including personal hygiene. Her shower schedule called for showers on Monday and Thursday nights, with complete shaves for men and women. Review of documentation showed her last recorded shower/bath was nearly a year earlier, with no indication of additional personal hygiene or facial hair removal on that date. Observations on two separate days showed long white hairs on her chin and jaw line, which a CNA later confirmed, stating facial hair removal should occur with baths/showers or as needed. A resident with end stage renal disease, respiratory failure, hyperlipidemia, and congestive heart failure, who had impaired cognition and required partial/moderate assistance with bathing and personal hygiene, was scheduled for showers on Wednesdays and Saturdays. Review of shower documentation from admission through early April revealed no showers provided or refusals documented on at least ten scheduled shower days. In interviews, this resident reported not receiving scheduled showers, was unsure of his shower days, and stated he could use a good scrub down, adding that he had asked aides who told him they did not have time. A CNA explained that shower days appear on shower sheets and in the computer and that CNAs are supposed to document daily, with nurses checking the documentation; the DON verified the resident had not received showers per schedule or preference. Another resident with a fracture of the lower end of the left humerus, hemiplegia and hemiparesis after cerebral infarction, rheumatoid arthritis, hypertensive heart disease, urinary retention, and osteoarthritis was care planned as non–weight bearing to the left upper extremity and requiring substantial/maximal assistance with showering/bathing. Her electronic record showed she was scheduled for showers on Wednesdays and Saturdays. The shower task question "did the resident receive a shower/bath/bed bath?" was documented as "no" on three dates, indicating no shower/bath/bed bath was completed, and left unanswered on three additional dates. The DON confirmed that one missed shower was due to an outside appointment, that on two dates the "no" response meant no bathing of any type occurred, and that on three dates there was no documentation at all. The resident, who was cognitively intact, reported that missing showers made her feel unimportant compared to others and that she did not feel clean when her shower was missed. Facility policy on routine resident care stated that showers, tub baths, and shampoos are to be scheduled according to person-centered care or state guidelines, with additional showers given upon request, but the documented and observed care did not reflect consistent provision of scheduled bathing and shaving for these residents.
Plan Of Correction
1. Resident #5 received a shower by the STNA on 4/13/26. Resident #8 received a shower by the STNA on 4/8/26. Resident #9 received a shower and had their chin shaved by the STNA on 4/14/26. Resident #70 received a shower by the STNA on 4/13/26. Resident #76 received a shower and had their chin shaved by the STNA on 4/15/26. 2. Like residents are identified as residents who need assistance with showering and shaving. Utilizing the Shower Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, an audit of like residents will be completed by the Director of Nursing or designee to ensure that showers and resident shaving are completed. This audit along with identified corrections will be completed on or before 5/13/26. 3. The Director of Nursing or designee will re-educate licensed nurses and STNA's on the Routine Resident Care Policy to include bathing and shaving residents. This education will be completed on or before 5/13/26. 4. Utilizing the Shower Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, the Director of Nursing or designee will complete an audit of 4-6 residents weekly for four weeks, beginning 5/14/26 to ensure that showers and resident shaving are completed. Noncompliance found during audits will be addressed and assistance with showers and/or shaving provided. Negative findings to be addressed immediately and negative trends or system wide issues will be reported to the QAPI committee, and the action plan will be adjusted as needed.
Uncovered Urinary Catheter Drainage Bag Compromises Resident Dignity
Penalty
Summary
The facility failed to maintain a resident’s right to privacy and dignity related to management of an indwelling urinary catheter. A resident admitted with malignant neoplasm of the esophagus and type II diabetes mellitus had a care plan identifying risk for urinary tract infection and catheter-related trauma due to an indwelling catheter for urinary retention. The care plan interventions included ensuring the catheter tubing was secured and the drainage bag was properly secured with a dignity cover in place. Physician orders directed that the resident’s 16 French indwelling urinary catheter be changed every 30 days and as needed, and the comprehensive MDS documented that the resident had an indwelling catheter and was cognitively intact. During observation, the resident was seen seated in a chair with the urinary catheter drainage bag hanging from the chair without a dignity cover, and dark yellow urine was visible in the bag from the hallway. In a later observation and interview, an LPN confirmed that the catheter bag was lying directly on the floor and did not have a dignity cover. Attempts to interview the resident to confirm cognitive status were unsuccessful, as the resident was unable to answer screening questions. Review of the facility’s “Resident Dignity & Personal Privacy” policy stated that the facility should provide care in a manner that respects and enhances each resident’s dignity, individuality, and right to personal property, which was not followed in this instance when the catheter drainage bag was left uncovered and visible.
Plan Of Correction
The Laurels of Athens wishes to have this plan of correction submitted as our written allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission to nor agreement with, either the existence of, or the scope and severity of, any of the cited deficiencies or conclusions set forth in the statement of deficiencies. This plan is prepared and/or executed to ensure continuing compliance with regulatory requirements. Our alleged date of compliance is 5/13/2026. 1. On 4/6/26, Resident #92's catheter bag was removed from the floor, the bag changed and covered for dignity by the licensed nurse. Resident #92 discharged from the facility on 4/11/26. 2. Like Residents are identified as residents who utilize urinary catheters. An audit will be completed by the Director of Nursing or designee for like residents utilizing the Urinary Catheter Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC to ensure catheter bags are covered for dignity and not laying directly on the floor. This audit along with identified corrections will be completed on or before 5/13/26. 3. The Director of Nursing or designee will re-educate licensed nurses on the Indwelling Urinary Catheter Policy as well as Resident Dignity & Personal Privacy Policy to include privacy covers are in place for urinary catheters and that the catheter is not laying on the floor. This education will be completed on or before 5/13/26. 4. Utilizing the Urinary Catheter Audit Tool which was created on 4/20/26 by the Director of Nursing for purpose of this POC, the Director of Nursing or designee will complete an audit of all residents with catheters weekly for four weeks, beginning 5/14/26 to ensure catheter bags are covered for dignity and not laying directly on the floor. Any catheters found to be touching the floor or uncovered will be removed from the floor, the bag changed and covered for dignity. Negative findings to be addressed immediately and negative trends or system wide issues will be reported to the QAPI committee, and the action plan will be adjusted as needed.
Failure to Prevent Possible Misappropriation and Poor Documentation of PRN Narcotics
Penalty
Summary
The deficiency involves failure to prevent potential misappropriation of a resident’s narcotic medication and failure to ensure accurate documentation of controlled substance administration. A cognitively intact resident with chronic pain related to an internal orthopedic device and left knee pain had an order for oxycodone 5 mg PO every four hours PRN for pain and a care plan directing staff to administer medications as ordered and observe for effectiveness and side effects. The resident’s MDS showed she rated her pain as 7/10 and received opioid medication. However, review of the February MAR and the narcotic log revealed multiple discrepancies between narcotic sign-outs and documented administration. On several occasions, oxycodone doses were signed out on the narcotic log by an RN without corresponding documentation on the MAR. Specifically, oxycodone was signed out on one evening at 9:30 p.m. with no MAR entry, and again on a subsequent night at 1:30 a.m. and 5:30 a.m. with no MAR entries for those times. Another dose was signed out at 9:00 p.m. while the MAR reflected administration at 10:16 p.m., and a later dose at 5:30 a.m. was documented on both the narcotic log and MAR. There was also no documentation of pain assessments before or after PRN opioid administration. These documentation gaps meant there was no evidence that all narcotic doses signed out were actually administered to the resident. Staff interviews further highlighted concerns about the handling of narcotics. A CNA/med tech reported frequently taking the narcotic keys from the RN and described the RN’s behavior as erratic, with repeated problems involving incorrect narcotic counts and missing documentation on both the MAR and narcotic log. The resident stated she did not receive oxycodone more than once or twice a day, preferring to take Tylenol the rest of the time, which conflicted with the number of oxycodone doses signed out. When questioned, the RN gave inconsistent explanations about how often she pulled and administered PRN narcotics and acknowledged struggling with the new system, while also suggesting the resident may have received PRN tizanidine instead of remembering oxycodone. The facility’s investigation concluded that evidence was inconclusive as to whether misappropriation occurred or whether the issue was solely lack of documentation, but confirmed there was no evidence the resident received all doses signed out on the narcotic log.
Plan Of Correction
1. Resident #99 had a Self-Reported Incident submitted and investigated via the EIDC on 3/2/26. The investigation was inconclusive as we could not prove that misappropriation occurred. On 2/24/26, Resident #99 was interviewed and pain assessed by Director of Nursing and resident had no ill effects related to the inconsistent documentation in the medical record as it relates to her controlled substance pain medication. 2. Like Residents are identified as residents who utilize controlled substance PRN pain medications. An audit will be completed by the Director of Nursing or designee for like residents utilizing the Controlled Substance Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC to ensure PRN controlled substance pain medications that are signed off the control sheet are documented in the resident medical record as well. This audit along with identified corrections will be completed on or before 5/13/26. 3. The Director of Nursing or designee will re-educate licensed nurses on the Controlled Substances Policy to include appropriate documentation of controlled substances. In addition, the licensed nurses will be re-educated by the Director of Nursing or designee on the Abuse Prohibition Policy to include misappropriation of resident property. This education will be completed on or before 5/13/26. 4. Utilizing the Controlled Substance Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, the Director of Nursing or designee will complete an audit three controlled substance sheets from each of the nine medication carts for a total of twenty-seven sheets weekly for four weeks, beginning 5/14/26 to ensure PRN controlled substance pain medications that are signed off the control sheet are documented in the resident medical record as well. Inconsistencies noted from the audit will be investigated for misappropriation. Negative findings to be addressed immediately and negative trends or system wide issues will be reported to the QAPI committee, and the action plan will be adjusted as needed.
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