Laurels Of West Carrollton The
Inspection history, citations, penalties and survey trends for this long-term care facility in West Carrollton, Ohio.
- Location
- 115 Elmwood Circle, West Carrollton, Ohio 45449
- CMS Provider Number
- 365598
- Inspections on file
- 27
- Latest survey
- March 19, 2026
- Citations (last 12 mo.)
- 16
Citation history
Health deficiencies cited at Laurels Of West Carrollton The during CMS and state inspections, most recent first.
A resident with multiple comorbidities and a documented fall risk experienced a mechanical fall when a bedside commode, which had been taped and was mechanically unstable, collapsed while in use, causing the resident to fall through and become stuck. Staff documentation and interviews confirmed that the commode’s bucket-support bar had been taped with surgical tape and failed under the resident’s weight, and that the equipment was not sturdy. Although an LPN completed a fall packet noting equipment malfunction and the commode being taped together, management did not obtain statements from involved CNAs or the LPN about who altered or placed the commode in the room, and there was no thorough investigation into which staff member taped the commode or how the unsafe equipment came to be used, despite a facility policy requiring IDT review and investigation of all falls.
A resident with Alzheimer’s disease, CHF, metabolic encephalopathy, an unstageable sacral pressure ulcer, and essential tremor, who had impaired cognition and required staff assistance with eating, toileting hygiene, bed mobility, and transfers, did not have weights monitored according to the facility’s Weight Management policy. The policy required weights on admission, weekly for four weeks, and then monthly, but documentation showed only three weights were obtained, with no further weights recorded before the resident was transferred to the hospital. The UM confirmed both the policy requirements and the absence of additional documented weights, resulting in a cited deficiency for failure to follow the facility’s weight-monitoring protocol.
A CNA entered and cleaned the room of a resident on contact and droplet isolation for COVID-19 without wearing PPE, despite posted signage and facility policy requiring PPE for all staff entering isolation rooms. The CNA was unsure if PPE was needed for housekeeping duties, leading to noncompliance with infection control protocols.
A nurse crushed and administered extended-release Potassium Chloride and delayed-release Omeprazole to a resident with multiple chronic conditions, despite both medications being on the facility's 'Do Not Crush' list and contrary to FDA guidance and facility policy.
A resident with a history of intracranial hemorrhage, COPD, and anxiety disorder was allowed to keep an albuterol inhaler at their bedside without a documented assessment or physician order for self-administration, as required by facility policy. Staff were aware of the medication at the bedside but did not follow the established process, and the care plan did not reflect self-administration authorization.
Three residents had care plans that did not accurately reflect their assessed smoking status or required supervision, with documentation indicating supervision was needed when evaluations and staff confirmed some could smoke independently and another was unsafe to smoke. Staff interviews revealed reliance on unedited, self-populated care plan templates, resulting in care plans that did not match current assessments or facility policy.
A resident with a history of malnutrition and dysphagia had a care plan that was not updated to reflect a change from NPO status to a pureed diet with honey thickened liquids. Despite new dietary orders and the resident being observed eating a pureed diet, the care plan continued to reference NPO status and tube feeding. Staff interviews confirmed that care plans should be updated in real time, but this did not occur, resulting in outdated information remaining in the resident's care plan.
A resident with hemiplegia, hemiparesis, diabetes, and chronic kidney disease did not receive required nail care, as their fingernails were observed to be long and untrimmed on multiple occasions. Facility policy and the care plan required regular nail care, and staff interviews confirmed that only nurses could trim nails for diabetic residents. Despite these requirements, the resident's nails were not trimmed as expected.
A resident with intact cognition and a history of respiratory conditions was found with multiple prescription and OTC medications at their bedside, despite not being assessed or authorized for self-administration. Facility staff confirmed that medications are not permitted in resident rooms without proper authorization, and the care plan did not reflect self-administration. The medications remained accessible to the resident for several weeks without staff awareness, in violation of facility policy.
A resident with severe cognitive impairment and an indwelling Foley catheter was observed to have their catheter tubing unsecured during care, resulting in repeated tugging on the tubing by staff. Despite care plan interventions requiring the tubing to be anchored to prevent trauma, staff confirmed that no anchor was in place since the resident's return from the hospital, and the DON expected all such residents to have an anchor.
A resident with diabetes and severe cognitive impairment was administered insulin glargine on two occasions when their blood sugar was below the physician-ordered threshold. Staff failed to follow the specific order to withhold insulin if blood sugar was under 140, resulting in a significant medication error despite facility policy and leadership expectations.
Staff failed to follow Enhanced Barrier Precautions during wound care for a resident with an indwelling catheter and unhealed pressure ulcers. Two LPNs provided wound treatment using gloves but did not wear gowns, despite facility policy and care plan directives. Interviews revealed staff were aware of EBP requirements but did not adhere to them during the observed care.
The facility did not complete or document required smoking assessments for three residents who used tobacco, failing to follow its own policy for evaluation upon admission, readmission, and at regular intervals. Staff interviews and record reviews showed that assessments were missing or incomplete, and some staff were unaware of the policy's requirements.
A resident with moderate cognitive impairment was admitted with a significant sum of money, which was counted and placed in a medication cart's narcotic drawer by staff. The money was later found missing, and despite staff interviews and an internal investigation, the funds were never recovered. The facility failed to safeguard the resident's property as required by policy.
A resident with moderate cognitive impairment was admitted with a significant amount of money, which was placed in a medication cart's narcotic drawer by staff. The money later went missing, and although staff became aware of the loss, the incident was not reported to the state survey agency within the required timeframe. Facility policy required prompt reporting of such allegations, but the delay was confirmed through documentation and staff interviews.
A resident with moderate cognitive impairment was admitted with a significant amount of money, which was placed in a double-locked medication cart drawer by an LPN. The money was later discovered missing, and although several staff had access to the cart during the relevant period, most were not interviewed as part of the investigation. The facility's policy required a thorough investigation, but this was not completed, as acknowledged by the DON and Administrator.
A facility failed to report an allegation of sexual abuse involving a resident with severely impaired cognition to the state agency, as required by their policy. The resident, who required extensive assistance for daily activities, was discharged against medical advice. A hospital evaluation later revealed the abuse allegation, which was reported to the police and Ombudsman. The facility's Administrator acknowledged the failure to file a self-reported incident (SRI) with the state agency, resulting in a deficiency citation.
A facility failed to investigate an allegation of sexual abuse involving a resident with severely impaired cognition. The resident, who required extensive assistance, was discharged against medical advice and later reported an abuse allegation during a hospital evaluation. The facility's Administrator did not conduct a thorough investigation as per policy, only verbally questioning male staff without obtaining written statements or documentation.
The facility failed to accurately transcribe and administer medications for a resident upon admission, resulting in multiple medication omissions and errors. The resident did not receive Atenolol and Lidocaine Patch EX for several days, and there were transcription errors for Buprenorphine HCl-Naloxone HCl and Alendronate Sodium. These issues were confirmed through medical record reviews and staff interviews.
Unrepaired Bedside Commode and Incomplete Fall Investigation
Penalty
Summary
The deficiency involves the facility’s failure to ensure that durable medical equipment, specifically a bedside commode, was maintained in good repair, resulting in a resident fall. The resident had multiple diagnoses including depression, COPD, CHF, severe kyphosis, osteoarthritis, osteopenia, and a history of compression fractures, and was care planned as being at risk for falls related to weakness, incontinence, psychotropic medication use, and prior falls. The resident’s MDS showed intact cognition with a BIMS score of 14, independence with eating, moderate assistance needed for bed mobility and transfers, and dependence on staff for toileting hygiene, with one fall documented in the lookback period. On the day of the incident, the resident experienced a fall while using a bedside commode. Documentation from the emergency room and the facility’s fall packet indicated that the resident had a mechanical fall when she fell through the bedside commode after the bucket fell out, leaving her stuck in the device and yelling for help. The fall packet identified equipment malfunction as a factor, describing that the bedside commode collapsed and that the commode was unstable and had been taped together prior to use. An LPN who responded to the resident’s call for help found the resident folded up in the commode, assisted her out, assessed her, and noted that the thin bar holding the bucket had been taped with surgical tape where it connected to the front of the commode frame, and that this bar gave way when the resident sat down. Staff interviews and observations further established that the commode was mechanically unsecure and had been altered with tape before the fall, and that this condition was known or observable to staff. A CNA reported seeing tape on the bedside commode and stated it was not sturdy equipment, and confirmed that no one from management had asked her for a statement or about who taped or placed the commode in the room. The LPN who completed the fall investigation packet confirmed that no management followed up with her regarding the fall or the condition of the commode. The DON acknowledged that the resident had a fall due to an issue with the bedside commode, was unaware the commode had been taped until reviewing the fall packet, and confirmed there was no investigation into which staff member taped the commode or left it in the resident’s room, nor into what should be done with mechanically unstable equipment. The facility’s fall management policy required the IDT to review all resident falls within 24–72 hours and evaluate and investigate the circumstances and probable cause, but the described follow-up did not include a thorough investigation into the commode’s condition or staff actions related to it.
Failure to Monitor Resident Weights per Facility Policy
Penalty
Summary
The facility failed to obtain and monitor a resident’s weights in accordance with its Weight Management policy, which required all residents to be weighed on admission, weekly for four weeks, and then monthly or as indicated by the physician. One resident with diagnoses including Alzheimer’s disease, an unstageable sacral pressure ulcer, metabolic encephalopathy, congestive heart failure, and essential tremor was admitted with impaired cognition, required moderate assistance with eating, and was dependent on staff for toileting hygiene, bed mobility, and transfers. Record review showed this resident was weighed on admission at 164 lbs and then on two subsequent occasions at 165.2 lbs and 164.2 lbs, with no further weights documented before the resident was hospitalized and did not return. In an interview, the unit manager confirmed the facility’s weight-monitoring expectations and verified that no additional weights were obtained or recorded for this resident beyond the three documented weights, despite the resident remaining in the facility until hospital transfer. This deficiency was cited as non-compliance with the facility’s weight management policy under Complaint Number 2709811.
Staff Failure to Use PPE in Isolation Room
Penalty
Summary
The facility failed to ensure that staff wore personal protective equipment (PPE) when entering the room of a resident on contact and droplet isolation precautions for COVID-19. Medical record review showed that a resident with end stage renal disease, dependence on renal dialysis, and atrial fibrillation was placed on isolation precautions per physician order. During observation and interview, a CNA was seen entering and cleaning the resident's room without donning PPE, despite posted signage indicating the need for PPE and facility policy requiring all staff to wear appropriate PPE when entering rooms of residents on COVID-19 isolation. The CNA stated she was unsure if PPE was required for housekeeping duties. Facility policy review confirmed that all staff, regardless of their role, are required to use PPE in such situations.
Improper Administration of Extended-Release and Delayed-Release Medications
Penalty
Summary
The facility failed to ensure proper administration of delayed-release and extended-release medications for a resident with chronic diastolic congestive heart failure, type II diabetes mellitus, and aphasia following cerebral infarction. A registered nurse was observed crushing Potassium Chloride Extended Release (ER) and Omeprazole Delayed Release (DR) tablets, mixing them with pudding, and administering them to the resident. The nurse confirmed during interview that both medications were crushed prior to administration. Review of FDA guidance and the facility's own policies revealed that both Potassium Chloride ER and Omeprazole DR are not to be crushed, as this can affect the efficacy and safety of the medications. The facility's policy required staff to check a 'Do Not Crush' list and consult with a pharmacist or physician if a medication could not be crushed. Both medications administered in this manner were listed on the facility's 'Medications Not To Be Crushed' list, indicating a failure to follow established protocols and safe medication administration practices.
Failure to Assess Resident for Self-Administration of Medication
Penalty
Summary
The facility failed to assess a resident for self-administration of medications prior to allowing the resident to keep medication at their bedside. A resident with a history of nontraumatic intracranial hemorrhage, COPD, and anxiety disorder was admitted and had a BIMS score indicating intact cognition, but required moderate assistance with all activities of daily living. The resident's care plan did not indicate the ability to self-administer medication, and there was no physician order or documented assessment for self-administration in the medical record. Despite this, repeated observations over several days showed the resident kept an albuterol inhaler at their bedside. Interviews revealed that staff were aware of the inhaler at the bedside but had not questioned the resident about it or followed the facility's process for self-administration of medications. The RN was unsure of the process and only removed the medication after being made aware of the issue. The DON confirmed that the facility policy required an assessment and physician order for self-administration, neither of which had been completed for this resident. The facility policy also required self-administration to be reflected in the care plan, which was not done.
Failure to Accurately Individualize Smoking Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans that accurately reflected the smoking status and required level of care for three residents. For each of these residents, there were discrepancies between their assessed ability to smoke safely and the interventions documented in their care plans. Specifically, care plans indicated that residents required supervision while smoking, despite smoking evaluations and staff interviews confirming that some residents were safe, independent smokers who did not require supervision, while another was assessed as an unsafe smoker who should not have been allowed to smoke independently. Resident records showed that assessments, such as the Minimum Data Set (MDS) and smoking evaluations, were completed and indicated the residents' cognitive status and smoking safety. However, the care plans were not updated to reflect these assessments. Staff interviews revealed that the care plans were often not individualized, with some staff relying on self-populated templates without editing goals and interventions to match the residents' current needs. This led to care plans that did not accurately represent the residents' smoking status or the facility's actual practices regarding supervision and safety measures. Facility policy required that care plans be specific, individualized, and based on interdisciplinary assessments, including the degree of supervision necessary for residents who smoke. Despite this, the care plans for the three residents did not align with their most recent smoking evaluations or the facility's smoking policy. Interviews with nursing staff, the DON, and the administrator confirmed that the care plans were inaccurate and not up to date, and that staff did not always understand the need to personalize care plans beyond the default information provided by the electronic system.
Failure to Update Care Plan Following Diet Change
Penalty
Summary
The facility failed to update a resident's care plan to accurately reflect a change in diet from nothing by mouth (NPO) to a pureed diet. The resident, who had a history of protein-calorie malnutrition and dysphagia, was initially admitted with orders for NPO status and tube feeding. Despite subsequent changes in the resident's dietary orders, including the introduction of a pureed diet and honey thickened liquids, the care plan continued to include outdated interventions and need statements referencing NPO status and tube feeding. Observations confirmed that the resident was receiving a pureed diet, yet the care plan was not consistently updated to reflect this change. Interviews with facility staff, including the MDS nurse, DON, and Administrator, revealed that care plans were expected to be updated in real time and during regular reviews, but this did not occur for the resident in question. The facility's policy required care plans to be individualized and updated with significant changes, but the care plan for this resident retained obsolete information and did not accurately communicate the current dietary needs to staff. This failure was identified through record review, staff interviews, and direct observation of the resident receiving oral nutrition.
Failure to Provide Required Nail Care for Dependent Resident
Penalty
Summary
The facility failed to provide appropriate nail care for a resident who required assistance with activities of daily living (ADLs) due to hemiplegia and hemiparesis following a cerebrovascular event, as well as other medical conditions including type 2 diabetes mellitus and chronic kidney disease. Facility policy required daily personal hygiene, including nail care, and specified that nails should be kept neatly trimmed. The resident's care plan also directed staff to keep fingernails trimmed and clean. Despite these requirements, observations on multiple occasions revealed that the resident's fingernails on the hemiparetic hand were long and extended past the fingertips. The resident reported wanting their nails trimmed and stated that only a nurse could perform this task due to their diabetes diagnosis. Interviews with staff confirmed that certified nurse aides were responsible for cleaning nails during ADL care, but only nurses were permitted to trim nails for diabetic residents. Both the RN and DON acknowledged that the resident's fingernails should have been trimmed and should not extend past the fingertips, in accordance with facility policy and expectations. The administrator also confirmed that nails should be kept clean and trimmed to the resident's preference. Despite these expectations and policies, the resident did not receive the required nail care, resulting in a deficiency.
Failure to Prevent Resident Access to Unsecured Medications
Penalty
Summary
The facility failed to ensure a resident's environment was free from accident hazards by allowing a resident to keep multiple medications, including prescription and over-the-counter items, at their bedside without an assessment for self-administration or a physician's order permitting self-administration. The resident, who had a history of acute and chronic respiratory failure, pneumonia, and COPD, was observed with fluticasone nasal spray, saline nasal spray, triple antibiotic ointment, and eye drops on their bedside table. The resident reported having ordered and received these items independently and kept them within reach for personal use, without staff knowledge or documentation in the care plan regarding self-administration. Staff interviews confirmed that facility policy prohibits residents from keeping medications in their rooms unless specifically authorized by a physician and following a self-administration assessment. Multiple staff members, including a CNA, LPN, RN, and the DON, verified that medications should not be left at the bedside and that no residents in the facility were authorized to self-administer medications at the time. The presence of these medications in the resident's room was not identified or addressed by staff until observed during the survey, indicating a lapse in supervision and adherence to facility policy.
Failure to Secure Indwelling Catheter Tubing During Resident Care
Penalty
Summary
A deficiency was identified when a resident with a history of benign prostatic hyperplasia, obstructive and reflux uropathy, and urinary retention, who was dependent on staff for toileting and had an indwelling urinary catheter, was observed to have their catheter tubing unsecured during care. The resident's care plan specifically required that the catheter tubing be secured to prevent trauma and that staff observe and document for pain or discomfort related to the catheter. Despite these interventions, during catheter care, staff were observed to tug on the catheter tubing multiple times while providing care and repositioning the resident's brief, and the tubing was not anchored to the resident's thigh as required. Interviews with staff confirmed that the resident had not had a catheter anchor since returning from a recent hospital stay, and the CNA providing care acknowledged the absence of an anchor. The RN was unaware of the lack of an anchor, and the DON stated that all residents with indwelling catheters were expected to have an anchor to prevent trauma. The administrator deferred nursing issues to the DON and indicated that a physician order would be obtained if needed.
Failure to Prevent Significant Medication Error in Insulin Administration
Penalty
Summary
A deficiency occurred when a resident with type 2 diabetes mellitus and severe cognitive impairment received insulin glargine injections despite physician orders specifying that the medication should not be administered if the resident's blood sugar was below 140. Documentation showed that the resident was given insulin on two occasions when their blood sugar levels were 118 and 126, both below the ordered threshold. The resident's care plan directed staff to administer medications as ordered and to report abnormal findings to the physician. Interviews with the DON and Administrator confirmed that staff were expected to follow physician orders and seek clarification if there was any uncertainty. Facility policy also required medications to be administered in accordance with written physician orders. Despite these expectations and policies, the insulin was administered outside of the prescribed parameters, resulting in a significant medication error.
Failure to Implement Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with significant risk factors, including an indwelling catheter, severe cognitive impairment, and multiple unhealed pressure ulcers. According to the resident's care plan and physician orders, EBP was required due to the presence of open wounds and a urinary catheter, as well as a history of MRSA. During an observed wound care session, two LPNs provided treatment without donning gowns, although gloves were used. Their scrub tops came into contact with the resident's bed and covers during the procedure. PPE supplies were available outside the room, but the required gowns were not utilized. Interviews with the involved LPNs and facility leadership confirmed that staff were aware of the EBP requirements and had been trained to use both gloves and gowns during high-contact care activities such as wound care. One LPN incorrectly believed that EBP was no longer necessary since the resident had completed antibiotics and was not on contact isolation, while the Infection Preventionist and Director of Nursing clarified that EBP should have been maintained due to the ongoing presence of wounds and a catheter. Facility policy explicitly required the use of gloves and gowns for residents with wounds or indwelling devices during high-contact care, but this protocol was not followed during the observed incident.
Failure to Complete and Document Smoking Assessments per Facility Policy
Penalty
Summary
The facility failed to implement its smoking policy as required, specifically by not completing smoking assessments fully or in a timely manner for three residents who used tobacco products. According to the facility's policy, residents who smoke must be evaluated upon admission, readmission, with significant change, and at regular intervals thereafter. However, documentation and interviews revealed that these assessments were either missing or incomplete at critical times, such as after readmission or during required evaluation periods. One resident with a history of acute kidney failure was admitted and later readmitted, but did not have a smoking evaluation completed upon readmission as required by policy. Another resident with chronic diastolic heart failure was also readmitted without a subsequent smoking evaluation. A third resident with polyneuropathy had a smoking evaluation on file, but the assessment was left incomplete, with the summary section blank, failing to indicate whether the resident was a safe or unsafe smoker. Interviews with facility staff, including the MDS nurse, ADON/Infection Preventionist, DON, and Administrator, confirmed that smoking assessments were not consistently completed according to the facility's policy. Some staff were unaware of the specific requirements for reassessment, and documentation in the medical records did not reflect adherence to the policy. The facility's own smoking policy clearly outlined the need for timely and complete evaluations, but these procedures were not followed for the residents reviewed.
Failure to Protect Resident from Misappropriation of Property
Penalty
Summary
A resident with moderate cognitive impairment and a diagnosis of spinal stenosis was admitted to the facility with $669 in their wallet, as documented on the Inventory of Personal Effects. Upon admission, a CNA and the resident counted the money, and the CNA handed it to a nurse, who placed it in a medication cart's narcotic drawer. The charge nurse notified a unit manager about the money, and the unit manager instructed the charge nurse to store it in the narcotic drawer. When the charge nurse returned to work, the money was missing from the drawer. Multiple staff interviews confirmed that the money was last seen when placed in the medication cart, and no one reported moving or seeing the money afterward. The resident later requested their money, but staff were unable to locate it. The facility's investigation, which included staff interviews and a review of the medication cart assignments, was unable to determine what happened to the resident's money or who took it. The incident was reported to the police, and the facility's policy required protection of residents from misappropriation of property. The money was never recovered, and the facility was found to have failed to protect the resident's right to be free from misappropriation of property.
Failure to Timely Report Misappropriation of Resident Property
Penalty
Summary
The facility failed to report an allegation of misappropriation of property within 24 hours, as required by policy and regulation. A resident with moderate cognitive impairment was admitted with $669.00 in their wallet, which was placed by staff in a narcotic drawer of a medication cart upon admission. When the charge nurse returned to the facility, the money was missing, and no staff could account for its location after it was initially stored. The incident was documented, and the facility's investigation indicated that the money was in the facility's possession but was not stored or reported correctly to the Administrator or Director of Nursing (DON). Staff became aware of the missing money on one date, and the resident inquired about it several days later, but the incident was not reported to the state survey agency until nearly two weeks after the initial discovery. The facility's policy required immediate reporting of such allegations to the Administrator and DON, and notification to state or federal agencies within specified timeframes. Interviews confirmed that the DON was not aware of the allegation until much later, and the Administrator acknowledged the delay in reporting to the state survey agency.
Failure to Thoroughly Investigate Misappropriation of Resident Property
Penalty
Summary
The facility failed to thoroughly investigate an allegation of misappropriation of property involving a resident who was admitted with a diagnosis of spinal stenosis and had moderate cognitive impairment, as indicated by a BIMS score of 10. Upon admission, the resident had $669.00 in their wallet, which was placed by a charge nurse in a double-locked narcotic drawer in a medication cart, as directed by a unit manager. When the charge nurse returned several days later, the money was missing, and the unit manager denied moving it. The incident was reported to the Administrator and Director of Nursing after the resident inquired about the missing money. Facility investigation documents showed that several staff members who had access to the medication cart during the relevant period were not interviewed, and there was no evidence of statements or interview details for most of the nurses identified as having access. The facility's policy required a thorough investigation, including interviews with all staff who may have had contact with the resident or knowledge of the incident. Both the DON and Administrator acknowledged that the investigation was not thorough, as required by facility policy.
Failure to Report Allegation of Sexual Abuse
Penalty
Summary
The facility failed to report an allegation of sexual abuse involving a resident to the state agency, as required by their policy. The incident involved a resident with severely impaired cognition, who required extensive assistance for daily activities and was dependent for eating. The resident was admitted with a diagnosis of acute respiratory failure and later discharged against medical advice. After the resident's discharge, a hospital evaluation revealed an allegation of sexual abuse, which was reported to the police and Ombudsman. The facility's Administrator became aware of the allegation after reviewing hospital documentation, but acknowledged that the facility did not file a self-reported incident (SRI) with the state agency. The facility's policy mandates that allegations of abuse be reported within two hours or no later than 24 hours, depending on the severity. The Administrator confirmed that the facility did not adhere to this policy, resulting in a deficiency being cited under Complaint Number OH00160670.
Failure to Investigate Allegation of Sexual Abuse
Penalty
Summary
The facility failed to investigate an allegation of sexual abuse involving a resident with severely impaired cognition, as indicated by a Brief Interview Mental Status (BIMS) score of two. The resident required extensive two-person assistance for bed mobility, transfers, and toileting, and was dependent on eating. The resident was admitted to the facility with a diagnosis of acute respiratory failure and later discharged against medical advice. A subsequent hospital evaluation revealed an allegation of sexual abuse, which was reported to the police and Ombudsman, and a Sexual Assault Nurse Examiner (SANE) evaluation was conducted. The facility's Administrator became aware of the allegation after reviewing hospital documentation but did not conduct a thorough investigation as required by the facility's Abuse Prohibition Policy. The policy mandates that investigations be completed within five days and include interviews with the person reporting the incident, the resident if possible, any witnesses, staff in contact with the resident, and a review of all circumstances surrounding the incident. However, the Administrator only questioned male staff verbally and did not obtain written statements or any other investigative documentation, confirming that no evidence of a completed investigation was available.
Medication Transcription and Administration Errors
Penalty
Summary
The facility failed to ensure that a resident's medications were accurately transcribed upon admission, resulting in multiple medication omissions and errors. Specifically, Resident #217, who was admitted with diagnoses including surgical aftercare, spinal stenosis, reduced mobility, and muscle weakness, did not receive Atenolol and Lidocaine Patch EX from 03/25/24 through 03/28/24. Additionally, there was a transcription error for Buprenorphine HCl-Naloxone HCl, which was incorrectly ordered and documented as given when it was not available. Alendronate Sodium was also administered on the wrong day due to an incorrect transcription in the electronic medication record (EMR). These errors were confirmed through medical record reviews and staff interviews, including admissions from LPN #222 and LPN/Unit Manager #187 that the medications were not given as ordered or were incorrectly transcribed. The nurse practitioner's progress note on 03/26/24 indicated that Resident #217 was clinically stable but had not received Suboxone since admission, despite a history of drug use. The physician's orders from 03/24/24 were not accurately transcribed, leading to the administration of Alendronate on Monday instead of Friday, and the omission of Atenolol and Lidocaine Patch EX until 03/29/24. The Buprenorphine HCl-Naloxone HCl was incorrectly transcribed and documented as given on 03/26/24, although it was not available from the pharmacy. Interviews with LPN #222 and LPN/Unit Manager #187 confirmed these discrepancies and the lack of proper medication administration. Further interviews revealed that the facility had reached out to a local Suboxone Clinic prior to Resident #217's admission, but there was no follow-up, and the clinic personnel did not visit the resident. The Regional Clinical Coordinator confirmed that the facility's protocol involves contacting the Suboxone clinic to ensure continuity of care for residents on Suboxone. This deficiency was investigated under Complaint Number OH00152864 and represents non-compliance with the requirement to provide pharmaceutical services to meet the needs of each resident.
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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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