Longmeadow Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Ravenna, Ohio.
- Location
- 565 Bryn Mawr, Ravenna, Ohio 44266
- CMS Provider Number
- 365354
- Inspections on file
- 26
- Latest survey
- April 1, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Longmeadow Care Center during CMS and state inspections, most recent first.
A resident with paraplegia and multiple comorbidities developed a new sacral pressure ulcer that rapidly worsened from Stage II to Stage 4 due to delayed and missed wound care treatments as ordered by the wound NP. The treatment administration records showed repeated failures to complete and document prescribed wound care for the sacral and ankle ulcers, despite the resident's dependence on staff for repositioning and care. Staff interviews confirmed these lapses, and the facility's policy requiring timely and documented treatment was not followed.
Surveyors found that the garbage disposal area was not maintained in a clean and sanitary condition, with both dumpster lids and side doors left open and garbage overflowing. This was confirmed by the Dietary Manager and had the potential to affect all residents.
Surveyors found that the facility failed to effectively use its resources to maintain resident well-being, including not reporting or investigating two resident elopements, not updating care plans, missing or delayed treatments for pressure ulcers, not applying splints as ordered, missing recommended weekly weights, and lacking an effective antibiotic stewardship program. Staff were often unaware of orders or requirements, and documentation was incomplete or missing in several areas.
Surveyors found that insulin pens for several residents were not dated when opened, and medications were left unattended at a bedside. Nursing staff did not verify or document insulin opening dates before administration, and a medicine cup with multiple pills was left on a resident's bedside table without supervision, contrary to facility policy requiring medications to be locked or attended by licensed staff.
The facility did not effectively monitor or document antibiotic use, resulting in multiple residents receiving antibiotics that did not meet established criteria for necessity. Staff failed to communicate these findings to prescribing providers or discuss them in QAPI meetings, and required documentation and oversight were not maintained according to facility policy.
A resident with multiple serious health conditions did not have a signed and dated DNR Comfort Care-Arrest form in their medical record, despite a physician's order for DNR status. The signed DNR form was found only in admission paperwork and was not accessible to nursing staff for emergencies or transfers, contrary to facility policy.
The facility did not report two separate incidents of resident elopement to the state agency as required by policy. In both cases, residents with significant cognitive and physical impairments left the facility unsupervised and were found outside by staff or their responsible party. Interviews confirmed that the required self-reported incidents were not completed for either event.
Two residents with significant cognitive and physical impairments exited the facility without staff knowledge, and the facility failed to conduct thorough investigations into how the elopements occurred. In both cases, required interventions such as Wander Guards and activity programs were either not in place or not monitored, and the investigations lacked key details and root cause analysis.
Two residents with complex medical needs did not have comprehensive care plans addressing all aspects of their care. One resident's ongoing pain management was not included in the care plan despite staff awareness and active treatment, while another resident's supervised smoking status was omitted from their care plan. Staff confirmed these omissions during interviews.
Two residents with significant cognitive and physical impairments eloped from the facility due to inadequate supervision and monitoring. One was found several blocks away in a wheelchair, while another was located by a responsible party walking outside in cold weather. The Wander Guard system was not active on all exits, and staff did not promptly notice or respond to the residents' absence.
Surveyors found that several residents' rooms contained oxygen tanks or equipment without the required warning signage on the doors, in violation of facility policy. In some cases, oxygen equipment was stored in rooms of residents who were not prescribed oxygen, and staff confirmed the lack of signage and improper storage practices.
Two residents received PRN opioid and non-opioid pain medications without documented attempts at non-pharmacological interventions and without clear parameters guiding when to use Acetaminophen versus opioids. An LPN confirmed the absence of required documentation and parameters, despite facility policy mandating non-pharmacological approaches prior to medication.
A resident with multiple chronic conditions had a urinalysis showing abnormal findings, but the physician was not notified of the results. An LPN confirmed that there was no documentation of physician notification, despite facility policy requiring such communication when there are changes in treatment or acute conditions.
An LPN failed to follow professional standards by preparing and administering medications for two residents at the same time, instead of handling each resident's medications separately as required. Both residents had complex medical conditions and multiple medications ordered, and the facility's policy and CDC guidelines specify that medications should be prepared and administered for one resident at a time to prevent contamination or infection.
A CNA provided direct care to a resident with a stage three pressure ulcer and an indwelling urinary catheter without donning a gown, despite physician orders and facility policy requiring enhanced barrier precautions. The CNA was unaware of the need for these precautions, even though a sign was posted outside the room, and assisted the resident without appropriate PPE during wound care.
Two residents did not receive splint application as ordered and recommended by therapy, due to incorrect entry of orders in the electronic medical record and lack of staff awareness. Staff did not document or consistently apply the required splints, and observations confirmed the devices were not in use. Facility policy required systematic prevention of decline in range of motion, but these procedures were not followed.
A resident with significant medical issues and a feeding tube experienced ongoing weight loss, and the dietician repeatedly recommended weekly weights to monitor the situation. Despite these recommendations and facility policy allowing for more frequent weights when ordered, staff failed to consistently obtain and document weekly weights, with several weeks missing. The issue was not addressed in risk meetings, and both the dietician and ADON confirmed the omission without explanation.
The facility failed to maintain safe water temperatures on a specific hall, affecting nine residents. An observation revealed that the shower room's water temperature was 90.4°F after running for seven minutes, and the sink's temperature decreased from 101°F to 99°F after three minutes. The Maintenance Director stated that the water temperature should be between 110 to 120°F and required weekly adjustments based on weather conditions.
The facility failed to deliver unopened mail and packages to residents, affecting two individuals and potentially impacting all residents. One resident reported receiving opened mail and packages, while another found items missing from a delivery. Staff interviews revealed that nurses opened parcels before delivery due to past incidents. The facility's policy stated residents should be free from involuntary searches, indicating a breach of privacy rights.
A resident with cognitive impairment and mobility issues did not receive routine showers as scheduled, despite being dependent on staff for assistance. The facility's policy required regular bathing, but documentation showed multiple periods where the resident was not bathed, and no refusals were recorded. The DON confirmed the lack of compliance with the bathing schedule.
A resident with schizoaffective disorder, HIV, and Alzheimer's disease experienced a change in skin condition that was not timely reported or addressed by the facility. Despite a physician's order for zinc oxide cream application, the resident's peri area was observed to be deep red with crusty particles, and there was no documentation of this condition. Interviews revealed that STNAs did not report the redness to the RN, who later confirmed the condition and initiated treatment for a yeast infection.
A resident with Alzheimer's disease was found with zinc oxide ointment within reach, despite a history of attempting to eat it. Staff interviews revealed a lack of communication and awareness about the resident's behavior. The DON acknowledged the practice of keeping zinc oxide in rooms but noted it was not acceptable if consumed. The facility's dementia care policy was not followed, as the environment was not modified to meet the resident's needs.
A resident with respiratory failure and atrial fibrillation received Midodrine despite physician orders to hold the medication if systolic blood pressure exceeded 120. The MAR showed multiple instances where the medication was administered contrary to these orders, confirmed by interviews with an LPN and the DON. The facility policy required holding medications outside prescribed parameters, which was not followed.
Failure to Timely Implement and Document Pressure Ulcer Treatments Resulting in Harm
Penalty
Summary
A paraplegic resident with a history of diabetes, pressure ulcers, and congestive heart failure developed an in-house acquired Stage II pressure ulcer to the sacrum, which was not treated in a timely manner as ordered by the wound nurse practitioner. The initial treatment order for Medi Honey and silicone bordered foam dressing was not implemented until three days after it was prescribed. During this period, the wound rapidly deteriorated, increasing in size and severity, eventually becoming unstageable with significant slough and discoloration, and later progressing to a Stage 4 ulcer with exposed bone. The treatment administration records (TAR) showed multiple instances where wound care treatments were not completed as ordered, with several days left blank, indicating missed treatments. The resident was dependent on staff for most activities of daily living, including transfers and repositioning, and preferred to lie on his back despite education. The care plan included interventions such as wound treatment, limiting time out of bed, and use of pressure-reducing devices, but these were not consistently implemented or documented. The wound nurse practitioner was not informed that her treatment orders were not being followed promptly, and she confirmed that the wound's rapid decline occurred during the period when treatments were missed or delayed. The facility's own policy required that treatments be provided and documented for all residents with pressure ulcers, but this was not adhered to in this case. In addition to the sacral ulcer, the resident had pressure ulcers on both ankles, with similar failures to complete and document wound care treatments as ordered. The TARs for both the left and right lateral ankle wounds showed multiple missed treatments, though both wounds eventually healed. Interviews with facility staff confirmed the gaps in treatment and documentation. The deficiency affected one of two residents reviewed for pressure ulcers, and the facility census was 73 at the time of the survey.
Improper Garbage Disposal and Overflowing Dumpsters
Penalty
Summary
Surveyors observed that the facility failed to maintain its garbage disposal area in a clean and sanitary condition. During an inspection of the garbage disposal area with the Dietary Manager, both dumpster lids and side doors were found open, and garbage was overflowing. This situation was confirmed by the Dietary Manager at the time of observation. The deficiency had the potential to affect all 73 residents in the facility. No additional details about individual residents or their medical conditions were provided in the report.
Failure to Administer Facility to Ensure Effective Resource Use and Resident Well-Being
Penalty
Summary
The facility failed to administer its operations in a manner that ensured effective and efficient use of resources to maintain the highest practicable well-being of all residents. Surveyors identified multiple deficiencies, including the failure to report and thoroughly investigate two incidents of resident elopement. The Administrator confirmed that no self-reported incident had been completed for these events and was unaware of the reporting requirement. Additionally, the facility did not conduct a root cause analysis to determine how the residents left the facility undetected, nor could staff confirm if care-planned interventions were in place at the time of the incidents. Care planning was also found to be deficient, as not all care plans were updated regularly, with one LPN acknowledging that no one was assigned to oversee care plan accuracy during her absence. The facility failed to implement and document treatment orders for a resident with multiple pressure ulcers, resulting in a significant decline in the resident's condition. Treatment records showed numerous missed or undocumented treatments, and the resident's pressure ulcer progressed from Stage II to Stage IV. Additionally, the facility did not ensure that splints and other therapeutic devices were applied as ordered, with staff unaware of existing orders due to errors in the electronic medical record system, and some devices not being used consistently as required. Further deficiencies included the failure to obtain resident weights according to dietician recommendations, with several weekly weights missing and no clear reason provided by staff. The facility also lacked an effective antibiotic stewardship program, as there was no documentation to confirm that antibiotics met established criteria for use, nor evidence that inappropriate antibiotic use was communicated to medical providers or discussed in quality assurance meetings. The infection control preventionist had not attended QAPI meetings or provided relevant logs for review, and there was no documentation of physician or nurse practitioner awareness regarding antibiotics that did not meet criteria.
Failure to Properly Label Insulin and Secure Medications
Penalty
Summary
Surveyors identified that the facility failed to ensure proper labeling and storage of insulin for three residents with diabetes. Specifically, insulin pen injectors for multiple residents were found opened but not dated, contrary to facility policy which requires dating upon opening to ensure safe administration within usage guidelines. Licensed nursing staff did not verify or document the opening dates prior to administering insulin, and this was confirmed during interviews. The care plans for these residents did not include interventions related to labeling and dating insulin when opened. Additionally, the facility failed to prevent medications from being left unattended at a resident's bedside. During observation, a medicine cup containing approximately 16 pills was found on a bedside table next to a resident who was asleep. The resident confirmed that staff usually supervise medication administration, but on this occasion, the medication was left at the bedside. A CNA confirmed that medications should not be left unattended, and facility policy states that only licensed nurses may access medications, which must be locked or attended by authorized personnel. The deficiencies were observed on the Blue Unit and involved residents with diagnoses including diabetes, hypertension, chronic obstructive pulmonary disease, heart failure, and other chronic conditions. The findings were based on direct observation, interviews with staff and residents, review of medical records, and facility policies regarding medication administration and storage.
Failure to Monitor and Document Appropriate Antibiotic Use
Penalty
Summary
The facility failed to maintain an effective antibiotic stewardship program, as evidenced by the lack of appropriate monitoring and documentation regarding antibiotic use for 21 residents who were prescribed antibiotics over a two-month period. The facility's own surveillance logs indicated that these antibiotic prescriptions did not meet McGeer's criteria for appropriate use, yet there was no evidence that this information was communicated to the prescribing physicians or nurse practitioners. Additionally, the infection control logs maintained by the Infection Control Preventionist did not include any documentation regarding whether the antibiotics met established criteria for necessity. Interviews with staff revealed further deficiencies in the stewardship process. The Infection Control Preventionist, who was responsible for overseeing the infection control program and maintaining logs, confirmed that she had not documented whether antibiotics met McGeer's criteria and had not informed medical providers when antibiotics were deemed unnecessary. She also stated that she had not participated in Quality Assurance and Performance Improvement (QAPI) meetings or provided relevant data for review, despite the facility's policy requiring such actions. The Director of Nursing, who completed the antibiotic surveillance logs, also verified that there was no documentation of physician or NP awareness regarding antibiotics that did not meet criteria, nor was this issue discussed in QAPI meetings. The facility's policy on antibiotic stewardship required the implementation of protocols, monitoring systems, and documentation of actions related to antibiotic use, including maintaining assessment forms, protocols, data collection, and discussion of findings in QAPI meetings. However, the observed practices did not align with these requirements, as there was a lack of documentation, communication, and oversight regarding inappropriate antibiotic use, affecting all residents who received antibiotics during the specified period.
Failure to Ensure Signed DNR Form in Medical Record
Penalty
Summary
The facility failed to ensure that a signed advance directive/Do Not Resuscitate (DNR) form was present in the medical record for a resident with multiple diagnoses, including paraplegia, diabetes, a sacral pressure ulcer, and congestive heart failure. Although there was a physician's order for DNR Comfort Care-Arrest, the DNR form found in the resident's medical record was undated and lacked the required signature from a physician, Physician Assistant (PA), or Nurse Practitioner (NP). The form indicated that such a signature was necessary, but it was not completed. During a review of the resident's hard and electronic medical records, the Assistant Director of Nursing (ADON)/LPN confirmed the absence of a signed and dated DNR form. It was later discovered that a properly signed DNR form existed in the resident's admission paperwork, but it had not been incorporated into the resident's active medical record. As a result, nursing staff did not have access to the signed DNR form for use during appointments, EMS transfers, or emergencies. The facility's policy required that advance directives be copied and placed in the chart upon admission, but did not specify the need for the DNR form to be signed and dated by the appropriate medical professional.
Failure to Report Resident Elopements to State Agency
Penalty
Summary
The facility failed to report two separate incidents of resident elopement to the state agency, as required by policy. In the first incident, a resident with a history of colon cancer, diabetes, epilepsy, depression, muscle weakness, and macular degeneration, who was care planned as high risk for elopement, was found three blocks from the facility in a wheelchair. The resident was agitated, unable to explain his actions, and required emergency services to return to the facility. The care plan for this resident included interventions such as a Wander Guard and one-to-one supervision, but the incident was not reported to the state agency. In the second incident, another resident with diagnoses including respiratory failure, prostate cancer, and lung cancer, and who was severely cognitively impaired, was found missing from the facility. The resident's responsible party located him walking down the sidewalk and returned him to the facility. The resident was assessed for injuries and a Wander Guard was applied upon return. The investigation did not clarify how the resident exited the building unnoticed, and there was no evidence that the incident was reported to the state agency. Interviews with facility staff, including the Administrator, confirmed that both elopements occurred and that there was no evidence of a self-reported incident being completed for either event. The facility's policy required reporting such incidents to the state survey agency, but this was not done in either case.
Failure to Investigate Resident Elopements
Penalty
Summary
The facility failed to thoroughly investigate two separate incidents of resident elopement, affecting two residents who were both at high risk for elopement and had significant cognitive and physical impairments. In the first incident, a resident with diagnoses including colon cancer, diabetes, epilepsy, depression, muscle weakness, and macular degeneration, and who was rarely or never understood, exited the facility in a wheelchair and was found three blocks away. The resident was agitated and unable to explain his actions. The care plan for this resident had previously identified him as high risk for elopement, with interventions such as a Wander Guard and activity programs, but an elopement assessment later indicated he was not at risk. The facility's investigation did not determine how the resident exited the building without staff knowledge and lacked a root cause analysis. In the second incident, another resident with severe cognitive impairment and a history of respiratory failure and cancer was found missing from the facility. The resident's responsible party found him walking outside, about half a mile from the facility, and returned him. The elopement protocol was initiated after the resident was discovered missing, but the facility's investigation did not document what the resident was wearing or how he exited the building unnoticed. The resident's care plan identified him as high risk for elopement, and a Wander Guard was ordered after the incident. Interviews revealed that the Wander Guard system was not active on the front door, and staff were expected to monitor this area when the receptionist was not present. Both incidents revealed that the facility's investigations were incomplete, lacking essential details such as the means of exit and whether care-planned interventions were in place at the time. The facility did not conduct a root cause analysis for either event, and there was no evidence that all required interventions to prevent elopement were being implemented or monitored. The facility policy required thorough documentation and investigation when neglect was suspected, but this was not achieved in these cases.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to ensure that care plans were comprehensive for two residents, as identified through record review and staff interviews. For one resident with multiple diagnoses including respiratory failure, congestive heart failure, COPD, kidney disease, sleep apnea, glaucoma, and depression, the medical record showed ongoing pain management needs, including scheduled and as-needed analgesic and opioid medications. Despite staff being aware of the resident's chronic pain and the use of both pharmacological and nonpharmacological interventions, there was no evidence that the resident's care plan addressed her pain needs. For another resident with bladder cancer and kidney failure, documentation indicated that the resident was a supervised smoker. However, review of the baseline care plan revealed that smoking was not addressed. Staff confirmed that this aspect of the resident's care was omitted from the care plan. The facility's own policy required the development and implementation of a comprehensive, person-centered care plan addressing all medical, mental, and psychosocial needs, which was not followed in these cases.
Failure to Prevent Resident Elopements Due to Inadequate Supervision and Monitoring
Penalty
Summary
The facility failed to prevent elopements for two residents who were identified as being at risk for wandering or had significant cognitive impairment. One resident, with diagnoses including colon cancer, diabetes, epilepsy, depression, muscle weakness, and macular degeneration, had a history of elopement and was previously care planned for high elopement risk, including interventions such as a Wander Guard and activity diversion. However, the elopement assessment later indicated the resident was not at risk, and the care plan was resolved and then reimplemented. Despite these measures, the resident was found three blocks from the facility in a wheelchair, agitated and unable to explain his actions, requiring emergency services to return him to the facility. Another resident, with severe cognitive impairment and diagnoses of respiratory failure, prostate cancer, and lung cancer, was also assessed as not at risk for elopement. This resident was later found missing from the facility and was located by his responsible party walking outside, about half a mile from the facility, in cold weather. The responsible party reported that it took approximately 15-20 minutes before staff began searching for the resident. There was no documentation of how the resident exited the building or what he was wearing at the time, and the investigation noted a prior history of attempted elopement at another facility. Interviews with staff revealed that the Wander Guard system was not active on the front door, and staff were expected to monitor this entrance when the receptionist was not present. The administrator confirmed both elopements occurred and was unaware of the requirement to self-report the incidents. Facility policy defined neglect as the failure to provide necessary goods and services to avoid harm, and required the establishment of a safe environment to prevent abuse and neglect.
Failure to Post Oxygen Signage in Resident Rooms
Penalty
Summary
The facility failed to ensure proper signage indicating the presence of oxygen in resident rooms, as required by facility policy. During observations, surveyors found that three residents' rooms contained oxygen equipment or tanks without appropriate warning signs on the doors. In one instance, a resident's room was used to store other residents' wheelchairs and a portable oxygen e-cylinder, despite the resident not being prescribed or using oxygen. The resident confirmed that the oxygen tank and wheelchairs belonged to others and expressed concern about his room being used for storage. Nursing staff verified that oxygen signage was missing and that oxygen equipment should not be stored in rooms of residents who do not use it. Additional observations revealed that another resident's room contained an oxygen tank without signage, even though the resident did not have a physician's order for oxygen and was not care planned for its use. A third resident, who did have an as-needed order for oxygen, also had both an oxygen tank and concentrator in her room without the required signage. The facility's policy mandates that oxygen warning signs must be placed on the door of any room where oxygen is present, but this was not followed in the cases observed.
Failure to Attempt Non-Pharmacological Pain Interventions and Lack of PRN Pain Medication Parameters
Penalty
Summary
The facility failed to ensure that non-pharmacological interventions were attempted prior to administering as needed (PRN) pain medications and did not establish clear parameters for when to administer Acetaminophen versus opioid pain medications. This deficiency was identified through interviews, record reviews, and policy review, affecting two residents out of five reviewed for unnecessary medications. One resident with multiple chronic conditions, including respiratory failure, heart failure, COPD, kidney disease, and depression, had physician orders for both scheduled and PRN Acetaminophen, as well as PRN Oxycodone. Medication administration records showed frequent administration of Oxycodone for varying pain levels, but there was no documentation that non-pharmacological interventions were attempted before giving these medications. Additionally, there were no documented parameters guiding staff on when to use Acetaminophen versus Oxycodone for pain management. Another resident with diagnoses such as schizophrenia, emphysema, heart disease, and a history of stroke also had orders for PRN Acetaminophen and Dilaudid. The records indicated that both medications were administered for different pain levels, but again, there was no evidence that non-pharmacological interventions were tried first, nor were there parameters for selecting which pain medication to administer. An LPN confirmed the lack of documentation and absence of medication administration parameters. Facility policy required non-pharmacological approaches to be attempted before medication, but this was not followed in these cases.
Failure to Notify Physician of Abnormal Lab Results
Penalty
Summary
The facility failed to notify the physician of laboratory results for one resident. Record review showed that a resident with multiple diagnoses, including respiratory failure, congestive heart failure, COPD, kidney disease, sleep apnea, glaucoma, and depression, had a urinalysis performed that revealed abnormal findings such as nitrites, epithelial cells, bacteria, hyaline casts, mucous, and white blood cell clumps. There was no evidence in the medical record that the physician was informed of these results. An interview with an LPN confirmed that the laboratory results were not reported to the physician. Facility policy required physician consultation when there was a change in treatment, including new or acute conditions, but this was not followed in this instance.
Failure to Follow Professional Standards for Medication Administration
Penalty
Summary
The facility failed to ensure that medications were administered to two residents according to professional standards of practice. During an observation, an LPN dispensed medications for two residents into two medication cups at the same time and proceeded to administer the medications, rather than preparing and administering medications for one resident at a time as required by accepted standards. The LPN confirmed during interview that medications should have been dispensed and administered separately for each resident. Both residents involved had complex medical histories, including conditions such as atrial fibrillation, hypertension, heart disease, and Alzheimer's disease, and had physician orders specifying multiple medications to be administered upon rising. Review of CDC nursing standards and facility policy confirmed that medications should be prepared for one resident at a time and administered in accordance with professional standards to prevent contamination or infection.
Failure to Use Enhanced Barrier Precautions During Wound Care
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to don appropriate personal protective equipment (PPE) while providing direct care to a resident with a stage three pressure ulcer and an indwelling urinary catheter. The resident's care plan, revised on 12/13/24, indicated a need for enhanced barrier precautions due to the presence of wounds and medical devices. Physician orders specified that gloves and a gown were to be worn during high-contact care activities, including dressing changes, bathing, transferring, and wound care. Despite these orders and a sign posted outside the resident's room, the CNA assisted the resident without wearing a gown. The CNA confirmed during an interview that she was unaware of the requirement for enhanced barrier precautions for this resident, even though a sign was present outside the room. Facility policy required the use of gown and gloves for residents with wounds or indwelling devices to prevent the transmission of multidrug-resistant organisms. The failure to follow these precautions was observed during care of the resident's sacral pressure ulcer, which was uncovered and treated with a moisture barrier cream at the time of the incident.
Failure to Apply and Document Splint Use as Ordered
Penalty
Summary
The facility failed to ensure that splints were applied as ordered and per therapy recommendations for two residents who required them to maintain or improve range of motion. For one resident with a history of cerebral infarction, hemiplegia, and cognitive impairment, there was a physician order and occupational therapy recommendation for a left-hand splint to be applied in the morning and removed in the evening. However, there was no documentation of splint application on the Treatment Administration Record (TAR) or task bar, and multiple staff interviews revealed a lack of awareness of the order. The splint was consistently observed unused on the resident's dresser, and it was later determined that the order had been entered incorrectly into the electronic medical record, preventing it from appearing on staff task lists and the TAR. Another resident with a history of stroke, diabetes, muscle weakness, and heart failure had a physician order for a right-hand thumb spica to be applied in the morning and removed in the evening. Review of the TAR showed multiple dates where the spica was not applied as ordered. Observations confirmed the resident was not wearing the device, and staff interviews revealed the device could not be located and was not consistently used. The rehabilitation director confirmed the resident had used the spica for an extended period and was unaware of the inconsistent application. The facility's policy required systematic prevention of decline in range of motion, including assessment, care planning, and provision of appropriate equipment such as splints. Despite these policies, the lack of proper documentation, communication, and staff awareness led to the failure to provide care as ordered for residents requiring splints, as evidenced by the absence of documentation and direct observations of non-use.
Failure to Obtain Weekly Weights per Dietician Recommendation
Penalty
Summary
A deficiency was identified when the facility failed to obtain weights for a resident according to the recommendations of the dietician. The resident in question had multiple medical diagnoses, including cerebral infarction, diabetes, hypertension, and was dependent on a gastrostomy tube for nutrition. The care plan recognized the resident's risk for malnutrition and significant weight changes, but only included monthly weight monitoring, not the weekly weights recommended by the dietician. The dietician had documented significant and undesired weight loss for the resident over several months and repeatedly recommended weekly weights to monitor the situation. Despite these recommendations, the facility's records showed that weekly weights were not consistently obtained, with several weeks missing data. The dietician and ADON both confirmed in interviews that the recommended weekly weights were not completed and could not provide a reason for the omission. Additionally, the issue of missing weights was not discussed in the facility's regular risk meetings, even though residents at nutritional risk were routinely reviewed. Facility policy required that residents be weighed weekly on admission for three weeks and then monthly unless otherwise ordered by a physician or dietician. The policy also stated that the dietician would track weights and collaborate with the facility to review trends and determine if further interventions were needed. In this case, the facility did not follow the dietician's order for weekly weights, resulting in a failure to adequately monitor the resident's nutritional status as recommended.
Facility Fails to Maintain Safe Water Temperatures
Penalty
Summary
The facility failed to maintain safe and comfortable water temperatures for residents on [NAME] Hall, affecting nine residents. During an observation, the shower room's water temperature was recorded at 90.4 degrees Fahrenheit after running for seven minutes, while the sink's water temperature started at 101 degrees Fahrenheit but decreased to 99 degrees Fahrenheit after three minutes. The Maintenance Director acknowledged that the water temperature should be between 110 to 120 degrees Fahrenheit and mentioned that adjustments were made weekly based on weather conditions. This deficiency was identified during an investigation under Complaint Number OH00160559.
Facility Fails to Deliver Unopened Mail and Packages
Penalty
Summary
The facility failed to ensure that residents' mail and personal packages were delivered unopened, affecting two residents and potentially impacting all residents. Resident #1, who was cognitively intact and used a wheelchair for mobility, reported receiving mail and packages that were opened without her permission. Interviews with staff revealed that the Activity Director delivered mail, but nurses opened parcels before delivery due to past incidents of residents receiving prohibited items. The Activity Director found opened mail and packages belonging to Resident #1 in her mailbox and reported the issue to the previous Administrator without resolution. Resident #24, also cognitively intact and using a walker and wheelchair, reported that his packages were opened before delivery, with items such as hot dogs being removed and returned later. The facility's policy on resident rights stated that residents should be free from involuntary searches of their personal possessions. This deficiency was investigated under Complaint Number OH00155925, highlighting a breach of residents' rights to privacy in their communication and personal belongings.
Failure to Provide Scheduled Showers to Resident
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident #5, received routine showers or baths according to their preference and the facility's schedule. Resident #5, who was moderately cognitively impaired and required assistance for activities of daily living due to conditions such as autistic disorder, morbid obesity, and malignant neuroleptic syndrome, was dependent on staff for showering. The care plan indicated that Resident #5 needed weight-bearing assistance for showering and was scheduled to receive showers twice a week on Mondays and Thursdays. Interviews and record reviews revealed that Resident #5 did not consistently receive the scheduled showers. The Director of Nursing (DON) confirmed that there were multiple periods, spanning from June to August 2024, where there was no documentation or evidence that Resident #5 received or was offered a shower or bath. The facility's policy required residents to be bathed or assisted to shower routinely and as needed per their preference. However, the lack of completed shower sheets and documentation of refusals indicated non-compliance with this policy, as confirmed by the DON.
Failure to Report and Address Change in Skin Condition
Penalty
Summary
The facility failed to timely report and address a change in skin condition for Resident #21, who was diagnosed with schizoaffective disorder, HIV, and Alzheimer's disease. The resident was dependent on staff for personal hygiene and was always incontinent of bowel and bladder. A physician's order dated 10/17/22 required the application of zinc oxide cream to the resident's bilateral buttocks every shift and as needed for skin integrity. However, during an observation on 08/19/24, the resident's entire peri area, including the penis, scrotum, under the scrotal area, upper thighs, and the fold between the buttocks, was found to be deep red with multiple small white crusty particles under the scrotum. Despite this, there was no documentation in the resident's medical record of the peri/rectal area being red. Interviews revealed that the State Tested Nursing Assistants (STNAs) responsible for the resident's care did not report the change in skin condition to the Registered Nurse (RN) on duty. The RN confirmed that the STNAs routinely applied zinc oxide as a moisture barrier but did not report the redness, which would have required different treatment. A progress note later documented by the RN confirmed the presence of reddened and excoriated areas, and a physician ordered treatment for a yeast infection. An STNA mentioned that the resident had been red for about a month, and despite informing the nurses, they were instructed to continue using the zinc barrier cream.
Failure to Prevent Resident from Accessing Poisonous Substance
Penalty
Summary
The facility failed to ensure proper interventions were in place to prevent a resident with Alzheimer's disease from consuming poisonous substances. The resident, who was rarely or never understood and required assistance with activities of daily living, was observed with a 16-ounce jar of zinc oxide ointment within reach on their bedside stand. Despite the resident's history of attempting to eat the ointment, as noted by a State Tested Nursing Assistant (STNA), the ointment was left accessible, posing a risk of ingestion. Interviews with staff revealed a lack of awareness and communication regarding the resident's behavior of eating the zinc oxide cream. One STNA, who frequently worked with the resident, was aware of the behavior and had previously informed a nurse, but could not recall who. Another STNA, who was less familiar with the resident, was unaware of the risk and left the ointment on the nightstand. The Director of Nursing acknowledged that while it was common practice to keep zinc oxide in residents' rooms, it was not acceptable if residents were consuming it. The facility's dementia care policy indicated that the environment should be modified to meet individual care needs, which was not adhered to in this case.
Failure to Hold Medication as Ordered
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically concerning the administration of Midodrine, a medication used to increase blood pressure. The resident, who was cognitively intact and had diagnoses including respiratory failure with hypoxia and atrial fibrillation, had a physician's order to hold Midodrine if the systolic blood pressure (SBP) was above 120. However, the Medication Administration Record (MAR) indicated that the medication was administered multiple times despite the resident's SBP being above the prescribed threshold on several occasions. Interviews with the Licensed Practical Nurse (LPN) and the Director of Nursing (DON) confirmed that the MAR showed the medication was given when it should have been held according to the physician's orders. The facility's policy on medication administration required that vital signs be recorded and medications held if they were outside the prescribed parameters. The failure to adhere to these orders and policies resulted in the resident receiving Midodrine when it was contraindicated by their blood pressure readings.
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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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