Meadowbrook Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Cincinnati, Ohio.
- Location
- 8211 Weller Road, Cincinnati, Ohio 45242
- CMS Provider Number
- 365375
- Inspections on file
- 33
- Latest survey
- May 15, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Meadowbrook Care Center during CMS and state inspections, most recent first.
Surveyors identified multiple deficiencies in food storage, labeling, and sanitation, including open and undated food items in refrigerators and dry storage, incomplete temperature logs, improper drying of dishware, and staff failing to follow proper glove use and hand hygiene. Additionally, several dietary staff with facial hair did not wear beard restraints during food preparation, all contrary to facility policy. These failures had the potential to affect all residents in the facility.
Surveyors found that washers in the laundry room had visible build-up and that water was leaking from the water reserve tank, causing water to pool on the floor. The Housekeeping Supervisor confirmed these issues and stated the tank had been overflowing for over a week, potentially affecting all residents.
The facility did not document or follow up on concerns raised by residents during Resident Council meetings, as shown by blank 'Old Business' sections in meeting minutes and confirmed by resident and staff interviews. Issues such as staffing, call lights, medications, laundry, and menus were not addressed, despite facility policy requiring documentation and resolution of these concerns.
A resident with severe cognitive impairment and dependent on staff for ADLs did not have adequate lighting in their room during wound care, requiring staff to sometimes use a flashlight. Additionally, an LPN confirmed the presence of brown skid marks and an unidentifiable brown substance in the C Hall shower room, which was accessed by multiple residents.
The facility did not provide required bed hold notices or notify the Ombudsman when several residents, including those with heart failure, hip fracture, and chronic illnesses, were transferred or discharged to the hospital. Medical record reviews and staff interviews confirmed that these notifications and documents were missing for multiple residents during their hospitalizations.
Six residents with physician-ordered pureed diets were served incorrect food portions when staff used the wrong scoop sizes, contrary to the Registered Dietitian's plan and facility guidelines. The Dietary Manager confirmed the error, and facility policy required staff to be trained in proper portioning.
Staff did not inform a resident's medical provider of a significant weight loss, despite facility policy requiring such notification. The resident, who had chronic medical conditions and an order for daily weights, lost over 9% of body weight in two days. Both the dietician and NP confirmed that the provider was not notified of this change.
The facility did not accurately complete MDS assessments for three residents, resulting in incorrect documentation of dental status and range of motion. One resident was not coded as edentulous despite having no natural teeth, another was not coded for a left-hand contracture despite therapy records and observation, and a third was not coded for broken teeth despite clear evidence. The MDS RN confirmed these inaccuracies.
A resident admitted with a hospital exemption and a diagnosis of intellectual disability did not have a PASARR completed within 30 days as required. The resident's medical record and staff interview confirmed the absence of the PASARR, despite facility policy and hospital documentation indicating the need for timely completion.
A resident with multiple chronic conditions began receiving hospice services following a physician's order, but facility staff did not complete an updated PASARR assessment after this significant change in condition. This lapse was confirmed through medical record review and staff interview.
The facility did not develop complete care plans for two residents, omitting necessary interventions for one resident's use of a hypnotic medication and another resident's edentulous status. These omissions were confirmed through record review, observation, and staff interviews.
The facility did not conduct quarterly care conferences as required for three residents, including individuals with dementia, Parkinson's disease, and chronic obstructive pulmonary disease, all of whom required staff assistance with ADLs. Social Services Directors confirmed the absence of these care conferences, and facility policy requiring resident and/or representative involvement in care planning was not followed.
A resident with multiple chronic conditions was not reassessed for nutritional status after returning from a hospital stay for volume overload, during which a significant amount of fluid was removed. Facility dietary staff were unaware of the hospitalization and did not update or complete a nutrition assessment upon the resident's readmission.
A resident with multiple medical conditions did not have weights obtained according to physician orders, with several days and weeks missed despite clear instructions for daily, weekly, and monthly monitoring. Staff confirmed the failure to follow the prescribed schedule.
A resident with a gastrostomy tube was found with a partially used bag of Jevity 1.5 formula hanging on the pump, and a piece of paper towel was inserted into the end of the g-tube tubing to prevent spillage. Nursing staff confirmed the formula should have been discarded after the feeding was stopped, and facility policy required proper handling and timely disposal of enteral feeding formulas.
A resident with multiple chronic conditions and severe cognitive impairment refused the influenza vaccine, but there was no documentation of vaccine consent or declination, nor evidence that education on the vaccine's benefits and risks was provided, as required by facility policy. The DON confirmed the absence of this documentation.
A resident with multiple chronic conditions and severe cognitive impairment was not offered the COVID-19 vaccine as required, and there was no documentation of vaccine consent or declination in the medical record. The DON confirmed the lack of documentation regarding the vaccine offer or administration.
Staff failed to protect resident privacy by posting a resident's photo on social media without consent, providing incontinence care without closing the window curtain, and performing a blood sugar check in a public dining area without visual privacy. These actions involved residents with severe cognitive impairment and violated facility policies regarding confidentiality and resident rights.
A resident was given Ambien for sleep assistance without a documented sleep disorder or related diagnosis, and the care plan did not address or monitor the use of this hypnotic medication. The DON confirmed the absence of both an appropriate indication and a care plan, contrary to facility policy requiring clinical justification and monitoring for psychotropic medications.
The facility did not adequately assess or document pressure ulcers for two residents at high risk, failing to measure and describe new wounds and not following physician orders for wound care. Required treatments were not consistently recorded or completed, and staff did not always use the correct wound care products as ordered. These deficiencies were confirmed by interviews and review of facility policies.
A nurse failed to verify a resident's identity and administered medications intended for another resident, resulting in the resident being hospitalized for altered mental status and accidental drug overdose. The error was discovered after administration, and the resident required monitoring and treatment before returning to baseline.
Surveyors found that insulin pens for three residents with diabetes were not dated when removed from refrigeration or placed in medication carts, as confirmed by LPNs and the DON. The facility lacked a specific policy for insulin storage and dating, and the consulting pharmacist confirmed the requirement for dating insulin upon first use.
A resident with end stage renal disease, CHF, and diabetes was not provided with the prescribed renal diet, including limits on juice, milk, and sugar intake. Despite clear physician orders and meal ticket instructions, the resident was repeatedly served and consumed excessive amounts of milk and juice, as well as regular sugar syrup, due to errors by dietary and nursing staff. Interviews confirmed the resident was unaware of dietary restrictions and consistently received incorrect items.
Staff did not adhere to infection control protocols, including enhanced barrier precautions and proper hand hygiene, during care of two residents. An LPN failed to perform hand hygiene before tracheostomy care, used a non-disinfected surface for sterile supplies, and compromised aseptic technique. In a separate incident, a CNA wore the same gloves while moving a resident from their room to the dining area without changing gloves or performing hand hygiene.
A facility failed to implement its abuse policy when two residents were found in bed together, one undressed. The male resident, with moderate cognitive impairment, was confused and mentioned the female resident's odor. Despite the situation, no formal investigation was conducted, and the incident was not reported immediately to the DON or Administrator, as required by policy. Staff accounts were inconsistent, and a Self-Reported Incident was not completed.
A facility failed to timely report an alleged abuse incident involving two residents in a secured memory care unit. One resident was found undressed in another's bed, and staff inconsistencies delayed reporting to the DON and Administrator. The facility did not conduct a formal investigation or complete a Self-Reported Incident (SRI) as required by state regulations.
A facility failed to ensure staff wore appropriate PPE during high-contact care for a resident under Enhanced Barrier Precautions (EBP) due to Candida Auris. An STNA provided incontinence care without a gown, despite signage and policy requirements. The STNA was unaware of EBP protocols, leading to noncompliance with infection control measures.
A resident with hemiplegia and moderately impaired cognition was left without access to a call light, despite facility policy requiring it to be within reach. Staff failed to ensure the call light was accessible during multiple visits, leading to a deficiency finding.
A resident with multiple health conditions did not receive wound care as ordered after sustaining a skin tear. Despite a physician's order for daily dressing changes, the dressing was not updated for several days, as confirmed by an LPN. This noncompliance with the facility's wound care policy was identified during a complaint investigation.
A resident with chronic pain did not receive a one-time dose of Oxycodone in a timely manner due to a nurse leaving the floor without notice. The resident had difficulty finding a nurse for pain relief, and the medication was administered hours after the order was placed. The facility's policy requires timely medication administration, and the incident led to a deficiency finding.
The facility failed to administer medications as ordered, resulting in a 13.3% error rate. Two residents did not receive their prescribed medications due to unavailability, despite the facility's policy requiring adherence to prescriber orders. This deficiency was identified during a medication pass observation.
A facility failed to ensure a pressure ulcer dressing change was completed per physician orders for a resident with a stage four pressure ulcer. The LPN on the night shift did not perform the treatment and falsely documented it as completed, despite the resident not refusing the care.
The facility failed to ensure proper colostomy care for a resident, as an LPN did not follow hand hygiene protocols during the procedure. The LPN did not change gloves or perform hand hygiene when moving from dirty to clean tasks, resulting in improper care.
The facility failed to ensure the attending physician completed visits every 60 days, affecting two residents who had no physician visits from December 2023 through May 2024. Both residents were severely cognitively impaired, and the MD confirmed the oversight.
Deficient Food Storage, Sanitation, and Staff Hygiene Practices
Penalty
Summary
Surveyors observed multiple failures in food storage, labeling, and sanitation practices within the facility's dietary services. Open and undated food items, such as jars of jelly, pitchers of drinks, cartons of thickened beverages, and containers of sauces and dressings, were found in both the free-standing and walk-in refrigerators, as well as in the dry storage area. Temperature logs for the walk-in refrigerator were incomplete, and several food items in dry storage, including boxes and bowls of cereal and cornstarch, were also open, unlabeled, and undated. The facility's policy required all food to be covered, labeled, and dated, and for refrigeration temperatures to be monitored and documented, which was not followed. Additional deficiencies were noted in food preparation and handling. Insulated lids used to cover breakfast plates were stored in a way that allowed water to pool inside, rather than being stored upside down to dry properly. During meal preparation, a dietary staff member was observed wearing the same pair of gloves while touching various surfaces, utensils, and food items, and did not change gloves or wash hands as required by facility policy. Furthermore, several dietary staff members with facial hair were not wearing beard restraints while preparing food, contrary to facility policy. These actions and inactions had the potential to affect all residents in the facility, which had a census of 89 residents at the time of the survey.
Laundry Room Equipment Not Maintained in Clean and Safe Condition
Penalty
Summary
Surveyors observed that the facility's laundry room contained four washers with visible brown, blue, and white build-up on the tops and sides. Additionally, water was seen leaking from the water reserve tank located behind the washers, resulting in water pooling on the floor in front of the machines. During an interview, the Housekeeping Supervisor confirmed the presence of the build-up and the ongoing water leakage, stating that the water reserve tank had been overflowing onto the laundry room floor for over a week. These conditions were directly observed and confirmed by staff, and had the potential to affect all 89 residents in the facility. No specific residents or their medical conditions were mentioned in relation to this deficiency.
Failure to Document and Follow Up on Resident Council Concerns
Penalty
Summary
The facility failed to document and follow up on concerns raised by residents during Resident Council meetings, as evidenced by a review of meeting minutes from May 2024 to April 2025. The section of the minutes designated for follow-up on previous concerns, labeled 'Old Business,' was consistently left blank and did not address issues previously brought up by residents, including topics such as agency staffing, call lights, medications, laundry, and menus. Interviews with residents who regularly attended the meetings, including the Resident Council president, confirmed that the facility had not provided any follow-up on concerns raised. Additionally, the Activities Director acknowledged that there was no documentation of follow-up to the concerns discussed in the Resident Council meetings during the specified period. Review of the facility's policy indicated that the facility was required to track and document responses and resolutions to concerns raised by Resident Council members, but this was not done.
Inadequate Lighting and Unclean Shower Room Environment
Penalty
Summary
The facility failed to provide adequate lighting in a resident's room, as observed during wound care performed by an LPN. The resident, who had severe cognitive impairment and was dependent on staff for activities of daily living, did not have sufficient overhead lighting when the curtain was closed. The available light sources included a sink light, a bathroom light, and an over-the-bed light, but these were not adequate for performing wound care, leading staff to sometimes use a flashlight to provide care. Additionally, the facility did not maintain a clean environment in the C Hall shower room, which was used by 48 residents. Observations revealed brown skid marks of an unidentified substance on the wall by the toilet and a layer of brown unidentifiable material along the walls surrounding the shower area, approximately two inches up from the floor. An LPN confirmed the presence of these substances and that all residents on the C Hall had access to the affected shower room.
Failure to Provide Required Bed Hold Notices and Ombudsman Notifications During Hospital Transfers
Penalty
Summary
The facility failed to provide required documentation and notifications related to residents' needs, appeal rights, and bed-hold policies during instances of discharge or transfer to the hospital. Specifically, the facility did not issue appropriate bed hold notices to residents or their representatives and did not notify the Ombudsman when residents were transferred or discharged to the hospital. This deficiency was identified through medical record reviews and staff interviews, affecting four out of five residents reviewed for discharge and hospitalization. For example, one resident with acute on chronic diastolic heart failure was discharged to the hospital and did not return, but there was no documentation of Ombudsman notification. Another resident with right hip fracture and osteomyelitis was transferred to the hospital twice, with no Ombudsman notification documented for either transfer. Additional cases included residents with hypothyroidism, cardiomegaly, atrial fibrillation, diabetes, schizoaffective disorder, and chronic kidney disease, where bed hold notices were not provided and Ombudsman notifications were not documented. Staff interviews confirmed these failures in documentation and notification.
Failure to Serve Dietitian-Planned Pureed Food Portions
Penalty
Summary
The facility failed to serve food portions as planned by the Registered Dietitian (RD) for six residents who had physician's orders for a pureed diet. During a lunch observation, staff member #18 used a four-ounce scoop for pureed barbeque ham sandwiches and a three-ounce scoop for pureed potatoes, instead of the required five and one-half ounces for the sandwich and four ounces for the potatoes as indicated on the dietary spreadsheet. A poster in the kitchen provided coded measurement indicators for reference, but these were not followed. The Dietary Manager confirmed that the incorrect scoop sizes were used and that the staff member did not adhere to the spreadsheet planned and approved by the RD. Review of the facility's policy on kitchen weights and measures indicated that staff were to be trained on the appropriate measurement and type of serving utensil for each food. This deficiency affected six residents with pureed diet orders and was identified during the investigation of two complaint numbers.
Failure to Notify Provider of Significant Weight Loss
Penalty
Summary
Staff failed to notify the resident's physician or medical provider of a significant weight loss experienced by a resident with diagnoses including COPD, panic disorder, and pulmonary hypertension. The resident had an order for daily weights, and records showed a drop from 187 pounds to 169 pounds over two days, amounting to a 9.3% loss. Despite facility policy requiring staff to report significant weight changes to the provider, interviews with the dietician and nurse practitioner confirmed that no notification was made regarding this weight loss. The nurse practitioner stated she was not informed and would have ordered lab work if notified.
Inaccurate MDS Assessments for Dental Status and Mobility
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for three residents regarding dental status and range of motion/mobility. For one resident with benign prostatic hyperplasia, chronic kidney disease, and intellectual disabilities, the admission MDS did not indicate that the resident was edentulous, despite direct observation and resident/staff interviews confirming the absence of natural teeth upon admission. Another resident with cerebral infarction, asthma, and anxiety disorder had a left-hand contracture documented in therapy records and observed during the survey, but the quarterly MDS did not reflect any upper extremity impairment. Interviews confirmed the contracture and the use of a carrot splint, which was omitted from the MDS coding. A third resident with type 2 diabetes, peripheral vascular disease, and cerebral infarction was not coded for broken natural teeth on the admission MDS, even though both observation and resident interview confirmed the presence of a broken tooth and possible cavities. In each case, the MDS Registered Nurse acknowledged that the MDS assessments were not accurately completed, resulting in discrepancies between the residents' actual conditions and the documented assessments.
Failure to Complete PASARR Within Required Timeframe for Resident with Intellectual Disability
Penalty
Summary
A deficiency occurred when the facility failed to complete a Preadmission Screening and Resident Review (PASARR) within 30 days for a resident admitted with a hospital exemption. The resident was admitted with diagnoses including osteoarthritis, benign prostatic hyperplasia, chronic kidney disease stage three, and unspecified intellectual disabilities. The resident's intellectual disability, which manifested prior to age 22, was documented in both the hospital exemption and the facility's diagnosis list at the time of admission. The hospital exemption specifically indicated that the facility was responsible for electronically initiating a PASARR prior to the 30th day following admission. Despite these requirements, a review of the resident's medical record revealed that a completed PASARR was not present. The admission Minimum Data Set (MDS) assessment indicated the resident was moderately cognitively impaired and required staff assistance with activities of daily living. Staff interview confirmed that the PASARR had not been completed for the resident, and facility policy stated that the PASARR should be provided prior to or upon admission.
Failure to Update PASARR Assessment After Significant Change in Condition
Penalty
Summary
Facility staff failed to update the Preadmission Screening and Resident Review (PASARR) assessment for a resident with multiple diagnoses, including cerebrovascular disease, chronic obstructive pulmonary disease, neurocognitive disorder, and diabetes, after a significant change in condition. The resident was admitted and later began receiving hospice services as ordered by a physician. Despite this change, the medical record review and staff interview confirmed that the facility did not complete an updated PASARR assessment when the resident was enrolled in hospice, as required. This deficiency was identified during a review of four residents for PASARR completion, affecting one resident out of a facility census of 89.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for two residents, as required by policy. For one resident with diagnoses including dysphagia, generalized anxiety disorder, and cerebral infarction, the care plan did not address the use of Ambien, a hypnotic medication, despite a physician's order for its use and documentation that the resident received the medication. The resident was cognitively intact and required staff assistance with activities of daily living. The Director of Nursing confirmed that a care plan for the use of Ambien had not been initiated. For another resident with benign prostatic hyperplasia, chronic kidney disease, and unspecified intellectual disabilities, the care plan did not address the resident's edentulous status, even though the resident was observed and confirmed to be edentulous upon admission. The admission MDS assessment did not correctly code the resident's dental status, and the dental care plan failed to include interventions specific to being edentulous. The MDS Registered Nurse confirmed these omissions during an interview.
Failure to Conduct Required Quarterly Care Conferences
Penalty
Summary
The facility failed to conduct quarterly care conferences as required for three out of four residents reviewed for care planning. For one resident with severe cognitive impairment and multiple diagnoses including dementia, schizophrenia, bipolar disorder, and diabetes, there was no documented quarterly care conference for the first, second, and third quarters of the year, with only one care conference recorded in the fourth quarter. Another resident with Parkinson's disease and dementia, who had intact cognition and required staff assistance with ADLs, did not have any care conference conducted during the year. A third resident with chronic obstructive pulmonary disease, hypertension, and atrial fibrillation, also with intact cognition and requiring staff assistance, did not have a care conference in the first quarter of the year. Interviews with the Social Services Directors confirmed that quarterly care conferences were not conducted as required for these residents. Review of the facility's policy indicated that care planning should include the resident and/or their representative and that meetings should be scheduled at a convenient time, but this process was not followed for the affected residents.
Failure to Reassess Nutritional Status After Hospitalization
Penalty
Summary
The facility failed to reassess the nutritional status of a resident following a hospitalization for volume overload. The resident, who had diagnoses including end stage renal disease, congestive heart failure, and diabetes mellitus, was admitted to the hospital where 44 pounds of fluid were removed. Upon return to the facility, there was no documentation of a nutritional assessment being completed, despite significant changes in the resident's weight and clinical status. Interviews with the Dietitian Technician and Registered Dietitian confirmed that neither had updated or completed a nutritional assessment for the resident after readmission. Both staff members were unaware of the resident's recent hospitalization and the substantial fluid loss, and acknowledged that a nutritional assessment should have been performed due to the nutritional significance of the hospitalization.
Failure to Obtain Resident Weights as Ordered by Physician
Penalty
Summary
The facility failed to obtain resident weights as ordered by the physician for one resident with diagnoses including hypothyroidism, cardiomegaly, and atrial fibrillation. The physician's order specified that the resident's weight should be obtained upon admission, daily for the following two days, weekly for four weeks, and then monthly. Review of the Medication Administration Record showed that weights were recorded on the first, second, and fourth days after admission, but not on the third day as ordered, and no weights were recorded for the remainder of the month. This failure to follow the physician's order was confirmed by staff interview. The facility's policy indicated that the physician, with staff input, determines the appropriate intervals for weight assessments.
Unsanitary Administration of Tube Feeding
Penalty
Summary
Staff failed to administer tube feedings in a sanitary manner for a resident with a gastrostomy tube. The resident, who was cognitively intact and had a history of dysphagia following cerebral infarction, was observed lying in bed with a tube feeding pump that was not running. A partially used container of Jevity 1.5, dated the previous day, was hanging on the pump and connected to the g-tube tubing, which had a piece of paper towel stuck in the end to prevent the formula from spilling out. Interviews with nursing staff confirmed that the tube feeding had been disconnected earlier in the day and that the partially used bag of Jevity 1.5 should have been discarded after the feeding was stopped. Facility policy required that reconstituted formulas be refrigerated and discarded within 24 hours. The presence of the used formula and unsanitary paper towel in the tubing indicated a failure to follow proper procedures for tube feeding administration and formula handling.
Lack of Documentation and Education for Influenza Vaccine Refusal
Penalty
Summary
The facility failed to ensure that a resident and/or their representative received education regarding the benefits and potential side effects of the influenza immunization. Medical record review for a resident with diagnoses including type two diabetes mellitus, schizoaffective disorder, and chronic kidney disease showed an order for the influenza vaccine, which the resident refused. However, there was no documentation in the medical record of an influenza vaccine consent or declination form, nor evidence that the required education was provided. The resident was noted to be severely cognitively impaired and required staff assistance with activities of daily living. The DON confirmed that the resident refused the vaccine, but the necessary documentation and education were not present in the record, contrary to facility policy.
Failure to Offer and Document COVID-19 Vaccination for Resident
Penalty
Summary
The facility failed to ensure that a resident was offered the COVID-19 vaccine in accordance with its policy and CDC guidance. Medical record review showed that the resident, who had diagnoses including type two diabetes mellitus, schizoaffective disorder, and chronic kidney disease, was admitted to the facility after having received a COVID-19 booster prior to admission. Despite being severely cognitively impaired and requiring staff assistance with activities of daily living, there was no documentation in the resident's medical record from the time of admission through the review period indicating that the COVID-19 vaccine was offered, declined, or administered. Additionally, there was no consent or declination form present in the chart, and the DON confirmed the absence of such documentation.
Failure to Protect Resident Privacy and Confidentiality
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of residents' personal and medical information, affecting three residents. For one resident with severe cognitive impairment and multiple diagnoses, the facility posted the resident's picture on social media without obtaining written consent from the resident or their representative, despite the representative's explicit request not to do so. The facility's policy required explicit written consent prior to releasing or transmitting resident images, which was not followed in this case. Another resident, also with severe cognitive impairment, was provided incontinence care by staff without the window curtain being closed, exposing the resident to potential view from the staff parking lot. Staff confirmed the curtain should have been drawn to ensure visual privacy. In a separate incident, a resident with Alzheimer's disease and other conditions had her blood sugar checked by an RN in the dining room in the presence of other residents, without visual privacy or obtaining consent. These actions were in direct violation of the facility's policies and residents' rights to privacy.
Hypnotic Medication Administered Without Proper Indication or Monitoring
Penalty
Summary
A deficiency was identified when a resident was prescribed Ambien, a hypnotic medication, for sleep assistance without an appropriate diagnosis or medical indication documented in the medical record. The resident, who had diagnoses including dysphagia, generalized anxiety disorder, and cerebral infarction, did not have a documented sleep disorder or related diagnosis to justify the use of Ambien. The physician's order for Ambien was present, but the necessary clinical justification was absent. Further review revealed that the resident's care plan did not address the use of Ambien, nor did it outline any monitoring for the effects or adverse consequences of the hypnotic medication. Interviews with the DON confirmed both the lack of an appropriate diagnosis for hypnotic use and the absence of a care plan for monitoring. The facility's policy required that psychotropic medications be clinically indicated and that residents be monitored for adverse effects, but these requirements were not met in this case.
Failure to Assess, Document, and Follow Orders for Pressure Ulcer Care
Penalty
Summary
The facility failed to timely and adequately assess the skin of a resident at very high risk for pressure ulcers. Despite physician orders for preventative skin care and weekly skin checks, documentation revealed that when an open area was discovered on the resident's right hip by family, staff did not measure or describe the wound as required by facility policy. Subsequent documentation and observation confirmed the presence of a facility-acquired unstageable pressure ulcer, but initial assessments lacked necessary details such as measurements, staging, and wound description. Additionally, the facility did not follow physician orders for wound care for another resident admitted with multiple pressure ulcers. Wound care orders for cleansing and dressing changes were not transcribed onto the Treatment Administration Records (TAR) for several periods, and there was no evidence that the prescribed treatments were completed. Documentation was also missing for specific dates, and staff used wound cleanser instead of normal saline on a wound, contrary to the physician's order. Interviews with nursing staff and the Director of Nursing confirmed these lapses in assessment, documentation, and adherence to physician orders. Facility policies required full assessment and documentation of pressure ulcers and completion of wound treatments as ordered, but these protocols were not followed for the affected residents.
Failure to Prevent Significant Medication Error Due to Improper Resident Identification
Penalty
Summary
A significant medication error occurred when a registered nurse administered a set of medications intended for another resident to a resident with multiple chronic conditions, including chronic diastolic heart failure, anxiety disorder, acute respiratory failure with hypoxia, hypertension, chronic obstructive pulmonary disease, and chronic kidney disease. The resident had intact cognition and required staff assistance with activities of daily living. The nurse failed to verify the resident's identity before administering the medications, as required by facility policy, and did not ask the resident's name or attempt any identification. Approximately 20 minutes after the error, the nurse realized the mistake, notified management, and assessed the resident. Following the administration of the incorrect medications, the resident's physician and emergency contact were notified, and the resident was monitored per physician orders. The resident's family requested hospital transfer, and the resident was sent to the hospital, where she presented with altered mental status and was diagnosed with accidental drug overdose and altered mental status. Hospital evaluation included lab work and EKG, which showed no significant abnormalities, and the resident was treated with intravenous fluids and monitored until returning to baseline. The incident was documented in the medical record, medication error report, and hospital records.
Failure to Properly Label and Store Insulin Pens
Penalty
Summary
Surveyors identified that the facility failed to ensure proper labeling and storage of insulin pens for three residents with diabetes mellitus. Medical record reviews and observations revealed that insulin pens for these residents were not dated when removed from refrigeration or placed in the medication cart, as required by professional standards. Interviews with LPNs confirmed that the insulin pens were not dated, and staff acknowledged that insulin is to be dated upon removal from refrigeration or when placed in the medication cart. Further interviews with the Director of Nursing and the consulting pharmacist confirmed the expectation that insulin should be dated when removed from refrigerated storage or first used. The Director of Nursing also confirmed that the facility did not have a policy specific to the storage and dating of insulin. These findings were based on direct observation, staff interviews, and review of medical records and physician orders for the affected residents.
Failure to Provide Physician-Ordered Renal Diet
Penalty
Summary
A deficiency occurred when a resident with end stage renal disease, congestive heart failure, and diabetes mellitus, who was prescribed a renal diet with low concentrated sugar and a fluid restriction, was not provided with the specified foods according to physician's orders. Medical record review and meal ticket documentation indicated the resident was to receive limited amounts of juice and milk, as well as a low concentrated sugar diet. However, observations revealed the resident was served and consumed six ounces of orange juice and eight ounces of milk at breakfast, exceeding the prescribed limits. The resident also received and consumed regular sugar syrup instead of the required sugar-free syrup. Interviews with the resident, dietary manager, and registered nurse unit manager confirmed that the resident was not provided with the correct diet as ordered. The dietary manager acknowledged that both the CNA and kitchen staff made errors in serving the incorrect items. The resident was unaware of the dietary restrictions and consistently received and consumed the wrong items. Facility policy required therapeutic diets to be prescribed by the physician to support the resident's treatment plan, but this was not followed in this instance.
Failure to Follow Enhanced Barrier Precautions and Hand Hygiene During Resident Care
Penalty
Summary
Staff failed to follow infection prevention and control guidelines during care of residents, specifically in the application of enhanced barrier precautions (EBP) and hand hygiene protocols. For one resident with a tracheostomy, an LPN did not perform hand hygiene with alcohol-based hand sanitizer or soap and water before entering the room and donning a gown. After donning the gown, the LPN washed hands for only eight seconds, which is less than the recommended duration. The LPN also failed to disinfect the overbed table before using it as a workspace for sterile tracheostomy supplies and compromised aseptic technique by placing a non-sterile gloved thumb inside the sterile tracheostomy kit. These actions were confirmed by both the LPN and the Director of Nursing during interviews. Facility policy required EBP, including targeted gown and glove use during high-contact care activities such as tracheostomy care, and specified that hand hygiene should be performed before aseptic tasks. The policy also outlined that handwashing should last at least 15 seconds and that gloves do not replace hand hygiene. The tracheostomy care policy required aseptic technique and sterile gloves during procedures, as well as hand hygiene before and after glove use. These protocols were not followed during the observed tracheostomy care event. In a separate incident, a CNA was observed entering a resident's room wearing gloves, then exiting the room and assisting the resident to the dining room without removing or changing gloves. The CNA confirmed that the same gloves were worn throughout both activities. This practice did not align with infection control standards, which require glove removal and hand hygiene between resident care activities to prevent cross-contamination.
Failure to Implement Abuse Policy in Resident Incident
Penalty
Summary
The facility failed to implement its abuse policy when staff discovered a male and female resident in bed together. This incident involved two residents, one of whom was deemed incompetent and resided in a secured memory care unit. The male resident had moderate cognitive impairment and was generally independent in his activities of daily living, while the female resident had severe cognitive impairment and required varying levels of assistance for her daily activities. The incident occurred when a CNA found the female resident undressed in the male resident's bed, with the male resident sitting on the side of the bed. The male resident appeared confused and mentioned that the female resident had an odor. Despite the situation, the facility did not conduct a formal investigation or issue formal findings. Staff statements were collected, and it was noted that the incident was not reported immediately to the Director of Nursing or the Administrator, as required by the facility's policy. Interviews with staff revealed inconsistencies in their accounts of the incident. The CNA initially reported seeing the male resident on top of the female resident but later stated he was lying next to her. The Director of Nursing and the Administrator confirmed that they were not notified of the incident until the following day, and a Self-Reported Incident was not completed. The facility's policy mandates immediate reporting and investigation of such incidents, which was not adhered to in this case.
Failure to Timely Report Alleged Abuse Incident
Penalty
Summary
The facility failed to timely report an alleged incident of abuse involving two residents in the secured memory care unit. Resident #4, who was admitted with Alzheimer's disease, dementia, and other conditions, was found undressed in Resident #41's bed. Resident #41, who has dementia and diabetes, was sitting on the side of the bed and appeared confused. The incident was initially observed by CNA #550, who reported seeing Resident #41 lying next to Resident #4. However, there were inconsistencies in the accounts provided by the staff involved, including LPN #415 and Medication Technician #575. The facility's policy on abuse and neglect requires immediate reporting of any suspected incidents to the Director of Nursing and the Administrator. However, the Director of Nursing was not notified until the day after the incident, and the Administrator was also informed late. The facility did not conduct a formal investigation or issue a formal report on the incident, and no Self-Reported Incident (SRI) was completed as required by state regulations. The staff involved did not follow the protocol for reporting and investigating the alleged incident, leading to a delay in addressing the situation. Interviews with the staff revealed a lack of clarity and consistency in their observations and actions. CNA #550 initially reported seeing Resident #41 on top of Resident #4 but later stated he was lying next to her. LPN #415 did not witness the incident but reported it to RN #320, who also delayed notifying the Director of Nursing. The facility's failure to adhere to its abuse and neglect protocol resulted in noncompliance with state regulations, as the incident was not reported within the required timeframe, and a formal investigation was not conducted.
Failure to Adhere to Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure that staff wore appropriate Personal Protective Equipment (PPE) when providing high-contact care to residents under Enhanced Barrier Precautions (EBP). This deficiency was identified during an observation where a State tested Nurse Aide (STNA) provided incontinence care to a resident without wearing a gown, despite the presence of a sign indicating the requirement for gowns and gloves for high-contact care. The resident in question had been admitted with diagnoses including hemiplegia, type II diabetes, and chronic viral hepatitis C, and was under EBP due to a positive Candida Auris test. The STNA involved in the incident sanitized her hands and donned gloves before entering the resident's room but did not wear a gown as required by the facility's EBP policy. During an interview, the STNA confirmed her lack of compliance with the gown requirement and admitted to not being aware of the specific EBP protocols or the reason for the resident's EBP status. The facility's policy, dated August 2022, clearly stated that gloves and gowns should be applied prior to high-contact resident care to prevent the spread of multi-drug resistant organisms.
Failure to Ensure Resident Access to Call Lights
Penalty
Summary
The facility failed to ensure that residents had access to call lights, affecting one resident out of five sampled. Resident #46, who was admitted with diagnoses including hemiplegia, hemiparesis, type II diabetes, and chronic viral hepatitis C, was observed without access to a call light. The resident had moderately impaired cognition and required staff assistance for activities of daily living. The care plan for the resident included keeping the call light within reach and encouraging its use for assistance. On the morning of the observation, a State Tested Nurse Aide (STNA) entered the resident's room, provided care, and left without ensuring the call light was within reach, leaving it on the floor. Another STNA later entered the room, removed breakfast dishes, and also failed to check the call light's accessibility. It was only after a subsequent visit that the call light was clipped to the resident's blanket. The facility's policy required call lights to be within easy reach, which was not adhered to in this instance, leading to the deficiency noted in the report.
Failure to Provide Ordered Wound Care
Penalty
Summary
The facility failed to provide wound care as ordered for a resident, leading to a deficiency. The resident, who was admitted with multiple diagnoses including ataxic cerebral palsy, morbid obesity, and type II diabetes, was at increased risk for pressure ulcer development. The care plan included administering treatments as ordered to prevent skin breakdown. However, after the resident reported hitting his leg on an air conditioning unit, a physician ordered daily dressing changes for a skin tear on the left shin. Despite this order, the dressing was not changed as required. On observation, the resident's dressing, dated three days prior, showed signs of drainage, indicating it had not been changed according to the physician's instructions. An LPN confirmed the dressing had not been updated since the date marked on it. The facility's wound care policy, which mandates wound care per physician's orders to promote healing, was not followed, resulting in noncompliance identified during a complaint investigation.
Failure to Administer Pain Medication Timely
Penalty
Summary
The facility failed to ensure timely administration of pain medication for a resident, leading to a deficiency. Resident #75, who was admitted with multiple diagnoses including chronic pain, had a physician's order for routine Oxycodone 10 mg four times a day and a one-time dose for pain. However, the one-time dose was not administered until several hours after it was ordered. The resident reported difficulty in locating a nurse for pain relief, and it was discovered that a nurse had left the floor without notifying staff, resulting in a delay in medication administration. Interviews revealed that the nurse responsible for administering the medication had left the facility for an unspecified reason and was terminated following an investigation. The Director of Nursing confirmed the delay in administering the medication, and the facility's policy required medications to be administered timely according to prescriber orders. The deficiency was identified during a complaint investigation, highlighting a lapse in the facility's medication administration process.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure that residents received medications as ordered, resulting in a medication error rate exceeding the acceptable threshold of 5%. Specifically, two residents were affected by this deficiency. Resident #41, who has multiple diagnoses including ataxic cerebral palsy, type II diabetes, and chronic heart failure, did not receive their prescribed medications, including Amlodipine, Cymbalta, and Pataday, due to unavailability. Similarly, Resident #51, diagnosed with Parkinsonism and dementia, did not receive their prescribed Rytary medication for Parkinson's. During a medication pass observation, an LPN administered only 26 out of 30 ordered medications to five residents, resulting in a 13.3% error rate. The LPN confirmed that the medications for Residents #41 and #51 were unavailable, leading to the failure in administration. The facility's policy on administering medications, dated April 2019, mandates that medications be administered according to prescriber orders, which was not adhered to in this instance. This deficiency was investigated under specific complaint numbers.
Failure to Complete Pressure Ulcer Dressing Change as Ordered
Penalty
Summary
The facility failed to ensure a pressure ulcer dressing change was completed per physician orders for Resident #93. The resident, who was cognitively intact and had a stage four pressure ulcer on her sacrum, was supposed to have her wound dressing changed every shift as per the physician's order dated 04/18/24. However, on 04/30/24, the dressing change was not performed during the night shift. The Treatment Administration Record (TAR) inaccurately documented that the treatment was completed. An observation on 05/01/24 revealed the dressing was undated, and the resident confirmed that the dressing was not changed on 04/30/24 and denied refusing the treatment. An interview with the agency Licensed Practical Nurse (LPN) who was responsible for the night shift on 04/30/24 confirmed that she did not complete the wound treatment. The LPN stated that the resident refused the treatment but admitted she did not document the refusal and instead falsely recorded that the treatment was completed. This deficiency was identified during an investigation under Complaint Number OH00152739.
Failure to Ensure Proper Colostomy Care
Penalty
Summary
The facility failed to ensure proper colostomy care for Resident #77, who was cognitively intact and required substantial assistance for toileting and moderate assistance for bed mobility and transfers. During an observation of colostomy care, LPN #140 did not follow proper hand hygiene protocols. Specifically, LPN #140 did not change gloves or perform hand hygiene when moving from dirty to clean tasks while providing colostomy care. This resulted in dried feces being present on the resident's skin, which was not properly cleaned before applying new dressings and wafers. The facility's policy on colostomy care, revised in October 2010, clearly outlined the steps for proper hand hygiene and glove use, which LPN #140 failed to follow. The policy required washing and drying hands thoroughly, removing gloves after handling dirty items, and putting on clean gloves before proceeding with clean tasks. LPN #140's failure to adhere to these procedures was confirmed during an interview, where he acknowledged not performing hand hygiene or changing gloves during the colostomy care for Resident #77.
Failure to Ensure Timely Physician Visits
Penalty
Summary
The facility failed to ensure the attending physician completed resident visits every 60 days, affecting two residents. Resident #2, admitted with diagnoses including hypertension, hyperlipidemia, and dementia, had no evidence of a physician visit from December 1, 2023, through May 7, 2024. Similarly, Resident #3, admitted with diagnoses including hypertension, dementia, hyperlipidemia, and traumatic brain injury, also had no evidence of a physician visit during the same period. Both residents were severely cognitively impaired according to their quarterly Minimum Data Set (MDS) assessments. Interviews with the Nurse Practitioner and Medical Doctor revealed that the MD only visited the facility for new admissions or if a resident was sick, and confirmed that the MD had not seen Residents #2 and #3 since December 2023. The facility's policy required physician visits at least every 30 days for the first 90 days following admission and then at least every 60 days thereafter. This deficiency was investigated under Master Complaint Number OH00153494.
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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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