Momentous Health At Richfield
Inspection history, citations, penalties and survey trends for this long-term care facility in Richfield, Ohio.
- Location
- 4360 Brecksville Rd, Richfield, Ohio 44286
- CMS Provider Number
- 365370
- Inspections on file
- 34
- Latest survey
- June 11, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Momentous Health At Richfield during CMS and state inspections, most recent first.
Multiple deficiencies were identified, including unclean and poorly maintained resident rooms and common areas, inadequate hot water temperatures, and a lack of clean washcloths for resident care. Residents reported inconsistent cleaning and unaddressed maintenance requests, while observations confirmed soiled floors, broken fixtures, and pervasive odors throughout the facility.
Surveyors found that the facility did not consistently serve palatable meals at safe and appetizing temperatures. Food temperatures dropped significantly between preparation and service, and some residents received cold cereal and plastic spoons due to shortages. Two residents reported that meals were often cold and that the kitchen frequently ran out of food. Resident council minutes also documented concerns about repetitive meals and a lack of fresh fruit.
The facility did not ensure that all nurses providing direct care maintained current CPR certification, as required by their job descriptions. An LPN was found to have a gap in CPR certification, and this lapse could have affected all residents with full code status who required resuscitative measures. The DON confirmed that all nurses were expected to have current CPR certification.
A resident with multiple complex medical conditions experienced several significant changes in condition, including bleeding and respiratory distress, resulting in hospital transfers and returns. Despite special instructions and facility policy requiring notification, the POA was not informed of these events, as confirmed by medical record review and interviews with the resident and DON.
A resident with multiple complex medical conditions was not weighed upon readmission from the hospital, and there was no documentation of a refusal to be weighed. The last recorded weight was prior to hospitalization, and no new physician orders for weight monitoring were present. Facility policy required a weight to be obtained and documented within 24 hours of readmission, but this was not done.
Two residents with significant risk factors for pressure ulcers did not receive timely and comprehensive assessment, documentation, or intervention for skin integrity issues. One resident developed a Stage III pressure ulcer due to delayed prevention measures and lack of wound tracking, while another resident's in-house acquired pressure ulcer was not consistently measured or documented, and lacked appropriate PRN wound care orders. Facility policy requirements for wound assessment and care planning were not followed.
Multiple residents experienced harm due to the facility's failure to provide timely and necessary medical interventions after significant changes in condition, including persistent pain after a fall, untreated COVID-19 symptoms, and delayed diagnostic testing. In each case, staff did not follow up on ongoing symptoms, failed to administer ordered medications or obtain labs, and did not implement appropriate care planning or monitoring, resulting in hospitalizations and, in one case, death.
Two CNAs did not receive annual performance evaluations or the required 12 hours of in-service training, as confirmed by personnel file reviews and interviews with the COO. This lack of documentation and training had the potential to impact all 54 residents in the facility.
Surveyors found expired and unlabeled food items in the kitchen's walk-in cooler and dry stock room, including expired cream, lettuce, coleslaw, and thickened dairy beverages. A package of bologna was also found without a label or date. The Dietary Manager confirmed that required checks and documentation for expired food had not been completed as per facility policy, potentially affecting all residents receiving meals.
The facility failed to provide effective administrative oversight, resulting in repeated deficiencies including incomplete QAPI processes, lack of consistent infection control practices, environmental hazards, and unaddressed care concerns such as medication errors, privacy violations, and inadequate documentation of advance directives. Key staff and governing body members were not consistently involved in required meetings, and there was no evidence that action plans or PIPs were completed to address previously identified issues.
The facility's assessment contained incorrect information about its licensed capacity and was not implemented as required, resulting in incomplete staff training and missing annual evaluations for two CNAs. Not all staff received the mandated in-service education, and the deficiencies were confirmed by facility leadership.
The medical director did not fulfill required duties related to the coordination of medical care, implementation of facility policies, and participation in QAPI activities, as evidenced by a lack of documentation and oversight over a 12-month period. This deficiency impacted all residents in the facility.
The facility did not maintain an effective QAPI committee, as action plans for previously identified deficiencies—such as dignity, privacy, abuse reporting, medication errors, infection control, food storage, advance directives, and environmental concerns—lacked evidence of completion or follow-up. Repeat deficiencies were found during the annual survey, including issues with pressure ulcers, expired foods, and environmental hazards. Leadership interviews confirmed the absence of a reporting mechanism for staff and residents and a lack of documentation for QAPI activities.
The facility did not ensure that all required QAPI committee members, including the Medical Director, a governing body representative, and the Infection Preventionist (IP), attended quarterly meetings as required. Documentation showed repeated absences and missing records, and the facility could not provide evidence of IP certification for staff who temporarily filled the role. This deficiency affected all residents.
The facility did not ensure a qualified infection preventionist (IP) was consistently designated or present to oversee the infection prevention and control program. Review of QAPI meetings and staff records showed inconsistent IP participation, lack of documentation for required IP certification, and reliance on staff who were either not regularly onsite or unable to provide proof of qualifications. This affected all residents in the facility.
The facility did not ensure that residents were properly offered, screened, educated, or administered influenza and pneumococcal vaccines, and failed to document consent or declination as required. Multiple residents and their guardians reported not being informed or given the opportunity to receive these vaccines, and facility records lacked evidence of vaccine offers, education, or documentation. Some residents were hospitalized for pneumonia or COVID-19 complications, and in one case, a resident died after hospitalization for pneumonia. Facility leadership confirmed missing documentation and lack of awareness regarding vaccination processes.
The facility did not provide required education, screening, or offers of COVID-19 vaccination to residents and staff, nor did it document vaccination status, consent, or declination. Multiple residents with complex medical conditions and staff members were affected, with no evidence of vaccination management or communication with responsible parties or guardians.
Two CNAs did not receive required annual performance reviews, as shown by missing documentation in their personnel files. This was confirmed by facility leadership and meant that identified weaknesses could not be addressed through training as outlined in the facility's assessment.
Multiple residents experienced issues with cold or inconsistent water temperatures, non-functioning showers and toilets, and broken blinds. Observations revealed widespread maintenance problems, including damaged walls, chipped paint, missing furniture parts, and loose handrails. Staff reported a lack of maintenance personnel and no system for reporting or tracking repairs, with no maintenance records available for the past year.
Staff did not follow established menu portion sizes and dietary orders during meal service, resulting in residents on mechanical soft and low-concentrated sweets diets receiving incorrect portions of food and dessert. Dietary staff and management confirmed that serving utensils used did not match the required portions, and all residents received the same size dessert regardless of dietary restrictions.
Multiple residents reported that hot meals were served cold and unpalatable, with direct observation confirming that food temperatures dropped significantly between preparation and service. The Dietary Manager acknowledged that hot foods were not at the required minimum temperature at the point of service, affecting nearly all residents receiving meals.
Multiple failures in infection prevention and control were identified, including incomplete infection tracking, lack of adherence to local health department directives for a resident with an MDRO, inadequate COVID-19 outbreak surveillance and reporting, missing or insufficient legionella water management documentation, improper implementation of EBP and TBP for residents with wounds or medical devices, and failure to ensure TB screening for new employees. These deficiencies were observed through record reviews, staff interviews, and direct observations.
The facility did not maintain consistent or complete documentation of advance directives for several residents, resulting in discrepancies between electronic and paper medical records. In multiple cases, the EMR indicated a DNRCCA order while the paper record listed full code or lacked a signed DNR form, despite facility policy requiring regular review and accurate documentation of advance directives.
Several residents with complex medical conditions did not receive complete or accurate MDS assessments, as key sections for cognitive patterns, mood, and pain were left incomplete or marked as not assessed. The MDS Coordinator, working offsite, depended on other staff for information, but lack of coordination and timely interviews led to these deficiencies.
The facility did not develop or implement comprehensive, individualized care plans for several residents, resulting in missing or incomplete guidance for staff regarding ADL assistance, infection management, and advance directives. Some residents with complex medical and cognitive needs lacked integrated care plans, and care plans often contained placeholders instead of specific instructions, as confirmed by facility leadership.
The facility failed to implement individualized fall prevention interventions for two residents at high risk for falls, did not assess or investigate repeated incidents of a resident being found on the floor, and did not ensure proper disposal of cigarette butts in the smoking area, resulting in unsafe conditions despite existing policies.
Pharmacy recommendations for medication management, including adding stop dates, dose reductions, and clinical documentation for psychotropic and other medications, were not addressed or documented by staff or physicians for multiple residents. The DON confirmed that pharmacy recommendations were not available in medical records and had not been acted upon in a timely manner, contrary to facility policy.
Several residents with complex medical histories had outdated physician orders for COVID-19 contact and droplet precautions that remained active in their medical records and on the TAR, even after recovery. Nursing staff continued to sign off on these precautions, and observations confirmed the residents were not on such precautions. The DON and staff verified that the orders should have been discontinued, resulting in incomplete and inaccurate documentation.
Several dependent residents did not receive scheduled showers or assistance with bathing, as required by facility policy, due to missed care, lack of documentation, and non-functioning shower facilities. Interviews and record reviews revealed that some residents went weeks without showers, and staff were unable to provide documentation of care or refusals, despite procedures for recording such events.
The facility did not ensure proper antibiotic stewardship, as antibiotics were prescribed and administered to a resident for UTI symptoms without supporting lab evidence or meeting McGeer's Criteria. Additionally, infection control logs for multiple residents were incomplete, missing key details needed for tracking and trending infections. Staff confirmed gaps in documentation and reliance on physician orders even when criteria for infection were not met.
The facility did not obtain proper authorization or third-party witnessing for managing the personal funds of two residents, one with heart disease, anxiety, and dementia, and another with dementia and depression. In both cases, funds were managed without the required signatures from the residents or their representatives, and the facility's policy lacked clear procedures for authorization.
The facility did not ensure that personal funds belonging to two deceased residents were disbursed to their estates within the required timeframe. Both residents had significant fund balances remaining after their deaths, and the responsible staff member was unaware of the required process and timeframe for transferring these funds.
A resident with mental health and medical conditions was unable to access a phone in private, as required by his documented preferences. The only available phone was at the nurse's station and had to be used in a hallway, and an LPN denied the resident's repeated requests to use the phone due to being occupied with admissions. The facility did not have a policy on phone use or privacy.
A resident admitted with multiple fractures, encephalopathy, hallucinations, and alcohol withdrawal did not receive a nursing admission assessment as required. Review of the medical record confirmed the assessment was missing, and facility leadership verified this omission. No policy regarding nursing assessment timing was available.
A resident admitted with multiple fractures, encephalopathy, hallucinations, and alcohol withdrawal did not have a baseline care plan developed or implemented within 48 hours of admission, as required by facility policy. Review of records and staff interview confirmed the absence of this essential care planning step.
The facility did not update care plans to reflect changes in advance directives for three residents with complex medical conditions. Although the electronic medical records showed a DNRCCA status, the care plans and paper records continued to list these residents as full code. This discrepancy was confirmed by staff interviews and was not in accordance with facility policy requiring timely review and revision of care plans.
A resident with multiple medical conditions did not have an anchoring device in place for an indwelling urinary catheter, despite a care plan intervention requiring a leg strap. Observation showed the catheter tubing was under tension and the drainage bag was improperly positioned, with an LPN confirming the lack of an anchoring device and the DON verifying the absence of a facility catheter policy.
A resident requiring hemodialysis did not receive required pre- and post-dialysis assessments, and there was no effective communication or documentation exchanged between the facility and the dialysis center. Multiple LPNs and the DON confirmed the absence of assessment forms and communication sheets, and the facility lacked a valid, dated contract with the dialysis provider to ensure proper care coordination.
A resident with a history of behavioral issues was physically assaulted by another cognitively intact resident with a record of aggressive behaviors. The aggressor followed the victim in a motorized wheelchair and struck her repeatedly with a shoe, causing her to fall from her wheelchair and sustain a skin tear and pain. Witnesses confirmed the attack was unprovoked, and staff were not present to intervene. The facility's abuse prevention policy lacked specific protocols for responding to resident-to-resident abuse.
Two residents experienced failures in timely reporting and investigation of suspected misappropriation and injury of unknown origin. In one case, a cognitively intact resident reported a missing tablet and alleged staff involvement, but the incident was not reported promptly and the investigation was incomplete. In another case, a dependent resident with severe cognitive impairment suffered a fall and was later found to have a pelvic fracture, yet the facility did not report or investigate the injury as required. Staff interviews confirmed that reporting and investigation procedures were not followed according to policy.
The facility did not conduct thorough investigations into allegations of misappropriation and injury involving two residents. In one case, a resident's missing tablet was not fully investigated, with key interviews and documentation missing. In another case, a resident with cognitive impairment suffered a fall and subsequent pain, but the facility failed to review video evidence or interview the family member who reported concerns. Both incidents lacked comprehensive investigation as required by facility policy.
Three independent residents did not receive scheduled showers due to incomplete care plans, lack of documentation, and a broken shower room. One resident with COPD and heart failure had no shower records for over two months, another with psychiatric diagnoses had only one documented refusal and no other shower records, and a third with dementia was not included on the shower schedule and reported not bathing for three weeks. The DON confirmed missing documentation and scheduling errors.
A resident with multiple behavioral health diagnoses was not provided with necessary behavioral health care, as staff failed to implement care plan interventions such as diversional activities and engagement. The resident was repeatedly left in bed or on a floor mat, yelling for help, without staff addressing his behavioral needs. Staff interviews revealed a lack of understanding of behavioral interventions, and the facility was unable to provide a behavioral healthcare policy or evidence of adequate staff training.
A resident with multiple medical conditions did not receive several prescribed medications as ordered due to delays in obtaining them from the pharmacy and missed administrations, as confirmed by MAR review and DON interview. This failure was identified during a complaint investigation and was not in accordance with facility policy.
A resident with complex medical and psychiatric conditions did not receive multiple prescribed medications, including Carbidopa-Levodopa, Clozaril, Lorazepam, Vraylar, and Zoloft, as ordered or within the required time frame. Medication Administration Records showed missed and delayed doses, and interviews confirmed that these lapses led to difficulties during meals. Facility policy requiring timely medication administration was not followed.
The facility failed to submit investigation findings of abuse incidents within the required five working days, affecting three residents. The incidents involved a resident with a history of substance abuse and dementia striking and hitting other residents. The facility's policy requires timely completion and reporting of such investigations.
The facility failed to maintain a safe kitchen environment and ensure functional equipment for food preparation, affecting all residents served from the kitchen. A non-functional steamer and missing floor tiles were identified, with staff using inappropriate cooking methods as a workaround. Communication lapses and unresolved financial issues contributed to the deficiency.
A resident with severe cognitive impairment was left naked and exposed on a bare mattress by an STNA who failed to provide proper care and dignity. The STNA used a soiled towel for cleaning without changing gloves and left the resident in an awkward position while seeking assistance, with the call light out of reach. The incident was confirmed by family and facility staff, highlighting a violation of resident rights.
A resident with severe cognitive impairment and on anticoagulant therapy was found with multiple bruises on her arms, which were not reported to the State Agency as required. The facility's investigation suggested the bruises might have occurred during transfers in a room with a smaller bathroom, but no clear cause was identified.
A resident with severe cognitive impairment and on anticoagulant therapy was found with bruises on her arms, which were not thoroughly investigated by the facility. The resident's care plan required two staff for transfers, but she was observed being transferred by one STNA, leading to her arms bumping against the door frame. The facility failed to report the incident to the State Agency and did not complete required assessments, representing a deficiency in compliance with their abuse prevention policy.
Failure to Maintain Safe, Clean, and Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, and homelike environment for its residents, as evidenced by multiple ongoing issues with cleanliness, maintenance, and environmental conditions throughout the building. Observations and interviews revealed that rooms and common areas were not consistently cleaned, with soiled floors, stained and bulging ceiling tiles, missing or broken furniture, and pervasive odors present in several locations. Residents reported that their rooms were not cleaned regularly, and some had requested repairs or replacements, such as new mattresses or blinds, which had not been addressed. Additionally, there were instances of missing or soiled privacy curtains, broken light fixtures, and debris such as used medical supplies found in hallways. Water temperatures in resident bathrooms and shower rooms were found to be below the required minimum of 105 degrees Fahrenheit, with several logs and direct measurements confirming that hot water did not reach appropriate or homelike temperatures. This issue persisted despite facility policies requiring regular monitoring and maintenance of water temperatures. The lack of adequate hot water was confirmed by both staff and administrative personnel during the survey. The facility also failed to maintain an adequate supply of clean washcloths for resident use, with observations confirming that some shower rooms had no washcloths available and laundry staff reporting frequent shortages. The absence of clean linens and washcloths further contributed to the lack of a clean and comfortable environment for residents. These deficiencies were confirmed by facility leadership during the environmental tour and through review of facility policies, which require a clean, sanitary, and homelike setting for all residents.
Failure to Serve Palatable Meals at Safe and Appetizing Temperatures
Penalty
Summary
The facility failed to serve palatable meals at appetizing and safe temperatures to all residents, as evidenced by direct observation, interviews, and review of facility menus and policies. During breakfast service, initial food temperatures on the steam table were within safe ranges, but by the time trays were delivered to residents, food temperatures had dropped significantly, with items such as cheese omelets and sausage measuring between 106 and 118 degrees Fahrenheit, and milk at 65 degrees Fahrenheit. Additionally, the facility ran out of oatmeal and spoons during tray line, resulting in the last four residents receiving cold cereal and plastic spoons instead of the planned meal and standard utensils. A taste test confirmed the food was not warm enough and lacked desirable flavor, particularly the pureed omelet, which was described as bland and tasteless. Resident interviews corroborated these findings, with multiple residents reporting that meals were often cold and that the kitchen frequently ran out of food. Review of Resident Council Meeting Minutes further revealed ongoing concerns about repetitive meals and requests for more fresh fruit. The facility's own policy requires best efforts to present hot food hot and cold food cold at point of service, using appropriate equipment and periodic test tray evaluations, but these standards were not met during the observed meal service.
Failure to Maintain Current CPR Certification for Nursing Staff
Penalty
Summary
The facility failed to ensure that all nurses providing direct care to residents maintained current cardiopulmonary resuscitation (CPR) certification, as required by their job descriptions. Review of personnel files revealed that one LPN had a gap in CPR certification, with no evidence of active certification for a specific period. Interviews with the Business Office Manager and the LPN confirmed the lapse in certification, and it was further established that the LPN could be assigned to any unit within the facility. Additional review showed that other LPNs had previously had gaps in certification, but current documentation was eventually provided for them. This deficiency had the potential to affect all 37 residents in the facility who had advanced directives listed as full code, meaning they required all resuscitative measures, including CPR, if needed. The Director of Nursing confirmed that all facility nurses were expected to maintain current CPR certification, and the job description for LPNs also specified this requirement. The census at the time was 51 residents.
Failure to Notify POA of Change in Condition
Penalty
Summary
The facility failed to notify the power of attorney (POA) of a resident's change in condition, as required by both the resident's special instructions and facility policy. The resident, who had diagnoses including metabolic encephalopathy, acute and chronic respiratory failure, obstructive sleep apnea, congestive heart failure, and morbid obesity, was dependent on staff for activities of daily living but had intact cognition. The medical record indicated that the POA requested to be notified of any behaviors or concerns. Despite this, there was no documented evidence that the POA was informed when the resident experienced significant changes in condition, including episodes of bleeding that required hospital transfer, worsening symptoms such as shortness of breath and grogginess, and subsequent returns from the hospital. Nursing progress notes showed that while medical staff and nurse practitioners were notified of the resident's condition changes and hospital transfers, the POA was not notified at any point during these events. Interviews with the resident and the Director of Nursing confirmed that the POA was not informed as required, and the facility's policy stated that the resident, physician, and family/POA/guardian should be promptly notified of changes in medical status. This deficiency was identified during a complaint investigation and affected one resident out of four reviewed for notification of change in condition.
Failure to Obtain and Document Resident Weight Upon Readmission
Penalty
Summary
The facility failed to obtain a weight for a resident upon readmission from the hospital and did not document any refusal to be weighed. The resident, who had diagnoses including metabolic encephalopathy, acute and chronic respiratory failure, obstructive sleep apnea, congestive heart failure, and morbid obesity, was dependent on staff for activities of daily living and had intact cognition. The last recorded weight for the resident was 536 pounds, taken prior to the hospital stay. Upon readmission, the nursing admission assessment and progress notes did not include a new weight or any documentation of the resident refusing to be weighed. Additionally, there were no physician orders for weight monitoring frequency following the resident's return from the hospital. The facility's policy required residents to be weighed within 24 hours of admission or readmission, then weekly for four weeks, and monthly thereafter, with all weights to be recorded and trended in the medical record. The Director of Nursing confirmed that no weight was obtained and no refusal was documented as required by policy.
Failure to Provide Adequate Pressure Ulcer Prevention and Care
Penalty
Summary
The facility failed to implement an adequate and effective pressure ulcer prevention and treatment program for two residents with significant risk factors and existing wounds. For one resident, who was cognitively impaired, dependent on staff for activities of daily living, and incontinent, there was no initial care plan for skin integrity upon admission, despite the presence of skin tears and an open area to the coccyx. Nursing documentation lacked detailed assessment, staging, or description of the wound, and pressure ulcer prevention interventions were not initiated in a timely manner. Pressure relieving interventions and wound treatments were delayed, and comprehensive wound measurements and documentation were not performed until several weeks after admission, by which time the wound had deteriorated to a Stage III pressure ulcer. For another resident, who was also cognitively impaired, dependent on staff, and had multiple comorbidities, the facility failed to ensure accurate and comprehensive weekly skin assessments for an in-house acquired pressure ulcer. The wound nurse practitioner did not measure wounds, and there was a lack of consistent wound tracking and documentation. The resident's care plan included monitoring and documentation of wound status, but nursing notes and wound assessments frequently omitted measurements and detailed descriptions. Additionally, there was no PRN order for wound care in case the dressing needed to be changed outside of scheduled times, and hospice staff were responsible for dressing changes only on specific days. Facility policy required comprehensive assessment and documentation of all skin conditions, including location, stage, measurements, and presence of exudates or necrotic tissue, as well as regular physician evaluation and care plan updates. However, these requirements were not met for either resident, as evidenced by incomplete assessments, delayed interventions, and lack of proper wound tracking. Interviews with staff and review of records confirmed that wound measurements and documentation were not consistently performed, and care plans were not updated in a timely manner to address the residents' needs.
Failure to Provide Timely and Adequate Medical Intervention Following Change in Condition
Penalty
Summary
The facility failed to provide timely and necessary interventions following changes in condition for multiple residents, resulting in actual harm. One resident with Parkinson's disease, osteoporosis, and dementia experienced an unwitnessed fall and subsequently reported persistent pain in the left hip and groin. Despite ongoing complaints of pain, limited mobility, and inability to participate in therapy, the facility did not conduct further diagnostic evaluation after an initial negative x-ray. The resident's pain continued for over two weeks before being transferred to the hospital, where an acute pelvic fracture was diagnosed. Documentation revealed a lack of care planning for pain, insufficient follow-up on the resident's condition, and no evidence of an interdisciplinary review or root cause analysis of the fall and subsequent injury. Another resident with chronic obstructive pulmonary disease, chronic kidney disease, and dementia tested positive for COVID-19 and developed symptoms including cough, nasal congestion, nausea, vomiting, and loose stools. Orders for Dexamethasone and other treatments were not administered due to medication unavailability, and laboratory tests were not completed as ordered. The resident's condition deteriorated, with ongoing symptoms and dark, tarry stools, leading to hospitalization for pneumonia and subsequent death. Facility leadership and staff were unaware of the resident's hospitalization and death, and there was no evidence of appropriate monitoring or intervention in response to the resident's change in condition. A third resident with diabetes, bipolar disorder, and intellectual disabilities experienced prolonged symptoms of respiratory illness, including cough, congestion, vomiting, and diarrhea. Despite these symptoms, COVID-19 testing and other interventions were delayed or not performed, and laboratory tests were not obtained as ordered. The resident was eventually hospitalized for acute hypoxic respiratory failure, pneumonia, and COVID-19. Facility staff and leadership were unaware of the resident's hospitalization and the extent of the outbreak, and there was no evidence of a COVID-19 tracking log or outbreak management. Facility policies required monitoring and intervention for changes in condition, but these were not followed for the affected residents.
Failure to Complete CNA Performance Reviews and In-Service Training
Penalty
Summary
The facility failed to ensure that two Certified Nursing Assistants (CNAs) received annual performance evaluations and the required 12 hours of in-service training. Review of the personnel files for both CNAs showed no documentation of annual performance reviews or evidence of completed in-service hours. The Chief Operating Officer confirmed during interviews that the facility was unable to provide records of these evaluations or training for the CNAs in question. The facility assessment indicated that areas of weakness identified in nurse aide performance reviews would be addressed through training and in-services, with topics including communication, resident rights, abuse, infection control, culture change, and dementia management. However, the lack of documented performance evaluations and in-service training for the CNAs had the potential to affect all 54 residents residing in the facility.
Expired and Unlabeled Food Found in Kitchen Storage
Penalty
Summary
Surveyors observed multiple instances of improper food storage and labeling in the facility's kitchen. During a walkthrough with the Dietary Manager, expired cartons of cream, bags of salad lettuce, and coleslaw were found in the walk-in cooler. Additionally, a package of bologna was discovered without a label or date. In the dry stock room, nine expired cartons of thickened dairy beverage were found intermixed with in-date products. The Dietary Manager confirmed these findings and stated that the first shift cook was responsible for checking and removing expired food, a task that should be documented on cleaning sheets. A review of the cleaning schedules revealed that the morning cook had not documented the removal of out-of-date items on certain days, with the last completion recorded several days prior to the observation. Facility policies require all foods to be labeled and dated to reduce the risk of foodborne illness and mandate the use of the First In, First Out (FIFO) method, discarding any items past their expiration date. These policies were not followed, resulting in expired and unlabeled food being stored in areas accessible for meal preparation, potentially affecting all residents receiving meals from the kitchen.
Failure of Facility Administration and Oversight Leading to Multiple Deficiencies
Penalty
Summary
The facility failed to ensure effective administration and oversight, resulting in multiple deficiencies affecting the care and well-being of all 54 residents. The Administrator and DON had recently assumed their positions, but review of job descriptions and interviews revealed a lack of comprehensive and effective administrative oversight. QAPI meeting minutes and sign-in sheets showed that the Medical Director and governing body members were not consistently present, and the Infection Preventionist's involvement was not documented. There were also missing QAPI meeting minutes for certain periods, and action plans from previous surveys lacked evidence of completion or follow-up, with repeat deficiencies identified during the current survey. Physical observations of the facility revealed environmental concerns, including loose hand-rails, broken blinds, discolored ceiling tiles, dented and chipped walls, and a broken shower room. The facility did not have a maintenance director at the time of the survey. Additionally, water temperatures throughout the facility were inconsistent and did not provide a comfortable, homelike environment for residents. The Housekeeping Director confirmed that water temperatures had not been routinely checked or recorded prior to the survey. The infection control program was found to be lacking, with no legionella water management program, incomplete infection tracking and trending logs, and inconsistent documentation of infection preventionist involvement. There were also issues with timely collaboration with the local health department regarding suspected infections and failure to implement Enhanced Barrier Precautions as indicated. Documentation showed concerns with vaccine administration and advance directives, and there was no evidence that corrective actions or Performance Improvement Projects (PIPs) were completed for identified issues. During the survey, repeat deficiencies were found in areas such as privacy, reporting and investigating abuse, activities of daily living, quality of care, falls, medication errors, and infection control.
Inaccurate Facility Assessment and Incomplete Staff Training
Penalty
Summary
The facility failed to accurately complete and implement its facility-wide assessment, which is required to determine the necessary resources for competent resident care during both routine operations and emergencies. The assessment contained incorrect information regarding the facility's licensed capacity, listing 118 beds instead of the approved 72, and did not reflect the actual average daily census. This inaccuracy was confirmed by the Administrator during an interview. Additionally, the facility did not follow its own assessment regarding staff training and education. Review of in-service records showed that not all employees received the required trainings, and personnel files for two CNAs revealed they had not completed the mandated 12 hours of annual in-service education nor received annual performance evaluations as specified in the facility assessment. The COO and Administrator both verified the lack of required training and evaluations for these staff members.
Failure of Medical Director to Fulfill Oversight and Quality Assurance Responsibilities
Penalty
Summary
The facility failed to ensure that the medical director fulfilled responsibilities related to the coordination of medical care, implementation of facility policies and procedures, and participation in Quality Assurance and Performance Improvement (QAPI) activities. Review of documentation revealed that only one medical director report was available for a 12-month period, and this report did not document any concerns regarding resident care, such as pressure areas, falls, or changes in condition. The medical director, who had been in the role since July 2024, did not identify or communicate any issues related to the effective administration of the facility or areas needing attention to ensure appropriate care and services for residents. Interviews with facility leadership confirmed the lack of required documentation and oversight by the medical director, as well as a lack of evidence of participation in QAPI or the implementation of resident care policies. The medical director agreement and facility policy outlined specific responsibilities, including oversight of medical and clinical care, policy implementation, and active involvement in quality assessment activities, but these duties were not demonstrated in practice. This deficiency affected all 54 residents residing in the facility.
Failure to Implement Effective QAPI Committee and Follow Through on Corrective Actions
Penalty
Summary
The facility failed to ensure an effective Quality Assurance and Performance Improvement (QAPI) committee that identified and addressed quality concerns in a timely and effective manner. Review of QAPI meeting minutes and Performance Improvement Plan (PIP) documentation revealed multiple action plans related to previous survey citations, including issues with dignity, privacy, quality of care, abuse reporting and investigation, activities of daily living, nutrition, medication errors, infection control, food storage, advance directives, and environmental concerns. However, these plans lacked evidence of completion, revision, or follow-up, as columns for completion dates and follow-up actions were consistently left blank. There was also no documentation to verify that corrective actions or PIPs were completed or that ongoing monitoring was conducted to prevent recurrence of identified issues. During the most recent annual survey, repeat deficiencies were found in several of the same areas previously cited, such as privacy, homelike environment, abuse reporting and investigation, activities of daily living, quality of care, falls, significant medication errors, infection control, expired and undated foods, advance directives, and pressure ulcers. For example, a resident with an in-house acquired pressure ulcer did not have their wound measured weekly as required, and concerns regarding pressure ulcers persisted. Additionally, environmental issues continued despite the initiation of an environmental PIP, and expired or undated foods were still present in the facility. Interviews with facility leadership, including the Administrator, DON, and COO, revealed that the QAPI process was not being effectively implemented. The COO was unaware that full PIPs, evidence of auditing, education, or other corrective measures were not completed for identified concerns. The Administrator confirmed that there was no mechanism in place for residents and staff to report issues to the QAPI program. The facility's QAPI policy stated that a comprehensive, data-driven program should be maintained, but documentation and evidence of ongoing QAPI activities were lacking.
Failure to Ensure Required QAPI Committee Members Attend Quarterly Meetings
Penalty
Summary
The facility failed to ensure that all required members of the Quality Assurance and Performance Improvement (QAPI) committee attended meetings at least quarterly, as mandated. Review of QAPI meeting minutes and sign-in sheets from January 2024 through February 2025 showed that the Medical Director did not attend several meetings between March and July 2024, and a member of the facility's governing body was not present until January 2025. Additionally, there was no evidence that the Infection Preventionist (IP) was present at QAPI meetings as required, and the facility could not provide IP certification for staff who temporarily covered the IP role. There were also missing meeting records for November and December 2024. Facility policy required specific staff, including the Medical Director/Physician, Administrator, and others, to participate in QAPI meetings, but did not initially specify the IP as a required member. However, a later policy update clarified that the IP must attend each QAPI meeting and report on infection prevention and control. Despite this, sign-in sheets and interviews confirmed the IP's routine absence from QAPI meetings, and the facility was unable to provide documentation to show compliance with these requirements. This deficiency affected all 54 residents in the facility.
Failure to Designate a Qualified Infection Preventionist
Penalty
Summary
The facility failed to ensure that a qualified infection preventionist (IP) was designated and consistently responsible for the infection prevention and control program. Review of QAPI meeting sign-in sheets from March 2024 to February 2025 showed no consistent designation or participation of an IP, except for two months when the Chief Operating Officer (COO) was present. Interviews revealed that the facility did not have a current IP employed, and while the COO and Director of Nursing (DON) claimed to have IP certificates, only the COO could provide evidence of certification. The DON was unable to provide documentation of her IP certificate, and the personnel file for the former Assistant Director of Nursing (ADON), who was reportedly the IP for several months, contained no evidence of IP certification. Further, the COO stated she was only present at the facility one day per week starting in January 2025, and the RN who assisted with infection prevention worked mostly offsite. This lack of a consistently present and qualified IP had the potential to affect all 54 residents in the facility, as there was no assurance that infection prevention and control measures were being properly overseen and implemented during the period reviewed.
Failure to Offer, Educate, and Document Influenza and Pneumococcal Vaccinations
Penalty
Summary
The facility failed to ensure that residents were properly offered, screened, educated, and administered influenza and pneumococcal vaccinations as required by policy and CDC guidance. Record reviews revealed that there was no documented evidence of pneumococcal vaccinations, consent/declination forms, screenings, or education for any residents during the specified review period. For influenza vaccinations, while some residents were listed as having received or refused the vaccine, there was no documentation of consent, declination, or education for any of these cases. Interviews with the DON and other facility leadership confirmed the absence of required documentation and a lack of knowledge regarding the vaccination process, with missing forms and unclear responsibilities for ordering and administering vaccines. Several residents and their guardians reported not being offered or educated about influenza or pneumococcal vaccines upon admission or during their stay. In multiple cases, residents who would have accepted the vaccines were not given the opportunity, and guardians were not informed or consulted. The facility's immunization reports and medical records consistently lacked evidence of vaccine offers, education, or documentation of consent or refusal, even for residents with significant risk factors such as chronic respiratory conditions, dementia, or immunocompromised states. The facility's own policies required assessment, education, and documentation for both vaccines, but these procedures were not followed. The deficiency affected multiple residents, including those who were hospitalized for pneumonia or COVID-19-related complications, and in at least one case, a resident died after being hospitalized for pneumonia. Facility leadership, including the DON, Administrator, and Infection Preventionist, were unaware of the vaccination status or related hospitalizations for several residents. The lack of an effective system to manage and document vaccinations had the potential to affect all residents in the facility, as confirmed by the absence of records and interviews with staff and residents.
Failure to Educate, Offer, and Document COVID-19 Vaccinations for Residents and Staff
Penalty
Summary
The facility failed to ensure that residents and staff were educated, screened, and offered COVID-19 vaccinations as required by facility policy and CDC guidance. Medical record reviews, immunization reports, and staff vaccination records revealed no evidence of COVID-19 vaccinations being completed, nor documentation of consent, declination, screening, or education for any residents or staff during the specified review period. Interviews with the DON, Administrator, COO, and Infection Preventionist confirmed the absence of vaccination records and a lack of awareness regarding the handling of vaccinations by previous nursing leadership. Several residents with significant medical histories, including asthma, pulmonary embolism, dementia, end stage renal disease, COPD, and other chronic conditions, were not offered or educated about COVID-19 vaccinations. In multiple cases, responsible parties or guardians were not contacted or informed about vaccination opportunities. Residents who were their own responsible parties also reported not being offered vaccines or receiving any education on the subject during their stay. For some residents, there was no documentation of historical vaccination status, and for others, records showed they were not up to date with recommended COVID-19 vaccinations. The deficiency extended to staff, as evidenced by the lack of documentation showing that staff members were offered or educated about COVID-19 booster doses. The facility's failure to implement an effective vaccination management program affected all residents and staff, as confirmed by the absence of required documentation and the inability of facility leadership to provide additional information or records related to COVID-19 vaccination efforts.
Failure to Complete Annual CNA Performance Reviews
Penalty
Summary
The facility failed to ensure that two Certified Nursing Assistants (CNAs) received annual performance reviews, as evidenced by the absence of documented annual performance evaluations in their personnel files. Both CNAs had been employed since 06/03/21, and a review of their files showed no evidence of these required reviews. This deficiency was confirmed during an interview with the Chief Operating Officer, who acknowledged the lack of annual performance reviews for the identified CNAs. The facility assessment indicated that areas of weakness identified in nurse aide performance reviews would be addressed through training and in-services, but the absence of these reviews meant this process was not followed for the affected CNAs.
Failure to Maintain Safe, Clean, and Homelike Environment
Penalty
Summary
The facility failed to provide a safe, clean, and homelike environment for its residents, as evidenced by multiple issues with water temperature, bathroom and shower functionality, and general maintenance. Several residents reported that water in their rooms and shared shower areas was either too cold or fluctuated between too hot and too cold, with some unable to access working showers or toilets for extended periods. Observations confirmed that water temperatures in various sinks and showers were below comfortable levels, and maintenance logs or records of water temperature checks were not available for the past year. The maintenance supervisor was new to the position and had not previously checked or adjusted water temperatures, despite facility policy requiring regular monitoring. Additional environmental deficiencies were observed throughout the facility, including broken blinds in multiple resident rooms, discolored and sagging ceiling tiles, patched and unpainted dents in walls, chipped paint on door frames and resident doors, and damaged furniture such as missing drawers and cabinet doors. Some rooms had large holes in the walls, and one room had a piece of plywood leaning against the wall. These issues were confirmed by both the administrator and the housekeeping and maintenance supervisor during facility tours. Safety hazards were also present, with several handrails in hallways found to be loose and not securely attached to the walls. Staff interviews revealed that there was a period without a maintenance person on staff, and non-emergency maintenance issues were not being reported or addressed in a timely manner. The administrator was unable to provide any maintenance records for the previous 12 months, indicating a lack of ongoing facility upkeep and documentation.
Failure to Follow Menu Portion Sizes and Dietary Orders
Penalty
Summary
The facility failed to follow its established menu spreadsheets and portion control policies during meal service, resulting in residents not receiving the correct portion sizes as specified. On the observed lunch meal, the menu called for specific portion sizes for each food item, including four ounces of seasoned rice and a full or half portion of yellow cake depending on dietary restrictions. However, staff used smaller scoops than required for both the rice and ground pork, and all residents, including those on low-concentrated sweets (LCS) diets, received a full portion of cake instead of the prescribed half portion. These discrepancies were confirmed through observation, interviews with dietary staff, and review of production sheets and diet lists. Eight residents were on mechanical soft diets and eight on LCS diets, with one resident ordered nothing by mouth (NPO). Staff interviews confirmed that the serving utensils used did not match the portion sizes outlined in the menu spreadsheets, and the Dietary Manager acknowledged the deviations. Additionally, a resident reported dissatisfaction with the food, stating it was inadequate. Facility policies required strict adherence to specified portion sizes using designated utensils, but these were not followed during the observed meal service.
Failure to Serve Palatable Meals at Safe Temperatures
Penalty
Summary
The facility failed to serve palatable meals at appetizing and safe temperatures, as evidenced by multiple resident interviews and direct observation. Several residents reported that hot food was served cold, tasted terrible, and was of low quality, leading some to purchase their own food. On the day of observation, the lunch menu included smothered pork chop, seasoned rice, a vegetable blend, yellow cake, and a beverage. Food temperatures were initially measured at appropriate levels before service, but by the time trays reached the unit and were sampled, the hot foods had dropped significantly in temperature, with readings of 116°F for pork, 112°F for rice, and 115°F for vegetables. The milk was measured at 45°F. The sampled foods were described as lukewarm and not palatable at the time of service. The Dietary Manager confirmed during the sampling that the hot foods were not at the required minimum temperature of 145°F at the point of service, and acknowledged that the food was lukewarm and not palatable. The deficiency had the potential to affect all 53 residents receiving meals from the kitchen, as only one resident was on a nothing-by-mouth order. The findings were based on resident interviews, review of the menu, and direct observation of food preparation and service.
Widespread Infection Control Program Failures and Lapses in Surveillance
Penalty
Summary
The facility failed to develop, maintain, and implement an effective infection prevention and control program, as evidenced by multiple deficiencies in infection surveillance, communication, and adherence to protocols. There were significant lapses in following local health department directives for a resident with a multidrug-resistant organism (MDRO), including lack of documentation, failure to initiate enhanced barrier precautions (EBP), and delayed or incomplete screening and communication with public health authorities. The infection control logs were incomplete and inaccurate, lacking essential details such as dates of onset, culture results, symptoms, and isolation status, which prevented effective tracking and trending of infections. During a COVID-19 outbreak, the facility did not maintain proper infection tracking or surveillance for staff and residents. There was no evidence of outbreak testing or accurate reporting to the local health department, and several residents who tested positive for COVID-19 did not have timely or appropriate transmission-based precautions (TBP) orders. Staff interviews revealed confusion about testing procedures and a lack of a system for monitoring staff illness. Additionally, the facility was unable to provide documentation of a legionella water management program, and the available policies and plans did not meet requirements for risk assessment, control measures, or monitoring. The facility also failed to ensure proper implementation of EBP and TBP for residents with wounds, indwelling medical devices, or MDROs. Observations showed missing or unclear signage, lack of readily available personal protective equipment (PPE), and staff uncertainty regarding the reasons for precautions. Wound care was not performed according to policy, with instances of wounds not being cleansed during dressing changes. Furthermore, the facility did not ensure tuberculosis screening upon hire for several employees, as required by policy.
Inconsistent Documentation of Advance Directives Across Medical Records
Penalty
Summary
The facility failed to ensure that advance directive orders were consistent and accurately documented across both electronic and paper medical records for five residents. For each of these residents, there were discrepancies between the advance directive status listed in the electronic medical record (EMR) and the paper medical record. In several cases, the EMR indicated a Do Not Resuscitate Comfort Care Arrest (DNRCCA) order, while the paper record incorrectly listed the resident as full code, or lacked a signed DNR form altogether. These inconsistencies were confirmed through interviews with the Social Service Designee, who acknowledged the inaccuracies and incomplete documentation in the paper records. The affected residents had various diagnoses, including schizoaffective disorder, hypertension, dementia, diabetes, traumatic brain injury, and other chronic conditions. The facility's policy required that advance directives be reviewed upon admission, re-admission, quarterly, and annually, and that staff be knowledgeable about residents' resuscitative status. Despite these requirements, the facility did not maintain accurate or complete documentation of advance directives in the residents' records, leading to discrepancies between the EMR and paper files and missing signed DNR forms.
Incomplete and Inaccurate MDS Assessments
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments for several residents were complete and accurate, as required. For four residents reviewed, key sections of the MDS, including cognitive patterns, mood, and pain assessments, were either left incomplete or marked as not assessed, despite indications that interviews should have been conducted. In multiple cases, the initial screening questions were answered affirmatively, indicating that interviews for mental status, mood, or pain should proceed, but subsequent required questions were left blank or marked with dashes. For example, one resident with chronic obstructive pulmonary disease, hypertension, and heart failure had a quarterly MDS assessment where the cognitive patterns section was not completed, and the pain assessment section was also left incomplete. Another resident with dementia, Parkinson's disease, and anxiety had both cognitive and mood interview sections marked as not assessed, despite being eligible for interviews, and the pain assessment was similarly incomplete. Additional residents with complex medical histories, including diabetes, depression, and chronic pain, also had incomplete pain assessments on both admission and quarterly MDS assessments. Interviews with facility staff revealed that the MDS Coordinator completed assessments offsite and relied on other staff, such as the Social Services Director and nursing leadership, to provide information for specific sections. However, there was a lack of coordination and communication, resulting in incomplete assessments. Staff responsible for completing certain sections admitted to not always conducting interviews within the required time frames, and the MDS Coordinator confirmed that required sections were not completed for the affected residents.
Failure to Develop Comprehensive and Individualized Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans that addressed all identified needs for multiple residents. In several cases, care plans for activities of daily living (ADLs) lacked specific details regarding the type and amount of assistance required, leaving staff without clear guidance on how to support residents with bathing, bed mobility, dressing, personal hygiene, and toileting. For example, care plans for certain residents included placeholders such as '(specify what assistance)' instead of individualized instructions, which was confirmed by the Director of Nursing as insufficient for providing resident-centered care. Additionally, some residents with significant medical histories, such as chronic obstructive pulmonary disease, heart failure, multiple fractures, and cognitive impairments, did not have care plans that comprehensively addressed their physical, emotional, intellectual, and social needs. In one instance, a resident with impaired cognition and depression had care plans for specific areas but lacked an integrated, comprehensive plan to guide staff in meeting all of his needs, as verified by the Chief Operating Officer. The deficiency also extended to the omission of care plans for critical issues such as advance directives and infection management. Residents with documented Do Not Resuscitate Comfort Care Arrest (DNRCCA) orders did not have corresponding care plans addressing these directives. Furthermore, residents who experienced infections, including those with recent hospitalizations for cellulitis or positive cultures for multidrug-resistant organisms (MDROs), did not have care plans developed to address infection management or MDRO status. These omissions were confirmed through interviews with facility staff, including the Social Service Designee and the Director of Nursing.
Failure to Implement Fall Prevention and Safe Smoking Practices
Penalty
Summary
The facility failed to develop and implement a comprehensive and individualized fall prevention program for two residents identified as being at risk for falls. One resident with diagnoses including Parkinson's disease, osteoporosis, dementia, and generalized muscle weakness, who was dependent on a wheelchair, experienced a fall after attempting to pick something up from the floor. Although there were physician orders for fall prevention interventions such as a hand reacher tool, Dycem strips, and non-skid floor strips, there was no evidence these interventions were implemented or available at the time of the fall. Additionally, after the resident received two doses of anti-anxiety medication, there was no documented evaluation of her safety needs or fall risk, and no routine or appropriate fall follow-up, monitoring, or interdisciplinary review was found in the medical record. The facility's leadership was unable to provide details or documentation regarding the incident, interventions, or investigation, despite facility policy requiring such actions. Another resident with diagnoses including paranoid schizophrenia, hypertension, diabetes, and dementia, who was at high risk for falls and had a history of falls, was repeatedly found on the floor beside his bed. Nursing staff did not assess the resident after these incidents, did not document them as falls, and did not implement new interventions to prevent future occurrences, believing the behavior was intentional. The DON confirmed that no fall investigations or interventions were put in place for this resident, despite facility policy requiring documentation, investigation, and development of a plan to prevent recurrence for all falls or incidents. Additionally, the facility failed to ensure proper disposal of cigarette butts in the designated smoking area. Observations revealed cigarette butts scattered in mulch, rocks, flower pots, wooden flower beds, sidewalks, and grass areas. Staff confirmed that residents frequently disposed of cigarette butts improperly, and although attempts were made to clean the area daily, the issue persisted. Facility policy required the establishment and maintenance of safe smoking practices, but these were not effectively implemented.
Failure to Timely Address Pharmacy Drug Regimen Review Recommendations
Penalty
Summary
The facility failed to act upon pharmacy drug regimen review recommendations in a timely manner for five residents who were reviewed for unnecessary medications. In each case, pharmacy recommendations regarding medication management, such as adding stop dates to PRN medications, reducing dosages, attempting gradual dose reductions, or providing clinical documentation for continued use, were not addressed or documented by the facility staff or physicians. The recommendations were often left blank, unsigned, and undated, with no evidence in the medical records or nurses' notes that they had been reviewed or acted upon. For example, one resident with multiple diagnoses including heart failure, schizophrenia, and diabetes continued to receive PRN Ativan and hydroxyzine without stop dates for several months despite repeated pharmacy recommendations to add stop dates. Another resident with schizoaffective disorder and dementia had pharmacy recommendations to reduce doses of Xarelto and Zyrtec, but these were not addressed. Additional residents were prescribed multiple antipsychotic medications or psychotropic drugs, and pharmacy recommendations to document clinical rationale, attempt dose reductions, or adjust therapy were not acted upon or documented by the facility or attending physicians. Interviews with the DON confirmed that pharmacy recommendations were not available in the residents' medical records and had to be obtained from the pharmacy during the survey. The DON also verified that the recommendations for all five residents had not been addressed in a timely manner, and there was no evidence of physician or prescriber follow-up. Review of the facility's policy indicated that drug regimen reviews should be conducted monthly by a licensed pharmacist, and any medication irregularities should be reviewed and documented by the attending physician, but this was not followed in practice.
Failure to Discontinue Outdated COVID-19 Precaution Orders in Medical Records
Penalty
Summary
The facility failed to ensure that medical records for several residents were complete and accurate, specifically regarding the continuation of contact and droplet precaution orders for COVID-19 after the residents had recovered. For four residents with various diagnoses, including dementia, COPD, heart failure, Parkinson's disease, and schizophrenia, physician orders for COVID-19 precautions remained active in their records and on the Treatment Administration Records (TAR) for months after the residents were no longer symptomatic or required such precautions. Nursing staff continued to sign off on these outdated orders, and observations confirmed that the residents were not on the specified precautions during the review period. Interviews with the Director of Nursing (DON) and staff confirmed that the orders for contact and droplet precautions should have been discontinued after the residents' recovery from COVID-19, but this was not done in a timely manner. The DON acknowledged that the outdated orders were still present and being signed off by staff, despite the residents no longer needing those precautions. This failure resulted in incomplete and inaccurate medical records for the affected residents.
Failure to Provide Scheduled Showers and ADL Assistance for Dependent Residents
Penalty
Summary
The facility failed to provide scheduled showers and assistance with activities of daily living (ADLs) for dependent residents, as evidenced by record reviews and resident interviews. Four residents who required varying levels of assistance for bathing and showering did not receive showers as scheduled, and documentation of provided care was missing or incomplete. For example, one resident with chronic medical conditions and intact cognition was scheduled for showers twice weekly but did not receive 16 scheduled showers over nearly two months, with no documentation to support that care was offered or provided. Another resident with impaired cognition and mobility issues had only one documented shower over a six-week period, and reported not receiving any showers since admission, with the shower room observed to be out of order. Additional residents also experienced missed or undocumented showers. One resident requiring moderate assistance had multiple refusals documented, but there was no evidence that showers were consistently offered or provided as scheduled. Another resident, who was cognitively intact and required set-up assistance, had no shower data for the past 30 days and reported not having a shower for two weeks due to both showers on the unit being out of order. Staff interviews confirmed that refusals were to be documented, but records were incomplete or missing, and the DON was unable to provide additional documentation for any of the affected residents. The facility's policy required residents to bathe at least twice per week unless otherwise specified, with staff providing necessary support when residents could not perform ADLs independently. Despite this policy, the lack of documentation, missed scheduled showers, and reports of non-functioning shower facilities resulted in dependent residents not receiving the required assistance with bathing and hygiene.
Failure to Implement Antibiotic Stewardship and Incomplete Infection Control Documentation
Penalty
Summary
The facility failed to implement appropriate antibiotic stewardship measures, as evidenced by the lack of proper documentation and adherence to established criteria for antibiotic use. For one resident with multiple complex diagnoses, including dementia, chronic kidney disease, and a history of UTIs, antibiotics were prescribed and administered for UTI symptoms without documented evidence of a urinalysis or culture to support the diagnosis. The Antibiotic Use Audit Tools indicated that this resident did not meet McGeer's Criteria for a UTI, yet antibiotics were still given. Interviews with facility leadership confirmed the absence of required laboratory documentation and reliance on family reports and physician orders, even when criteria for infection were not met. Additionally, the facility's infection control logs from June to December were incomplete, lacking essential information such as date of onset, culture results, symptoms, isolation status, and organism sensitivities. The logs only recorded basic information and did not allow for adequate tracking and trending of infections. Audit tools further revealed that none of the residents treated with antibiotics during this period met McGeer's Criteria for infection. Facility staff acknowledged gaps in infection control documentation and antibiotic stewardship program records, and confirmed that antibiotics were often continued based on physician preference, regardless of whether established criteria were met.
Failure to Obtain Proper Authorization for Resident Fund Management
Penalty
Summary
The facility failed to ensure that residents authorized the management of their personal funds and that such authorization was witnessed by a third party, as required. For one resident with heart disease, anxiety, and dementia, the Human Resources Director opened a Resident Fund Management Service (RFMS) account and deposited funds transferred from another facility. Despite repeated attempts, the resident did not sign the authorization form, expressing a desire to read it and ultimately refusing to sign. The resident had a financial guardian, but the facility did not contact the guardian for authorization to manage the funds. In another case, a resident with dementia and depression also had an RFMS account established without the required signature from either the resident or their representative, and the form was not witnessed by a third party. Both residents had significant balances in their RFMS accounts at the time of review. The facility's policy on resident funds did not specify the process for obtaining signatures or third-party witnessing for RFMS account authorization.
Failure to Timely Disburse Resident Funds After Death
Penalty
Summary
The facility failed to disburse personal funds to the estates of two deceased residents within the required 30-day timeframe. One resident, who had diagnoses including heart disease, anxiety, and dementia, passed away with a personal fund balance of $2,000.29, and the facility had not transferred these funds to his estate as of the review date. The Human Resource Director confirmed attempts to contact the resident's guardian but was unaware of the required timeframe for disbursement. Similarly, another resident with dementia and depression passed away with a personal fund balance of $5,239.68, and these funds also remained undistributed to the estate. The Human Resource Director stated that this resident had a financial power-of-attorney but was again unaware of the required timeframe for disbursement. Review of the facility's policy revealed it did not specify the process for disbursing funds after a resident's death.
Failure to Provide Private and Reasonable Phone Access
Penalty
Summary
The facility failed to ensure that a resident had reasonable access to and privacy during phone use. The resident, who had diagnoses including bipolar disorder, anxiety, and hypertension, was documented in the Minimum Data Set (MDS) as having adequate hearing, clear speech, and the ability to communicate, though with impaired cognition. It was specifically noted in the resident's preferences that private phone use was very important to him. Despite this, the only phone available for resident use was a corded phone at the nurse's station, which was handed through a hole in a plastic barrier, requiring the resident to use it in the hallway without privacy. On one occasion, the resident requested to use the phone multiple times but was denied access by an LPN who was busy with admissions. The LPN confirmed that she had refused the resident's request several times before he was eventually allowed to use the phone later. When the resident did use the phone, it was in the hallway, lacking privacy. The facility was unable to provide a policy regarding phone use or resident privacy during phone calls.
Failure to Complete Nursing Admission Assessment
Penalty
Summary
The facility failed to complete a nursing assessment upon admission for one resident who was admitted with multiple medical conditions, including multiple rib fractures, encephalopathy, hallucinations, and alcohol withdrawal. Review of the resident's electronic and paper medical records showed that no nursing admission assessment was performed at the time of arrival. This was confirmed during an interview with the Chief Operating Officer, who acknowledged the absence of the required assessment. Additionally, the facility was unable to provide a policy regarding nursing assessments and their required timing.
Failure to Develop Baseline Care Plan Upon Admission
Penalty
Summary
The facility failed to develop and implement a baseline care plan for a resident within 48 hours of admission, as required by facility policy. The resident was admitted with multiple medical conditions, including multiple rib fractures, encephalopathy, hallucinations, and alcohol use with withdrawal. A review of the resident's electronic and paper medical records showed that no baseline care plan was completed after admission. This was confirmed during an interview with the Chief Operating Officer, who verified that the baseline care plan had not been completed since the resident's admission. The facility's policy states that the interdisciplinary team, along with the resident, their representative, and physician, should develop and implement a baseline care plan upon admission to provide effective and person-directed care. However, this process was not followed for the resident in question.
Failure to Update Care Plans for Changes in Advance Directives
Penalty
Summary
The facility failed to timely update care plans to reflect changes in residents' advance directives, as evidenced by the records of three residents. For each of these residents, the electronic medical record indicated an advance directive of Do Not Resuscitate Comfort Care Arrest (DNRCCA), while both the care plan and paper medical record continued to list the resident as full code. Interviews with the Social Service Designee confirmed that the care plans were not revised to reflect the current advance directives, despite the facility's policy requiring care plans to be reviewed and revised by the interdisciplinary team after each assessment. The affected residents had complex medical histories, including diagnoses such as schizoaffective disorder, hypertension, insomnia, muscle weakness, diabetes, dementia with agitation, alcohol dependence, generalized anxiety disorder, paranoid personality disorder, delusional disorders, chronic kidney disease, and traumatic brain injury. The lack of timely updates to the care plans resulted in discrepancies between the residents' documented wishes regarding resuscitation and the information available to staff in the care plans and paper records.
Failure to Provide Catheter Anchoring Device
Penalty
Summary
The facility failed to implement an anchoring device for a resident's indwelling urinary catheter, as required by the resident's care plan. The resident, who had diagnoses including paranoid schizophrenia, hypertension, diabetes mellitus, Alzheimer's Disease, and dementia, had a care plan intervention specifying the use of a leg strap to anchor the catheter. However, there were no physician's orders for an anchoring device, and observation revealed the resident's catheter tubing was stretched tightly with the drainage bag placed under a mat, and no anchoring device was present. An LPN confirmed the absence of an anchoring device, and the DON verified that the facility did not have a urinary catheter policy.
Failure to Complete Dialysis Assessments and Ensure Care Coordination
Penalty
Summary
The facility failed to provide safe and appropriate dialysis care for a resident dependent on hemodialysis by not completing required pre- and post-dialysis assessments and not ensuring effective communication and collaboration with the outside dialysis center. Record review showed that the resident, who had multiple diagnoses including traumatic brain injury, vascular dementia, and chronic kidney disease, was scheduled for dialysis three times a week. However, there was no evidence in the medical record of completed pre- and post-dialysis assessment tools or communication of assessment findings with the dialysis center. Interviews with multiple LPNs and the Director of Nursing confirmed that the resident did not return from dialysis with any forms or assessments, and the facility did not maintain a dialysis binder or communication sheets. The facility's policy referenced the need for individualized care planning and assessment but did not specify procedures for communicating assessment information with the dialysis center. Additionally, the facility did not have a valid, dated contract with the outside dialysis center to ensure coordination of care. The transfer agreement between the facility and the dialysis provider was undated, and the administrator confirmed that a previous contract was unavailable for review. This lack of a valid contract further contributed to the failure to coordinate all care and services related to dialysis treatment for the resident.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to prevent resident-to-resident physical abuse, resulting in one resident being physically assaulted by another. The incident involved a cognitively intact female resident with a history of behavioral issues, including delusions and aggression, and a cognitively intact male resident with a history of schizoaffective disorder, depression, and prior aggressive behaviors. The male resident initiated a physical altercation by following the female resident in his motorized wheelchair and striking her multiple times in the back of the head with his shoe, causing her to fall out of her wheelchair and sustain a small skin tear and complaints of pain. Multiple witness statements confirmed that the male resident was the aggressor, and the female resident did not provoke the incident. The altercation occurred in a hallway after a smoke break, and staff were not present at the time to intervene. The facility's investigation substantiated the occurrence of resident-to-resident physical abuse, and the affected resident required assessment and pain management following the incident. Review of the facility's abuse prevention policy revealed that while the policy addressed assessment, care planning, and monitoring of residents with aggressive behaviors, it did not include specific response protocols for instances of resident-to-resident abuse. The lack of clear protocols and staff presence contributed to the failure to prevent the physical abuse between residents.
Failure to Timely Report and Investigate Allegations of Misappropriation and Injury of Unknown Origin
Penalty
Summary
The facility failed to timely report allegations of misappropriation and injury of unknown origin, affecting two residents. In the first case, a cognitively intact resident with a history of anxiety and PTSD reported her tablet missing, alleging that a CNA took it and sold it to another resident. The initial report of the missing tablet was made to the Social Service Designee (SSD) on 01/04/25, but the facility did not file a Self-Reported Incident (SRI) until 01/06/25, which was not in accordance with facility policy. The investigation into the alleged misappropriation was minimal, with only two staff statements collected and no direct interview or written statement from the resident. The facility ultimately determined the allegation to be unsubstantiated, but documentation and interviews confirmed that the reporting and investigation were incomplete and not timely. In the second case, a resident with severe cognitive impairment, Parkinson's disease, osteoporosis, and total dependence on staff experienced a fall and was later found to have a pelvic fracture. The resident was found on the floor by staff, and although an x-ray was performed, the fracture was not initially detected. The resident continued to experience pain and was later hospitalized, where the fracture was identified. The resident's sister reported concerns about the resident's pain and care, providing videos showing the resident in distress during care activities. Despite these concerns and the subsequent discovery of a serious injury, the facility did not file an SRI to rule out potential abuse or injury of unknown origin as required by policy. There was no evidence of a thorough investigation, interdisciplinary review, or root cause analysis related to the fall and injury. Interviews with facility staff, including the Chief Operating Officer and Administrator, confirmed that the required reporting and investigation procedures were not followed in both cases. The facility's own policy mandated immediate or timely reporting of suspected abuse, misappropriation, and injuries of unknown origin, as well as comprehensive follow-up and documentation. The lack of timely reporting and incomplete investigations for both the missing property and the injury of unknown origin constituted non-compliance with regulatory requirements.
Failure to Thoroughly Investigate Allegations of Misappropriation and Injury
Penalty
Summary
The facility failed to thoroughly investigate allegations of misappropriation and injury of unknown origin involving two residents. In the first case, a cognitively intact resident with a history of anxiety and PTSD reported her tablet missing, alleging that a CNA took it and sold it to another resident. The facility's investigation was limited to two staff statements and did not include an interview or written statement from the resident, the alleged perpetrator, or other involved staff. The facility's documentation was insufficient, and there was no evidence that all relevant parties were interviewed or that the resident's account was fully considered, despite the resident later locating her tablet in another resident's room. In the second case, a resident with severe cognitive impairment, Parkinson's disease, and osteoporosis experienced a fall and subsequently complained of pain for several days. The resident was later hospitalized and diagnosed with a pelvic fracture. The resident's sister reported concerns about the care provided, including rough handling by a CNA and inadequate pain management, and submitted video evidence to the facility. However, the facility's self-reported incident investigation did not include interviews with the sister, review of the provided videos, or consideration of the resident's fall and subsequent pain. The investigation was limited in scope and did not address all aspects of the reported concerns. Facility policy required comprehensive investigations of abuse allegations, including interviews with all involved parties, review of medical records, and documentation of all evidence. In both cases, the facility did not follow its own policy, as investigations lacked necessary interviews, review of available evidence, and complete documentation. These deficiencies resulted in incomplete investigations of serious allegations affecting resident safety and property.
Failure to Provide Scheduled Showers for Independent Residents
Penalty
Summary
The facility failed to ensure that independent residents received scheduled showers, as evidenced by record review, observation, and interviews. Three residents who were independent with activities of daily living (ADLs) did not receive showers as scheduled. For one resident with chronic obstructive pulmonary disease, hypertension, and heart failure, there was no documentation of showers for over two months, and the care plan did not specify the level of assistance required. The resident reported not receiving showers due to a broken shower room, which was confirmed by observation of a sign indicating the shower was out of order. The Director of Nursing (DON) was unable to locate any shower documentation for this resident. Another resident with paranoid schizophrenia, depression, and anxiety, who required only set-up help for bathing, had only one documented shower refusal and no other records of showers since admission. This resident also reported not receiving scheduled showers. A third resident, independent with bathing and mobility and diagnosed with dementia and other psychiatric conditions, was not listed on the facility's shower schedule, had no shower data for the past 30 days, and reported not having a shower or bed bath for three weeks. The DON confirmed the absence of shower documentation and that this resident should have been on the schedule. Facility staff interviews indicated that refusals were to be documented, but records did not reflect this. The facility's policy required residents to bathe at least twice per week unless otherwise specified.
Failure to Provide Necessary Behavioral Health Care and Services
Penalty
Summary
The facility failed to provide necessary behavioral health care and services to a resident with diagnoses including paranoid schizophrenia, Alzheimer's disease, and dementia. The resident was care planned for behavioral issues such as agitation, yelling out, and rolling off the bed onto a mat on the floor. Interventions in the care plan included inviting the resident to activities, encouraging participation, and providing diversional activities tailored to his interests. However, observations revealed that staff did not implement these interventions. The resident was repeatedly found on the floor mat or in bed, yelling for help, without being offered any diversional activities or engagement. Staff responses were limited to addressing immediate physical needs, such as returning the resident to bed, without addressing underlying behavioral health needs or providing activities as care planned. Further interviews with staff indicated a lack of understanding or implementation of behavioral interventions, with some staff leaving the resident in bed due to safety concerns and not providing alternative activities. The DON confirmed that diversional activities should have been provided, and the Administrator was unable to provide evidence of recent staff education on behavioral health care beyond a single in-service focused on drug and alcohol withdrawal. Additionally, the facility could not produce a behavioral healthcare policy and procedure, indicating a systemic failure to ensure necessary behavioral health care and services for the resident.
Failure to Timely Obtain and Administer Medications as Ordered
Penalty
Summary
The facility failed to ensure that medications were obtained from the pharmacy and administered as ordered for a resident with diagnoses including asthma, anxiety, and chronic pain. Medical record review showed that the resident had physician orders for several medications, including Fluticasone Propionate Nasal, Hydroxyzine HCl, Cran-B-OTC Oral Liquid, and Tizanidine. The Medication Administration Records (MAR) revealed multiple instances where these medications were not administered as prescribed. Specifically, Cran-B-OTC was missed on several dates in January and February, Hydroxyzine HCl was not given on multiple occasions in January and March, and Fluticasone was not administered on two dates in February due to unavailability and being on order from the pharmacy. Tizanidine was also not administered on one occasion in March. An interview with the Director of Nursing confirmed that the medications were not given as ordered, as reflected in the MAR. The facility's policy required medications to be administered as prescribed, but this was not followed in the instances noted above. The deficiency was identified during a complaint investigation and affected one resident out of 28 reviewed for medication administration, with a facility census of 54.
Failure to Administer Medications as Ordered and Timely
Penalty
Summary
The facility failed to ensure that a resident received medications as ordered, resulting in significant medication errors. The resident, who had multiple diagnoses including Parkinson's disease, dysphagia, schizophrenia, depression, dementia with severe behavioral disturbance, and anxiety disorder, had several physician orders for medications such as Vraylar, Lorazepam, Carbidopa-Levodopa, Clozaril, and Zoloft. Review of the Medication Administration Records (MAR) and Administration History Reports revealed multiple instances where Carbidopa-Levodopa was either not administered at all or was given outside the prescribed time window. There were also delays in administering Clozaril, Lorazepam, Vraylar, and Zoloft, with some medications being given hours after the scheduled time. Facility policy required medications to be administered within one hour before or after the prescribed time, which was not followed in these cases. Interviews and observations further confirmed the deficiency. The resident’s sister expressed concerns about the timeliness of medication administration, particularly for Carbidopa-Levodopa and morning psychotropic medications, noting that delays led to difficulties during meals. Observation of a breakfast meal showed the resident experiencing coughing while eating, despite being on the correct diet, which the sister attributed to the delayed medication. The DON confirmed that the resident did not receive medications as ordered or in a timely manner. This deficiency was identified during a complaint investigation and affected one resident out of 28 reviewed for medications.
Delayed Reporting of Abuse Investigation Findings
Penalty
Summary
The facility failed to submit their self-reported incident (SRI) investigation findings within the required five working days, as per their abuse prevention policy. This deficiency affected three residents out of five reviewed for abuse. The incidents involved resident-to-resident altercations, where one resident scratched and later struck another resident, and also hit two residents with a walker. The facility's policy mandates that investigations of abuse allegations be completed and reported to the Department of Health within five working days of discovery. Resident #5 had diagnoses including fibromyalgia, PTSD, anxiety disorder, and major depressive disorder. Resident #21 had dementia with agitation, depression, moderate intellectual disability, and anxiety disorder. Resident #37, who was involved in both incidents, had vascular dementia with psychotic disturbance, major depressive disorder, anxiety disorder, and a history of substance abuse in remission. The investigation for the first incident was completed seven business days after discovery, and the second incident was completed six business days after discovery, both exceeding the policy's timeframe.
Deficiency in Kitchen Equipment and Safety
Penalty
Summary
The facility failed to ensure a safe environment and properly functioning equipment for food preparation, which had the potential to affect all residents served food from the kitchen. During an observation, it was noted that the kitchen staff were hurriedly preparing the lunch meal due to a mandatory meeting that caused a delay. A steamer, essential for food preparation, was found to be non-functional and had not been repaired for an extended period. The kitchen staff had to use metal pans without handles, designed for the oven, to cook food on the stove as a workaround. Additionally, the kitchen floor had missing tiles, creating a trip hazard due to the uneven surface. Interviews with various staff members revealed a lack of communication and responsibility regarding the broken steamer. The Dietary Supervisor had informed the Maintenance Supervisor and the Administrator about the issue, but no action was taken. The Maintenance Supervisor, who recently transitioned from housekeeping, was aware of the problem but was unable to proceed with repairs due to outstanding bills from the previous facility owners. The Administrator was unaware of the steamer issue until the day of the survey and acknowledged the unresolved problem with the kitchen floor tiles. The deficiency was investigated under Complaint Number OH00154653.
Resident Dignity and Respect Violation
Penalty
Summary
The facility failed to ensure a resident was treated with dignity and respect, as evidenced by observations from camera footage, interviews, and record reviews. The resident, who had severe cognitive impairment and was dependent on staff for toileting, was observed lying naked on a bare mattress without any clothing, bed sheets, or blankets covering her. The state-tested nursing assistant (STNA) involved used a towel to wipe the resident's perineum and other areas, placing the soiled towel back on the bare mattress, and did not change gloves while handling the resident's personal items. The STNA left the resident in an awkward and exposed position while she went to find another aide to assist with a sit-to-stand mechanical lift. During this time, the resident's call light was out of reach, and she remained uncovered and exposed. The STNA returned with another aide after several minutes, during which the resident was left unattended and unclothed. Interviews with the resident's family member, ombudsman, and facility administrator confirmed concerns about the resident's care and the STNA's actions. The facility's policy on resident rights emphasized treating residents with kindness, respect, and dignity, which was not upheld in this incident. The deficiency was investigated under a complaint number, indicating non-compliance with regulatory standards.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin for a resident to the State Agency, which is a requirement under their abuse prevention policy. The resident, who had severe cognitive impairment and was dependent on staff for activities of daily living, was found to have multiple bruises on her arms. These bruises were discovered by a State Tested Nursing Assistant (STNA) and reported to a Licensed Practical Nurse (LPN), who then notified the Director of Nursing (DON) and the resident's physician. The physician was not concerned due to the resident's anticoagulant medication, which made her prone to bruising. The investigation revealed that the resident had been moved to a new room with a smaller bathroom, making it difficult to maneuver the mechanical lift used for her transfers without bumping her arms. Despite this, the facility did not submit a Self-Reported Incident (SRI) to the State Agency, as required by their policy. Interviews with staff indicated that the resident's arms may have been bumped during transfers, but there was no clear observation or explanation for the bruises, classifying them as injuries of unknown origin. The facility's policy mandates immediate reporting of such injuries to the State Department of Health, but this was not done. The failure to report the incident as required by the facility's policy represents a deficiency in compliance with regulatory requirements for reporting suspected abuse, neglect, or injuries of unknown origin.
Failure to Investigate Resident's Injury of Unknown Origin
Penalty
Summary
The facility failed to ensure a thorough investigation of a resident's injury of unknown origin, specifically bruises on her bilateral arms. The resident, who had severe cognitive impairment and was nearly dependent for all activities of daily living, was on anticoagulant therapy, making her prone to bruising. Despite this, her care plan did not include interventions related to anticoagulant medication. The facility's policy required immediate reporting and investigation of such injuries, but the incident was not reported to the State Agency. The resident was observed on camera being transferred by a single STNA using a mechanical lift, contrary to the care plan that required two staff members for transfers. During this transfer, bruises were visible on the resident's arms. Staff interviews revealed that the resident's arms were seen bumping against the door frame during transfers, and the resident had been moved to a room with a smaller bathroom, which made transfers more challenging. However, there was no documentation of these bruises in the resident's assessments and progress notes until they were noticed by another STNA. The facility's incident log and interdisciplinary team post-incident investigation summary noted the bruises as an injury of unknown cause. Despite staff education on monitoring body positioning during transfers, the facility did not complete a weekly head-to-toe assessment as required, and the resident's anticoagulant care plan was missing. The facility's failure to report the incident to the State Agency and the lack of a thorough investigation into the cause of the bruises represent a deficiency in compliance with their abuse prevention policy.
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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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