Rae Ann Geneva
Inspection history, citations, penalties and survey trends for this long-term care facility in Geneva, Ohio.
- Location
- 839 W Main Street, Geneva, Ohio 44041
- CMS Provider Number
- 366047
- Inspections on file
- 22
- Latest survey
- January 20, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Rae Ann Geneva during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, multiple comorbidities, incontinence, and total dependence for ADLs had a coccyx pressure ulcer that was not consistently measured, accurately documented, or treated as ordered. Early wound care orders were not always carried out, the MDS inaccurately recorded no pressure ulcers or nutrition interventions, and there were extended gaps in wound assessments and in transcribing and implementing treatment orders. During a period without an in‑house wound team, an LPN who could not stage wounds performed assessments with RN assistance, and the DON later confirmed that orders were missed and treatment lapsed while wound care providers were transitioning. Over time, the coccyx ulcer progressed from Stage II to Stage III, then to unstageable with 100% slough, and ultimately to Stage IV, in the context of poor nutritional intake, frequent hospitalizations, and inconsistent implementation of the pressure ulcer prevention and treatment program.
A staff member was hired and worked in the capacity of a CNA for an extended period without ever obtaining CNA certification or being listed on the Nurse Aide Registry. HR records and interviews showed that the individual completed two Nurse Aide Training classes and repeatedly failed the written competency test, yet was still permitted to perform CNA duties and provide direct care to residents. The personnel file contained only training completion certificates and no verification of an active CNA certification or registry check, affecting care provided to all residents in the facility.
A resident with severe cognitive impairment, total dependence for ADLs and mobility, and multiple chronic conditions, including CHF, COPD, CKD, osteoarthritis, and legal blindness, complained of right knee pain. An x-ray showed a broken osteophyte at the superior margin of the patella and moderate osteoarthritis. Facility staff, including the DON, could not determine how the knee injury occurred and acknowledged that an internal investigation was conducted. Despite a written policy requiring immediate reporting of suspected abuse, neglect, exploitation, misappropriation, or injury of unknown source to the administrator and appropriate authorities, the facility did not submit a self-report of this injury to the State Survey Agency.
Two residents received care that did not follow infection prevention standards when staff failed to perform required hand hygiene and use appropriate PPE. During incontinence care for a dependent resident with multiple comorbidities, an LPN and a CNA removed a soiled brief, provided perineal care, and then either changed gloves or continued care without performing hand hygiene between contact with soiled items and clean clothing and briefs, contrary to facility policy and CDC guidance. In a separate incident, an LPN performed wound care on a cognitively intact resident with a Stage III ankle pressure ulcer who was on enhanced barrier precautions, but only used gloves and did not don the additional PPE required by the posted EBP signage and facility policy, despite completing the full wound cleansing and dressing change procedure.
The facility did not ensure the medical director attended QAPI meetings, as shown by a review of attendance records over an extended period and confirmed by the administrator. The facility's QAPI policy also lacked details on required members and attendance frequency.
The facility did not maintain floors in a safe and clean condition, with observations of soiled, stained, cracked, and sunken flooring in multiple areas, including hallways, nurses' stations, and resident rooms. Staff confirmed awareness of these hazards, including a sloping floor that posed a fall risk, and acknowledged that some stains were permanent and deep cleaning was not always routine. The Administrator was aware of the issues but no formal repair plan was in place.
Quarterly MDS assessments were not completed within the required timeframe for multiple residents with complex medical conditions, as confirmed by record review and staff interviews.
The facility did not complete or submit MDS assessments and associated CAAs within the required 14-day timeframes for multiple residents with various medical conditions, as verified by record review and staff interviews. These delays occurred despite facility policy requiring timely completion in accordance with the RAI User Manual.
The facility did not revise care plans to include and monitor the use of seat belts and alarms as restrictive devices for two residents with cognitive impairment and mobility issues, and failed to complete comprehensive care plans within the required timeframe for two other residents. Staff interviews and record reviews confirmed these deficiencies, with care plans either lacking necessary interventions or being completed late.
Insulin pens for several residents were found opened but not dated, and some were not disposed of according to manufacturer guidelines. Nursing staff confirmed that insulin should be dated when opened, but there was confusion about proper disposal timelines. Facility policies required dating multi-dose containers but did not specify insulin use duration, leading to improper storage and potential use of expired insulin.
A resident with multiple health conditions and on anticoagulation therapy was found with extensive bruising during a shower. Although administration was notified, there was no documentation that the PCP was informed of the unknown injury, as required by facility policy. Interviews confirmed the lack of physician notification despite the resident's care plan and facility protocols.
Two residents with cognitive and physical impairments were provided with seat belts and alarms for safety without required assessments or documentation to determine necessity, appropriateness, or least restrictive use. Staff did not monitor or reassess these devices as required by facility policy, and documentation was lacking regarding their use or removal.
A resident with severe cognitive impairment and multiple psychiatric diagnoses received a PRN psychotropic medication without practitioner review for necessity and appropriateness within the required 14-day period. Despite pharmacy recommendations and facility policy, the order was not reviewed or updated in a timely manner, and the medication was administered during this lapse.
A resident with chronic obstructive pulmonary disease and type 2 diabetes did not receive a required annual comprehensive MDS assessment within the mandated timeframe. Review and staff interview confirmed the assessment was overdue, contrary to facility policy requiring annual completion.
Two residents with significant medical and cognitive needs were not provided with written summaries of their baseline care plans, despite facility policy requiring this within 48 hours of admission. Although care conferences were held and baseline care plans were developed, there was no documentation or confirmation that the residents or their representatives received the written summaries.
Two residents with PTSD and other mental health diagnoses did not have trauma-informed care addressed in their care plans. Trauma assessments were not completed as required, and care plans, nursing notes, and Kardexes lacked information on trauma, triggers, or related interventions. Staff confirmed that trauma-related needs were not included in the residents' care planning or daily care routines.
A resident with cognitive impairment and a history of falls had physician orders for a wheelchair seat belt and pressure alarm, but the facility failed to complete required assessments, did not update the care plan, and did not document or monitor the use or removal of these safety devices. Staff signed off on checks that were not performed, and the interventions were not in place as ordered, contrary to facility policy.
Two residents with PTSD and other mental health diagnoses did not receive trauma-informed care due to the absence of trauma assessments, lack of trauma-related care planning, and insufficient staff training. Staff interviews confirmed no awareness of trauma triggers or interventions, and facility policy requirements for trauma screening and training were not met.
The facility did not ensure accurate documentation on the MAR and TAR for two residents. One resident's IV antibiotic administration was not properly recorded, and staff could not confirm if doses were given. Another resident's required safety devices were not in place as ordered, yet the TAR was signed as if they were checked. Staff interviews and observations confirmed these documentation lapses.
A resident with multiple chronic conditions used a CPAP device nightly, but staff failed to clean the equipment and mask as required by facility policy. There was no documentation or care plan intervention for cleaning, and staff interviews revealed confusion about responsibility and lack of a cleaning schedule. The resident expressed concern about infection risk due to the unclean equipment.
Staff failed to consistently use Enhanced Barrier Precautions (EBP) during high-contact care for two residents with wounds or indwelling devices. In both cases, staff wore gloves but did not don gowns, resulting in direct contact between their uniforms and the residents during IV medication administration and catheter care. Despite clear signage, available PPE, and physician orders requiring EBP, staff did not follow protocol, and care plans lacked EBP interventions.
The facility failed to serve food at appropriate temperatures, affecting 61 residents. A resident reported that food was often served cold. During an observation, scrambled eggs were lukewarm at 123°F, and toast was unpalatably cool. The Dietary Director confirmed these findings and acknowledged past concerns. The facility lacked a plate warmer and had limited dish containers to maintain heat. The policy required food to be served at a safe and appetizing temperature but did not specify an exact range.
Failure to Provide Consistent Assessment and Treatment of Pressure Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a comprehensive, individualized pressure ulcer prevention and treatment program for a resident with multiple comorbidities and severe functional dependence. The resident was legally blind, had osteoarthritis, dysphagia, heart disease with heart failure, COPD, chronic kidney disease, anemia, depression, anxiety, and a history of repeated falls and acute respiratory failure. She was severely cognitively impaired, dependent on staff for toileting, bathing, bed mobility, and transfers, had an indwelling urinary catheter, and was frequently incontinent of bowel. Despite these risk factors, the care plan for impaired skin integrity did not translate into consistent, accurate assessment and documentation of her coccyx pressure ulcer, and the 5‑Day MDS inaccurately documented that she had no pressure ulcers and no nutritional or hydration interventions for skin problems, even though she had a Stage II coccyx ulcer on readmission. The resident returned from the hospital on one occasion with a Stage II coccyx pressure ulcer that was not measured or described, and early treatment orders (e.g., zinc and foam dressing) were not documented as completed on multiple days. On a subsequent readmission, the coccyx wound was documented as Stage I with minimal description, and treatment orders again were not documented as completed on specified dates. By 10/13, the wound had progressed to a Stage III ulcer with 100% slough, and although wound care orders and nutritional supplements were initiated, the Prostat supplement was discontinued due to refusals. After another hospitalization, the resident returned with a Stage II coccyx ulcer and a suspected deep tissue injury to the buttock; wound care orders were in place and documented through the end of October, but the weekly wound summary on 10/31 showed the coccyx ulcer worsening in size and appearance and the buttock injury enlarging. In November, there were significant lapses in wound assessment and treatment implementation. From 11/08 through 11/21, there were no treatment orders or documented treatments for the coccyx wound, and there were no wound assessments between 10/31 and 11/13, and then no documented coccyx treatments from 11/13 through 11/20, despite a 11/13 note describing the coccyx as a Stage III ulcer with 90% slough. On 11/21, the coccyx wound was found to have deteriorated to an unstageable ulcer with 100% slough, erythema, and warmth, requiring sharp debridement and extensive diagnostic workup. The DON later confirmed that there was no in‑house wound care team for several months, that an LPN who could not stage wounds was performing wound assessments with RN assistance, and that orders were not transcribed, resulting in a lapse of treatment during the transition between wound care providers. The CNP acknowledged awareness of the gap in wound care from late October to late November and noted the resident’s poor intake and refusals to get out of bed, while the dietitian described ongoing weight loss, fluctuating supplement acceptance, and concerns about the resident’s nutrition and wound status since October. These combined assessment, documentation, and treatment failures led to the worsening of the resident’s coccyx pressure ulcer from Stage II to Stage IV.
Uncertified Staff Member Allowed to Perform CNA Duties
Penalty
Summary
The facility failed to ensure that a staff member working as a CNA met state and federal requirements before providing direct resident care. Human Resources records and interviews showed that this individual was hired as a CNA and provided care to residents for approximately 17 months without ever obtaining CNA certification or being listed on the Nurse Aide Registry. The HR Director reported that the staff member completed an initial Nurse Aide Training class and repeatedly attempted the CNA test but failed the written portion multiple times, then missed a subsequent test and was required to retake the entire training. After completing a second Nurse Aide Training class, the staff member again failed the written test and never achieved certification. Despite this, the facility allowed the individual to continue performing CNA duties and providing care to residents throughout the facility. Review of the personnel file confirmed only certificates of completion for two Nurse Aide Training classes and no documentation of a Nurse Aide Registry check or active certification. This deficiency was identified through personnel record review and staff interviews and was associated with complaint investigations, with the facility census noted as 60 residents at the time of the survey. The report states that this failure had the potential to affect all residents residing in the facility.
Failure to Report Injury of Unknown Origin to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to report an injury of unknown origin to the State Survey Agency as required by its own policy and regulations. A resident with multiple complex medical conditions, including local skin infection, congestive heart failure, pulmonary fibrosis, dysphagia, hypoxemia, hypertensive heart disease with heart failure, gout, anemia, osteoporosis, major depressive disorder, generalized anxiety disorder, hypothyroidism, chronic pain syndrome, chronic kidney disease, acute respiratory failure with hypoxia, myocardial infarction, osteoarthritis of the knee, cognitive communication deficit, COPD, repeated falls, and legal blindness, was admitted on 01/07/22. The resident’s MDS assessment showed a BIMS score of 00, indicating severe cognitive impairment, and documented that the resident was dependent on staff for all ADLs and mobility. On 06/05/25, the resident complained of right knee pain, and an x-ray was ordered and performed on 06/06/25. The x-ray results showed a broken osteophyte at the superior margin of the patella, likely chronic, and moderate osteoarthritis of the right knee joint. During an interview on 01/08/25, the DON stated that staff were unaware of how the resident’s knee injury occurred and confirmed that an investigation was conducted. However, no self-reported incident related to this injury of unknown origin was submitted to the State Survey Agency, despite the facility’s written policy requiring immediate reporting of suspected abuse, neglect, exploitation, misappropriation, or injury of unknown source to the administrator and appropriate officials within specified time frames. This failure to report was identified as an incidental finding during a complaint investigation.
Failure to Follow Hand Hygiene and PPE Requirements During Incontinence and Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure staff followed appropriate infection prevention and control practices during incontinence care for one resident and wound care for another. For the first resident, who had multiple medical conditions including vascular dementia, orthopedic aftercare needs, and complete dependence on staff for ADLs and continence care, surveyors observed incontinence care being performed by an LPN and a CNA. After removing the resident’s soiled brief and performing perineal care, the CNA removed her soiled gloves and immediately donned clean gloves without performing hand hygiene before obtaining and applying clean clothing. The LPN also did not change gloves or perform proper hand hygiene between handling the soiled brief and proceeding with the clean brief. Both staff members later confirmed they had not applied clean gloves or used proper hand hygiene between the soiled and clean portions of the care. The second deficiency involved wound care for another resident who was cognitively intact, independent with ADLs, and had a Stage III pressure ulcer on the right lateral ankle with care orders that included cleansing with normal saline, applying Skin-Prep, and covering with a bordered foam dressing. This resident had an active order for enhanced barrier precautions (EBP), and signage indicating EBP was posted on the door. During observed wound care, the LPN sanitized the bedside table, placed a barrier, gathered supplies, performed hand hygiene, and donned clean gloves, but did not don any additional PPE required under EBP before starting the procedure. The LPN removed the soiled dressing, discarded it, changed gloves with hand hygiene in between, cleansed the wound, applied Skin-Prep and a new foam dressing, and completed the task without ever using the additional PPE indicated by the EBP signage and facility policy. The facility’s own undated standard precautions policy required hand hygiene before and after direct contact with a resident’s skin, after contact with body fluids or excretions, and after glove removal. CDC guidance on hand hygiene and glove use, cited in the report, states that gloves are not a substitute for hand hygiene and that staff should change gloves and perform hand hygiene when moving from a soiled body site to a clean body site on the same patient. The DON confirmed that the facility had a policy requiring PPE use for wound care. The observed failures in hand hygiene and PPE use for these two residents were identified as deficiencies during a complaint investigation.
Medical Director Absence from QAPI Meetings
Penalty
Summary
The facility failed to ensure that the medical director attended the Quality Assurance and Performance Improvement (QAPI) meetings as required. Review of QAPI meeting attendance sign-in sheets over a period of more than a year showed that the medical director did not attend any of the meetings. This was confirmed during an interview with the administrator, who verified that there was no evidence of the medical director's attendance at any QAPI meeting during the specified timeframe. Additionally, the facility's QAPI policy did not specify the required members, including the medical director, nor did it outline the frequency of attendance for required members.
Plan Of Correction
All residents were immediately assessed and found to have no adverse effects. All QAPI reviewed and ensured that physician was in attendance Quarterly. Education immediately provided by admin to all staff required to be in attendance at QAPI regarding attendance requirements. Admin/Designee to review next 3 QAPI meetings to ensure all necessary attendees are present. Results to be reviewed in QAPI.
Failure to Maintain Safe and Clean Flooring Throughout Facility
Penalty
Summary
The facility failed to maintain the building floors in a safe and clean condition, as evidenced by multiple observations of soiled, stained, cracked, and sunken flooring throughout various areas, including the front foyer, hallways, nurses' stations, and resident rooms. Specific issues included dark soiled areas, worn and scratched surfaces, scuff marks, cracked and sunken tiles, and sloping floors that posed a fall hazard. The carpeted areas near the dining room and nurses' station were also noted to have permanent stains, and the floor bordering the nurses' station was observed to slope downward, increasing the risk of falls for residents who ambulate in that area. These conditions were confirmed by both staff interviews and direct observation. Interviews with staff, including an LPN and the Housekeeping Director, verified awareness of the floor hazards, including the sloping floor and the presence of permanent stains. The Housekeeping Director reported that floors were scrubbed monthly and mopped daily, with carpets cleaned weekly, but acknowledged that some stains were permanent and deep cleaning may not occur routinely each month. The Administrator confirmed knowledge of the floor conditions and ongoing discussions with ownership about floor replacement, but was unaware of any formal plan or scheduled dates for repairs. The deficiency had the potential to affect all 66 residents residing in the facility.
Plan Of Correction
All residents were immediately reviewed and found to have no adverse effects. All residents have the ability to be affected. Flooring was immediately reviewed by the Administrator, Housekeeping Supervisor, and Maintenance Department to ensure floors were safe and clean. Housekeeping Supervisor immediately buffed all tile flooring. Maintenance Department replaced all cracked and chipped tiles by 5/30/25. Housekeeping Supervisor deep cleaned all carpeting on 5/22/25. Maintenance/Designee to monitor flooring weekly for 4 weeks to ensure compliance. Results to be reviewed in QAPI.
Failure to Complete Timely Quarterly MDS Assessments
Penalty
Summary
The facility failed to complete quarterly Minimum Data Set (MDS) assessments within the required timeframe of 92 days for nine out of eleven residents reviewed. Record reviews showed that for each of these residents, the last quarterly or annual MDS assessment was not followed by a subsequent quarterly assessment as mandated. The residents affected had various diagnoses, including Parkinsonism, dementia, diabetes mellitus type two, chronic obstructive pulmonary disease (COPD), chronic respiratory failure, hypertensive heart disease, hemiplegia, hemiparesis, chronic pain syndrome, Alzheimer's disease, degeneration of the nervous system due to alcohol, epilepsy, congestive heart failure, and asthma. Interviews with the MDS Coordinator confirmed that the required quarterly assessments were not completed for these residents within the specified timeframe. The deficiency was identified through both record review and staff interviews, with the facility census at 66 residents at the time of the survey. No evidence was found in the records to indicate that the quarterly MDS assessments were completed as required for the identified residents.
Plan Of Correction
Residents #11, 20, 21, 22, 26, 29, 41, 42, and 60 were immediately assessed and found to have no adverse effects. All residents have the ability to be affected. Resident #11, 20, 21, 22, 26, 29, 41, 42, and 60 quarterly MDS assessments were immediately reviewed by MDS. Residents #11, 22, 26, 29 quarterly assessments were completed immediately, and residents #20, 21, 41, 42, and 60 quarterly assessments were completed on 5/29/25 by MDS. MDS reviewed all quarterly MDS assessments on 5/21/25. Admin provided the MDS Coordinator education on quarterly MDS assessment policy and timely submission. The DON/designee will audit 3 residents' charts weekly to ensure quarterly MDS assessments are submitted timely for 4 weeks. Results will be reviewed in QAPI.
Failure to Complete and Submit MDS Assessments Within Required Timeframes
Penalty
Summary
The facility failed to complete and submit Minimum Data Set (MDS) assessments within the required timeframes for all 11 residents reviewed. According to the findings, MDS assessments, including quarterly, annual, significant change, admission, and discharge assessments, were not completed or submitted within the 14-day period mandated after the assessment reference date (ARD) or relevant event, such as admission or discharge. In several cases, the Care Area Assessments (CAAs) associated with the MDS were also not completed within the required timeframe. Record reviews for each resident showed that the assessments were delayed, sometimes by several weeks beyond the required period. For example, one resident's quarterly MDS with an ARD of 12/31/24 was not completed until 02/13/25, and another resident's annual MDS with an ARD of 01/30/25 was not completed until 03/06/25. These delays were consistently verified through interviews with the MDS Coordinator, who acknowledged that the assessments and CAAs were not completed or submitted on time. The residents affected had a range of medical conditions, including Parkinsonism, dementia, diabetes mellitus, COPD, chronic pain syndrome, hypertensive heart disease, epilepsy, and metabolic encephalopathy. The facility's policy, revised in March 2022, required comprehensive assessments to be conducted in accordance with the Resident Assessment Instrument (RAI) User Manual, including completion by day 14 for admission assessments. Despite this policy, the facility did not adhere to the required assessment and submission timeframes for the residents reviewed.
Plan Of Correction
Residents #11, 20, 21, 22, 26, 29, 41, 42, 62, 70, and 60 were immediately assessed and found to have no adverse effects. All residents have the ability to be affected. Resident #11, 20, 21, 22, 26, 29, 41, 42, and 60 assessments were immediately reviewed by MDS. Residents #11, 22, 26, 29, 62, and 70 assessments were completed immediately, and residents #20, 21, 41, 42, and 60 quarterly assessments were completed on 5/29/25 by MDS. All resident MDS assessments were reviewed by MDS on 5/22/25. Admin provided MDS Coordinator education on MDS Assessment policy and timely submission on 5/21/25. Random weekly audits of comprehensive care plans are to be completed by the DON/Designee within 4 weeks. Results are to be reviewed in QAPI.
Failure to Revise and Timely Complete Comprehensive Care Plans
Penalty
Summary
The facility failed to revise and complete comprehensive care plans for four residents as required. For two residents with cognitive impairment and significant medical conditions, the care plans did not include the use and monitoring of seat belts and alarms as restrictive devices. Specifically, one resident with hemiplegia, hemiparesis, and vascular dementia had a physician order for a Velcro seat belt for positioning and safety, but the care plan only referenced the seat belt as a fall intervention and did not address monitoring or assessment of the device as necessary, appropriate, or least restrictive. Another resident with dementia and multiple comorbidities had orders for an alarming Velcro seat belt and a pressure alarm, but the care plan did not address these devices or include any plan for monitoring or assessment. Observations and interviews confirmed the devices were either in use without proper care plan documentation or had been removed without documentation or care plan revision. Additionally, the facility failed to complete comprehensive care plans within the required timeframe for two other residents. For both, the care area assessment and care plan were completed after the 21-day post-admission requirement. Interviews with the MDS Coordinator confirmed the late completion of these care plans. Record reviews, staff interviews, and facility policy review all supported these findings. The facility's policy indicated that care plans should be used in developing daily care routines and be available to staff responsible for resident care, but this was not consistently followed for the residents reviewed.
Plan Of Correction
Resident #3 and #25 were immediately assessed and found to have no adverse effects. All residents with restrictive devices and alarms have the ability to be affected. Seatbelt for resident #25 was DCed immediately by DON on 5/21/25. Seatbelt for resident #3 was requested to stay in place by resident. Chart was reviewed by DON immediately on 5/21/25 to insure proper documentation was in place. Resident #3 and #25 comprehensive care plan immediately reviewed and updated by MDS on 5/21/25. Admin immediately provided MDS Coordinator education on comprehensive care plan policy and timely submission. Education on appropriate alarm and restrictive device usage and documentation provided by DON to all staff on 5/22/25. All residents alarms/restrictive devices were reviewed by IDT on 5/28/25 to ensure appropriateness and supporting documentation in place. Weekly audits of three alarms/restrictive devices to be complete by DON/designee to ensure the care plan is accurate and the device in place is appropriate as the least restrictive option with proper monitoring for 4 weeks. Results to be reviewed in QAPI.
Failure to Date and Dispose of Insulin Pens per Manufacturer Guidelines
Penalty
Summary
The facility failed to ensure that insulin pens for multiple residents were properly dated upon opening and disposed of according to manufacturer guidelines. During observations of the East and North medication carts, opened insulin pens for several residents were found without dates indicating when they were first used. In one instance, an insulin pen was dated but had not been discarded after the recommended period. Interviews with nursing staff confirmed that insulin should be dated when opened, but there was uncertainty regarding the correct duration for use and disposal timelines. The facility's policies required dating multi-dose containers upon opening, but did not specify the required duration for insulin use after opening. Medical records showed that the affected residents had diagnoses including diabetes, hypertension, congestive heart failure, and other conditions requiring insulin therapy. Manufacturer guidelines for the insulins in use specified strict timeframes for discarding opened pens, ranging from 28 days to eight weeks, which were not consistently followed. The facility's failure to date and dispose of insulin as required had the potential to affect all residents with insulin orders, as staff could not determine when the insulin should be discarded.
Plan Of Correction
Resident #8, 11, 63, and 131 were immediately assessed and found to have no adverse effects. All residents with insulin orders have the ability to be affected. Resident #8, 11, 63, and 131 insulin pens were immediately dated by nursing. All insulin pens were audited immediately to ensure proper storage and labeling. Education was provided to all nursing staff by the DON on 5/22/25 regarding proper medication storage. The DON/Designee will audit 3 insulin pens per week for 4 weeks to ensure they are appropriately dated. Results will be reviewed in QAPI.
Failure to Notify Physician of Resident's Unknown Injury and Bruising
Penalty
Summary
A deficiency occurred when the facility failed to notify a resident's primary care physician (PCP) of an unknown injury involving significant bruising. The resident, who had a history of congestive heart failure, muscle weakness, cirrhosis of the liver, diabetes, and hypertension, was found during a shower to have large areas of discoloration on her right forearm, right arm, right inner thigh, right breast, and the inside of her left arm. The resident was on Plavix, an antiplatelet medication, and her care plan included monitoring for signs of bleeding or bruising and reporting these to the physician. Documentation showed that administration was notified of the bruising, but there was no evidence that the PCP was informed as required by facility policy. The incident was also reported as a self-reported incident (SRI) and an incident report was completed, both noting the extensive bruising and the resident's lack of awareness of how the injuries occurred. Interviews with the resident and the Director of Nursing (DON) confirmed that the PCP was not notified of the unknown injury. Facility policies required prompt physician notification for changes in condition, including injuries of unknown source, especially for residents on anticoagulation therapy. Despite these requirements, there was no documentation or evidence that the physician was contacted regarding the resident's condition.
Plan Of Correction
Resident #9 was immediately assessed and found to have no adverse effects. Open Risk assessments audited by DON to ensure all physicians were notified on 5/22/25. All residents have the ability to be affected. Education on appropriate physician notification for resident change in condition was provided by DON to all staff on 5/22/25. DON/designee to audit 2 charts a week for 4 weeks to ensure PCP was notified of change in condition. Results to be reviewed in QAPI.
Failure to Assess and Monitor Use of Restraints and Alarms
Penalty
Summary
The facility failed to routinely assess the necessity, appropriateness, and least restrictive use of seat belts and alarms for residents, as required by policy. For one resident with hemiplegia, hemiparesis, and moderate cognitive impairment, a Velcro seat belt was ordered and applied for positioning and safety, but there was no assessment at the time of application or thereafter to determine if the device was necessary, appropriate, or the least restrictive option. The care plan referenced the seat belt as a fall intervention but did not include any plan for monitoring or reassessment, and there was no documentation justifying its use or monitoring its continued need. Staff confirmed the seat belt was used to prevent unassisted rising, and the resident was able to self-release the belt with the unaffected hand, but this was not routinely assessed or documented. Another resident with multiple diagnoses, including dementia and moderate cognitive impairment, had both an alarming Velcro seat belt and a pressure alarm ordered for safety. There were no assessments completed upon application of these devices or subsequently to determine their necessity or appropriateness. The care plan addressed the pressure alarm but not the seat belt, and neither device was monitored or reassessed for continued need or least restrictiveness. Documentation did not justify the use of these devices, and there was no record of their removal, despite staff indicating the devices were no longer in use. Facility policy required a pre-restraining assessment and ongoing re-evaluation for any restrictive device, as well as documentation of the resident's response to interventions. The facility identified 13 residents with seat belts or alarms as restrictive devices, but failed to ensure assessments and documentation were completed as required. Observations and interviews confirmed that devices were used or removed without proper assessment, monitoring, or documentation, resulting in a deficiency related to the use of physical restraints and restrictive devices.
Plan Of Correction
Resident #3 and #25 were immediately assessed and found to have no adverse effects. All residents who utilize alarms or seatbelts have the ability to be affected. Seatbelt order for resident #25 was DCed immediately by DON on 5/21/25. Alarm for resident #3 was requested to stay in place by resident. Chart was reviewed by DON immediately on 5/21/25 to ensure proper documentation was in place. All residents with alarms/restrictive devices were reviewed by IDT on 5/28/25 to ensure the least restrictive device was in place and that remaining devices were appropriate. Education on appropriate alarm and restrictive device usage and ongoing assessment was provided by DON to all staff on 5/22/25. DON/designee to review 3 residents with an alarm or restrictive device in place weekly for 4 weeks to ensure they are necessary, being routinely reviewed, and least restrictive. Results of audit to be reviewed in QAPI.
Failure to Timely Review PRN Psychotropic Medication Orders
Penalty
Summary
The facility failed to ensure that a PRN psychotropic medication prescribed to a resident was reviewed by a practitioner for necessity and appropriateness within 14 days, as required. The resident, who had diagnoses including hemiplegia, major depressive disorder, adjustment disorder with anxiety, and vascular dementia, was admitted with severe cognitive impairment. The care plan identified the potential for adverse effects from antianxiety medications and included interventions for administering and monitoring these medications. A PRN order for Vistaril 25 mg every six hours for anxiety or agitation was initiated without a specified duration. Despite a pharmacy recommendation to review the PRN psychotropic order after 14 days, the physician did not review or address the order until over a month later. During this period, the medication was administered on two occasions. The facility's policy required practitioner review and documentation of rationale for continuing PRN psychotropic medications beyond 14 days, but this was not followed. The DON confirmed that the required review was not completed within the specified timeframe.
Plan Of Correction
Resident #33 was immediately assessed and found to have no adverse effects. All residents on a PRN antipsychotic medication have the ability to be affected. All residents on PRN antipsychotic orders were immediately audited by DON/designee to ensure all had stop dates in place. Education on antipsychotic usage, GDR process, and appropriate orders was provided by the DON to all nursing staff on 5/22/25. DON/designee to audit all PRN antipsychotic orders for stop date weekly for 4 weeks. Results to be reviewed in QAPI. Resident #22 was immediately assessed and found to have no adverse effects. All residents have the ability to be affected. MDS reviewed all residents for open annual MDS assessments on 5/22/25 to ensure they were complete. Resident #22’s annual MDS assessments were immediately reviewed and completed on 5/29/25 by MDS. Admin immediately provided MDS Coordinator education on MDS assessments policy and timely submission. DON/designee to audit 2 residents with annual MDS assessments due weekly for 4 weeks. Results to be reviewed in QAPI.
Failure to Complete Timely Annual MDS Assessment
Penalty
Summary
The facility failed to complete an annual comprehensive Minimum Data Set (MDS) assessment for one resident within the required timeframe of 366 days from the previous assessment. Record review showed that the resident, who had diagnoses including chronic obstructive pulmonary disease and type 2 diabetes mellitus, was admitted on a specified date and did not have a comprehensive MDS assessment completed after the last one documented. This was confirmed during an interview with the MDS Coordinator, who acknowledged that the required assessment had not been completed within the mandated period. Facility policy requires that comprehensive assessments be conducted according to the Resident Assessment Instrument (RAI) User Manual, with annual assessments completed at least every 366 days.
Plan Of Correction
Resident #22 was immediately assessed and found to have no adverse effects. All residents have the ability to be affected. MDS reviewed all residents for open annual MDS Assessments on 5/22/25 to ensure they were complete. Resident #22 annual MDS Assessments were immediately reviewed and completed on 5/29/25 by MDS. Admin immediately provided MDS Coordinator education on MDS Assessments policy and timely submission. DON/designee to audit 2 residents with annual MDS assessments due weekly for 4 weeks. Results to be reviewed in QAPI.
Failure to Provide Written Baseline Care Plan Summaries to Residents and Representatives
Penalty
Summary
The facility failed to provide residents and their representatives with a written summary of the baseline care plan within 48 hours of admission, as required by facility policy. For two residents reviewed, both with complex medical conditions and cognitive impairments, there was documentation of baseline care plans being developed and family conferences being held to discuss care. However, there was no evidence in the medical records, family conference forms, or nursing progress notes that the residents or their representatives received a written summary of these baseline care plans. Interviews with the MDS Coordinator confirmed that neither resident nor their representatives were given the required written summaries. The facility's policy, revised in March 2022, specifies that such summaries must be provided in a language understandable to the resident or representative. Despite this policy, the documentation and staff interviews verified that this step was not completed for the two residents reviewed.
Plan Of Correction
All residents have the ability to be affected. All baseline care plans reviewed by DON, MDS/designee to ensure they are in place on 5/22/25 and residents received a copy. Admin provided MDS Coordinator education on baseline care plan policy and importance of timely patient review and acknowledgment immediately on 5/21/25. DON provided all nursing staff education on baseline care plan policy and importance of timely patient review and acknowledgment on 5/22/25. DON/designee to audit 3 new admissions baseline care weekly to ensure timely receipt of baseline care plans for 4 weeks. Results to be reviewed in QAPI.
Failure to Implement Trauma-Informed Care Planning for Residents with PTSD
Penalty
Summary
The facility failed to implement a comprehensive care plan that addressed trauma-informed care for two residents with trauma-related diagnoses. For one resident with dementia, major depressive disorder, generalized anxiety disorder, and PTSD, there were no trauma screenings or assessments completed since admission, and no documentation in the care plan, nursing notes, or physician notes regarding trauma, triggers, or trauma-informed interventions. The resident's care plan only referenced cognitive impairment, depression, anxiety, and a history of alcohol abuse, without any mention of trauma-informed care. The nursing assistant Kardex also lacked any information related to trauma-informed care for this resident. Interviews with facility staff confirmed that no trauma assessments were completed and that trauma-related needs were not included in the care plan or daily care routines. Similarly, another resident with PTSD, major depressive disorder, generalized anxiety disorder, and other medical conditions did not have trauma-informed care addressed in the baseline care plan. The baseline care plan included information on adjustment issues, risk factors, and therapy needs, but omitted any reference to PTSD or trauma-informed interventions. Staff interviews revealed that a trauma assessment was not completed within the required timeframe after admission, and as a result, trauma care was not included in the resident's baseline care plan. The facility's own policies required trauma-informed, person-centered care planning, but these were not followed for the residents reviewed.
Plan Of Correction
All residents have the ability to be affected. Social Services and all staff educated by DON on Trauma-Informed Care 5/22/25. PCC Trauma-Informed Care assessment put in place and completed by social services on 5/22/25 for #25, #140, and on all appropriate residents. DON/designee to audit trauma-informed assessments on new admissions weekly for 4 weeks. Results to be reviewed in QAPI.
Failure to Monitor and Maintain Safety Interventions for Resident
Penalty
Summary
The facility failed to properly monitor and maintain safety interventions for a resident with multiple diagnoses, including dementia, impaired cognition, and a history of falls. Physician orders were in place for an alarming Velcro seat belt and a pressure alarm to the resident's wheelchair for safety and positioning. However, there were no assessments completed to determine the necessity or appropriateness of these devices, and the care plan did not address the seat belt or provide a plan for monitoring or assessment of either device. Documentation in the progress notes did not justify the use of the devices or monitor their continued need, and the seat belt order was not included in the nursing assistant Kardex. Observations revealed that neither the seat belt nor the pressure alarm was in place as ordered, despite being signed off as checked and in place on the Treatment Administration Record. Staff interviews confirmed the devices had been removed at some point without documentation of the removal or rationale, and staff could not specify when or why the devices were discontinued. Facility policy required monitoring and documentation of the efficacy of such interventions, but this was not followed, resulting in a lack of oversight and failure to ensure the resident's safety interventions were properly managed.
Plan Of Correction
Resident #25 was immediately assessed and found to have no adverse effects. All residents with safety interventions have the ability to be effected. Resident #25 seatbelt immediately DCed by DON. Education provided to all staff by DON on 5/22/25 regarding alarm/ restrictive device policy. All residents with orders for restrictive devices/alarms were audited by IDT team on 5/22/25 to ensure they are appropriate, in place, and have required documentation. Don/Designee to audit 2 residents weekly ensuring that proper documentation is in place for their safety interventions for 4 weeks to ensure compliance. Results to be reviewed in QAPI.
Failure to Provide Trauma-Informed Care and Staff Training
Penalty
Summary
The facility failed to provide trauma-informed care and culturally competent services to two residents with trauma-related diagnoses. Both residents had documented histories of PTSD and other mental health conditions, yet their care plans, assessments, and daily care documentation lacked any reference to trauma, triggers, or specific interventions related to their trauma histories. There was no evidence that trauma assessments or screenings were completed upon admission or thereafter for either resident, and their care plans did not address trauma-informed approaches as required by facility policy. Staff interviews revealed a lack of awareness and training regarding trauma-informed care. The Director of Nursing (DON), Certified Nursing Assistant (CNA), Registered Nurse (RN), and Social Services Director (SSD) all confirmed that no trauma assessments had been completed for the residents in question, and that staff had not received training on trauma-informed care, screening tools, or strategies to address trauma-related triggers. The SSD acknowledged that trauma assessments should have been completed within 48 hours of admission to inform the baseline and comprehensive care plans, but this was not done for either resident. Review of the facility's policy on trauma-informed care indicated that all staff were to be trained on trauma, its impact, and the use of screening tools, with universal screening of residents for trauma. However, there was no evidence that these policy requirements were met. The lack of trauma assessments, absence of trauma-related care planning, and insufficient staff training directly contributed to the facility's failure to provide trauma-informed care to residents with known trauma histories.
Plan Of Correction
Resident #25 and #140 were immediately assessed and found to have no adverse effects. All residents have the ability to be affected. Resident #25 and #140 chart immediately reviewed, trauma-informed assessment was added by Social Services. All residents were reviewed to ensure they had trauma-informed care plans in place. Education was provided to all staff by the DON on 5/22/25 regarding trauma-informed care importance and policy. The DON/Designee will complete weekly audits of new hire paperwork to ensure review of trauma-informed care for 4 weeks to ensure compliance. Results will be reviewed in QAPI plans.
Failure to Accurately Document Medication and Safety Device Administration
Penalty
Summary
The facility failed to ensure accurate and complete documentation on the medication administration record (MAR) and treatment administration record (TAR) for two residents. For one resident with chronic obstructive pulmonary disease, congestive heart failure, an indwelling urethral catheter, and neuromuscular dysfunction of the bladder, the MAR was left blank for scheduled doses of intravenous meropenem, an antibiotic ordered for a urinary tract infection. Interviews with nursing staff and the Director of Nursing confirmed that the MAR was not signed for these doses, and staff could not verify whether the medication was administered, despite facility policy requiring complete and accurate documentation. For another resident with multiple diagnoses including COPD, diabetes, dementia, and psychiatric disorders, the TAR was not signed to indicate that required safety devices—a seat belt and pressure alarm—were checked as ordered. Observations and interviews revealed that these devices were not in place as ordered, and staff could not specify when or why they were removed. Additionally, there was no documentation in the progress notes regarding the removal of these devices, despite ongoing documentation on the TAR indicating they were checked and in place.
Plan Of Correction
Resident #43 and #25 were immediately assessed and found to have no adverse effects. All residents have the ability to be affected. Resident #43 MAR was immediately updated. Resident #25 seat belt and chair alarm was immediately DCed by DON. Education provided to all staff by DON on 5/22/25 regarding appropriate and timely documentation. MAR and TAR reviewed on randomly selected residents 5/28/25 by IDT during Risk to ensure timely and accurate documentation. DON/Designee to audit 2 MAR and 2 TAR weekly for 4 weeks to ensure accurate documentation. Results to be reviewed in QAPI.
Failure to Clean and Document CPAP Equipment Maintenance
Penalty
Summary
The facility failed to ensure proper cleaning of a resident's CPAP equipment and mask as recommended by facility policy. The resident, who had diagnoses including COPD, obstructive sleep apnea, diabetes, and hypertension, used a BiPap with oxygen every night. The care plan did not include interventions related to cleaning respiratory equipment, and there were no physician orders or documentation in the Treatment Administration Record regarding cleaning of the CPAP equipment or mask. Nursing notes also lacked any mention of cleaning, and multiple observations confirmed that the equipment and mask were not cleaned. Interviews with nursing staff revealed confusion and lack of clarity regarding responsibility for cleaning the CPAP equipment, with no official cleaning schedule or documentation in place. The Director of Nursing confirmed that the facility did not have a system for cleaning or documenting the cleaning of CPAP equipment and masks. The facility's policy required weekly cleaning of the equipment, but this was not followed, and the resident expressed concern about the cleanliness of her equipment and the risk of infection.
Plan Of Correction
Resident #10 was immediately assessed and found to have no adverse effects. All residents with orders for a CPAP have the ability to be effected. Resident #10 CPAP was immediately cleaned by respiratory nurse. All CPAPs were immediately audited by respiratory nurse to ensure proper cleaning. Education was provided to respiratory nursing by DON on 5/22/25 regarding CPAP cleaning policy. DON/Designee to complete weekly audits to ensure all CPAPs are cleaned per policy for 4 weeks to ensure compliance. Results to be reviewed in QAPI.
Failure to Implement Enhanced Barrier Precautions During High-Contact Care
Penalty
Summary
Surveyors identified that the facility failed to implement Enhanced Barrier Precautions (EBP) as required for residents with wounds or indwelling medical devices. Specifically, two residents were observed during care activities where staff did not don gowns, despite clear signage and availability of personal protective equipment (PPE) at the room entrances. In both cases, staff only wore gloves and omitted the gown, resulting in direct contact between their uniforms and the residents during high-contact care activities. One resident with osteomyelitis, a chronic foot ulcer, diabetes, and a Med Port for intravenous antibiotics was observed receiving IV medication from an LPN who wore gloves but not a gown. The LPN's uniform came into direct contact with the resident during the procedure. The resident's care plan did not include EBP interventions, although physician orders specified EBP use. The LPN later confirmed awareness of the EBP requirement but admitted to not following it during the observed care. Another resident with an indwelling urinary catheter due to neurogenic bladder, as well as other chronic conditions, was assisted by a CNA with toileting and catheter care. The CNA wore gloves but not a gown, resulting in direct contact with the resident. The CNA was unsure of the EBP requirements despite prior training and signage. The resident's care plan also lacked EBP interventions, though physician orders required EBP. The DON confirmed that staff had ongoing issues remembering to use EBP, despite reminders and available PPE.
Failure to Serve Food at Appropriate Temperatures
Penalty
Summary
The facility failed to serve food at appropriate temperatures, affecting 61 residents who consume meals prepared by the facility. An interview with a resident revealed that food was often served cold. During an observation of a test tray for breakfast, the scrambled eggs were found to be lukewarm at 123 degrees Fahrenheit, and the toast was unpalatably cool, while the canned pears were not noted to have any temperature concerns. The food was served on a room temperature plate and covered with a clear plastic lid. The Dietary Director confirmed these findings and acknowledged past resident concerns about food temperature. The facility lacked a plate warmer and had only five rubber dish containers to maintain heat. The facility's food and nutrition services policy, dated October 2017, stated that food should be served at a safe and appetizing temperature but did not specify an exact range for warm foods.
Latest citations in Ohio
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
