Saint Luke Lutheran Home
Inspection history, citations, penalties and survey trends for this long-term care facility in North Canton, Ohio.
- Location
- 220 Applegrove Street Ne, North Canton, Ohio 44720
- CMS Provider Number
- 365521
- Inspections on file
- 32
- Latest survey
- March 10, 2026
- Citations (last 12 mo.)
- 49 (1 serious)
Citation history
Health deficiencies cited at Saint Luke Lutheran Home during CMS and state inspections, most recent first.
Facility administration failed to ensure effective oversight of staff orientation and reporting of abuse and neglect concerns. A CNA was observed kicking a resident’s bed and striking the resident with a closed fist, and that CNA’s orientation record lacked completion and signatures for key safety and care topics, including falls management, safe transfers, use of mechanical lifts, alarms, and behavior management. A resident’s allegation of neglect reported to nursing staff was not communicated to administration and no investigation was initiated. Staff did not report that other staff were taking pictures of a resident during care, and bruising on another resident’s arm was not adequately reported, assessed, or monitored. The Administrator and DON acknowledged these reporting and assessment failures, and the Medical Director stated he had not been informed of these concerns.
The facility failed to follow its own ADL policy and residents’ care plans by not consistently providing scheduled showers and grooming to several cognitively intact or moderately impaired residents who were dependent on staff for personal care. Multiple residents with chronic medical conditions and functional limitations had documented shower schedules but missed numerous scheduled showers over a two‑month period, as confirmed by shower sheets and the EMR, and reported not receiving showers as often as expected, with one resident stating she had to argue with staff to get showers. Another resident, unable to shave herself due to dementia and self‑care deficits, was repeatedly observed with significant chin hair despite expressing a preference to be shaved, and records showed no refusals of care. These actions and omissions resulted in residents not receiving the hygiene and grooming assistance required to maintain cleanliness and grooming as outlined in their care plans and the facility’s ADL policy.
The facility failed to consistently honor and document resident dietary preferences and to assist residents and families with menu selection. One cognitively impaired resident on a mechanical soft diet had no documented updates to food preferences or family involvement in nutrition assessments, and the family reported they were never offered the option to complete weekly menus. Another resident with intact cognition but dependent for ADLs reported repeatedly refusing chicken and requesting help with daily menus, yet continued to receive chicken and had no dislikes documented on the diet ticket. A third resident with dementia received incorrect breakfast items despite having requested specific foods, with a CNA confirming that dietary orders were often wrong. The RD acknowledged lack of evidence that preferences were updated, uncertainty about staff assistance with menus, and difficulty among dietary staff in knowing what each resident wanted, despite policies requiring diets to reflect residents’ informed choices and preferences.
The facility failed to provide palatable meals at safe and appetizing temperatures, affecting at least two residents and potentially all receiving kitchen-prepared meals. A resident who depended on staff for all ADLs reported that food was not always hot by the time assistance was provided, while another cognitively intact resident who ate independently reported that meals were frequently cold and unappetizing. Surveyors observed that while hot foods on the steam table initially met temperature standards, trays were then placed on delivery carts without heat or refrigeration, and a test tray later showed inadequately cooled dairy items and hot foods that were not maintained at appropriate temperatures. The Dietary Director acknowledged that cold items were not held at proper temperatures and that the hot foods were not warm or seasoned to a palatable standard, contrary to the facility’s policy requiring nourishing, palatable, and attractive meals.
Surveyors found that essential kitchen equipment was not kept in safe, working order. A high-temperature dishwasher was observed leaking significantly, with water running down a wall near electrical outlets and pooling on the floor where staff stood while operating it, despite multiple critical work orders being marked as completed and staff reporting the leak had persisted for weeks. In addition, a commercial food processor used for pureed foods was missing a key cover component, leading staff to improvise with aluminum foil, which allowed soup to spray onto surrounding surfaces and dishes; staff reported the part had been missing for several weeks while corporate dietary staff were still in the process of obtaining replacement parts.
Surveyors found that the facility did not maintain a clean, sanitary, and well-kept environment or ensure resident equipment was in good repair. Observations revealed a bed remote with exposed, taped wires, a bent curtain rod hanging at an angle above a bed, stained carpets, and walls with deep scratches and missing paint in several rooms. One wheelchair had dried brown debris on both footrest clips, which a family member believed was dried stool. The Maintenance Director confirmed these conditions, despite facility policy requiring a safe, clean, comfortable, and homelike environment.
Two residents with intact cognition and multiple comorbidities experienced unclean and non-homelike conditions when staff failed to remove soiled linens and incontinence wipes from a room, did not disinfect a tray table before serving a meal, and did not ensure pillows had clean pillowcases despite available linen supplies. One resident’s room contained dirty bed linens on a wheelchair, used wipes on the floor, and incontinence items on a tray table that was not cleaned before a meal was placed on it. Another resident repeatedly lacked pillowcases for multiple pillows, with staff variously stating that the prior shift forgot them, CNAs refused care, or the floor had run out, even though pillowcases were observed in the supply closet and on a laundry cart. These conditions did not meet the facility’s policy requiring a clean, sanitary, and orderly environment with clean bed and bath linens.
A cognitively impaired hospice resident with dementia and significant ADL needs was subjected to inappropriate physical interactions by a CNA during incontinence care, as captured on in-room video. The CNA was seen kicking the side of the resident’s mattress twice, causing the resident’s legs to lift, pulling back covers and tapping the resident’s leg with a gloved fist without explanation, and speaking in a loud, aggressive tone while directing the resident to sit and "sit back" when the resident attempted to get up. The resident repeatedly expressed gratitude and positive comments during care without receiving verbal responses. Family viewing the camera reported to police that the CNA appeared to strike the resident’s leg and either kick the leg or mattress forcefully. Staff who later viewed the videos described the actions as an aggressive slap and purposeful kick, and documentation showed a subsequent skin tear/scratch on the resident’s pinky toe. Surveyors concluded the facility failed to ensure the resident was free from physical abuse.
A cognitively intact resident with significant cardiopulmonary disease alleged that a CNA failed to properly restore his portable O2 after changing a battery, refused to assist further, and that he felt this was abuse and attempted murder; he reported this to an LPN, but the allegation was not documented, reported to the Administrator, or self-reported to the State. Another resident with severe cognitive impairment was observed with a large bruise on the forearm that had not been documented, assessed, or reported as an injury of unknown origin, despite facility policy. In a separate situation, a hospice resident dependent on staff for toileting and hygiene was depicted in complaint photos as naked and covered in dried feces, and staff reported hearing that an aide had taken and intended to send such photos to the State, yet these concerns were not reported up the chain of command as required by the facility’s abuse and neglect policy.
Two residents with severe cognitive impairment were involved in separate incidents where the facility failed to follow its abuse and injury investigation policies. In one case, a family member reported video evidence of a CNA kicking a bed, but the facility’s investigation included only the CNA’s statement and a census checklist, with no documented interviews of other staff or individualized resident responses, and key clinical leadership were not notified as required. In the other case, a resident was observed with a large purplish-red forearm bruise of unknown origin; staff had not documented the bruise, performed an assessment, reported it, or initiated an investigation, despite policy requiring investigation of injuries of unknown source.
A resident with Alzheimer’s disease, PVD, multiple diabetic foot ulcers, and a recent right great toe amputation was readmitted after hospitalization for sepsis and osteomyelitis with orders for a 6‑week course of Doxycycline and detailed daily wound care to multiple right and left foot sites. Review of the MAR showed several missed Doxycycline doses with no evidence of administration, and review of the TAR showed multiple dates with no documented wound care for the right second through fifth toes, right plantar foot incision, right fourth lateral toe, right great toe amputation site, and left medial foot, despite specific physician orders for cleansing, packing, and dressing changes. The wound nurse later confirmed unawareness of the missed antibiotics and lack of documented wound care, while the wound NP noted the resident had multiple incisions, gangrenous toes, self‑propelled striking his feet, and poor nutrition but expressed no concern about the wound care.
A resident with heart failure, diabetes, muscle weakness, bowel incontinence, and impaired mobility was care planned as being at risk for skin breakdown, with instructions to notify the physician of skin problems so treatments could be ordered. An aide later discovered a small coccyx pressure ulcer, which an RN assessed and covered with normal saline cleansing, ointment, powder, and a foam dressing. Review of records showed that no physician treatment orders were obtained for the ulcer over the following days, and during observed wound care an RN confirmed there was no ordered treatment in place, contrary to facility policy requiring evaluation, reporting, and documentation of skin changes and review of interventions.
Two residents with severe cognitive impairment and high fall risk did not receive required fall-related care. One resident experienced an unwitnessed fall captured on video, but the event was not documented in the medical record and the family was not notified. Another resident with multiple recent falls had a physician order and care plan for non-slip gripper socks while in bed, yet was observed in bed without the socks on or nearby, and a CNA confirmed they should have been in place.
Multiple residents did not receive ordered medications, including inhaled bronchodilators, antihypertensives, pain medications, lipid-lowering agents, GI medications, electrolyte supplements, and cognitive enhancers, at scheduled times. MARs showed missed doses or entries coded as "other" due to medications being on order or unavailable on the cart, and nursing notes either lacked reasons for omissions or only noted that drugs were on order or unavailable. Residents reported not consistently receiving their medications, and the DON confirmed the missed administrations and acknowledged there was no documentation that physicians were notified of these omitted doses, contrary to facility policy requiring timely administration per prescriber orders.
The facility failed to prevent significant medication errors for two residents. One resident with cellulitis and moderate cognitive impairment was ordered IV meropenem but instead was started on another resident’s IV daptomycin when an LPN did not double-check the medication before infusion and only recognized the error after the resident spoke up. Another resident with chronic respiratory failure, diabetes, depression, and anxiety had an order for lorazepam every eight hours for anxiety but missed multiple scheduled doses because the drug was unavailable, with incomplete documentation for the missed administrations; the resident and a psychotherapist reported the resident was very upset about not receiving the ordered medication, and an LPN confirmed the medication was not given due to lack of availability.
The facility failed to maintain required and comfortable room and common-area temperatures, with multiple locations measuring in the low-to-upper 60s and residents reporting feeling cold. Several residents with conditions such as diabetes, osteoarthritis, multiple sclerosis, hypothyroidism, depression, and anemia described persistently cold rooms, some for months, and were observed wearing extra clothing or blankets. A lounge heating unit was reported to blow only cold air, and a split heater in a resident room was described as not functioning correctly. CNAs stated that one hall was always freezing and that residents complained about cold temperatures and drafty windows, while leadership, including the DON and Administrator, reported they had not received complaints and attributed low temperatures to outside weather.
Surveyors found multiple instances of improper medication labeling and storage on two medication carts, including an unlabeled open vial of Lantus insulin that staff could only associate with a resident by process of elimination, and insulin vials where the open date was illegible or missing. Additional issues included an open Humalog pen without an open date, Lantus insulin with an open date suggesting use beyond the 28-day period, and loose, unidentified pills in a cart. These findings conflicted with the facility’s own policy requiring resident-specific labeling, dating of multi-dose vials, and storage of medications in their original packaging.
Surveyors found that the facility failed to protect two residents’ privacy and confidentiality. One resident’s identifiable medical information, including a medication list, name, photo, and room number, was left visible on an unattended medication cart computer in a hallway by an LPN, contrary to facility policy requiring screens to be locked when unattended. In a separate incident, an agency CNA provided incontinence care to another resident with the room door open and the privacy curtain not pulled, leaving the resident’s perineal area and buttocks visible from the hallway, despite no documented request by the resident to have the door remain open during care.
A resident with intact cognition and multiple medical conditions, requiring moderate assistance with bathing, did not consistently receive showers according to her stated preference to bathe before 7:30 A.M. The shower schedule listed specific days on day shift but did not reflect this time preference, and electronic records showed only one shower documented for an entire month, despite the resident reporting that staff sometimes did not provide showers and then recorded them as refusals. Nursing notes showed refusals when showers were offered after the resident’s preferred time, and the DON confirmed gaps in shower documentation, contrary to facility policy requiring bathing according to resident preferences and proper documentation.
A resident with multiple comorbidities and high risk for skin breakdown was care planned for incontinence-related skin monitoring but later developed moisture-associated skin damage (MASD) after being placed in incontinence briefs that were too small due to ongoing supply shortages. Nursing documentation noted redness once but did not include a comprehensive skin assessment of the MASD, and the wound nurse was not informed of the condition. Staff interviews revealed that larger-sized briefs were frequently unavailable, smaller briefs or doubled briefs were used as substitutes, and there was no systematic process in central supply to track residents’ brief sizes or determine appropriate quantities to order, leading to recurrent shortages and use of ill-fitting products.
Surveyors found that hazardous areas, including soiled and clean utility rooms, were left unlocked and accessible to residents on the memory care unit. The clean utility room contained germicidal wipes labeled to be kept out of reach, but these were stored within easy access. A supervisor confirmed the unsecured status and accessibility of these materials, in violation of facility policy and safety protocols.
A resident with multiple medical conditions was moved to a new room due to bed bugs, but the resident's representative was not notified in advance as required by facility policy. Staff interviews revealed that the responsibility for notification was not clearly executed, and the resident's family only learned of the change after the fact.
A resident with sepsis and osteomyelitis was admitted and required IV antibiotics, but experienced a significant delay in receiving the ordered medication due to issues with drug availability and delayed billing authorization for an alternative antibiotic. Despite ongoing communication between nursing, pharmacy, and administration, the necessary approval was not provided in a timely manner, resulting in missed doses and a delay in treatment.
A resident with multiple chronic conditions and urinary incontinence experienced a delay in assessment and treatment for a urinary tract infection after complaints of burning during urination were reported to an LPN. The symptoms were not documented or addressed for several days, and a urine specimen was not collected until days after the order was placed, resulting in a significant delay before antibiotic treatment was started.
The facility failed to maintain its boiler systems, resulting in ongoing inadequate hot water in resident areas. Staff, residents, and families reported cold or lukewarm water for weeks, impacting hygiene and daily care. Maintenance and contractor interviews confirmed only one boiler was operational, with hot water prioritized for kitchen and laundry, leaving resident rooms without sufficient hot water. Temperature checks and logs consistently showed water below the required 105°F, in violation of facility policy.
Surveyors identified that the facility failed to maintain adequate hot water for bathing, did not provide enough clean towels and washcloths for residents, and did not supply garbage bags for trash cans in resident rooms. Staff and families confirmed these issues had persisted for weeks to months, impacting residents' comfort and hygiene. Facility records and staff interviews supported ongoing problems with water temperature, linen shortages, and supply management.
Three residents receiving anticoagulant medications did not have comprehensive care plans addressing this therapy, despite physician orders and facility policy requiring such plans. Medical record reviews and staff interviews confirmed the absence of these care plans for residents with various diagnoses and cognitive statuses.
A resident with severe cognitive impairment and multiple psychiatric conditions did not have a care plan meeting offered for over five months, and the family was not properly notified or given the option for an in-person meeting as preferred. Facility staff confirmed that care conferences were typically conducted by phone, and documentation showed that invitations were only sent for phone meetings, resulting in the family not being able to participate in the care planning process as required.
A resident with multiple medical conditions did not have physician orders for orthostatic blood pressure monitoring followed, with incomplete or missing BP readings across several shifts. Despite multiple elevated BP results, nursing staff did not notify the physician or document any such notification, as confirmed by interviews with the DON, ADON, RN Coordinator, and the physician.
Meal trays were consistently delivered late to the Memory Care Unit, with staff and family members confirming delays of up to an hour past scheduled times. Observations showed residents waiting for meals, and both dietary and nursing staff acknowledged the recurring issue, despite facility policies requiring prompt meal delivery to ensure freshness and quality.
A nurse failed to follow infection control protocols by using bare hands to handle oral medication capsules and returning a touched capsule to the original medication bottle during administration to a resident with complex medical history. Facility policy and staff interviews confirmed that medications should not be handled with bare hands or returned to the bottle, indicating a lapse in infection prevention practices.
A resident diagnosed with dementia did not receive the necessary treatment and services to address their condition, resulting in a deficiency related to inadequate dementia care.
The facility did not consistently implement required interventions to manage and prevent pressure ulcers, resulting in inadequate care for a resident with existing or at-risk pressure ulcers.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, due to inadequate safeguards.
The facility did not provide adequate nursing staff to meet all residents' needs and failed to have a licensed nurse in charge on every shift, as required.
Several residents reported that their meals were unpalatable, cold, and difficult to eat, with test trays confirming that food and drink were served at inappropriate temperatures and lacked seasoning. Dietary staff verified these issues, and facility records showed ongoing concerns about ineffective warming plates.
The facility did not manage or allocate its resources in an effective and efficient manner, as required, resulting in a deficiency identified during the survey.
The facility's governing body failed to provide effective oversight and ensure compliance with financial obligations, resulting in nonpayment to key service providers such as the medical director, RD, landscaping, and spiritual care. Interviews revealed that both the administrator and board members were unaware of outstanding debts and board activities, and residents reported being denied access to their funds. This lack of oversight and management affected all residents in the facility.
Multiple areas of the facility, including resident rooms, shower rooms, and outdoor patios, were found to be unsanitary and poorly maintained. Issues included uncollected trash, food debris, grime, mildew, feces, urine stains, ants, and overgrown outdoor areas. Staff interviews confirmed that housekeeping was not consistently assigned to all units, resulting in incomplete cleaning and residents or their families having to clean rooms themselves.
A medication cart was left unlocked in the memory care unit dining room, with an open bottle of acetaminophen containing 15 to 20 tablets sitting on top. Nine residents with dementia were present in the area at the time. A CNA was assisting residents, and an LPN confirmed the cart was unsecured and the medication bottle was open, in violation of facility policy requiring medications to be locked and accessible only to authorized personnel.
A resident with dysphagia and cognitive impairments was not provided with food of the required smooth puree consistency, as both physician orders and facility policy specified. Observations and staff interviews confirmed that the puree chicken and vegetables served were lumpy, leading the resident to spit out the food. This issue had the potential to affect other residents on similar diets.
A resident with multiple medical conditions, who preferred to choose her own bedtime, was told by a CNA to go to bed while still eating dinner and was subjected to yelling and cursing directed at her son in her presence. The CNA removed the resident's dinner tray prematurely and insisted on an early bedtime, disregarding the resident's preferences and dignity, as confirmed by interviews and record review.
A resident's right to manage their own financial affairs was not honored, resulting in a violation of federal regulations regarding resident autonomy.
A resident with multiple diagnoses was administered Depakote despite the POA's explicit request to hold the medication until further discussion with the psychiatric provider. The POA's concerns were not effectively communicated among nursing staff, leading to the medication being given over several days. Some LPNs were unaware of the hold request, and documentation in the communication book was not consistently reviewed.
Staff did not promptly inform a resident, their physician, and a family member about important events such as injury, decline, or room changes, resulting in a breakdown of required communication.
A resident with dementia and a history of wandering and aggressive behaviors was admitted to the secure/memory care unit without an assessment to determine appropriateness for placement. The DON confirmed that the required assessment was not completed prior to admission, and only after placement was the resident's severe mentation impairment and exit-seeking behavior documented. This deficiency was identified during a complaint investigation.
A resident with dementia, behavioral issues, and a history of aggression was admitted without an individualized care plan or documented interventions for behaviors, despite known concerns and diagnoses. The DON expressed reservations about the admission and no immediate strategies were communicated to CNAs or implemented to address the resident's behavioral needs.
A resident dependent on staff for bathing, with multiple chronic conditions and cognitively intact, did not receive the required two showers per week as per facility policy. Documentation and interviews confirmed that only one shower per week was provided, with staff citing insufficient staffing as the reason for not meeting the resident's bathing preferences.
The facility failed to pay multiple vendors, resulting in interruptions to essential services such as trash removal, oxygen supply, staffing, linens, and laundry chemicals. Staff and residents reported shortages of basic care items, with staff resorting to cutting towels for use as washcloths and garbage accumulating in non-resident areas. The Administrator was often unaware of the extent of unpaid bills or service holds, and procurement was inconsistent, sometimes requiring staff to purchase supplies from retail stores. These actions and inactions led to potential neglect affecting all residents.
The facility did not ensure that care plans were comprehensive for two residents, one with severe cognitive impairment and behavioral symptoms, and another with multiple medical conditions and unstageable pressure ulcers. Staff were aware of the residents' needs and interventions were recommended, but these were not documented in the care plans, nor were specific instructions provided to staff. Facility policy required all identified needs to be addressed in the care plan, but this was not done.
Failure of Administration to Ensure Effective Staff Orientation, Reporting, and Response to Abuse/Neglect Concerns
Penalty
Summary
The deficiency involves ineffective facility administration that failed to ensure appropriate staff orientation, reporting, and follow-up of resident abuse and neglect concerns. A CNA was observed kicking a resident’s bed and hitting the resident with a closed fist. Review of this CNA’s Nursing Orientation Checklist showed the second page, which should have covered multiple care and safety topics such as resident property procedures, falls management, gait belt and safe transfers, use of mechanical lifts, call system basics, alarms, shift-to-shift walking rounds, morning care, management of difficult behaviors, avoiding bruising and skin tears, dementia bathing, restraints, and mood and behavior patterns, was incomplete and lacked signatures or dates from the employee or the orienting staff. Human Resources confirmed these orientation deficiencies. In addition, one resident reported an allegation of neglect to nursing staff, but this was not reported to administrative staff and no investigation was initiated; the Administrator confirmed he had not been informed of this allegation. Staff also failed to report that other staff were taking pictures of another resident during care, and failed to report and adequately assess and monitor bruising on a different resident’s right arm, as confirmed by the Administrator and DON. The Administrator and DON stated they had taken over a failing building and were in the process of replacing staff, and the Administrator confirmed he had assumed responsibility months earlier. The Medical Director reported he was not aware of the identified concerns and would need to work with administration to correct issues for effective administration.
Failure to Provide Scheduled Bathing and Grooming Assistance for Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide scheduled assistance with activities of daily living (ADLs), specifically bathing and grooming, to multiple residents who were dependent on staff for these services. Resident #1, admitted with chronic respiratory failure, diabetes mellitus, and repeated falls, had intact cognition and was dependent on staff for ADLs. His shower schedule indicated showers on Sunday and Thursday afternoons, but review of shower sheets and the electronic medical record from 01/01/26 through 03/01/26 showed multiple missed showers on specific dates. In interview, he reported that he was not receiving showers as scheduled and usually only received one shower per week, despite his preference for at least two showers weekly. The DON confirmed that all available shower documentation had been provided. Resident #4, with chronic kidney disease, hypertension, hemiplegia of the left non-dominant side, and anxiety, also had intact cognition and required substantial to maximum assistance for showers and bathing. Her shower schedule listed showers on Mondays and Thursdays on dayshift, yet documentation from 01/01/26 through 03/01/26 showed numerous dates on which showers were not provided. In interview, she stated she was not getting showers as scheduled according to her preferences. Resident #57, admitted with depression, chronic pain, and anemia, had intact cognition, no behaviors or rejection of care, needed substantial to maximum assistance for showers, and was occasionally incontinent of urine. Her shower schedule also indicated Monday and Thursday showers on dayshift, but records showed several missed showers over the same review period. She reported that she was not getting showers as she should and had to argue with staff to receive some showers. The DON verified that all shower documentation for these residents had been provided. Resident #13, admitted with Alzheimer’s disease, senile degeneration of the brain, depression, adult failure to thrive, history of falling, and unspecified dementia, had a moderate cognitive impairment. Observations on two separate days showed that this female resident had a significant amount of grey/white chin hair approximately one inch long. An LPN confirmed that the resident was unable to complete her own shaving and that someone would shave her. In a subsequent interview, the resident stated she preferred to have her chin hair shaved and requested shaving at that time; observation showed the chin hair was still present, and another LPN acknowledged the chin hair had not been shaved and said she would find someone to assist. Review of progress notes and behavioral tracking for March 2026 revealed no refusals of care related to shaving or personal care. The resident’s care plan documented a self-care deficit with goals for her to be clean and well-groomed, including dependent assistance with personal hygiene and bathing. The facility’s ADL policy required provision of appropriate support and assistance with hygiene, grooming, and other ADLs for residents unable to perform them independently, which was not followed for these residents.
Failure to Honor Resident Dietary Preferences and Assist With Menu Selection
Penalty
Summary
The deficiency involves the facility’s failure to honor and manage residents’ dietary preferences and menu choices in accordance with its own policies and physician/dietary orders. For one resident with Alzheimer’s disease and severe cognitive impairment, records showed orders for a regular mechanical soft diet with thin liquids and ice cream at lunch and dinner, along with a low BMI and moderate assistance needed for eating. Despite this, there was no documentation of updated dietary preferences, no evidence of family involvement in nutrition assessments, and no changes to the nutrition care plan over several months. The resident’s son reported that, due to her cognitive impairment, she could not remember to request alternative food items and that the family had not been asked to update preferences or informed they could complete weekly menus. Another resident, admitted with a fracture, anxiety disorder, morbid obesity, and intact cognition but dependent for all ADLs, had a physician order for a regular diet with thin liquids. The nutrition assessment and care plan noted a regular diet, set-up assistance, and some meal refusals, but did not document specific dietary preferences. This resident reported telling staff on the first day that chicken was disliked and being told the kitchen would be informed, yet continued to receive chicken. The resident also stated that daily menus were provided but staff did not consistently assist with filling them out. Review of the diet ticket confirmed a regular diet with no listed preferences or chicken dislike, and the RD acknowledged the absence of documented preferences and uncertainty about whether staff consistently passed out and assisted with daily menus. A third resident with unspecified dementia and a regular diet order had a care plan intervention to review food likes, dislikes, and meal preferences as needed. During a breakfast observation, the resident received a tray containing items such as a hard-boiled egg, oatmeal, hash brown, and a pastry, while the ticket listed cereal, hard-boiled egg, blueberry muffin, hash brown, milk, coffee, and juice. The resident appeared upset and stated only frosted flakes, coffee, and milk had been requested. A CNA confirmed the tray was incorrect and commented that dietary staff frequently made errors with residents’ orders. After the correct items were brought, the resident expressed ongoing dissatisfaction and confusion about why meals were always wrong. The RD later acknowledged awareness of this concern and stated that dietary staff were having difficulty knowing what each resident wanted. Review of facility policies showed that diets were to be determined in accordance with residents’ informed choices, preferences, treatment goals, and wishes, and regularly reviewed by the dietitian, nursing staff, and physician.
Failure to Maintain Palatable and Safe Meal Temperatures During Tray Service
Penalty
Summary
The facility failed to ensure that meals provided from the kitchen were palatable and maintained at safe and appetizing temperatures for residents, affecting at least two residents and potentially all residents receiving kitchen-prepared meals. One resident, admitted with a fracture of the lower end of the right radius, anxiety disorder, morbid obesity, and requiring assistance with all ADLs including eating, had a regular diet with thin liquids and intact cognition per a BIMS score of 13. This resident reported that food was not always hot by the time staff were able to assist with meals. Another cognitively intact resident, admitted with bilateral patella fractures, osteoporosis with current fracture, CHF, and CKD, and who was independent with eating, also had a regular diet with thin liquids and reported that meals were frequently cold and did not taste good. Surveyor observations of the meal service showed that hot foods on the steam table initially met appropriate temperatures, but meal trays were then loaded onto 11 delivery carts that had no heat or refrigeration sources. Disposable Styrofoam plates and cups with dome lids and paper bowls for soup were used due to dish machine repairs. When a test tray was evaluated after the last resident tray was served, several items were found at inadequate temperatures: yogurt at 73°F, milk at 61.3°F, mashed potatoes at 132.4°F, mechanical chicken at 101.3°F, and pureed bread at 119.3°F. The Dietary Director confirmed that cold items were not held at appropriate temperatures and stated that, from a personal perspective, the hot foods were not warm enough and some items were bland and needed more seasoning. The facility’s Community Dining and Meal Service Policy required that individuals be provided with nourishing, palatable, attractive meals that support nutritional and special dietary needs, which was not met under these observed conditions.
Failure to Maintain Safe, Functional Kitchen Equipment
Penalty
Summary
The facility failed to ensure essential kitchen equipment was maintained in safe, proper working order, specifically a high-temperature dishwasher and a commercial food processor (Robot Coupe). Surveyors observed the dishwasher operating with a visible leak, with water running out from under and along the side of the machine, down the wall near electrical outlets, and pooling on the floor to a depth of about an inch where staff were standing in wet shoes while operating it. A dish room worker stated it was a pain to stand in the water while keeping dishes moving. The Dietary Supervisor confirmed the dishwasher had been leaking for about three weeks. Maintenance work orders documented a critical-priority leak on one date that was marked completed the same day, and another critical-priority work order the next day stating the leak persisted and was worsening, which was also marked completed later that day. The Maintenance Director reported the concern was first reported when he was off work, that he attempted a repair when he returned, and that the leak continued to worsen. The Dietary Director stated the dishwasher was not actually fixed until a later date, and a plumbing contractor confirmed they were not contacted about repairs until after the surveyors were on site, despite prior failed repairs that had caused leaks. The facility also failed to maintain the Robot Coupe food processor in proper working condition. During observation of pureed food preparation, the food processor was missing the center part of the cover that both sealed the lid and allowed scraping of the sides while the machine was running. The Dietary Supervisor attempted to cover the opening with aluminum foil, but when the machine was turned on, soup sprayed out from under the foil onto the surrounding countertop and onto dishes on a nearby rack. The Dietary Supervisor confirmed the missing part made it more difficult and time-consuming to achieve a smooth puree and that the part had been missing for at least several weeks, with uncertainty about whether it had been ordered. Text messages and emails showed that information for ordering the necessary parts had been sent to corporate dietary staff, that a quote was being obtained, and that the parts were eventually ordered, but the Dietary Manager confirmed the replacement part had not yet been received at the time of the survey. The facility’s policy stated that all foodservice equipment would be clean, sanitary, and in proper working order and routinely maintained per manufacturer directions.
Failure to Maintain Clean, Sanitary, and Well-Maintained Resident Environment and Equipment
Penalty
Summary
Surveyors identified that the facility failed to ensure a clean, sanitary, and well-maintained environment and failed to maintain patient care equipment in good repair for multiple residents. During observations conducted with the Maintenance Director, one resident’s bed remote had exposed wires with tape wrapped around the cord from about halfway up to the remote, while another resident’s curtain rod was bent and hanging down at an angle above the bed. Additional observations showed stained carpet and deep drywall scratches with missing paint in two residents’ rooms, and another resident’s carpet with multiple stains. A further observation of a resident’s wheelchair revealed dried brown debris on both footrest clips, which the resident’s daughter stated was probably dried stool. The Maintenance Director confirmed these environmental and equipment concerns, and facility policy on a homelike environment stated residents were to be provided with a safe, clean, comfortable, and homelike environment.
Failure to Maintain Clean Rooms and Adequate Linens for Residents
Penalty
Summary
The deficiency involves the facility’s failure to maintain clean, sanitary, and homelike resident rooms and linens for two residents. One resident with chronic kidney disease, diabetes mellitus, heart failure, and anxiety, who had intact cognition and was dependent on staff for hygiene and transfers, was observed in bed with dirty bed linens draped over his wheelchair, dirty incontinence wipes on the floor beside his bed, and a bed pad with creams and medications on the corner of his tray table. His recliner had a white powdery substance on the back and seat. The resident stated these items were left by midnight shift staff who did not remove the dirty items from his room. A psychotherapist present for at least 30 minutes confirmed no staff had entered the room during that time. A CNA who entered the room acknowledged the presence of the dirty wipes, soiled linens, and incontinence care items on the tray table, and stated the soiled linens had not been there when she provided care earlier. She removed items and cleaned the room but did not clean or disinfect the tray table before later placing the resident’s lunch tray on it, and she confirmed she had not properly cleaned the tray table prior to serving the meal. The resident further reported that staff did not clean his room before leaving and that agency staff did not know how to do their job. The second resident, admitted and re-admitted with diagnoses including psychotic disorder with delusions, hemiplegia, and quadriplegia, and with intact cognition, was observed with four pillows behind her head without pillowcases. She confirmed she had no pillowcases and wanted them but did not know why they were missing. A CNA confirmed the lack of pillowcases and attributed it to the midnight shift forgetting them. Later, an RN confirmed the pillows still had no pillowcases and stated CNAs refused to provide care. On a subsequent day, the resident had four pillows under her head, with only two covered by pillowcases and two plastic pillows without cases; she reported staff had run out of pillowcases. Two CNAs stated the floor supply closet did not have enough pillowcases for the resident’s pillows. However, observation of the second-floor linen supply closet showed three pillowcases available, and a laundry aide showed a laundry cart with approximately seven or eight folded pillowcases and stated the facility had an appropriate number of linens, including pillowcases, and that a linen cart was sent to the floor twice daily. These conditions conflicted with the facility’s Homelike Environment policy requiring a clean, sanitary, orderly environment and clean bed and bath linens in good condition.
Failure to Protect Cognitively Impaired Hospice Resident From Physical Abuse by CNA
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from physical abuse. The resident had diagnoses including neurocognitive disorder with Lewy Bodies dementia, generalized anxiety disorder, and late-onset Alzheimer’s disease, and was receiving hospice services. An admission MDS showed severe cognitive impairment and a need for maximum assistance with toileting hygiene, and the care plan documented self-care deficits and functional decline requiring staff assistance with ADLs. On the evening of the incident, a nursing progress note documented that a skin sweep revealed no areas of concern, no signs of pain or distress, and that the resident was resting in bed, with no indication that the family had reported abuse or provided an in-room video at that time. Video surveillance from the resident’s room on the date of the incident showed multiple interactions between the resident and a CNA. In one video, the CNA entered the room and kicked the right side of the resident’s mattress twice with her right foot, causing the resident’s legs to lift up and down with each kick, then removed the covers without speaking. The resident stated, “You don’t like me,” to which the CNA replied, “Yes, I do,” and then walked toward the bathroom door; when the resident repeated, “No, you don’t like me,” the CNA did not respond. In another video, the CNA entered, pulled back the covers, and tapped the resident’s left leg with a gloved fist without appearing to speak, while the resident’s hands were up as if in confusion, and the CNA left the room without further interaction, leaving the resident appearing confused. A third video showed the CNA providing incontinence care. During this care, the resident repeatedly expressed gratitude and positive comments such as “Thank you,” “I like you a lot,” and “You’re so good at what you do,” without receiving any verbal response from the CNA. Later in the same video, the CNA told the resident to stand up; as the resident moved toward the edge of the bed and asked for clarification, the CNA, walking toward the bathroom, told her in a loud and aggressive tone to “Hold on, hold on.” When the resident attempted to get out of bed and placed her leg on the wheelchair seat, the CNA told her “No, sit down” and then ordered her in a loud aggressive manner to “Sit back.” A police report documented that the family reported seeing, via an in-room camera, the CNA appear to strike the resident’s leg with her hand and, in a second video, appear to either kick the resident’s leg twice or kick the mattress more forcefully than the hand strike. The police officer viewed the videos, spoke with the CNA, and noted the CNA denied striking the resident, stating she had used the bed frame to scratch an itchy foot while wearing gloves and that she did not lose her temper or patience. The facility’s self-reported investigation described the CNA contacting the bed frame with her foot in a non-aggressive manner and touching the resident’s leg as a cue during care, and concluded the allegation as unsubstantiated. However, interviews with facility staff, including an LPN and an RN coordinator who viewed the videos, described the CNA’s actions as an aggressive slap to the leg and a purposeful kick to the bed, and indicated they did not feel the CNA’s care was appropriate. Additional documentation showed that a skin assessment the day after the incident identified a skin tear to the resident’s left pinky toe, later documented as a scratch to the right foot pinky toe with treatment ordered and then discontinued when healed. Interviews revealed that another CNA working on the unit was not asked for a witness statement, the resident was unable to provide information due to severe cognitive impairment, and the social worker reported the resident was not provided psych services following the incident. The hospice RN stated hospice was not notified of the abuse allegation, and the medical director did not recall being notified. The facility’s abuse, neglect, exploitation, and misappropriation policy required investigation of all alleged violations and immediate reporting to the administrator and, when a crime is suspected, to law enforcement. The surveyors determined that the facility failed to ensure the resident was free from physical abuse based on the observed actions on video and corroborating staff interviews.
Failure to Report Alleged Abuse, Neglect, and Injury of Unknown Origin
Penalty
Summary
The deficiency involves the facility’s failure to follow its abuse, neglect, and injury-of-unknown-origin reporting policy in multiple situations. One cognitively intact resident with significant cardiopulmonary diagnoses, including ischemic cardiomyopathy, acute respiratory failure with hypoxia, chronic atrial fibrillation, COPD with acute exacerbation, and diabetes, had an order for continuous oxygen via nasal cannula. The resident reported that, after falling asleep in his motorized wheelchair, his portable oxygen battery lost charge and he became short of breath. He stated that when he urgently requested help from a CNA to change the battery, she told him not to be rude, changed the battery but did not turn the oxygen machine back on, and then told him to turn it on himself when he asked her to do so. The resident reported he then sought help from other CNAs on another hall, who turned the oxygen on and assisted him, and that he felt the CNA’s actions were an act of abuse and attempted murder, leading him to call 911. He reported this allegation to a unit manager LPN, who acknowledged being told of the incident and the resident’s belief that it was attempted murder, but did not report it to the Administrator. The facility did not self-report this allegation to the State Agency, and there was no nursing progress note or respiratory assessment documenting the incident. The deficiency also includes the facility’s failure to identify and report an injury of unknown origin for a resident with adult failure to thrive, paranoid schizophrenia, and dementia, who had severely impaired cognition. A nurse practitioner note shortly before the survey documented intact skin with no bruising, and the resident was not on anticoagulant or antiplatelet therapy. During observation, surveyors noted a purplish-red, circular bruise approximately the size of a half dollar on the resident’s right forearm, which the resident could not explain. A subsequent observation showed the bruise diminishing in size and color. The Director of Resident Services and Regional Director of Clinical Services confirmed the presence of the bruise and that staff had not documented it or completed an assessment. An LPN reported she had noticed the bruise but believed it was old, marked “no new skin issues” on the shower sheet, and did not report the bruise or complete any statements, despite the facility policy requiring investigation and reporting of injuries of unknown source. A further component of the deficiency concerns staff concerns and alleged neglect of care for another resident receiving hospice services, who had severely impaired cognition, was dependent on staff for toileting, and was occasionally incontinent of bowel. The resident’s care plan required staff assistance with ADLs and specified that the resident would be kept clean and well groomed, with staff treating the resident respectfully during care. Undated photographs submitted via a complaint to the State Agency showed an unidentified male, identified in the complaint as this resident, naked and covered in dried brown feces. The Administrator and DON stated they were unaware of pictures taken by staff of this resident during care. One CNA reported that another CNA had spoken to him about taking pictures of the resident to send to the State Agency, but he did not report this to his supervisor or the DON, assuming nursing staff at the nurse’s station had heard the conversation. An LPN also reported hearing rumors that an aide took pictures and was sending them to the State regarding lack of care for residents, but she did not inform the DON. These events occurred despite a written facility policy requiring staff to immediately report all allegations of abuse, neglect, exploitation, mistreatment, misappropriation of resident property, and injuries of unknown source to the Administrator and the State Agency.
Failure to Investigate Abuse Allegation and Injury of Unknown Source
Penalty
Summary
The deficiency involves the facility’s failure to conduct and document a complete investigation into an abuse allegation involving Resident #117. This resident, admitted with neurocognitive disorder with Lewy Bodies, generalized anxiety disorder, chronic pain syndrome, and Alzheimer’s dementia, had a BIMs score indicating severe cognitive impairment and required maximum assistance with toileting. A family member reported to police that an in-room camera showed a CNA kicking the resident’s bed, prompting police and family to come to the facility. The facility’s Self-Reported Incident noted the allegation and that the resident could not provide meaningful information due to dementia, and that no negative effects were observed at the time. However, the investigation file contained only a written statement from the accused CNA and a census sheet with check marks indicating residents felt safe, without documentation of individual resident responses or how non-interviewable residents were assessed. Further interviews revealed that staff who were present when police reviewed the video, including an RN Coordinator and another CNA, were not asked to provide witness statements. The DON confirmed she could not provide written evidence of staff interviews beyond the CNA’s statement or individual resident interview responses. The Medical Director did not recall being notified of the abuse allegation. The facility’s abuse policy required that all alleged violations involving abuse, neglect, exploitation, mistreatment, or misappropriation of resident property be investigated, including interviewing the resident, the accused, and all witnesses, and documenting evidence of the investigation. These policy requirements were not met in the handling of the allegation involving Resident #117. The deficiency also includes the facility’s failure to investigate an injury of unknown source for Resident #47. This resident, with adult failure to thrive, paranoid schizophrenia, and dementia, had severely impaired cognition and was documented as having intact skin with no bruising to the extremities in a recent NP note. She was not on anticoagulant or antiplatelet therapy. During surveyor observation, a circular purplish-red bruise approximately the size of a half dollar was noted on her right forearm, which the resident could not explain. There was no nursing documentation of the bruise, no assessment, and no investigation in the record. The Regional Director of Clinical Services and the DON confirmed that staff had not documented or investigated the bruise, and an LPN acknowledged noticing the bruise but did not report it or complete any statements. The facility’s abuse policy defined injuries of unknown source and required immediate reporting and investigation of such injuries, which did not occur in this case.
Missed Antibiotic Doses and Unperformed Wound Treatments for Resident With Diabetic Foot Ulcers
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered wound care treatments and prescribed antibiotics for a resident with multiple diabetic foot ulcers and recent right great toe amputation. The resident, who had Alzheimer’s disease, peripheral vascular disease, and documented memory problems, was readmitted after hospitalization for sepsis and osteomyelitis, during which the right great toe and associated structures were amputated and a right heel wound was debrided and treated with a wound vac. Infectious Disease ordered a six-week course of Doxycycline and Augmentin. Physician orders specified Doxycycline 100 mg orally twice daily for a wound infection, but the MAR showed multiple missed doses on several mornings and one evening with no evidence of administration. The resident had numerous documented wounds, including a right second toe diabetic ulcer with necrotic eschar, a right plantar foot diabetic wound with depth and tunneling, a right fourth lateral toe web ulcer with granulation tissue, a right fourth toe tip ulcer with eschar, a right great toe amputation site with granulation tissue, and a left plantar foot diabetic ulcer. Physician orders detailed specific wound care regimens for each site, including cleansing with normal saline, patting dry, applying calcium alginate, mesalt rope packing, oil emulsion, betadine, and appropriate dressings such as abdominal pads and kerlix, to be completed daily and as needed until resolved or healed. These orders were updated over time to reflect changes in wound status and treatment approach, including packing of the right plantar wound tunneling and shift-based care for the left medial plantar foot. Review of the treatment administration records revealed no evidence that ordered wound care was completed on multiple dates for the right second through fifth toes, the right plantar foot incision, the right fourth lateral toe, the right great toe amputation site, and the left medial foot. The wound nurse confirmed during interview that the resident’s diabetic foot ulcers began as a closed callus and became necrotic within two days, leading to hospitalization for osteomyelitis and amputation, and also confirmed she was unaware that multiple doses of Doxycycline had not been administered and that the medical record lacked documentation of wound care for multiple wounds. The wound NP reported the resident had multiple incisions and gangrenous toes, self-propelled and hit his feet on objects on the secured memory care unit, and had poor nutrition, but denied concern with the wound care. The facility’s wound care policy stated its purpose was to provide guidelines for wound care to promote healing, yet the record review showed missing antibiotic administrations and undocumented wound treatments contrary to physician orders.
Failure to Obtain Treatment Orders and Implement Care for New Pressure Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to implement pressure ulcer prevention interventions and obtain timely treatment orders after a pressure ulcer was identified. Resident #10 was admitted with diagnoses including heart failure, diabetes mellitus, and muscle weakness. A comprehensive MDS assessment showed the resident was dependent for toileting, showers, and transfers, was occasionally incontinent of bowel, and had no documented skin impairment at that time. The care plan identified the resident as at risk for skin breakdown due to bowel incontinence, an indwelling device, impaired mobility, weakness, and age-related changes, with interventions that included notifying the physician of skin problems so that treatments could be initiated per orders. On 03/02/26 at 10:41 p.m., a nursing progress note documented that an aide discovered a pressure wound on the resident’s coccyx. The nurse assessed the wound, which measured 0.5 cm by 0.2 cm with scant bleeding, and cleaned it with normal saline, applied Vitamin A and D ointment and powder, and placed a dry foam dressing. However, review of physician orders from 03/02/26 through 03/04/26 at 2:00 p.m. showed no treatment orders for the coccyx pressure ulcer. During observation of wound care on 03/04/26 at 2:01 p.m., the RN confirmed there was no treatment in place for the coccyx ulcer and verified there had been no physician orders for wound care or treatment from the time the wound was first observed until that date. This was inconsistent with the facility’s “Prevention of Pressure Injuries” policy, which required evaluation, reporting, and documentation of skin changes and review of interventions for effectiveness.
Failure to Document Fall and Implement Ordered Fall-Prevention Interventions
Penalty
Summary
The deficiency involves the facility’s failure to ensure a thorough fall investigation and proper documentation for one resident and failure to implement ordered fall-prevention interventions for another. One resident with Lewy Bodies dementia, Alzheimer’s disease, chronic pain syndrome, severe cognitive impairment, and a documented high risk for falls had a care plan that included analyzing previous falls, keeping the call light accessible, and assessing factors leading to any fall with notification of the physician and family. Video surveillance showed this resident on the floor in front of her door at 2:08 A.M., appearing to have fallen, with two staff members responding. However, this fall was not documented anywhere in the medical record, and the resident’s family confirmed they were not notified of the fall. The second resident, admitted with Alzheimer’s disease, essential hypertension, generalized anxiety disorder, severe cognitive impairment, and a high fall risk, had a physician’s order and care plan intervention for non-slip gripper socks to be worn while in bed as tolerated. This resident had sustained multiple falls in the weeks prior. During observation, the resident was lying in bed with both feet uncovered, and non-slip socks were not on the resident, on the bed, or on the floor near the bed. A CNA confirmed that the resident was supposed to have bilateral gripper socks on while in bed and that they were not present, despite the resident’s history of falls and the existing order and care plan intervention. The facility’s falls policy required monitoring and documenting residents’ responses to fall interventions and re-evaluating interventions if falls continued.
Failure to Administer and Document Ordered Medications and Physician Notification
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to ensure medications were administered as ordered and in accordance with physician prescriptions and facility policy. For one resident with chronic respiratory failure, diabetes mellitus, chronic kidney disease, and depression, physician orders included Albuterol Sulfate inhalation three times daily for shortness of breath, Clonidine every eight hours for hypertension, Gabapentin three times daily for pain, and Hydralazine three times daily for hypertension. Review of the MAR showed these medications were not administered on multiple specified dates and times, and nursing progress notes contained no explanation for the missed doses and no documentation that the physician was notified. The resident reported that at times medications were not administered as ordered, and the DON confirmed the medications were not given and could not explain why, nor was there documentation of physician notification. For a second resident with chronic kidney disease, depression, anxiety, and diabetes mellitus, physician orders included Gabapentin three times daily for pain, Lipitor at bedtime for hyperlipidemia, Pantoprazole Sodium in the morning for GERD, and cranberry twice daily for UTI prophylaxis. The MAR for January and February showed a code indicating “other” for several scheduled doses of these medications. Nursing progress notes documented that Gabapentin, Lipitor, and Pantoprazole were not administered because they were on order, and cranberry was not administered because it was unavailable on the cart. There was no documentation that the physician was informed that these medications were not administered. The resident reported not receiving medications as expected, and the DON verified the missed doses and lack of physician notification. For a third resident with paranoid schizophrenia, adult failure to thrive, depression, pain, and dementia, physician orders included Aricept in the afternoon for Alzheimer’s disease and Sodium Chloride tablets three times daily for low sodium. The MAR for February and March showed a code indicating “other” for multiple scheduled doses of Sodium Chloride and one dose of Aricept. Nursing progress notes indicated that Sodium Chloride and Aricept were on order and not available to be administered on the documented dates and times. There was no documentation that the physician was updated about these missed doses. The DON confirmed that the resident did not receive the ordered Sodium Chloride and Aricept doses and that the physician was not notified. Facility policy required medications to be administered in a safe and timely manner in accordance with prescriber orders, including required time frames.
Failure to Prevent Significant Medication Errors for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were free from significant medication errors. One resident with cellulitis, anemia, and depression, and with moderate cognitive impairment, had a physician’s order for IV meropenem every eight hours for cellulitis of both lower extremities. The care plan included administering medications as ordered. On one occasion, an LPN attempted to administer the ordered meropenem but instead hung and began infusing daptomycin, an IV antibiotic intended for another resident. The LPN did not double-check the medication before starting the infusion and only realized the error after the resident reported receiving the wrong medication approximately ten minutes after the infusion had started. Documentation showed the meropenem was recorded as administered, and both the resident and the LPN confirmed that the wrong antibiotic had been started. Another resident with chronic respiratory failure, diabetes mellitus, depression, and anxiety had a physician’s order for lorazepam 1 mg every eight hours for anxiety. Review of the MAR showed multiple missed doses over several days, with entries indicating the drug was not available and that pharmacy delivery was pending. Nursing progress notes documented that the medication was on order and unavailable, but there was no documentation explaining why lorazepam was not administered on subsequent days when doses were also missed. The resident reported not receiving medications as ordered and stated the facility had failed to order the medication. A psychotherapist reported the resident had high anxiety and was very upset about not receiving the ordered medication, and an LPN confirmed the lorazepam was not administered as ordered because it was unavailable, contrary to the facility’s policy that medications are to be administered in a safe and timely manner as prescribed.
Failure to Maintain Safe and Comfortable Room Temperatures for Residents
Penalty
Summary
The deficiency involves the facility’s failure to maintain resident rooms and common areas within required temperature ranges and for resident comfort. During a survey on 01/28/26, maintenance staff used an ambient thermometer and identified multiple rooms and lounges with temperatures below regulatory standards, ranging from 62 to 70 degrees Fahrenheit. In one shared room, the temperature measured 67 degrees on one side and 65–66 degrees on the other, and both residents reported feeling cold, with one wearing a sweater. Several common areas, including lounges and a memory care lounge, were also found to be cold, with one lounge measuring 62–66 degrees and another at 69 degrees, where residents were observed wrapped in blankets. Multiple residents with significant medical histories were affected and reported ongoing cold conditions. One resident with type 2 diabetes mellitus and hypertension reported that the room “stayed cold” and stated that staff who entered the room commented on how cold it was, but she had not seen anyone monitor the temperature after these complaints. Another resident with osteoarthritis, peripheral autonomic neuropathy, and adrenal gland disorders, who was cognitively intact, stated she had spoken to multiple nurses about the cold room and that nearly every staff member entering the room remarked on how cold it was. A cognitively intact resident with multiple sclerosis, hypothyroidism, depression, and anemia reported that her room had been cold for two months, that cold air hit her in the face when she returned to the room, and that she had spoken to multiple nurses, other staff, and the Administrator about the issue. Staff interviews and equipment issues further contributed to the deficiency. The maintenance technician reported that a wall heating unit in one lounge was not working and that he had turned it off because it was only blowing cold air; he also stated that a split heater unit in another resident’s room did not function correctly. CNAs described one hall as “always freezing,” especially certain rooms, and reported that residents complained about cold temperatures, with one resident routinely wearing mittens and others requesting plastic on drafty windows. Despite these conditions and resident complaints to various staff, the DON stated that nobody had reported problems maintaining appropriate room temperatures and that no residents had requested room changes due to cold, and the Administrator denied receiving any complaints about room temperatures, attributing the low readings to extremely cold outside weather.
Improper Labeling and Storage of Insulin and Other Medications
Penalty
Summary
Surveyors identified a failure to ensure medications remained in their original labeled packaging and that insulin products were properly labeled and not used past expiration. During observation of the Ridgeview medication cart with an LPN, an open vial of Lantus insulin was found without any label indicating the resident’s name, instructions for use, or the date it was opened. The LPN stated it must belong to a specific resident because he was the only one on that cart receiving Lantus, but confirmed the vial was unlabeled and would need to be discarded. In a separate observation, an RN prepared and administered insulin lispro to another resident from a vial whose refill date was visible but whose open date was illegible; a pharmacy representative confirmed the open date could not be read and that the insulin therefore should not be used. Further review of the Southern Hills medication cart with the RN revealed additional medication storage issues. One resident had an open Humalog insulin pen with no documented open date. Another resident had Lantus insulin labeled with an open date of 12/23/25, raising concern in light of reference information indicating opened insulin should be discarded after 28 days. Surveyors also found two loose, unidentified pills in the cart. Review of the facility’s Medication Labeling and Storage policy showed that medication labels must include the resident’s name, multi-dose vials must be dated when opened and discarded within 28 days unless otherwise specified, and medications must be stored in the original packaging or dispensing systems in which they were received. These observations demonstrated noncompliance with the facility’s own policy and accepted standards for medication labeling and storage.
Failure to Maintain Medical Record Confidentiality and Privacy During Personal Care
Penalty
Summary
The facility failed to maintain the privacy and confidentiality of one resident’s medical record when an LPN left a medication cart computer screen unattended in a hallway with identifiable medical information visible. For Resident #118, who had intact cognition and multiple diagnoses including diabetes, mild cognitive impairment, hypothyroidism, hypertension, generalized anxiety disorder, dementia, personality disorder, peripheral vascular disease, and bipolar disorder, surveyors observed that the computer screen on the unattended medication cart displayed the resident’s medication list along with the resident’s picture, name, and room number. The LPN later confirmed she had left the medical information visible and acknowledged she was supposed to lock the screen before walking away, contrary to the facility’s written policy on confidentiality and personal privacy. The facility also failed to ensure privacy during personal care for another cognitively intact resident with incontinence. Resident #54, who had diagnoses including anemia, hypothyroidism, chronic pain, hearing loss, viral herpes, major depressive disorder, insomnia, restless leg syndrome, rhinitis, and hypertension, was care planned to receive assistance with toileting and incontinence care. During observation, an agency CNA provided incontinence care with the resident’s door open and the privacy curtain not pulled, leaving the resident’s perineal area and buttocks visible from the hallway. The CNA stated the resident did not like her door closed but acknowledged she could have pulled the privacy curtain. The resident later reported she had never told staff to leave the door open during care and that most staff usually closed the door or at least pulled the curtain, and the care plan contained no documentation that the resident requested the door remain open during care, which conflicted with the facility’s policy to safeguard personal privacy.
Failure to Honor Bathing Preferences and Document Showers
Penalty
Summary
The facility failed to ensure a resident’s bathing preferences were accommodated and that showers were consistently provided and documented. The resident, who had intact cognition and did not refuse care per the Quarterly MDS, required moderate assistance with bathing and had multiple medical diagnoses including volvulus, UTI, osteoarthritis, peripheral neuropathy, breast cancer, skin cancer, acute embolism of the right lower extremity, and osteoporosis. Nursing notes documented that the resident refused showers on two occasions when staff attempted to bathe her after 7:30 A.M., stating she would not take a shower after that time. The shower schedule indicated the resident was to receive showers on the day shift on Mondays and Thursdays, but it did not reflect her preference to bathe before 7:30 A.M. Review of the electronic charting system showed that in December only one shower/bath was documented for the resident, on 12/22, with no documentation of showers from 12/01 through 12/21. During an interview, the resident reported she had not received a shower the prior week and stated that staff were documenting refusals when she had not refused, explaining that on days with only two aides working, showers were not done. She also stated she preferred to shower first thing in the morning and sometimes staff did not get to her in time, resulting in her not receiving a shower. The DON acknowledged awareness of issues with shower documentation and confirmed that the resident had no showers documented prior to 12/22, while also stating that the resident frequently refused showers if they were not offered before 7:30 A.M. The facility’s policy required residents to be bathed according to their preferences to promote cleanliness and comfort and to observe skin condition, which was not followed in this case.
Failure to Provide Properly Sized Incontinence Supplies and Assess MASD
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriately sized incontinence products and to comprehensively assess moisture-associated skin damage (MASD) for a resident. The resident was admitted with multiple diagnoses, including COPD, rheumatoid arthritis, CHF, atrial flutter, spinal stenosis, and insomnia, and had no skin issues on admission. An admission Braden Scale identified the resident as high risk for pressure ulcer development, and the admission MDS documented intact cognition, frequent bladder incontinence, no skin concerns, and a weight of 219 pounds. The care plan identified risk for skin breakdown related to incontinence, age-related changes, and impaired mobility, with interventions to notify nursing and providers of any skin abnormalities and to monitor skin daily during care. Subsequent documentation showed that a weekly skin assessment noted the resident as "red" on a specified date in December, but there was no further description of the redness. A physician’s order was then obtained to cleanse the bilateral buttocks/sacrum and apply stoma powder followed by A&D ointment every shift and as needed for MASD. However, the medical record contained no comprehensive skin assessment of the MASD, and nurse’s notes from the days surrounding the onset of MASD did not document the condition. The LPN responsible for wound rounds later stated she was unaware the resident had MASD and confirmed that, if present, it should have been assessed and documented per facility practice and policy. Interviews and observations revealed systemic issues with incontinence supply management that contributed to the deficiency. Multiple nurses reported the facility frequently ran out of larger-sized briefs and that staff sometimes used smaller briefs or doubled briefs when appropriate sizes were unavailable. One nurse confirmed the resident became excoriated from briefs being too tight. The resident reported that her usual size briefs ran out, she was placed in smaller briefs with an additional medium brief inside, and she developed excoriation on her bottom and groin from the brief rubbing. Central supply staff reported not having a list of residents’ brief sizes, ordering supplies based only on prior week usage, and lacking a system to determine how many of each size to order, which was corroborated by the absence of facility documentation showing such a system. Facility policies on skin care, wound care, and requisitioning daily supplies required monitoring for skin changes and maintaining adequate supplies, but the practices described did not align with these requirements.
Unsecured Hazardous Areas and Materials on Memory Care Unit
Penalty
Summary
Surveyors observed that the facility failed to secure hazardous areas and materials on the memory care unit, which could have affected 25 ambulatory residents. On two separate occasions, the doors to the soiled utility room and the clean utility room were found unlocked. The soiled utility room contained barrels for soiled linens, trash, and various equipment, while the clean utility room contained two containers of Microkill Germicidal Wipes, each with 160 wipes, stored on shelving accessible to residents. The wipes were labeled to be kept out of the reach of children. These unsecured rooms and accessible hazardous materials were directly observed by surveyors. During an interview, the Housekeeping Supervisor confirmed that the clean utility room was unlocked and that items marked to be kept out of reach were accessible to residents. The facility's own policy defined hazardous areas as those containing items or equipment that could cause injury or illness if accessed by vulnerable residents, and required such areas to be secured. Review of the MSDS for the wipes indicated the need for emergency medical attention if ingested. The facility's failure to secure these areas and materials was verified through observation, interview, and policy review.
Failure to Notify Resident Representative of Room Change
Penalty
Summary
The facility failed to ensure that a resident's representative was notified in writing prior to a room change, as required by policy. A resident with diagnoses including acute kidney failure, dementia, and unspecified psychosis, who resided on a secured memory care unit and was assessed as having intact cognition, was moved to a different room due to the presence of bed bugs. Documentation in the medical record confirmed the room change, but there was no evidence that the resident's representative was notified of this change. Interviews with facility staff, including the prior DON and an LPN, revealed that the responsibility for notifying the family was assumed to have been handled by the DON, but no notification was actually provided. The resident's son confirmed he was not informed of the room change and only learned about it after being contacted by facility staff the following day. The facility's policy required that all parties, including residents and their representatives, receive at least a day's notice prior to any room or roommate assignment changes, which was not followed in this instance.
Delay in Administration of IV Antibiotics Due to Authorization and Availability Issues
Penalty
Summary
A resident was admitted with diagnoses including sepsis due to pseudomonas, osteomyelitis of the right ankle and foot, and type 2 diabetes, and was ordered to receive intravenous antibiotics. Communication between the hospital and facility staff prior to admission established that the resident required Avycaz, an expensive intravenous antibiotic, or Fetroja as an alternative. The facility agreed to use Avycaz due to cost considerations. Upon admission, the infectious disease physician ordered ceftazidime 1.25 grams every eight hours, but the pharmacy informed staff that this dosage was not available, and Avycaz was the appropriate alternative. Despite early notification and ongoing communication about the need for Avycaz, there were delays in obtaining the medication due to a required billing authorization. The pharmacy requested approval to bill the facility for Avycaz, but the previous DON did not address the authorization in a timely manner. This resulted in missed doses of intravenous antibiotics for the resident. Documentation shows that the approval form was eventually signed and faxed to the pharmacy, but the medication was not delivered promptly due to ongoing cost and authorization issues. Interviews with facility staff, including the current DON, LPN, and pharmacy technician, confirmed that the delay in administering the ordered antibiotics was due to the unavailability of the correct dosage and the lack of timely authorization for the alternative medication. The LPN reported daily to the DON and ADON about the medication issues, but concerns were not addressed, leading to a significant medication error and a delay in treatment for the resident.
Delayed Assessment and Treatment of Urinary Tract Infection
Penalty
Summary
A deficiency occurred when the facility failed to timely assess and obtain necessary treatment for a resident who exhibited symptoms of a urinary tract infection (UTI). The resident, who had chronic atrial fibrillation, hypothyroidism, congestive heart failure, moderate cognitive impairment, and was always incontinent of urine, was dependent on staff for toileting. On one occasion, the resident's representative reported to an LPN that the resident was experiencing burning during urination. Although the LPN stated she notified the nursing coordinator and intended to order a urinalysis with culture and sensitivity, there was no documentation in the medical record of these actions or of the resident's symptoms at that time. The resident's symptoms were not addressed in the medical record until several days later, when a new order for a urine specimen was obtained and the family was notified. The urine sample was not collected until three days after the order, and the results, which confirmed a bacterial infection, were not reported until several days after that. Antibiotic treatment was initiated twelve days after the initial report of symptoms. Interviews with staff and the Director of Nursing confirmed the lack of timely documentation and response to the resident's symptoms, resulting in a delay in assessment and treatment.
Failure to Maintain Functional Boiler Systems Resulting in Inadequate Hot Water
Penalty
Summary
The facility failed to ensure that its boiler systems were functional and operational, resulting in inadequate hot water for residents and staff. Observations and interviews revealed that there had been ongoing issues with the hot water supply, particularly in the memory care and long-term care units, with water temperatures consistently below the facility's policy requirement of at least 105 degrees Fahrenheit. Staff, residents, and family members reported that the lack of hot water had persisted for weeks to months, affecting the ability to provide showers and meet hygiene needs. Temperature logs and direct measurements confirmed that water temperatures in multiple resident rooms ranged from 70.6 to 97.7 degrees Fahrenheit, even after running the water for several minutes. Maintenance staff and a mechanical contractor confirmed that the facility was operating with only one functional boiler, as the other boilers were either very old or had failed. The remaining boiler prioritized hot water supply to the kitchen and laundry, leaving resident areas with insufficient hot water. The kitchen had a booster for dishwashing, but still lacked hot water for cooking, and the laundry struggled to reach adequate temperatures. Maintenance records indicated repeated boiler failures, electrical issues, and a burst hot water holding tank, with repairs and replacements delayed or not completed. Facility policy required water heaters to maintain temperatures suitable for resident needs and to prevent scalding, specifically setting a range of 105 to 120 degrees Fahrenheit. Despite this, documentation showed repeated and prolonged periods without hot water, with staff frequently noting the deficiency in logs. The lack of hot water affected all 124 residents in the facility, as confirmed by staff, residents, and family interviews, and was not addressed in a timely manner.
Failure to Maintain Safe, Clean, and Homelike Environment Due to Water, Linen, and Supply Shortages
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for its residents, as evidenced by multiple deficiencies identified during an onsite investigation. Surveyors found that water temperatures in resident rooms and bathing areas were consistently below the facility's policy requirement of at least 105 degrees Fahrenheit, with temperatures often ranging from 70.6 to 97.7 degrees Fahrenheit even after running the water for several minutes. Staff, residents, and family members confirmed that the lack of hot water had persisted for weeks to months, impacting the ability to provide showers and basic hygiene. Facility logs and temperature records corroborated ongoing issues with the hot water supply, and mechanical inspection revealed that only one of two boilers was operational, with the other being very old. In addition to water temperature issues, the facility was found to have an inadequate supply of clean bath linens, such as towels and washcloths, for resident use. Observations of supply rooms on multiple units revealed insufficient quantities of these items, and interviews with staff and residents' families confirmed that this shortage had been an ongoing problem for years. Staff reported that laundry deliveries often arrived after showers had already started, further exacerbating the issue and leaving residents without necessary linens for personal care. The investigation also uncovered that garbage bags were not being provided in resident room trash cans, a recent change that staff and residents' families reported had been ongoing for at least a week to over a month. Observations confirmed the absence of garbage bags in multiple resident rooms, and staff interviews indicated that the facility had been running out of these supplies. Facility policy required housekeeping to maintain supplies and keep equipment stocked, but this was not being met, as confirmed by the newly hired Laundry/Housekeeping Supervisor and other staff members.
Failure to Develop Comprehensive Care Plans for Anticoagulant Therapy
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for residents receiving anticoagulant therapy, as required by facility policy. Specifically, three residents with physician orders for anticoagulant medications such as Eliquis, Apixaban, and Plavix did not have corresponding care plans addressing this therapy. Medical record reviews for these residents showed that despite their diagnoses—including pneumonia, surgical amputation, fractures, malignancy, and chronic venous hypertension—and documented cognitive status, there were no care plans in place to address the management and monitoring of their anticoagulant use. Interviews with the MDS Registered Nurse confirmed the absence of anticoagulant therapy care plans for each of the affected residents and acknowledged that such care plans should have been developed. The facility's own policy, revised in February 2025, requires a comprehensive, person-centered care plan with measurable objectives and timetables for each resident to meet their physical, psychosocial, and functional needs. This deficiency was identified during a complaint investigation and affected three out of ten residents reviewed for care plans, with a facility census of 124.
Failure to Offer Timely and In-Person Care Plan Meetings per Resident and Family Preference
Penalty
Summary
The facility failed to ensure that care plan meetings were offered in a timely manner, according to resident and family preferences, and in person as required. Specifically, for one resident with severe cognitive impairment and multiple psychiatric diagnoses, the family member reported not being offered a care conference for over five months, with the last meeting conducted by phone. The family member also indicated a preference for in-person meetings and noted that she had not received the usual letter invitation for a care conference during this period. Interviews with facility staff, including the DON and LSW, confirmed that care plan meetings are to be held on admission, quarterly, annually, with significant changes, or upon family request. However, there was no evidence that a care conference letter was mailed or an RSVP received for the most recent scheduled meeting. Facility documentation and policy review revealed that invitations were only sent for phone meetings, and the standard practice was to conduct care conferences by phone rather than in person, despite the stated option for in-person meetings. This resulted in the resident's family not being properly notified or given the opportunity to participate in the care planning process as preferred.
Failure to Follow Physician Orders and Notify Physician of Elevated Blood Pressure
Penalty
Summary
The facility failed to follow physician orders for a resident who was admitted with multiple diagnoses, including fractures, malignant neoplasm of the glottis, and chronic venous hypertension with ulcer. Physician orders required orthostatic blood pressure (BP) measurements (lying, sitting, and standing) every shift, as well as a two-person assist for transfers. Review of the resident's medical record revealed that BP readings were inconsistently documented, with several instances where only one or two positions were recorded and some shifts with no BP readings at all. Additionally, there were multiple elevated BP readings documented, but there was no evidence that the physician was notified of these findings, nor was there documentation in the progress notes regarding any such notification. Interviews with the DON, ADON, and RN Coordinator confirmed that physician orders for orthostatic BP monitoring were not followed and that the physician was not notified of high BP readings as required. The physician also confirmed he was not informed of the elevated BP results and expected to be notified for systolic BP readings of 160 or above and diastolic readings of 90 or above. The failure to follow physician orders and notify the physician of significant clinical findings was confirmed through record review and staff interviews.
Delayed Meal Service on Memory Care Unit
Penalty
Summary
The facility failed to ensure that meals were served in a timely manner on the Memory Care Unit, affecting all 33 residents residing there. Multiple interviews with residents' families, CNAs, dietary staff, and supervisors confirmed that meal trays were consistently late, with reports indicating delays of up to an hour. Direct observation showed residents seated and waiting for their lunch meals well past the scheduled delivery time, with the first meal cart arriving at 12:37 P.M. instead of the scheduled 12:00 P.M. for the first cart and 12:15 P.M. for the second cart. Staff interviews corroborated that late meal service was a recurring issue. Review of facility policies revealed that meal trays were expected to be delivered promptly to ensure freshness and quality, with specific delivery times outlined for the Memory Care Unit. Despite these policies, both dietary and nursing staff acknowledged that meals were not being served on time, and no specific reasons for the delays were consistently identified other than general untimeliness. The deficiency was substantiated through direct observation, staff and family interviews, and policy review, confirming non-compliance with established meal service protocols.
Failure to Follow Infection Control Procedures During Medication Administration
Penalty
Summary
During a medication administration observation, a registered nurse (RN) failed to follow infection control procedures when administering Vitamin D3 to a resident with a history of volvulus, malignant neoplasms, and absence of parts of the digestive tract, cervix, and uterus. The RN initially gave one capsule instead of the ordered two, then returned to the medication cart, used hand sanitizer, and placed two capsules in a medicine cup. Realizing only one additional capsule was needed, the RN used her bare hands to remove one capsule from the cup, touching the remaining capsule, and returned the removed capsule to the original medication bottle. The RN then administered the remaining capsule to the resident. Interviews with the RN, the Director of Nursing (DON), and the Nursing Coordinator confirmed that staff are not permitted to touch medications with bare hands or return medications to the original bottle. Facility policy requires an infection prevention and control program to prevent the transmission of communicable diseases and infections. The incident was identified as a failure to implement proper infection control procedures during medication administration.
Failure to Provide Appropriate Dementia Care
Penalty
Summary
A resident who displays or is diagnosed with dementia did not receive the appropriate treatment and services. The facility failed to ensure that the necessary care was provided to address the resident's dementia-related needs, as required by regulatory standards. This deficiency was identified during the survey process.
Failure to Provide Adequate Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevent the development of new ulcers. This deficiency was identified through surveyor observations and documentation review, which indicated that the necessary interventions to manage existing pressure ulcers and prevent new ones were not consistently implemented for affected residents. The report highlights lapses in the facility's pressure ulcer prevention and care protocols, resulting in inadequate care for residents at risk or with existing pressure ulcers.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by anybody. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the actions, inactions, or events leading to the deficiency, nor information about the residents involved or their medical conditions, are provided in the report.
Insufficient Nursing Staff and Lack of Licensed Nurse Coverage
Penalty
Summary
The facility failed to provide enough nursing staff each day to meet the needs of every resident and did not ensure that a licensed nurse was in charge on each shift. This deficiency was identified through observations and review of staffing patterns, which showed that staffing levels were insufficient to meet resident care needs and that there were shifts without a licensed nurse in charge. These findings indicate that the facility did not comply with requirements for daily nursing staff coverage and supervision by a licensed nurse on all shifts.
Failure to Provide Palatable and Properly Tempered Meals
Penalty
Summary
The facility failed to ensure that food and drink provided to residents were palatable, attractive, and served at safe and appetizing temperatures. Multiple residents reported dissatisfaction with the quality and temperature of their meals. One resident, with a history of nontraumatic intracranial hemorrhage, pneumonia, depression, anxiety, bipolar disorder, and dementia, stated that the chicken was too hard to chew and cold, resulting in her not eating it. Another resident with carcinoma of the rectum, cirrhosis of the liver, abdominal pain, urinary retention, and severe protein-calorie malnutrition reported that the food tasted bad. A third resident with a history of lumbar compression fracture, osteoporosis, and malignant neoplasms of the breast and pancreas described the food as terrible. A test tray sent to the Dementia Unit revealed that food temperatures were not within appropriate ranges, with items such as cottage cheese and milk being served below recommended temperatures, and hot foods like chicken, mashed potatoes, and noodles also being served at suboptimal temperatures. The chicken was found to be hard and chewy, and the noodles were clumped and cold. The Dietary Shift Leader confirmed that the food temperatures were not appropriate and that the chicken was difficult to eat. Facility meeting minutes indicated ongoing resident concerns about warming plates not being effective, and the Food Service Director was unable to provide additional documentation for other months. The facility's policy required meals to be well-seasoned and palatable, which was not met at the time of the survey.
Ineffective and Inefficient Use of Facility Resources
Penalty
Summary
The facility failed to administer its operations in a manner that enabled it to use its resources effectively and efficiently. This deficiency was identified during the survey process, as the facility did not demonstrate appropriate management or allocation of its available resources. Specific actions or inactions leading to this deficiency were not detailed in the report, nor were any particular events or resident cases described.
Failure of Governing Body to Ensure Financial Oversight and Policy Implementation
Penalty
Summary
The facility failed to ensure an effective governing body that was legally responsible for establishing and implementing policies regarding the management and operation of the facility, including compliance with all financial obligations for the delivery of care. Record review and interviews revealed that the facility had a history of financial solvency concerns, with a previous complaint survey identifying issues under neglect and substandard quality of care. Multiple service providers, including the former medical director, registered dietitian, landscaping company, and a pastor providing spiritual care, reported nonpayment for their services over extended periods. Additionally, the Ombudsman received complaints from residents about being denied access to their funds. Interviews with the facility administrator and board members indicated a lack of awareness and oversight regarding financial obligations and board activities. The administrator was unaware of outstanding balances owed to service providers and was unsure about the frequency of board meetings. Board members themselves were either unaware of their current roles or the financial issues facing the facility, and could not provide documentation of board meetings. Facility policy stated that the governing body was responsible for oversight, budget approval, and financial stewardship, but these responsibilities were not being fulfilled, resulting in noncompliance affecting all residents.
Failure to Maintain Sanitary and Homelike Environment
Penalty
Summary
The facility failed to maintain a sanitary and homelike environment, as evidenced by multiple observations and interviews. In one instance, a resident's room contained old spoons, cracker wrappers, and expired milk and cereal from the previous day, with an LPN unable to confirm if housekeeping had cleaned the room. Several shower rooms were found with black rings inside toilets, mildew on shower floors, feces on tiled floors, and urine stains, with maintenance and CNA staff confirming the lack of scheduled housekeeping on certain units. Another resident reported that her daughter had to clean her room due to the absence of housekeeping, and ants and excessive trash were observed in her room. Housekeeping staff confirmed that some units did not have assigned housekeepers due to staffing shortages, leaving CNAs to perform cleaning duties, which were not always completed. Additional observations included a resident's room with thick grime along the floor edges, a dull film of grime on the tiles, and dust on the dresser, with the resident stating that housekeeping had not cleaned the room for weeks. The outdoor patio for the dementia unit was found to have a rusted iron fence, a thick layer of dried leaves, overgrown bushes and grass, and unpruned trees, as verified by the DON. Facility policy required regular cleaning and maintenance of resident rooms, bathrooms, and outdoor areas, but these standards were not met, affecting several residents and potentially impacting all residents in the facility.
Unsecured Medication Cart and Open Medication Bottle in Memory Care Unit
Penalty
Summary
A deficiency occurred when medications were not properly secured on the memory care unit. During an observation, a medication cart was found in the dining room with the lock not engaged, and a large bottle of acetaminophen with the lid off and approximately 15 to 20 tablets exposed was sitting on top of the cart. At the time, nine residents were present in the dining room, all of whom had a diagnosis of dementia and were at risk for wandering. A CNA was assisting residents out of the dining room, and an LPN returned to the area, confirming the cart was left unlocked and the medication bottle was open. Facility policy requires all medications, except emergency drug kits, to be stored in a locked cabinet, cart, or medication room accessible only to authorized personnel.
Failure to Provide Properly Pureed Diet as Ordered
Penalty
Summary
The facility failed to provide a resident with food prepared in the appropriate puree texture as ordered by the physician. The resident, who had diagnoses including Alzheimer's disease, dementia, and dysphagia, was prescribed a puree diet with thin liquid consistency. Observations during meal service revealed that the puree chicken and vegetables prepared for the resident were lumpy and not of a smooth consistency, as required by both the physician's order and the facility's own policy. Multiple staff members, including the dietary shift leader and dietary director, confirmed that the food was not properly pureed and acknowledged the difficulty in achieving the correct texture, particularly with chicken. Further observation showed the resident spitting out the puree chicken during a meal, and a CNA verified that this was due to the presence of chunks in the food. The facility's policy specified that puree foods should have a smooth, pudding or mashed potato-like consistency, which was not met in this instance. This deficiency had the potential to affect other residents on puree diets, as similar food preparation practices were observed.
Failure to Honor Resident's Dignity and Bedtime Preferences
Penalty
Summary
A deficiency occurred when a resident, who was cognitively intact and had multiple medical diagnoses including hypertension, chronic kidney disease, and diabetes, was not treated with dignity and respect. The resident's care plan indicated it was very important for her to choose her own bedtime, and she required partial to moderate assistance for transfers. On the day of the incident, while the resident was still eating dinner, a CNA entered the room, removed her dinner tray, and insisted that the resident go to bed immediately or not at all. The resident's son objected, stating it was too early and the resident was still eating. The CNA became angry, yelled, and cursed at the resident's son in front of the resident, then left the room and continued to curse loudly in the hallway. Interviews confirmed that the CNA's behavior was inappropriate and unprofessional, and that the resident was told she had to go to bed much earlier than her preferred time. The DON acknowledged the incident and verified that there was no documentation of the resident's meal intake for that evening, nor could it be confirmed whether the resident had finished her meal before the tray was removed. Facility policies reviewed stated that residents are to be treated with dignity and respect at all times and have the right to retire and rise according to their reasonable requests.
Failure to Honor Resident's Right to Manage Financial Affairs
Penalty
Summary
A deficiency was identified regarding the facility's failure to honor a resident's right to manage his or her own financial affairs. The report notes that the resident's autonomy in handling personal finances was not respected, which is a violation of resident rights as outlined in federal regulations. No additional details about the specific actions or inactions, the resident's medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Honor POA Request to Hold Medication
Penalty
Summary
The facility failed to honor a resident's power-of-attorney (POA) request to hold Depakote, a mood stabilizer, resulting in the medication being administered despite explicit instructions from the POA. The resident, who had diagnoses including ataxia, dementia, psoriatic arthropathy, recurrent depressive disorder, wandering, and adult failure to thrive, was admitted with a POA who specifically requested that no medications with a black box warning be given. The POA communicated this request to staff and expected it to be addressed by the provider. However, a new order for Depakote was written and the medication was administered multiple times over several days. Interviews revealed that the POA had informed staff not to administer Depakote until she could speak with the psychiatric doctor, but the medication was still given. Nursing staff were not all aware of the request to hold the medication, and some believed the resident needed it. Communication about the POA's request was not effectively documented or relayed, as some nurses did not check the communication book or see the note to hold Depakote. The deficiency was identified during a complaint investigation.
Failure to Notify Resident, Physician, and Family of Significant Events
Penalty
Summary
Facility staff failed to immediately notify the resident, the resident's physician, and a family member about situations that affected the resident, such as injury, decline, or changes in room assignment. This lack of timely communication was observed and documented by surveyors as a deficiency in the facility's process for keeping relevant parties informed about significant events impacting the resident's care or condition.
Failure to Complete Assessment Prior to Secure Unit Placement
Penalty
Summary
The facility failed to complete an assessment prior to placing a resident on the secure/memory care unit. Record review showed that the resident was admitted with multiple diagnoses, including ataxia, dementia, psoriatic arthropathy, recurrent depressive disorder, wandering, and adult failure to thrive. The care plan identified the resident as an elopement risk due to behaviors such as pacing the halls and wandering into other resident rooms, and included interventions like checking the secure tech bracelet and encouraging family involvement. However, there was no evidence in the medical record that an assessment was conducted to determine the appropriateness of placement on the secure unit before admission. Interview with the DON confirmed that the assessment was not completed prior to the resident's admission to the secure unit. A functional assessment was only completed after the resident was already on the unit, which documented severe mentation impairment, uncooperative and resistive behaviors, wandering, verbal and physical abuse, social inappropriateness, and exit-seeking. The resident had a history of attempts to exit home, aggression, and had recently attempted to exit the building, triggering the alarm. This deficiency was identified during a complaint investigation.
Failure to Implement Individualized Behavioral Care Plan Upon Admission
Penalty
Summary
The facility failed to ensure that an individualized care plan addressing behavioral issues was in place for a resident admitted with multiple diagnoses, including ataxia, dementia, psoriatic arthropathy, recurrent depressive disorder, wandering, and adult failure to thrive. Upon admission, the resident was known to have inappropriate behaviors and was resistive to care, as documented in the care plan. However, the interventions for these behaviors were not communicated to the Certified Nursing Assistants (CNAs) via the Kardex or CNA report sheets, and there was no documentation of behavioral interventions or management strategies for wandering. Interviews revealed that the Director of Nursing (DON) had concerns about admitting the resident due to behavioral issues noted in hospital records, but no interventions were implemented to address these concerns upon admission. Further interviews indicated that the DON was not present at the time of admission and did not support the decision to admit the resident, citing the facility's lack of a behavior unit and the resident's history of aggressive behavior and need for antipsychotic medication. Despite a referral for psychiatric services being made after admission, there was a lack of immediate action to address the resident's behavioral needs within the first 48 hours. The deficiency was identified during a complaint investigation and affected one resident out of those reviewed for care plans.
Failure to Provide Required Showers for Dependent Resident
Penalty
Summary
A deficiency occurred when a resident who was dependent on staff for bathing did not receive the required two showers per week as documented in facility policy. The resident, who had multiple sclerosis, recurrent depressive disorders, and chronic kidney disease, was cognitively intact and expressed a preference for showers over bed baths. Medical record review showed the resident received only one shower per week over several weeks, with a bed bath provided instead of a second shower. Interviews with the resident and the DON confirmed the lack of scheduled showers, with the resident reporting that only one CNA ensured showers were given, and that other CNAs cited insufficient staffing as the reason for not providing showers. Facility policy required CNAs and nursing staff to provide and document daily ADL care, which was not consistently followed in this case.
Failure to Pay Vendors Results in Service Interruptions and Resource Shortages
Penalty
Summary
The facility failed to effectively manage its financial obligations, resulting in the inability to secure necessary resources and services required to meet the ongoing needs of its residents. Surveyors found that unpaid bills led to the suspension or interruption of essential services, including trash removal, utility services, telephone and cellular services, oxygen and respiratory supplies, staffing agencies, linens, laundry chemicals, and durable medical equipment. These lapses resulted in situations such as garbage piling up in the basement, trash blocking fire doors, and expired food being stored in a maintenance van due to the lack of trash removal. Staff interviews confirmed that these issues were recurrent and not isolated incidents. Residents and staff reported direct impacts from these deficiencies. Certified Nursing Assistants (CNAs) described frequent shortages of washcloths, requiring them to cut up towels for resident care, and residents confirmed that the lack of proper linens made personal hygiene more difficult. There were also periods when the facility could not order oxygen supplies due to non-payment, though no residents were reported to have run out of oxygen during the documented hold period. Staffing agencies placed the facility on hold due to overdue balances, limiting the facility's ability to supplement its workforce as needed. Additionally, the procurement process was inconsistent, with staff sometimes needing to purchase supplies from retail stores due to delays or shortages from regular vendors. Interviews with the facility Administrator and other staff revealed a lack of awareness or involvement in the details of vendor payments and procurement issues. The Administrator often deferred responsibility to the facility's back-office procurement team and was not always aware of which vendors were on hold or which services were affected. The facility's own assessment and policies required the provision of adequate resources and services to meet residents' needs, but the ongoing financial mismanagement led to repeated shortages and interruptions in essential services, creating potential situations of neglect for all residents.
Failure to Develop Comprehensive Care Plans for Residents with Behavioral and Skin Integrity Needs
Penalty
Summary
The facility failed to develop and implement comprehensive care plans that addressed all identified needs for two residents. For one resident with severe cognitive impairment and a history of heart disease, kidney disease, hearing loss, anxiety, and Alzheimer's disease, the care plan did not address her physical and verbal behavioral symptoms, including hitting, kicking, pushing, scratching, threatening, screaming, and frequent rejection of care. Interviews with LPNs and a CNA confirmed awareness of these behaviors and the use of interventions such as one-to-one attention or contacting the resident's daughter, but there was no documentation of these interventions in the care plan, nor were staff given specific instructions for managing the behaviors. Another resident with multiple diagnoses, including dementia with behavioral disturbance, anxiety disorder, congestive heart failure, chronic kidney disease, and chronic obstructive pulmonary disease, developed unstageable pressure ulcers on both heels. Although medical records and wound care notes documented the presence of these wounds and recommended interventions such as repositioning every two hours, offloading pressure, and using heel protectors, the care plan only addressed the potential for skin breakdown and did not include interventions for the resident's actual impaired skin integrity. Additionally, there was no care plan addressing the resident's non-compliance with offloading pressure from the heels, despite staff being aware of this issue. Facility policy required that care plans be reviewed and revised after each comprehensive and quarterly MDS assessment, and that all identified care area needs be included in the person-centered comprehensive care plan. However, the care plans for both residents failed to include measurable objectives and appropriate interventions for their specific needs, as confirmed by staff interviews and record review.
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.
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