Shady Lawn Nursing Home
Inspection history, citations, penalties and survey trends for this long-term care facility in Dalton, Ohio.
- Location
- 15028 Old Lincolnway East, Dalton, Ohio 44618
- CMS Provider Number
- 365591
- Inspections on file
- 20
- Latest survey
- May 12, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Shady Lawn Nursing Home during CMS and state inspections, most recent first.
A resident with a history of drug-seeking behavior accessed an unsecured staff purse at the nurses' station, ingested a large quantity of stimulant medication, and experienced a significant decline in condition. Staff failed to promptly recognize and report the change in condition, resulting in delayed transfer to the ER. The resident was later hospitalized, required CPR and intubation, and died after being transitioned to palliative care. The facility's failure to secure staff belongings and timely report condition changes led to neglect and actual harm.
A resident with a history of dysphagia and hypertension experienced multiple episodes of emesis, decreased fluid intake, and respiratory distress. Despite critical changes in vital signs and abnormal chest x-ray findings, staff failed to notify the physician or family or provide additional interventions. The resident was later found without vital signs, and interviews confirmed that required notifications and documentation were not completed.
Three residents experienced harm due to the facility's failure to implement individualized and effective pressure ulcer prevention and treatment, including the use of improperly sized incontinence briefs, delays and omissions in prescribed wound care, and lack of necessary wound care supplies. Staff did not consistently follow physician orders or ensure appropriate interventions, resulting in the development and worsening of pressure ulcers.
Surveyors found multiple expired food items and improperly stored pork in the facility's kitchen and nourishment areas. The Dietary Manager confirmed that expired foods and improperly wrapped meat were present, despite facility policies requiring daily and weekly checks and proper food rotation.
The facility was not administered in a way that ensured effective use of resources or the highest practicable well-being of all residents. Surveyors found neglect resulting in Immediate Jeopardy and actual harm, delays in care due to insufficient staffing, failure to address changes in condition, lack of assistance with outside appointments and alternate placement, poor infection control, unavailable care equipment, and inadequate wound and bariatric care, despite the facility's stated capabilities.
Staff did not follow infection control protocols by using personal equipment for a resident on droplet isolation for strep pharyngitis, failing to clean equipment properly, and neglecting hand hygiene after resident care. Facility policy required dedicated or disposable equipment and proper disinfection, but staff interviews and observations confirmed these practices were not followed.
A facility failed to secure an exit door equipped with a malfunctioning keypad and wanderguard system, allowing residents with severe cognitive impairment and a history of wandering to access an unsecured parking lot and busy highway. Maintenance and nursing staff confirmed the door's inconsistent locking and lack of alarm, and no staff were present to monitor the area, despite facility policy requiring supervision and functioning alarms for residents at risk of elopement.
Two residents discharged from skilled services were not given the required written Notice of Medicare Non-coverage (NOMNC) despite having benefit days remaining. Record review and staff interview confirmed the absence of these notifications for both individuals with complex medical conditions.
Two residents with cognitive capacity and specific activity preferences did not have their activity care plans reviewed or updated to reflect changes in their interests or participation. The Activities Director confirmed that care plans had not been revised for an extended period, and there was no documentation of changes in the residents' medical records, contrary to facility policy requiring ongoing assessment and updates.
The facility did not provide individualized activities to meet the needs and preferences of two residents, both of whom were cognitively intact and dependent on staff for engagement. Activities were often canceled, repetitive, or not tailored to resident interests, and outings were limited due to transportation constraints. The activities director did not document participation or changes in preferences, and one-on-one activities were not offered, resulting in unmet psychosocial needs.
A resident with respiratory failure and pneumonia was observed receiving oxygen at a flow rate higher than the physician-ordered two to three liters per minute. Multiple observations confirmed the oxygen was set at four liters, and an LPN verified this did not match the physician's order. Facility policy required oxygen to be administered as ordered by a physician.
A resident with multiple chronic conditions was prescribed Trazodone for insomnia without a corresponding diagnosis documented in the medical record, as required for psychotropic medications. Although the physician later agreed to add the diagnosis, it was not entered into the record in a timely manner, and staff confirmed the pharmacy's recommendation was not promptly addressed.
A resident with anxiety disorder did not have their psychotropic medication, Vistaril, decreased as ordered by the physician, despite a signed order and facility policy requiring gradual dose reductions. The medication dose remained unchanged for two months before being discontinued, and the DON confirmed the order to decrease the dose was not followed.
Two residents were affected by deficiencies: one experienced unclean conditions around a tube feeding pole, with dried nutritional supplement residue observed and confirmed by staff and family, while another non-smoking resident was exposed to cigarette smoke in her room due to the proximity of the smoking area and the design of the room's ventilation system, despite staff awareness and prior attempts to address the issue.
The facility failed to ensure psychotropic medications were necessary before administration, did not monitor their efficacy, and did not comprehensively assess for side effects. Two residents, one with severe cognitive impairment and another with schizoaffective disorder, were affected by lack of documentation regarding medication use, behavioral monitoring, and required assessments, contrary to facility policy.
Two residents dependent on staff for ADLs did not receive adequate assistance with hygiene and grooming. One resident, with significant physical and cognitive needs, did not receive showers as ordered due to equipment and transfer challenges, resulting in incomplete hygiene care. Another resident with cognitive impairment and behavioral issues was repeatedly found in unsanitary conditions, with no individualized care plan to address behaviors affecting cleanliness. Staff confirmed these deficiencies, and facility policy requirements for hygiene and grooming were not met.
Two residents with indwelling urinary catheters did not receive comprehensive and individualized care, as required. For both, there were no physician orders or care plans addressing catheter care, and documentation of catheter care was absent or outdated. Staff confirmed these omissions, and observations revealed issues such as lack of catheter site security and redness. The facility's own policy requiring catheter care every shift was not followed.
A scheduled LPN arrived late, left her assigned unit multiple times, and was eventually sent home, resulting in another LPN taking over and administering medications several hours late to multiple residents. This led to delayed administration of critical medications for residents with complex medical needs, as confirmed by staff and resident interviews and medication records.
A resident with lymphedema, Milroy's disease, and other complex conditions did not receive timely transition of care assistance from social services, resulting in a significant delay in referrals to facilities better equipped to meet their needs. Despite repeated requests from the resident's representative and a physician's order for referrals, the facility did not initiate the process for nearly three months, impacting the resident's access to appropriate care.
A controlled medication, Ativan, prescribed for a resident with neurocognitive disorder, was improperly administered to another resident. The DON confirmed that the medication was signed out for one resident but given to another by an LPN, with no documentation in either medical record. Facility policy required use of the contingency box if medication was unavailable, but this was not followed.
A resident with multiple medical and behavioral diagnoses, who was dependent for ADLs and required bariatric care, was not transported to scheduled medical appointments because local transportation companies could not accommodate bariatric transfers. Despite reminders from the resident's family and documentation in the facility assessment that bariatric care was provided, the facility did not ensure the resident attended necessary outside appointments.
A resident with multiple diagnoses and intact cognition was not offered the influenza vaccine as required, and there was no documentation of consent or refusal in the medical record. Facility policy mandates annual offering and proper documentation, but staff were unable to locate any related information for this resident.
Several residents with intact cognition and multiple medical conditions were not offered the COVID-19 vaccine, and the facility could not provide documentation of vaccine consent or refusal as required by policy. Interviews confirmed the absence of necessary records for these individuals.
A resident with complex medical and mobility needs was unable to be safely transferred or evacuated from his room due to the lack of appropriate bariatric equipment and a bed that was too wide to fit through the doorway. Multiple staff, including the DON, LPN, CNA, and physician, confirmed that the available Hoyer lift and lift pad were inadequate, and the resident could not be moved in the event of an emergency.
The facility failed to ensure that a resident on an anticoagulant was monitored and treated timely for bruising. Despite documented bruises on multiple occasions, there was no evidence that the physician was notified. Interviews with LPNs confirmed lapses in monitoring and reporting, and the DON acknowledged the deficiencies.
The facility failed to document wound care treatments for a resident with multiple severe wounds on two specific dates in March 2024. Despite performing the treatments, the staff did not sign off on the Treatment Administration Records (TAR) as required, leading to non-compliance with the facility's policies.
Failure to Secure Staff Belongings and Timely Report Change in Condition Resulting in Resident Death
Penalty
Summary
The facility failed to ensure that staff belongings, specifically prescription medication, were properly secured and inaccessible to residents. A resident with a history of drug use and drug-seeking behavior, residing on a secured behavior unit, was able to access a CNA's unsecured purse left at the nursing station. The resident obtained and ingested up to 20 tablets of Adipex, a stimulant medication, without staff knowledge. The purse was left in an area that was not secured, and the CNA did not have access to a designated secure area for personal belongings on the unit. Following the ingestion, the resident began to display significant changes in condition, including confusion, inability to stand or walk, rapid pulse, and hypertension. These changes were first noted at 7:40 A.M., but the response from nursing staff was delayed. The resident was not transferred to the emergency room until several hours later, despite ongoing and worsening symptoms such as shortness of breath, decreased oxygen saturation, and further decline in mobility and mental status. Documentation of the resident's condition and the actions taken was also delayed, with several progress notes entered as late entries. The resident was eventually transported to the hospital, where she required CPR and intubation and was found to have amphetamines in her system. She was admitted to the ICU with pneumonia and subsequently died after being transitioned to palliative care. The facility's failure to secure staff belongings and to promptly recognize and report the resident's change in condition resulted in resident neglect and actual harm, including the resident's death.
Failure to Provide Timely Medical Intervention After Acute Change in Condition
Penalty
Summary
A deficiency occurred when the facility failed to timely identify and obtain medical intervention for a resident following an acute change in condition. The resident, who had diagnoses including dysphagia and hypertension and required assistance with activities of daily living, was admitted with no terminal condition noted. Physician orders included increased fluid intake for dehydration and monitoring of fluid intake, but documentation of actual fluid intake was lacking. The resident experienced multiple episodes of emesis, decreased fluid intake, and adventitious lung sounds, yet there was no evidence that the physician or family were notified or that effective interventions were initiated at that time. On the day prior to the resident's death, staff documented further emesis, possible aspiration, and crackles throughout the lung fields. Orders were received for anti-emetic medication, a clear liquid diet, and intravenous fluids, and a STAT chest x-ray was ordered at the request of the resident's daughter. The x-ray, performed overnight, showed bilateral pulmonary infiltrates and cardiomegaly. At 1:07 A.M., the resident was found to have labored breathing, a respiratory rate of 39, oxygen saturation of 60% on oxygen, no obtainable blood pressure, and a heart rate of 39. Despite these critical findings, there was no documentation that the physician or family were notified, and no additional interventions were provided. There was no further documentation between 1:13 A.M. and 6:02 A.M., when the resident was found without vital signs. Interviews with facility leadership and medical providers confirmed that the nurse did not notify the physician or family of the resident's acute change in condition, as required by facility policy. The lack of timely notification and intervention following the resident's significant change in status resulted in actual harm.
Failure to Provide Comprehensive Pressure Ulcer Prevention and Treatment
Penalty
Summary
The facility failed to develop and implement a comprehensive, effective, and individualized pressure ulcer prevention and treatment program for three residents, resulting in the development and worsening of pressure ulcers. One resident, who was morbidly obese, incontinent, and dependent on staff for bed mobility and toileting, developed a dark purple, non-blanchable suspected deep tissue injury to the right posterior thigh. This injury was attributed to the use of incontinence briefs that were too small and fastened tightly, despite physician orders for the brief to remain unfastened while in bed. Staff did not measure residents for appropriate brief sizes, and the largest available size was still inadequate. Documentation indicated that the order to leave the brief unfastened was signed as completed, but observations and interviews revealed that staff routinely fastened the brief, contributing to ongoing skin breakdown and pain for the resident. Another resident, who was cognitively impaired, developed an unstageable pressure ulcer to the right buttock. The initial wound was identified as an abrasion, but it progressed to an unstageable ulcer without evidence of individualized or effective interventions to prevent its development. Although a wound care nurse practitioner recommended a specific treatment regimen, there was a delay in ordering and implementing the treatment, and staff continued to apply the previous, less appropriate treatment. Additionally, there were multiple documented instances where the prescribed wound care was not completed as ordered. A third resident with paraplegia and obesity had multiple pressure ulcers, including a Stage IV ulcer and new suspected deep tissue injuries. The resident's care plan included wound treatments and preventative interventions, but there were issues with the availability of necessary wound care supplies. On at least one occasion, the required Triad cream was not available, and an alternative treatment was used instead, despite documentation indicating the prescribed treatment was completed. Staff interviews confirmed frequent shortages of wound care supplies and inconsistent ordering practices, leading to lapses in appropriate wound care.
Expired and Improperly Stored Food Found in Facility
Penalty
Summary
Surveyors observed that the facility failed to properly store and discard expired food items in accordance with professional standards and facility policy. During a walk-through of the kitchen and nourishment areas, several expired food items were found, including four bags of carrots, a bag of English muffins, a loaf of bread, and a carton of nutritional supplement. Additionally, a sheet pan containing pork was found in the walk-in cooler with foil loosely covering it, exposing the contents to air. The pork was dated several days prior to the observation. Interviews with the Dietary Manager confirmed the presence of expired foods and the improperly wrapped pork. The Dietary Manager acknowledged that all staff were expected to check food stock daily to remove expired items and that unit refrigerators were to be checked weekly. Review of the facility's policy indicated that expired items must be discarded on the expiration date and not used for consumption, and that food should be rotated using the first in, first out (FIFO) method. Despite these policies, expired and improperly stored foods were present in areas accessible for resident consumption.
Failure to Administer Facility to Ensure Resident Well-Being and Resource Use
Penalty
Summary
The facility failed to be administered in a manner that enabled effective and efficient use of its resources to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Survey findings included situations of neglect resulting in Immediate Jeopardy and actual harm to residents. Additional deficiencies were identified, such as failure to address and report changes in resident condition in a timely manner, unmet staffing needs leading to delays in care, lack of assistance for residents to attend outside service appointments, and failure to help residents find alternate placement when the facility could not meet their needs. Infection control practices were not followed, and necessary equipment and supplies for resident care were not available to staff. Further observations revealed that comprehensive wound care was not provided, and appropriate care and services for bariatric residents were lacking, despite the facility's assessment indicating the ability to provide such services. The Administrator, responsible for day-to-day operations, confirmed being notified of all incidents and concerns. Review of the Administrator's job description emphasized responsibilities for ensuring safety regulations, maintaining the facility in good repair, and ensuring residents receive necessary care and services as defined by comprehensive assessments and care plans.
Failure to Provide Dedicated Equipment and Maintain Infection Control for Resident on Isolation
Penalty
Summary
Staff failed to maintain proper infection control practices and did not provide dedicated equipment for a resident on droplet isolation due to streptococcal pharyngitis. The resident, who was cognitively intact but dependent for bed mobility, was placed on droplet precautions per physician orders, with instructions for all care and activities to occur in the resident's room. Facility records indicated that 19 residents were on some form of isolation, and these residents were located throughout the facility. Observations and interviews revealed that staff, including LPNs, used their own personal equipment such as blood pressure cuffs, stethoscopes, thermometers, and pulse oximeters for resident assessments, as the facility did not provide these items. During a vital sign assessment for the resident on isolation, an LPN used personal equipment without cleaning it prior to use, placed the used equipment on top of an isolation cart containing PPE supplies, and performed inadequate cleaning of the equipment after use. The LPN did not allow for the required disinfectant contact time and did not perform hand hygiene after removing PPE or before leaving the resident's room. Interviews with the DON, infection preventionist, and other staff confirmed that the facility did not supply dedicated or disposable equipment for residents on isolation, and that staff routinely used personal equipment. Facility policy required the use of disposable or dedicated equipment for residents on transmission-based precautions and specified proper cleaning and hand hygiene procedures, which were not followed in practice.
Failure to Secure Exit Door for Residents at Risk of Elopement
Penalty
Summary
The facility failed to ensure that exit doors were properly secured to prevent residents at risk for elopement from exiting the building unassisted. Observations revealed that door #5, located in an area not visible from nursing stations or busy areas, was accessible to residents and could be opened to the outside without triggering an alarm. The door was equipped with both a keypad and a wanderguard system, but neither functioned as intended. The keypad had been nonfunctional for over a week, and the wanderguard system did not lock or alarm when tested with a bracelet identical to those worn by at-risk residents. Maintenance staff confirmed the door's inconsistent locking and lack of alarm, and that the door led directly to an unsecured parking lot and a busy highway. No staff were present to monitor the door during these observations. Record review and interviews confirmed that at least ten residents, including one with severe cognitive impairment and a history of wandering and elopement risk, resided outside the secured unit and had access to the unsecured door. The care plan for this resident included the use of a wanderguard device, and staff reported that the resident frequently attempted to open exit doors. The facility's policy required that residents at risk for elopement receive adequate supervision and that door alarms and locks be maintained to prevent accidents. Despite this, the malfunctioning door and lack of staff monitoring created a situation where residents at risk for elopement could have exited the facility undetected.
Failure to Provide Required Medicare Non-Coverage Notices
Penalty
Summary
The facility failed to provide required written notification to residents discharged from skilled services regarding the end of their Medicare coverage. Specifically, two residents with multiple diagnoses, including hyperlipidemia, dementia, hypertension, morbid obesity, diabetes, kidney disease, and dysphagia, were discharged from Medicare Part A covered stays while still having benefit days remaining. Record review showed no evidence that a Notice of Medicare Non-coverage (NOMNC) was issued to either resident. The facility's beneficiary notice list confirmed these discharges occurred within the last six months, and an interview with the Social Service Designee verified that there was no documentation of the NOMNC forms being provided.
Failure to Update and Revise Activity Care Plans
Penalty
Summary
The facility failed to ensure that care plans for activities were reviewed and revised as required for two residents. For one resident with an anxiety disorder, the care plan had not been updated since January of the previous year, despite the resident expressing dissatisfaction with the repetitive nature of activities and a desire for more challenging options, such as going for drives and enjoying new scenery. The resident was cognitively intact and had specific interests, but these preferences were not reflected in the most recent care plan. The Activities Director confirmed that there was no documentation of changes in participation or preferences in the resident's medical record. Another resident, with diagnoses including depression, hypertension, diabetes, schizoaffective disorder, insomnia, sleep apnea, and anxiety, also had a care plan that had not been updated since October of the previous year. This resident was cognitively intact and valued going outside and participating in favorite activities, but there was no evidence that the care plan had been revised to reflect any changes in interests or participation. The Activities Director acknowledged that care plans were only updated at scheduled conferences or when changes were noted, and could not provide evidence of recent updates for this resident. Facility policy requires ongoing assessment and updating of activity care plans based on residents' interests and needs.
Failure to Provide Individualized and Documented Activities for Residents
Penalty
Summary
The facility failed to provide individualized activities to meet the needs and preferences of its residents, as required by policy. For one resident with anxiety disorder and cognitive intactness, the care plan indicated a need for encouragement to participate in activities of interest, with a wide range of preferred activities such as crafts, music, outings, and computer-related tasks. However, observations revealed that scheduled activities were canceled or not conducted as planned, and the activities that did occur were repetitive and not challenging, leading to resident dissatisfaction. The resident expressed that activities were monotonous and that outings, which she enjoyed, were not made available to her, especially due to limitations with wheelchair accessibility on the facility van. Another resident with depression, schizoaffective disorder, and other chronic conditions was also dependent on staff for activities and social interaction. His care plan included encouragement for group activities, pet visits, and outings, with a particular interest in going outside and fishing. Despite these documented preferences, the activities director confirmed that one-on-one activities were not provided, outings were infrequent, and there was no evidence of the resident's participation in activities for several months. The director also stated that most activities for residents requiring one-on-one attention were limited to watching TV or coloring. Documentation practices were also deficient, as the activities director admitted to not recording activity participation or changes in resident preferences in the medical records for years. Attendance was tracked informally, and there was no documentation of individualized activity engagement or adjustments based on resident feedback. These failures affected at least two residents reviewed and were observed during a census of 77 residents.
Failure to Administer Oxygen per Physician Order
Penalty
Summary
The facility failed to administer oxygen therapy according to the physician's order for a resident with acute and chronic respiratory failure, hypoxia, anxiety, congestive heart failure, and pneumonia. The physician had ordered oxygen via nasal cannula at two to three liters per minute every shift, and the resident's care plan included interventions to provide oxygen as ordered and to monitor oxygen saturation. However, during multiple observations, the resident's oxygen was found to be set at four liters per minute, exceeding the prescribed amount. This was confirmed by an LPN, who acknowledged that the oxygen flow rate did not match the physician's order. The facility's policy required oxygen to be administered only as ordered by a physician, except in emergencies.
Failure to Timely Address Pharmacy Medication Recommendations
Penalty
Summary
The facility failed to ensure that pharmacy recommendations regarding a resident's medication regimen were addressed in a timely manner. A resident with multiple diagnoses, including major depressive disorder, dementia, hypertension, hypothyroidism, type 2 diabetes, malignant neoplasm of the pituitary gland, dysphagia, anxiety, and vitamin D deficiency, was prescribed Trazodone 25 mg at bedtime. The pharmacy identified that Trazodone was ordered for insomnia, but the resident did not have a documented diagnosis of insomnia, which is required for the use of psychotropic medications. Although the physician later agreed to add the diagnosis of insomnia, the medical record did not reflect this addition as of the review date. Facility staff, including a registered nurse, confirmed that the pharmacy's recommendation was not addressed promptly and the necessary diagnosis was not documented in the resident's medical record, contrary to facility policy.
Failure to Decrease Psychotropic Medication as Ordered
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident's psychotropic medication, Vistaril (hydroxyzine pamoate), was decreased as ordered by the physician. The resident, who had a diagnosis of anxiety disorder and was cognitively intact, had been receiving Vistaril 25 mg at bedtime. A consultant pharmacy recommendation was made to attempt a gradual dose reduction, and the physician accepted this recommendation, modifying the order to decrease the dose to 12.5 mg at bedtime for anxiety. This order was signed and dated by the physician. Despite the physician's order to decrease the medication, review of the Medication Administration Record (MAR) for the following two months showed that the Vistaril dose was not reduced as directed. The medication was only discontinued later, rather than being tapered as ordered. The Director of Nursing confirmed that the dose reduction order was not implemented and acknowledged that the medication should have been decreased according to the physician's instructions. Facility policy required the use of the lowest possible dose of psychotropic medications and gradual dose reductions unless clinically contraindicated, but this was not followed in this instance.
Failure to Maintain Cleanliness of Medical Equipment and Provide Smoke-Free Environment
Penalty
Summary
Surveyors identified that a resident with severe cognitive impairment, quadriplegia, and multiple complex medical conditions, including a feeding tube, was living in an environment that was not maintained in a clean and sanitary manner. Observations on multiple occasions revealed that the resident's tube feeding pole had a dried brown substance, consistent with dried Nutren, on the feet of the pole. The family reported scraping dried substances off the floor near the pole, and an LPN confirmed the presence of the dried substance. These findings indicate that the equipment and surrounding area used for enteral feeding were not kept clean as required. Additionally, another resident with paraplegia, who was cognitively intact and dependent on a wheelchair, reported that the designated smoking area for residents was located outside her window. She stated that cigarette smoke entered her room through the heating/air conditioning unit, causing the smell to permeate her clothing and leaving black spots. Despite the administrator's request for residents to smoke further away, observations confirmed that multiple residents continued to smoke near her window, and staff verified that the room's ventilation system drew in outside air, including cigarette smoke, when in use.
Failure to Ensure Proper Use and Monitoring of Psychotropic Medications
Penalty
Summary
The facility failed to ensure that psychotropic medications were necessary prior to administration, did not monitor the efficacy of these medications, and did not comprehensively assess residents for side effects. For one resident with severe cognitive impairment and multiple diagnoses including major depressive disorder and dementia, there was a lack of documentation regarding behaviors that would warrant the use of Ativan, as well as no record of the medication being administered or its effects, despite staff statements indicating it was given. The facility's policy required adequate indication for use and documentation of medication effects, which was not followed in this case. Another resident with diagnoses including depression, schizoaffective disorder, and anxiety had not received a quarterly Abnormal Involuntary Movement Scale (AIMS) assessment since the previous year, despite being on antipsychotic medication known to cause tardive dyskinesia. The resident exhibited behavioral issues, but there was inconsistent documentation of these behaviors to monitor the efficacy of the prescribed psychotropic medications. The Director of Nursing confirmed these lapses in monitoring and documentation, which were contrary to facility policy.
Failure to Provide Adequate ADL Assistance and Hygiene for Dependent Residents
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs) and maintain proper hygiene and grooming for two residents who required such care. One resident with lymphedema, autism, ADHD, and expressive language disorder was dependent for ADLs and weighed 544 pounds. Despite physician orders for regular showers to prevent skin breakdown, documentation showed the resident received showers less frequently than ordered. Staff interviews confirmed that multiple staff were needed for transfers, the shower bed did not fit properly in the shower room, and the resident could not be fully cleaned during showers. The resident experienced pain and shearing injuries during transfers, and the physician's orders were changed due to these difficulties, but the resident still did not receive showers as ordered. Another resident with a history of intracranial injury, psychosis, Alzheimer's disease, and impaired cognitive processes was observed in unsanitary conditions on multiple occasions. The resident's room and bathroom had visible smears of stool and blood, soiled linens, and personal hygiene was neglected, as evidenced by impacted fingernails and open sores from skin picking. Staff confirmed the resident was a 'picker' and often smeared stool and blood throughout the room. The care plan did not address these behaviors, and staff interviews revealed that while the resident received some hygiene care on scheduled days, there was no individualized plan to manage the behaviors affecting cleanliness and hygiene. Facility policy required that residents unable to perform ADLs receive necessary services to maintain hygiene and grooming, but observations, record reviews, and staff interviews demonstrated that these standards were not met for the two residents. The lack of individualized care planning and failure to follow physician orders for hygiene contributed to the deficiencies observed.
Failure to Provide Comprehensive Catheter Care and Documentation
Penalty
Summary
The facility failed to provide comprehensive and individualized treatment and maintenance plans for residents with indwelling urinary catheters, as evidenced by the care of two residents. For one resident, medical records showed an indwelling catheter was reinserted following a urology appointment, but there were no corresponding physician orders for catheter care or documentation of catheter care in the Treatment Administration Record (TAR) for several months. Observations revealed the resident had a catheter in place with visible urine and sediment, and the insertion site was slightly red. Staff interviews confirmed the absence of catheter care orders, lack of daily documentation of urine output, and that the catheter was not properly secured. Nursing staff acknowledged that catheter care orders and documentation should have been present and that the catheter should not have been clamped after placement. For the second resident, medical records indicated the presence of a suprapubic catheter and multiple diagnoses related to urinary retention and bladder disorders. However, there were no physician orders for catheter care, and the resident's care plan did not address catheter care. The last documented catheter care was over two months prior to the survey, and the TAR for the relevant period did not include any catheter care treatments. Staff interviews confirmed the absence of catheter care orders, care plan interventions, and recent documentation of catheter care. A review of the facility's catheter care policy revealed that catheter care should be performed every shift and as needed, with specific instructions for maintaining privacy, changing bags, and ensuring proper drainage. The facility did not follow its own policy, as evidenced by the lack of orders, documentation, and care planning for residents with indwelling catheters.
Failure to Maintain Adequate Nursing Staff Resulting in Delayed Medication Administration
Penalty
Summary
The facility failed to maintain adequate nursing staff levels to meet the needs of residents, specifically regarding timely medication administration. On the night in question, an LPN who was scheduled to work from 6:00 P.M. to 6:00 A.M. arrived late, left the unit multiple times, and was absent from her assigned area for extended periods. Statements from staff indicated that the LPN spent significant time in her vehicle and was eventually sent home around 1:00 A.M. by another LPN, who then assumed responsibility for the unit. As a result, several residents did not receive their scheduled evening medications on time. Three residents were directly affected by the delayed medication administration. One resident with multiple chronic conditions, including multiple sclerosis, diabetes, and hypertension, did not receive several scheduled medications until after midnight, despite them being ordered for the evening. Another resident with chronic kidney disease and diabetes received insulin several hours late, and a third resident with dementia, psychosis, and anxiety received both an antihistamine and acetaminophen later than scheduled. Interviews with these residents confirmed that their medications were administered much later than expected, with some residents remaining awake until the medications were provided. The deficiency was substantiated through review of facility records, time punches, staff and resident interviews, and medication administration records. The documentation confirmed that the absence and inaction of the scheduled LPN led to a delay in medication administration for multiple residents, and that the facility did not have adequate licensed nursing staff present and available on the unit throughout the shift to meet resident needs.
Delay in Transition of Care Assistance for Resident with Complex Medical Needs
Penalty
Summary
The facility failed to provide timely and appropriate transition of care assistance for a resident with complex medical needs, specifically related to lymphedema and Milroy's disease. The resident was admitted with multiple diagnoses, including lymphedema, Milroy's disease, autistic disorder, attention deficit hyperactive disorder, and expressive language disorder. A physician requested referrals to other facilities better equipped to address the resident's needs, but there was a significant delay of almost three months before any referrals were made. During this period, the resident's representative repeatedly requested updates on placement options but was informed that no progress had been made in locating a suitable facility, particularly one capable of providing necessary transportation and specialized care. Interviews with facility staff confirmed that the resident required a higher level of care than the facility could provide, and documentation showed that referrals were not initiated in a timely manner. The facility's assessment indicated that it provided care for residents with morbid obesity and bariatric needs, but did not address the specific requirements for lymphedema specialty care. The deficiency was identified during a review of records, interviews, and the facility assessment, affecting one resident out of two reviewed for discharge planning.
Misappropriation of Controlled Medication Due to Improper Administration
Penalty
Summary
The facility failed to prevent the misappropriation of a controlled medication when Ativan, prescribed for one resident, was administered to another resident. The affected resident had a history of neurocognitive disorder with Lewy Bodies, anxiety, and depression, and was cognitively intact at the time of the incident. Physician orders specified that Ativan was to be administered intramuscularly as needed for seizures, and the medication was discontinued after a set period. Review of the controlled drug records showed that a dose of Ativan was signed out for administration, but it was not given to the intended resident. An interview with the Director of Nursing (DON) confirmed that the Ativan intended for one resident was instead administered to another resident, and there was no documentation in either resident's medical record regarding this transfer. The DON acknowledged signing out the medication but stated that an LPN actually administered it. The facility's medication administration policy required verification of the resident's name and medication details before administration, and specified that if a medication was unavailable, the contingency box should be used. However, the LPN failed to follow this policy and took the medication from another resident's supply instead.
Failure to Provide Transportation for Bariatric Resident to Medical Appointments
Penalty
Summary
The facility failed to provide required transportation services for a resident with multiple complex medical conditions, including lymphedema, Milroy's disease, autistic disorder, attention deficit hyperactive disorder, and expressive language disorder. The resident was cognitively intact but dependent for activities of daily living. Medical records indicated that the resident had scheduled appointments with a cardiologist and a plastic surgeon, but was not transported to these appointments as ordered. The resident's mother repeatedly reminded staff about the need for a signed referral and the upcoming appointments. Interviews with the DON and the resident's physician confirmed that the resident had not attended any outside medical appointments due to the inability of local transportation companies to transfer bariatric residents. The facility assessment documented that the facility provided care for residents requiring bariatric care, yet no arrangements were made to ensure transportation for this resident. The resident's mother expressed concern about the lack of transportation and the need for transfer to a facility that could meet this requirement.
Failure to Offer and Document Influenza Vaccination
Penalty
Summary
The facility failed to ensure that Resident #64 was offered the influenza vaccine during the period from 02/27/25 to 03/31/25. Record review showed that Resident #64, who was admitted with diagnoses including altered mental status, muscle weakness, cognitive communication deficit, and major depressive disorder, had intact cognition according to the Minimum Data Set assessment. Despite facility policy requiring annual offering of the flu vaccine and documentation of consent or refusal in the medical record, there was no evidence in the resident's medical record that the vaccine was offered, nor was there documentation of consent or refusal. During an interview, the Regional Director of Clinical Services confirmed that no information regarding the resident's consent or refusal for the influenza immunization could be located.
Failure to Offer and Document COVID-19 Vaccination for Residents
Penalty
Summary
The facility failed to ensure that the COVID-19 immunization was offered to residents, as required by policy. Record reviews for four residents with various medical conditions, including cerebral palsy, COPD, heart failure, diabetes, demyelinating disease, paraplegia, asthma, cellulitis, MRSA infection, and altered mental status, revealed no evidence that these residents were offered the COVID-19 vaccine. All four residents had intact cognition according to their Minimum Data Set assessments. Interviews with the Regional Director of Clinical Services confirmed that the facility was unable to locate documentation of COVID-19 vaccine consent or refusal for these residents. The facility's policy required that residents be offered the vaccine, sign consent prior to administration, and that documentation of consent or refusal be retained in the medical record. However, for these residents, there was no such documentation present.
Failure to Ensure Safe Emergency Evacuation for Dependent Resident
Penalty
Summary
The facility failed to ensure that a resident with significant mobility and medical needs could be safely transferred and evacuated from his room in the event of an emergency. The resident was admitted with diagnoses including lymphedema, Milroy's disease, autistic disorder, attention deficit hyperactive disorder, and expressive language disorder, and was primarily nonverbal and totally dependent on staff for all activities of daily living. Documentation and staff interviews revealed that the resident's weight exceeded the capacity of the available bariatric Hoyer lift, and the facility did not have a lift pad that would properly fit him. As a result, the resident could not be moved out of bed except when transferred to a shower bed, and attempts to reposition him caused elevated heart rate and shortness of breath. Further investigation showed that the resident's bariatric bed was too wide to fit through the doorway of his room, as confirmed by direct measurement and staff interviews. The resident's mother and the Assistant Fire Chief both verified that the bed could not be used for evacuation, and the facility lacked an alternative plan or equipment to evacuate the resident in an emergency. Multiple staff, including the DON, LPN, CNA, and physician, confirmed the inability to use the Hoyer lift or evacuate the resident from his room, demonstrating a failure to provide a safe and accessible environment for the resident.
Failure to Monitor and Report Bruising in Resident on Anticoagulant
Penalty
Summary
The facility failed to ensure that Resident #72, who was on an anticoagulant, was monitored and treated timely for bruising. Resident #72 had diagnoses including cerebral infarction, unspecified dementia, polyp of colon, and age-related osteoporosis, and had severely impaired cognition. The care plan included monitoring for signs of bleeding or bruising due to anticoagulant use. However, the Treatment Administration Record (TAR) for March and April 2024 revealed that the order to monitor for signs and symptoms of bleeding or bruising was not signed off as completed on multiple occasions. Additionally, shower sheets documented bruises on Resident #72's legs and thighs on several dates, but there was no documented evidence that the physician was notified of these findings. Interviews with Licensed Practical Nurses (LPNs) confirmed that they did not observe or report the bruising as required by the facility's policy on anticoagulant therapy. The Director of Nursing (DON) confirmed the lapses in monitoring and documentation. The facility was notified of the issue via email from the ombudsman after Resident #72 was transferred to a new facility, which noted bruises on admission. An investigation was initiated, but it failed to include the bruising noted on the shower sheets from March and April 2024. The allegation was unsubstantiated, stating that no bruises were noted while Resident #72 was a resident in the facility. However, interviews and documentation revealed that the required monitoring and reporting were not consistently performed, leading to a deficiency in the care provided to Resident #72.
Failure to Document Wound Care Treatments
Penalty
Summary
The facility failed to ensure documentation was completed on the Treatment Administration Records (TAR) as required after treatment was provided for Resident #73. This affected one resident out of three reviewed for wounds. Resident #73 had multiple severe wounds, including stage IV pressure ulcers and suspected deep tissue injuries, which required specific treatments and regular documentation. However, the treatments for Resident #73's wounds were not signed off as completed on the TAR for two specific dates in March 2024. The resident was admitted with multiple wounds, including a stage IV pressure ulcer on the sacrum and other severe wounds on the legs and foot. The wound care physician provided detailed treatment plans, including the use of wound vacs, silver alginate, and other dressings. Despite these detailed plans, the facility's staff failed to document the completion of these treatments on the specified dates. Interviews with the Director of Nursing (DON) and Licensed Practical Nurses (LPNs) confirmed that the treatments were performed but not documented as required. The facility's policy required that wound care and treatments be documented at the time of service or no later than the shift in which the care occurred. The failure to document these treatments as completed was confirmed through interviews and a review of the facility's policies. This deficiency represents non-compliance with the facility's own policies and accepted professional standards for maintaining medical records and safeguarding resident-identifiable information.
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Surveyors found that multiple hazardous storage areas, including a closet near medical records, a beauty salon used to store chemical cases, a supply room in one nursing station, a room leading to a smoking area, a housekeeping room near therapy, and a lobby storage room, lacked required self-closing or automatic-closing doors. These conditions did not comply with NFPA 101 requirements for hazardous area enclosure and had the potential to affect all residents and staff in an emergency.
Surveyors found that the facility did not conduct fire drills on every shift each quarter and did not vary drill conditions as required by NFPA 101. Record review showed that one shift lacked a documented drill for an entire quarter, and the pattern of drill times and dates did not demonstrate varied conditions. The Maintenance Director confirmed the incomplete and noncompliant fire drill schedule, which affected all residents and staff emergency preparedness.
Surveyors found that the facility did not maintain clear egress corridors as required by NFPA 101, with a TV/video cart plugged into a corridor outlet and multiple unsecured chairs placed in the hallway near resident rooms and the secured unit dining room, including directly in front of a fire extinguisher. These items projected about 29 inches into an approximately eight-foot-wide corridor and were located in front of the handrail, potentially affecting 28 residents and staff’s ability to assist in an emergency. The Maintenance Director confirmed these corridor obstructions during the survey.
A resident with intact cognition receiving Medicare Part A skilled services for metabolic encephalopathy had services discontinued while benefit days remained, but the facility did not issue the required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN). The Social Services Director later confirmed that no SNF ABN was provided and reported she believed only a Notice of Medicare Non-Coverage (NOMNC) was needed when all skilled services were stopped. This practice conflicted with the facility’s written policy, which required SNF ABNs to be issued when extended care items or services were initiated, reduced, or terminated due to expected non-coverage by Medicare.
Surveyors identified that the facility exceeded the acceptable medication error rate when two residents with type 2 DM received insulin doses that were not administered according to orders or manufacturer instructions. In two separate observations, an LPN administered Novolog and another LPN administered insulin glargine and insulin lispro without priming the insulin pens, and the insulin lispro and Novolog were given after the residents had already consumed a significant portion of their breakfast meals, despite orders for administration before meals. Manufacturer information for both insulin products required priming before each injection to ensure accurate dosing, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and specified time frames.
The facility failed to maintain accurate and complete crash cart audits for multiple full-code residents. Surveyors, accompanied by the DON, found that daily crash cart checks did not include verification of supply expiration dates, and that an extension cord documented as present on several audit dates was not actually in the cart. Audit logs also conflicted with the cart’s contents by indicating that required items such as eye protection, saline, and clear plastic were present when they were not. These findings were inconsistent with the facility’s policy requiring the crash cart to be checked every 24 hours and after each use, with prompt replacement of equipment and supplies.
A resident with chronic respiratory failure on supplemental O2, COPD, and cognitive risk factors was repeatedly documented as non-compliant with the smoking policy, including going out to smoke outside designated times and retaining cigarettes and lighters provided by family. Despite prior assessments identifying this resident as unsafe to smoke without supervision, a later assessment classified the resident as safe to smoke independently without documented rationale or care plan update. The resident subsequently went outside alone with an O2 nasal cannula in place, lit a cigarette, and sustained facial burns when the cannula ignited, as observed by staff and confirmed by EMS and ED records. In a separate case, another cognitively impaired resident with a history of falls had a care-planned intervention for non-skid strips in front of a recliner, but observation and staff confirmation showed the strips were not present, despite remaining on the active fall-risk care plan.
Multiple dependent residents did not receive scheduled showers, bed baths, or shaving as outlined in their care plans and the facility’s routine care policy. One resident recovering from spinal surgery missed numerous scheduled showers over several months. Another resident who relied on staff for self-care repeatedly requested shaving but was not shaved, and visible facial hair was observed after a recent shower. A resident with chronic respiratory failure and a tracheostomy, requiring substantial/maximal assist with personal hygiene, had no documented showers for an extended period and was observed with long facial hair, which staff acknowledged should be removed during bathing or as needed. A cognitively impaired resident with ESRD and CHF, scheduled for twice-weekly showers, had multiple undocumented or missed showers and reported not getting showers despite asking aides who said they lacked time. Another cognitively intact resident with hemiplegia and multiple comorbidities, also scheduled for twice-weekly showers, had several dates where documentation showed no shower/bath/bed bath provided or no entry at all, and she reported feeling unclean and unimportant when her showers were missed.
A resident with an indwelling urinary catheter for urinary retention, and care plan interventions requiring the drainage bag to be properly secured with a dignity cover, was observed seated in a chair with the catheter drainage bag uncovered and containing visible dark yellow urine that could be seen from the hallway. Later, an LPN confirmed the catheter bag was lying directly on the floor without a dignity cover. This situation occurred despite facility policy requiring care to be provided in a manner that respects and enhances each resident’s dignity and personal privacy.
A cognitively intact resident with chronic orthopedic pain had a PRN oxycodone order, but multiple doses were signed out on the narcotic log by an RN without corresponding entries on the MAR or documented pain assessments. A CNA/med tech reported frequent problems with this RN’s narcotic counts and documentation, describing erratic behavior when handling narcotic keys. The resident reported taking oxycodone only once or twice daily and otherwise using Tylenol, which conflicted with the number of oxycodone doses signed out. The facility’s investigation found it was inconclusive whether narcotics were misappropriated or whether there was a failure of documentation, but confirmed there was no evidence that all signed-out doses were administered.
Failure to Maintain Self-Closing Doors for Multiple Hazardous Storage Areas
Penalty
Summary
Surveyors identified a deficiency related to hazardous area protection and door requirements under NFPA 101, 2012 Edition. During facility tours, they observed that multiple hazardous storage areas did not have self-closing or automatic-closing doors as required for hazardous areas such as combustible storage and chemical storage. These areas included a closet next to medical records, a beauty salon being used to store cases of chemicals, a supply room in Station #2, and the room leading to the smoking area in Station #3. On a subsequent tour, surveyors observed additional hazardous areas without self-closing doors. The housekeeping room across from therapy and the lobby storage room were both noted to lack self-closing door mechanisms. The facility census at the time was 59 residents, and the surveyors stated that this deficient practice had the potential to affect all residents and staff's ability to assist in an emergency. The Maintenance Director verified these findings at the time they were observed.
Plan Of Correction
K 0321 This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be admissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as its allegation of substantial compliance as of 06/12/2026 K-0321 Doors with Self-Closing Devices Corrective action for resident/s: 1. The closet door next to medical records was lacking a self-closing door on 5/19/2026. Maintenance director to add self-closing device to closet door next to medical records on or before 06/12/2026 in accordance with applicable code. 2. The beauty salon had chemicals stored in it on 5/19/2026. Maintenance director moved chemicals from beauty salon on 05/20/2026 in accordance with applicable code. 3. The supply room on station 2 was lacking a self-closing door on 5/19/2026. Maintenance director to add self-closing door to supply room on station 2 on or before 06/12/2026 in accordance with applicable code. 4. The room to the smoking area on station 3 was lacking a self-closing door on 5/19/2026. Maintenance director to add a self-closing door to the smoking are on station 3 on or before 06/12/2026 in accordance with applicable code. 4. The housekeeping room across from therapy was lacking a self-closing door on 5/19/2026. Maintenance director to add a self-closing door to the housekeeping room across from therapy gym on or before 06/12/2026 in accordance with applicable code. 5. The lobby storage room was lacking a self-closing door on 5/19/2026. Maintenance director to add a self-closing door to the lobby storage room on or before 06/12/2026 in accordance with applicable code. Identification of other residents who may be affected: LNHA and Maintenance director/designee completed a full facility audit for doors with self-closing devices on 05/26/2026. Any corrective action, including, doors identified as needing self-closures will be added on or before 06/09/2026 in accordance with applicable code. Measures for systemic change: LNHA educated Maintenance Director on 05/26/2026 regarding NFPA 101-2012 sections 19.3.2.1 and 19.3.5.9 specifically regarding doors with self-closing devices. How Corrective Action will be monitored Ongoing "Doors with Self-Closing device audit" to be completed weekly x 2 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 06/12/2026
Failure to Conduct Required Quarterly Fire Drills on All Shifts
Penalty
Summary
The facility failed to conduct fire drills in accordance with NFPA 101, 2012 Edition, sections 19.7.1 through 19.7.1.8, specifically by not holding drills every shift each quarter and not varying drill conditions as required. Record review on 06/09/25 at approximately 10:32 A.M. showed there was no fire drill conducted for the first shift during the third quarter. The documented first-shift fire drills occurred on 01/30/26 at 2:42 P.M., 04/30/26 at 1:51 P.M., and 10/31/25 at 10:58 A.M., indicating a missed quarter. Second-shift fire drills were recorded on 02/26/26 at 5:20 P.M., 06/03/25 at 4:35 P.M., 08/29/25 at 3:46 P.M., and 11/25/25 at 5:09 P.M., and third-shift drills on 02/28/26 at 11:47 P.M., 05/30/25 at 12:18 A.M., 07/22/25 at 11:34 P.M., 09/26/25 at 11:40 P.M., and 12/15/25 at 5:17 A.M. The surveyor determined that drills were not conducted under varied conditions and that the required quarterly drill on each shift was not consistently performed. The Maintenance Director confirmed these findings at the time they were identified, and the deficiency had the potential to affect all 59 residents and staff response in an emergency. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency related to facility-wide emergency preparedness practices and documentation of fire drills.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 05/29/2026 K-0712 Fire Drills Corrective action for resident/s: There were no records of a fire drill for the first shift of the third quarter of 2025. First shift fire drill completed on 5/24/2026 by maintenance director/designee with no findings or corrective action necessary. Identification of other residents who may be affected: On 5/26/2026 Maintenance director/designee completed 100% audit of the scheduled fire drills to ensure a drill is scheduled quarterly each shift with no findings or corrective action necessary. Measures for systemic change: LNHA educated Maintenance Director on 05/26/2026 regarding NFPA 101-2012 section 19.7.1.4 through 19.7.1.7. specifically including fire drill frequency requirements. How Corrective Action will be monitored Ongoing "Fire Drill Audit" to be completed weekly x 2 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 05/29/2026
Obstructed Egress Corridors Due to Equipment and Chairs
Penalty
Summary
The facility failed to maintain required clear egress widths in corridors in accordance with NFPA 101, 2012 Edition, sections 19.2.3.4 through 19.2.3.5 and 7.3.2 through 7.3.2.3, creating projections into the egress corridor that exceeded allowable limits. Surveyors observed that on one day in Station #3, a cart with a television and video equipment was plugged into an outlet in the corridor by room 38, and five activity room chairs were placed in the corridor near the secured unit dining room directly in front of a fire extinguisher. On the following day, surveyors again observed chairs in the Station #3 corridor, with four by room 35 and four by the activities room, and the same television cart still in the corridor; the chairs were not secured. The corridor was approximately eight feet wide, and the projections extended approximately 29 inches into the corridor in front of the handrail. These conditions had the potential to affect 28 residents in the facility and the staff’s ability to assist in an emergency, and the Maintenance Director confirmed the observations at the time of discovery. No specific resident medical histories or conditions were described in the report, only that 28 residents were potentially affected and the facility census was 59.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be subsequent remedial measures and should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 05/29/2026 K-0232 Clear path of egress Corrective action for resident/s: 1. On 05/18/2026 station 3 had a cart with a television parked in the corridor by room 38 that exceeded allowable limits. Maintenance director/designee moved the TV cart into the activity room, out to the corridor on 05/18/2026 in accordance with applicable code. 2. On 5/18/2026 station 3 had 5 chairs in the corridor near the dining room directly in front of the fire extinguisher. Maintenance director/designee moved the chairs into the dining room, out of the corridor on 5/18/2026 in accordance with applicable code. 3. On 5/19/2026 station 3 had 4 chairs by the activity room and 4 by room 35. In addition, the TV cart was in the corridor. The maintenance director/designee moved the chairs and TV cart into the dining room, out of the corridor on 5/19/2026 in accordance with applicable code. Identification of other residents who may be affected: Maintenance director/designee completed a 100% facility audit for clear paths of egress on 5/26/26 with no findings or corrective action necessary. Measures for systemic change: Maintenance Director/designee educated staff on 5/26/2026 regarding NFPA 101-2012 section 19.2.3.4 and 19.2.3.5 specifically including maintaining a clear path of egress. How Corrective Action will be monitored Ongoing "Path of Egress Audit" to be completed weekly x 2 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 05/29/2026
Failure to Issue Required SNF ABN When Discontinuing Medicare Part A Services
Penalty
Summary
The deficiency involves the facility’s failure to issue a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) when Medicare Part A services were discontinued for a resident who still had available benefit days. The resident was admitted with a diagnosis of metabolic encephalopathy and had intact cognition per the Minimum Data Set assessment. The facility’s own SNF Beneficiary Notification Review documented that Medicare Part A skilled services began on 02/11/26 and the last covered day was 03/11/26, and that the facility initiated discharge from Medicare Part A services before the resident’s benefit days were exhausted. Despite this, no SNF ABN was provided to the resident or the resident’s representative. During interviews, the Social Services Director stated that the SNF ABN was issued hours prior to the last covered day but, upon reviewing her files, confirmed that no SNF ABN had actually been issued for this resident. She further explained that she believed an SNF ABN was only required if one skilled service remained and that if all skilled services were being discontinued, only the Notice of Medicare Non-Coverage (NOMNC) needed to be issued. The Administrator, however, stated that a resident should always receive both a SNF ABN and a NOMNC when Medicare Part A services are discontinued and benefit days remain. Review of the facility’s written policy dated 03/28/23 showed that the facility was required to issue SNF ABNs for initiation, reduction, or termination of extended care items or services when Medicare payment was not expected, which did not occur in this case.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as its allegation of substantial compliance as of 05/29/2026 F-0582 Corrective action for resident/s: On 5/14/26 Resident #34 was informed of rights and responsibilities related to Advanced Beneficiary Notice and voiced understanding of information for future reference by administrator. Identification of other residents who may be affected: Any resident receiving skilled services from nursing or therapy services. The Administrator audited all residents who were discharged from skilled services in the past 30 days to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary Notice on 5/29/26. No non-compliance was noted. Measures for systemic change: On 5/14/2026 Business Office Manager, Director of Rehab, Minimum Data Set nurse, Director of Nursing and Social Services Director were educated on proper procedure of issuing of Notice Of Medicare Non Coverage and Advanced Beneficiary Notice by administrator. All upcoming discharges from skilled services will be reviewed weekly at Utilization Review meeting to ensure notices will be delivered timely. How Corrective Action will be monitored: Administrator or designee to complete audits of all residents being discharged from skilled services to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 5/29/26
Insulin Administration Errors and Failure to Prime Insulin Pens
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5%, with surveyors identifying 3 errors out of 28 medication administration opportunities, resulting in a 10.71% error rate. For one resident with type 2 diabetes mellitus and moderate cognitive impairment, the physician’s order directed Novolog insulin 10 units via subcutaneous pen-injector to be given before meals. During an observed medication pass, the LPN administered 10 units of Novolog insulin without priming the pen and did so after the resident had already consumed approximately 50% of the breakfast meal. The LPN later confirmed she did not prime the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer instructions for the Novolog FlexPen specified that an air shot (priming) must be performed before each injection to ensure proper dosing. Another resident, also diagnosed with type 2 diabetes mellitus and with intact cognition, had orders for insulin glargine 35 units subcutaneously twice daily and insulin lispro 20 units subcutaneously before meals, plus 12 units subcutaneously if blood glucose was between 251 mg/dL and 300 mg/dL. During an observed medication administration, an LPN administered 35 units of insulin glargine and 32 units of insulin lispro without priming the insulin pens and after the resident had consumed approximately 90% of the breakfast meal, despite orders for insulin lispro to be given before meals. The LPN later stated she could not remember if she had primed the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer information for insulin lispro stated that the pen must be primed before each injection to confirm insulin delivery and remove air, and that failure to prime could result in too much or too little insulin. The DON confirmed the expectation that insulin be administered as ordered, including priming each pen with two units before dialing the prescribed dose, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and required time frames.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 5/29/2026. F-0759 Corrective action for resident/s: Residents #21 and #22 were assessed and evaluated by nurse and Director of Nursing 5/14/26. Resident #21 and #22 both denied any adverse effects and none were noted upon assessment by the Director of Nursing on 5/14/2026. Notification made to physician on 5/14/2026. LPN # 2 competency Eval on insulin administration with the Director of Nursing completed 5/14/2026. Identification of other residents who may be affected: Diabetic residents on assignment of LPN #2/station 2 have the potential to be affected and were assessed by the DON/Designee on 5/14/26 and found to be within normal limits. Measures for systemic change: All Nurses were educated by the Director of Nursing on the steps for Insulin administration per competency, diabetes clinical protocol policy, Medication and treatment orders policy, administering medications policy, and Obtaining fingerstick Glucose Level policy On 5/14/2026. How Corrective Action will be monitored: Director of Nursing and Assistant Director of Nursing will complete insulin administration audits on 5 nurses. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance: 5/29/2026
Inaccurate Crash Cart Audits and Missing Emergency Equipment
Penalty
Summary
The facility failed to ensure accurate and complete crash cart audits for residents requiring basic life support, affecting eighteen of thirty-five residents who were designated as full code. During an observation of the crash cart with the DON, surveyors found that the daily audit documentation for the month did not include verification of expiration dates for crash cart supplies. Review of the crash cart audit logs showed that an extension cord was documented as being in the cart on multiple dates, but the extension cord was not present in the cart at the time of inspection. Additionally, the audit documentation indicated that required items, including eye protection, saline, and clear plastic, were not present in the crash cart, yet they were documented as being in the cart. The facility’s undated “Emergency Crash Cart” policy stated that the crash cart is to be checked every 24 hours and after every use, and that equipment and supplies are to be noted and replaced promptly, but the observed documentation and contents of the cart did not match these requirements. This deficiency was verified with the DON at the time of the survey and was cited under the requirement that personnel provide basic life support, including CPR, to residents requiring emergency care, subject to physician orders and advance directives, and was investigated under Complaint Number 2687380.
Plan Of Correction
Cridersville Care Center Provider Number:366171 Survey Type: Complaint Survey Survey Date: 04/29/26 This Plan of Correction (PoC) outlines the actions completed by the facility with regards to the deficiency citation. This Plan of correction does not constitute any admission of guilt or liability by the facility and is submitted only in response to the regulatory requirements. Please accept the following as the facility's credible allegation of compliance as of 4/30/26. F678 CPR All Full Code residents #18 have the potential to be affected by the alleged deficiency. On 4/27/26 the DON/ADON re-stocked the crash cart per the inventory sheet for all missing items. Crash cart inventory sheet updated and new one will go into effect on 5/1/26. All licensed nursing staff provided with training related to crash cart inventory being a daily audit review using inventory sheet on 4/27/26 per DON/designee. The DON/designee will conduct clinical rounds and conduct a random audit of crash cart three times per week for 4 (four) weeks to ensure compliance. The results of the audit will be documented. The facility conducted an Ad-Hoc QAPI meeting on 4/27/26 and discussed the alleged deficiency and corrective actions. Date when corrective action will be completed: 4/30/26
Unsafe Smoking Practices with Oxygen and Missed Fall-Prevention Interventions
Penalty
Summary
The deficiency involves the facility’s failure to provide a safe smoking environment, adequate supervision, and appropriate implementation of its smoking policy for a resident who used oxygen and smoked, as well as failure to implement fall-prevention interventions as care planned for another resident. One resident had multiple relevant diagnoses, including chronic respiratory failure with hypoxia, COPD, end-stage renal disease, dependence on supplemental oxygen, diabetes, and necrotizing fasciitis. Her care plans identified impaired visual function, risk for respiratory complications related to a history of smoking, and risk for cognitive decline, with interventions including use of oxygen per order and observation for understanding. A smoking-related care plan created earlier documented that she wished to use smoking products, had been assessed as safe to smoke "with supervision," and was non-compliant with the smoking policy, with family continuing to provide smoking supplies despite education and a verbal warning for non-compliance. Smoking assessments and progress notes showed a pattern of non-compliance and inconsistent classification of this resident’s smoking safety. Multiple smoking observation/assessments completed earlier in March documented that she had no cognitive loss, visual deficits, or dexterity problems but was unsafe to smoke without supervision because she did not return smoking materials and did not follow designated smoke times. Progress notes described her going out to smoke multiple times by herself or with family, including sneaking out next door with a cigarette and going out multiple times in one evening, with staff documenting that she was "reeducated" and that family brought in cigarettes and lighters which she did not return to staff. Despite this history, a smoking assessment completed after a three-day hospital stay assessed her as safe to smoke without supervision, with no documentation explaining how this conclusion was reached or evidence that her care plan was updated accordingly. On the day of the incident, the resident reported she had cigarettes and a lighter on her person after returning from dialysis and stated she "could not find a nurse" and went outside to smoke, saying she "guessed" she forgot she had her oxygen on. A CNA observed her outside and saw a flame coming through the resident’s oxygen nasal cannula tubing, turned off the oxygen tank, removed the tubing, and patted out sparks on the resident’s shirt sleeve. The resident’s face and hands appeared black in color, and EMS documented first-degree burns to the head and face, with the resident stating she lit a cigarette with her nasal cannula on, causing the burn. The hospital record described her face as black from smoke and her lips and mouth as "burnt and charred," with a recommendation for intubation that she refused. The facility’s incident report recorded that she went outside with oxygen on to smoke without notifying staff, that staff witnessed the occurrence as she walked through the dining room door to the courtyard, and that she stated she thought she had turned her oxygen off. The facility’s smoking policy required interdisciplinary evaluation to determine safe versus unsafe smokers, staff maintenance of all smoking paraphernalia for both safe and unsafe smokers, and progressive consequences for policy violations. A separate deficiency involved another resident at risk for falls whose care plan included use of non-skid strips on the floor in front of her recliner as a fall-prevention intervention. This resident had severe cognitive impairment, used a walker and wheelchair, required supervision or touching assistance for transfers and ambulation, and had experienced two or more falls without injury since the prior assessment. The fall-risk care plan, initiated at admission, specified non-skid strips in front of the recliner beginning in November. However, nursing staff interviewed were not familiar with all of the resident’s fall-prevention interventions without checking the record, and observation of the room showed two recliners with no non-skid strips on the floor in front of them. An LPN confirmed that the non-skid strips were not present despite the intervention remaining active in the care plan, and moving the recliners did not reveal any strips. The facility’s fall management policy required identification of hazards and risk factors, implementation of interventions to minimize falls and injuries, and development and implementation of a care plan based on interdisciplinary evaluation, with interventions related to identified risk factors.
Plan Of Correction
Smoking: On 03/21/26 at 3:16 P.M. 911 response was activated for Resident #11 and Medical Director #601 was notified by Registered Nurse (RN) #322. On 03/21/26 at 3:18 P.M. on-call Nurse/Social Services #423 immediately notified the Administrator and Director of Nursing (DON) #304 of the incident involving Resident #11. On 03/21/26 at 3:22 P.M. Emergency Medical Services (EMS) arrived onsite. At 3:30 P.M. Resident #11 was transported to the emergency room. On 03/21/26 at 3:30 P.M. RN #322 completed a smoking re-assessment of Resident #11 assessing the resident to be an unsafe smoker requiring supervision due to failure to remove oxygen prior to entering designated smoking area. On 03/21/26 from 3:38 P.M. through 7:57 P.M. Licensed Practical Nurse (LPN) #337, #336, #335, #338; RN #334, and DON #304 re-assessed residents (who smoke). This included Resident #22, Resident #3, Resident #47, Resident #50, Resident #60, Resident #150, Resident #86, and Resident #10 to determine smoking safety (via smoking assessment). Each resident was re-educated regarding the facility smoking policy and staff verified there were no smoking materials on their person. The residents' smoking materials would be maintained by facility staff and distributed per policy. On 03/21/26 at 4:30 P.M. DON #304 responded to facility and an Ad Hoc (not scheduled) Quality Assurance (QA) meeting was held via telephone with the Administrator, DON #304 and Medical Director #601 to review investigative findings and plan of action. A root cause analysis was completed and determined Resident #11 had smoking materials on her person (believed to be obtained from family without staff knowledge) and failed to remove her oxygen. The QA team discussed a corrective action plan. On 03/21/26 from 5:00 P.M through 03/22/26 at 3:00 P.M. 26 RNs, 13 LPNs, one medical technician (MT), 54 Certified Nursing Assistants (CNA) four activities staff, one central supply staff, 11 dietary staff, 12 housekeeping staff, three laundry staff, one medical records staff, two social designees, two maintenance staff, nine administrative staff, and 19 therapy staff (158 staff at the time of the incident) were provided education regarding the facility smoking policy by DON #304 and the Administrator. This was completed via 1:1, small group in-services or via phone. Newly hired staff would receive education during general orientation regarding the facility's smoking policy. On 03/21/26 at 5:00 P.M. DON #304 completed an audit of all residents who smoke (Resident #22, Resident #3, Resident #47, Resident #50, Resident #60, Resident #150, Resident #86, and Resident #10) to verify smoking evaluations and plans of care accurately reflected the residents' smoking safety needs. The residents were educated on the facility smoking policy, and smoking materials were to be maintained at the nurses' station. An audit was completed which included verification of required safety measures present in designated smoking areas, including an ash can, fire extinguisher, fire blanket, ash trays and no oxygen signs. There were no identified concerns or changes made because of the audits. On 03/21/26 at 8:55 P.M. Resident #11 returned from the ED. LPN #332 verbally educated the resident regarding the facility smoking policy which included the need for supervision, a smoking apron (to be worn) and the facility smoke times. LPN #332 verified no smoking materials were on the resident's person or in her room at this time. On 03/23/26 at 11:00 A.M. the Interdisciplinary Team (IDT) (Administrator, DON #304, Medical Director #601, RN #302, Social Services #427, Social Services #423, DON #300, and Maintenance #436) met in-person to review the plan of action with DON #304/designee to complete weekly monitoring of residents who smoke and designated smoking areas weekly for four weeks with Housekeeping responsible to complete the cleaning. Housekeeping staff were responsible for cleaning ashtrays and the designated smoking area daily. Audits to be reviewed and any further actions required to be directed by the Quality Assurance and Performance Improvement (QAPI) Committee during scheduled meetings. The IDT also reviewed all current smoking assessments and care plans for residents who smoke. Resident #50 required a change in supervision levels with smoking due to cognition levels and her plan of care as well as Resident #11's plan of care was updated to reflect supervision/safety. On 03/23/26 from 3:45 P.M. to 8:55 P.M. Social Services #423 re-educated residents who smoke (Resident #22, Resident #3, Resident #47, Resident #50, Resident #60, Resident #150, Resident #86, Resident #10) and responsible parties, if applicable regarding the facility smoking policy and supervision levels. On 03/23/26 at12:13 P.M. Social Services #427 contacted Resident #11's family member (#602) to schedule a care conference. Family member #602 and Family Member #603 were not available to meet until 03/27/26. On 03/23/26 at 1:00 P.M. staff education related to smoking areas, removal of oxygen prior to entering smoking area and maintaining smoking materials at the nurses' station for residents who smoke was initiated by DON #304 and the Administrator via 1:1, small group in-services or via phone call. Education was completed for all 158 staff by 03/24/26 at 1:00 P.M. Newly hired staff would be educated during general orientation regarding the facility's smoking policy. The facility does not utilize agency staff. On 03/27/26 at 11:00 A.M. a care conference was held with Resident #11 and Family Members #602 and #603, the Administrator, Social Services #423 and Social Services #427. The facility smoking policy was reviewed. The resident and family were informed an involuntary discharge would be initiated should the resident exhibit non-compliance moving forward and supervision would be increased beyond the two-hour standard of care to monitor more closely for non-compliance with the facility smoking policy. Family Member #602 stated he educated his siblings as well. On 04/10/26 at 2:00 P.M. DON #304 initiated education with 26 RNs and 13 LPNs (100% of nurses educated) regarding completion of the smoking evaluation via 1:1, small group in-services, or phone. The education was completed by 6:00 P.M. on 04/10/26. A new resident who smokes must remain supervised until the interdisciplinary team (IDT) reviews and determines smoking safety, at which time the care plan is developed and resident and family education is provided. The communication through the staff would be the care plan. Newly hired staff receive education during general orientation regarding the facility's smoking policy and completion of smoking evaluation via Point Click Care (PCC). On 04/10/26 at 4:29 P.M. DON #304 initiated an order in PCC for the nurse to verify, each shift, that Resident #11's smoking materials were maintained at the nurses' station. On 04/13/26 at 5:30 P.M. DON #304 initiated orders in PCC for nurses to verify, each shift, that all residents who smoke would have smoking materials maintained at the nurses' station. An updated list of smokers included: Resident #60, Resident #50, Resident #11, Resident #86, Resident #113, and Resident #151. On 04/13/26 at 5:45 P.M. DON #304 initiated questionnaires for staff regarding the smoking policy with re-education provided as needed via 1:1 and small group in-services for staff currently in the facility with all staff to be questioned/educated prior to working their next scheduled shift. Falls: On 4/9/26, Maintenance Director placed non-skid strips on the floor in front of Resident #12's recliner. Like Residents are identified as residents who have had a fall within the facility. Utilizing the Fall Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, an audit of falls and appropriate interventions for the past 30 days will be completed by the Director of Nursing or designee to ensure fall interventions are in place per plan of care. This audit along with identified corrections will be completed on or F 0689 before 5/13/26. The Director of Nursing or designee will re-educate licensed nurses and STNA/CNAs on the Fall Management Policy to include fall interventions to be in place per the care plan. This education will be completed on or before 5/13/26. Utilizing the Fall Management Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, the Director of Nursing or designee will complete an audit of new admissions, new readmissions and residents who experience a fall within the last 7 days, weekly for four weeks, beginning 5/14/26 to ensure fall safety interventions are in place per plan of care. Current fall interventions found to not be in place will be corrected with all intervention in place per plan of care. Negative findings to be addressed immediately and negative trends or system wide issues will be reported to the QAPI committee, and the action plan will be adjusted as needed.
Removal Plan
- Activated 911 response for Resident #11 and notified the Medical Director.
- On-call Nurse/Social Services immediately notified the Administrator and DON of the incident.
- EMS arrived onsite and Resident #11 was transported to the emergency room.
- Completed a smoking re-assessment of Resident #11, determining the resident was an unsafe smoker requiring supervision due to failure to remove oxygen prior to entering the designated smoking area.
- Re-assessed all residents who smoke (Residents #22, #3, #47, #50, #60, #150, #86, and #10) to determine smoking safety via smoking assessment.
- Re-educated residents who smoke regarding the facility smoking policy and verified there were no smoking materials on their person.
- Implemented that smoking materials would be maintained by facility staff and distributed per policy.
- Held an ad hoc QA meeting to review investigative findings and plan of action.
- Completed a root cause analysis determining Resident #11 had smoking materials on her person and failed to remove oxygen.
- Developed a corrective action plan.
- Provided facility-wide education to staff on the facility smoking policy.
- Implemented that newly hired staff would receive smoking policy education during orientation.
- Completed an audit of all residents who smoke to verify smoking evaluations and plans of care accurately reflected smoking safety needs.
- Ensured smoking materials were maintained at the nurses’ station.
- Audited designated smoking areas for required safety measures (ash can, fire extinguisher, fire blanket, ash trays, and no-oxygen signs).
- Provided verbal education to Resident #11 on smoking policy (supervision, smoking apron, smoke times).
- Verified no smoking materials were on Resident #11’s person or in her room.
- Conducted an in-person IDT meeting to implement weekly monitoring of residents who smoke and designated smoking areas weekly for four weeks.
- Assigned housekeeping to clean ashtrays and the designated smoking area daily.
- Directed audits to be reviewed by QAPI.
- Reviewed all current smoking assessments and care plans for residents who smoke.
- Updated Resident #50’s supervision level.
- Updated Resident #11’s plan of care to reflect supervision/safety.
- Re-educated residents who smoke and responsible parties (as applicable) regarding the facility smoking policy and supervision levels.
- Contacted Resident #11’s family to schedule a care conference.
- Initiated additional staff education regarding smoking areas, removal of oxygen prior to entering smoking area, and maintaining smoking materials at the nurses’ station.
- Held a care conference with Resident #11 and family to review smoking policy.
- Informed resident/family that involuntary discharge would be initiated for future non-compliance.
- Increased supervision beyond the two-hour standard of care to monitor more closely for non-compliance.
- Provided education to all nurses regarding completion of the smoking evaluation.
- Implemented that new residents who smoke must remain supervised until IDT review determines smoking safety and care plan/education are completed.
- Entered an order in PCC for nursing to verify each shift that Resident #11’s smoking materials were maintained at the nurses’ station.
- Entered orders in PCC for nursing to verify each shift that all residents who smoke have smoking materials maintained at the nurses’ station.
- Initiated staff questionnaires regarding the smoking policy with re-education as needed.
- Required all staff to be questioned/educated prior to working their next scheduled shift.
Failure to Provide Scheduled Bathing and Shaving Assistance for Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide scheduled and needed bathing and shaving assistance to multiple dependent residents in accordance with their care plans, preferences, and the facility’s routine care policy. One resident with spinal stenosis and recent L2–L5 decompression fixation fusion was care planned for substantial/maximal assistance with shower/bath and toileting hygiene and was scheduled for showers on Tuesdays and Fridays. Electronic documentation from early January through early April showed this resident did not receive a shower or bed bath on 11 identified scheduled days, and the DON confirmed these missed bathing events. Another resident with dysphagia and developmental issues, who required assistance with self-care and mobility, reported that she asked staff to shave her but they did not, which bothered her. During an observation following a recent shower, she stated she had not been shaved and that the hair "itched"; small gray hairs were visible on her chin. A CNA confirmed the presence of gray chin hairs and acknowledged the resident needed shaving, stating it would be addressed with the next scheduled shower. A further resident with chronic respiratory failure, tracheostomy status, heart failure, moderate intellectual disabilities, anxiety, depression, and PTSD required substantial/maximal assistance with personal hygiene and had a care plan for assistance with self-care, including personal hygiene. Her shower schedule called for showers on Monday and Thursday nights, with complete shaves for men and women. Review of documentation showed her last recorded shower/bath was nearly a year earlier, with no indication of additional personal hygiene or facial hair removal on that date. Observations on two separate days showed long white hairs on her chin and jaw line, which a CNA later confirmed, stating facial hair removal should occur with baths/showers or as needed. A resident with end stage renal disease, respiratory failure, hyperlipidemia, and congestive heart failure, who had impaired cognition and required partial/moderate assistance with bathing and personal hygiene, was scheduled for showers on Wednesdays and Saturdays. Review of shower documentation from admission through early April revealed no showers provided or refusals documented on at least ten scheduled shower days. In interviews, this resident reported not receiving scheduled showers, was unsure of his shower days, and stated he could use a good scrub down, adding that he had asked aides who told him they did not have time. A CNA explained that shower days appear on shower sheets and in the computer and that CNAs are supposed to document daily, with nurses checking the documentation; the DON verified the resident had not received showers per schedule or preference. Another resident with a fracture of the lower end of the left humerus, hemiplegia and hemiparesis after cerebral infarction, rheumatoid arthritis, hypertensive heart disease, urinary retention, and osteoarthritis was care planned as non–weight bearing to the left upper extremity and requiring substantial/maximal assistance with showering/bathing. Her electronic record showed she was scheduled for showers on Wednesdays and Saturdays. The shower task question "did the resident receive a shower/bath/bed bath?" was documented as "no" on three dates, indicating no shower/bath/bed bath was completed, and left unanswered on three additional dates. The DON confirmed that one missed shower was due to an outside appointment, that on two dates the "no" response meant no bathing of any type occurred, and that on three dates there was no documentation at all. The resident, who was cognitively intact, reported that missing showers made her feel unimportant compared to others and that she did not feel clean when her shower was missed. Facility policy on routine resident care stated that showers, tub baths, and shampoos are to be scheduled according to person-centered care or state guidelines, with additional showers given upon request, but the documented and observed care did not reflect consistent provision of scheduled bathing and shaving for these residents.
Plan Of Correction
1. Resident #5 received a shower by the STNA on 4/13/26. Resident #8 received a shower by the STNA on 4/8/26. Resident #9 received a shower and had their chin shaved by the STNA on 4/14/26. Resident #70 received a shower by the STNA on 4/13/26. Resident #76 received a shower and had their chin shaved by the STNA on 4/15/26. 2. Like residents are identified as residents who need assistance with showering and shaving. Utilizing the Shower Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, an audit of like residents will be completed by the Director of Nursing or designee to ensure that showers and resident shaving are completed. This audit along with identified corrections will be completed on or before 5/13/26. 3. The Director of Nursing or designee will re-educate licensed nurses and STNA's on the Routine Resident Care Policy to include bathing and shaving residents. This education will be completed on or before 5/13/26. 4. Utilizing the Shower Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, the Director of Nursing or designee will complete an audit of 4-6 residents weekly for four weeks, beginning 5/14/26 to ensure that showers and resident shaving are completed. Noncompliance found during audits will be addressed and assistance with showers and/or shaving provided. Negative findings to be addressed immediately and negative trends or system wide issues will be reported to the QAPI committee, and the action plan will be adjusted as needed.
Uncovered Urinary Catheter Drainage Bag Compromises Resident Dignity
Penalty
Summary
The facility failed to maintain a resident’s right to privacy and dignity related to management of an indwelling urinary catheter. A resident admitted with malignant neoplasm of the esophagus and type II diabetes mellitus had a care plan identifying risk for urinary tract infection and catheter-related trauma due to an indwelling catheter for urinary retention. The care plan interventions included ensuring the catheter tubing was secured and the drainage bag was properly secured with a dignity cover in place. Physician orders directed that the resident’s 16 French indwelling urinary catheter be changed every 30 days and as needed, and the comprehensive MDS documented that the resident had an indwelling catheter and was cognitively intact. During observation, the resident was seen seated in a chair with the urinary catheter drainage bag hanging from the chair without a dignity cover, and dark yellow urine was visible in the bag from the hallway. In a later observation and interview, an LPN confirmed that the catheter bag was lying directly on the floor and did not have a dignity cover. Attempts to interview the resident to confirm cognitive status were unsuccessful, as the resident was unable to answer screening questions. Review of the facility’s “Resident Dignity & Personal Privacy” policy stated that the facility should provide care in a manner that respects and enhances each resident’s dignity, individuality, and right to personal property, which was not followed in this instance when the catheter drainage bag was left uncovered and visible.
Plan Of Correction
The Laurels of Athens wishes to have this plan of correction submitted as our written allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission to nor agreement with, either the existence of, or the scope and severity of, any of the cited deficiencies or conclusions set forth in the statement of deficiencies. This plan is prepared and/or executed to ensure continuing compliance with regulatory requirements. Our alleged date of compliance is 5/13/2026. 1. On 4/6/26, Resident #92's catheter bag was removed from the floor, the bag changed and covered for dignity by the licensed nurse. Resident #92 discharged from the facility on 4/11/26. 2. Like Residents are identified as residents who utilize urinary catheters. An audit will be completed by the Director of Nursing or designee for like residents utilizing the Urinary Catheter Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC to ensure catheter bags are covered for dignity and not laying directly on the floor. This audit along with identified corrections will be completed on or before 5/13/26. 3. The Director of Nursing or designee will re-educate licensed nurses on the Indwelling Urinary Catheter Policy as well as Resident Dignity & Personal Privacy Policy to include privacy covers are in place for urinary catheters and that the catheter is not laying on the floor. This education will be completed on or before 5/13/26. 4. Utilizing the Urinary Catheter Audit Tool which was created on 4/20/26 by the Director of Nursing for purpose of this POC, the Director of Nursing or designee will complete an audit of all residents with catheters weekly for four weeks, beginning 5/14/26 to ensure catheter bags are covered for dignity and not laying directly on the floor. Any catheters found to be touching the floor or uncovered will be removed from the floor, the bag changed and covered for dignity. Negative findings to be addressed immediately and negative trends or system wide issues will be reported to the QAPI committee, and the action plan will be adjusted as needed.
Failure to Prevent Possible Misappropriation and Poor Documentation of PRN Narcotics
Penalty
Summary
The deficiency involves failure to prevent potential misappropriation of a resident’s narcotic medication and failure to ensure accurate documentation of controlled substance administration. A cognitively intact resident with chronic pain related to an internal orthopedic device and left knee pain had an order for oxycodone 5 mg PO every four hours PRN for pain and a care plan directing staff to administer medications as ordered and observe for effectiveness and side effects. The resident’s MDS showed she rated her pain as 7/10 and received opioid medication. However, review of the February MAR and the narcotic log revealed multiple discrepancies between narcotic sign-outs and documented administration. On several occasions, oxycodone doses were signed out on the narcotic log by an RN without corresponding documentation on the MAR. Specifically, oxycodone was signed out on one evening at 9:30 p.m. with no MAR entry, and again on a subsequent night at 1:30 a.m. and 5:30 a.m. with no MAR entries for those times. Another dose was signed out at 9:00 p.m. while the MAR reflected administration at 10:16 p.m., and a later dose at 5:30 a.m. was documented on both the narcotic log and MAR. There was also no documentation of pain assessments before or after PRN opioid administration. These documentation gaps meant there was no evidence that all narcotic doses signed out were actually administered to the resident. Staff interviews further highlighted concerns about the handling of narcotics. A CNA/med tech reported frequently taking the narcotic keys from the RN and described the RN’s behavior as erratic, with repeated problems involving incorrect narcotic counts and missing documentation on both the MAR and narcotic log. The resident stated she did not receive oxycodone more than once or twice a day, preferring to take Tylenol the rest of the time, which conflicted with the number of oxycodone doses signed out. When questioned, the RN gave inconsistent explanations about how often she pulled and administered PRN narcotics and acknowledged struggling with the new system, while also suggesting the resident may have received PRN tizanidine instead of remembering oxycodone. The facility’s investigation concluded that evidence was inconclusive as to whether misappropriation occurred or whether the issue was solely lack of documentation, but confirmed there was no evidence the resident received all doses signed out on the narcotic log.
Plan Of Correction
1. Resident #99 had a Self-Reported Incident submitted and investigated via the EIDC on 3/2/26. The investigation was inconclusive as we could not prove that misappropriation occurred. On 2/24/26, Resident #99 was interviewed and pain assessed by Director of Nursing and resident had no ill effects related to the inconsistent documentation in the medical record as it relates to her controlled substance pain medication. 2. Like Residents are identified as residents who utilize controlled substance PRN pain medications. An audit will be completed by the Director of Nursing or designee for like residents utilizing the Controlled Substance Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC to ensure PRN controlled substance pain medications that are signed off the control sheet are documented in the resident medical record as well. This audit along with identified corrections will be completed on or before 5/13/26. 3. The Director of Nursing or designee will re-educate licensed nurses on the Controlled Substances Policy to include appropriate documentation of controlled substances. In addition, the licensed nurses will be re-educated by the Director of Nursing or designee on the Abuse Prohibition Policy to include misappropriation of resident property. This education will be completed on or before 5/13/26. 4. Utilizing the Controlled Substance Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, the Director of Nursing or designee will complete an audit three controlled substance sheets from each of the nine medication carts for a total of twenty-seven sheets weekly for four weeks, beginning 5/14/26 to ensure PRN controlled substance pain medications that are signed off the control sheet are documented in the resident medical record as well. Inconsistencies noted from the audit will be investigated for misappropriation. Negative findings to be addressed immediately and negative trends or system wide issues will be reported to the QAPI committee, and the action plan will be adjusted as needed.
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