Stellar Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Woodsfield, Ohio.
- Location
- 47045 Moore Ridge Road, Woodsfield, Ohio 43793
- CMS Provider Number
- 366448
- Inspections on file
- 23
- Latest survey
- January 28, 2026
- Citations (last 12 mo.)
- 43 (1 serious)
Citation history
Health deficiencies cited at Stellar Care Center during CMS and state inspections, most recent first.
A resident with a PICC line for IV cefepime therapy and multiple comorbidities received IV medication from an LPN who attached IV tubing directly to the open end of the PICC line without a needleless connector, after cleaning only the open hub. The LPN stated that PICC lines do not have valves, despite reporting prior IV therapy training. Facility leadership and HR reported they did not maintain competency or training records for agency staff, and one agency only verified licensure while another provided a self-assessment showing the LPN rated IV skills as limited and requiring supervision, even though the facility’s contract assigned responsibility for orientation, education, and competency of agency staff to the facility.
A resident with a suprapubic catheter did not receive comprehensive and individualized catheter care as ordered, including missed catheter changes and inadequate documentation. Staff were unaware of or misunderstood physician orders, and catheter care was not consistently performed due to staffing shortages and lack of training. These failures led to the resident developing a severe UTI, sepsis, and acute kidney injury, requiring hospitalization and intensive care.
The facility did not pay multiple vendor and utility bills on time, resulting in overdue accounts, shut-off notices for water and electricity, and delayed payments to the medical director. Staff reported supply delays and concerns about payroll, while the business office manager repeatedly forwarded unpaid bills to corporate accounts payable with limited resolution. All residents, who have complex medical needs, were at risk due to the facility's failure to maintain financial solvency and ensure uninterrupted essential services.
The facility did not adequately assess or provide for the activity needs of all residents, resulting in repetitive and limited programming, lack of specialized activities for memory care residents, and widespread dissatisfaction among both residents and staff. Observations and interviews revealed that scheduled activities were often not meaningful or engaging, and that some residents, including those with mental health conditions, were left without appropriate opportunities for socialization and stimulation.
The facility did not maintain adequate nursing staff, resulting in delayed or missed care such as bathing, feeding, and incontinence care. Staff and residents reported long wait times for assistance, unsafe transfers, and unmet personal care preferences. Facility records and leadership confirmed that current staffing levels were insufficient to meet the needs of residents requiring assistance with ADLs.
The facility did not provide specialized memory care services as advertised, with residents on the memory care unit receiving the same activities as the rest of the facility and lacking individualized programming. Observations and staff interviews revealed minimal engagement, no separate activity calendar, and inadequate staffing, resulting in periods of unsupervised residents and unmet psychosocial needs. Families and staff expressed concerns about the lack of stimulation, safety, and the absence of meaningful activities tailored to residents with dementia.
The facility did not manage its resources effectively, resulting in overdue utility and vendor bills, delayed payments to the Medical Director, and insufficient dietary staffing as outlined in the facility assessment. Administrative staff were often absent or unresponsive, and the dietary department was understaffed, causing delays in meal preparation and requiring CNAs to assist with kitchen duties, impacting all residents.
A facility-wide assessment failed to accurately account for the number of residents dependent on staff for ADLs such as toileting, dressing, bathing, and transferring, resulting in staffing levels that did not meet the actual needs of the resident population. Interviews with the DON, Administrator, and Dietary Director confirmed that both direct care and dietary staffing were insufficient compared to the requirements outlined in the assessment, leading to inadequate care coverage during both routine operations and emergencies.
Multiple residents did not receive prescribed treatments, such as wound care and nutritional supplements, and there were repeated failures to document care or notify providers of significant changes, including missed skin assessments and unreported rapid weight gain in a resident with CHF. Staff interviews confirmed lapses in following care protocols and physician orders, resulting in unaddressed changes in condition and incomplete care documentation.
Two residents did not receive required fall prevention interventions or post-fall assessments, as one lacked a care planned floor mat and another did not have a post-fall assessment documented after an unwitnessed fall. Additionally, hazardous chemicals were left unsecured and accessible to all residents on the memory care unit while staff were not present, as confirmed by an LPN. These deficiencies were identified through observation, interviews, and record reviews.
A resident with multiple chronic conditions was discharged home without comprehensive discharge instructions or documentation of a discharge note in the medical record. The discharge summary lacked evidence of education on diet or activities, and the DON confirmed the documentation was incomplete.
Two residents admitted with complex medical conditions did not have complete baseline care plans developed within 48 hours of admission. Only partial care plans, such as dietary or nutrition/hydration risk, were initiated, while other required care plans were delayed. Facility leadership confirmed that care plans were not completed in accordance with policy, and care conference documentation was incomplete.
Two residents who were dependent on staff for bathing, due to conditions such as Alzheimer's disease and mobility impairments, did not receive showers according to their preferences and scheduled times. Documentation and staff interviews confirmed that multiple showers were missed, and in some cases, behavioral challenges were cited as reasons for not providing care. The facility's policy allowed residents to choose the frequency and timing of bathing, but this was not followed.
A resident with multiple chronic conditions was admitted and continued to receive oxygen therapy at 2 LPM via nasal cannula, but there was no physician order for this treatment. Both the DON and Administrator confirmed that an order was required, and facility policy mandates physician orders for oxygen administration except in emergencies.
A resident with multiple serious conditions experienced moderate to severe pain over several days due to a delay in receiving ordered Tramadol. During this period, there was no documentation of alternative pain management interventions, despite ongoing pain reports and facility policy requiring appropriate pain assessment and treatment.
A resident with a history of depression, anxiety, and alcohol dependence was unable to attend AA meetings due to a broken facility van, and no alternative support or social services were provided during this period. The resident, who relied on AA for social interaction and emotional support, did not receive follow-up or in-house interventions from the social worker or other staff, despite clear care plan directives and facility policy requirements.
Two residents did not receive prescribed medications as ordered due to delays in pharmacy delivery and issues with the facility's medication ordering process. One resident missed several days of an ear wax removal treatment, while another experienced unmanaged pain due to a week-long delay in receiving Tramadol. Staff and nursing interviews confirmed ongoing problems with obtaining both prescription and OTC medications, and the facility did not notify physicians when medications were unavailable.
Two residents with special dietary needs received meals that were unpalatable, lacking flavor, and had poor texture, as confirmed by dietary staff and resident feedback. One resident on a pureed diet received food that was stringy, lumpy, and watery, while another resident reported their meal had no flavor. These deficiencies were observed and verified during meal preparation and service.
Two residents did not receive food prepared in the required texture for their prescribed diets. One was served a whole hot dog instead of a mechanical soft diet, and another received pureed foods that were stringy, lumpy, and lacked flavor, despite orders for a pureed diet. Dietary staff and the dietary director confirmed the food did not meet required consistency standards.
A resident with a suprapubic catheter had monthly catheter changes documented as completed by LPNs, but interviews revealed that the procedure was never actually performed. Staff misunderstood the order, believing it referred to changing the catheter bag, and some lacked training on the procedure. The physician was not notified of the missed catheter changes, and the DON confirmed the inaccurate documentation.
A resident with an indwelling catheter and severe cognitive impairment was observed multiple times with their catheter bag lying on the floor while resting in bed. An LPN confirmed the observation, indicating a failure to follow infection prevention and control practices for catheter care.
A resident with multiple comorbidities and an unstageable pressure ulcer did not receive wound care in accordance with infection control protocols. An LPN and the ADON entered the room without donning gowns as required by enhanced barrier precautions, and the LPN used improper wound cleaning techniques and failed to clean equipment between uses. Staff interviews confirmed that infection control policies were not followed during the procedure.
Medication and treatment carts were left unlocked and unattended at the nurses' station while an LPN was off the unit and a CNA was serving breakfast in the dining room. Several cognitively impaired residents, all able to ambulate independently and known to wander, had access to the area. Facility policy required carts to be locked when unattended, but this was not followed.
A resident with complex medical conditions did not receive all required components of their comprehensive MDS assessments. Specifically, the annual MDS was missing the Cognitive Pattern: Brief Interview for Mental Status and Pain Assessment interview, and the quarterly MDS lacked the Pain Assessment interview. These assessment omissions were verified by the ADON.
Two residents with complex medical needs did not have comprehensive care plans or discharge plans developed, despite being cognitively intact and expressing goals to return to the community. Both lacked documented referrals and active discharge planning, and one resident did not have a pain management care plan, even though pain was regularly assessed and treated.
A resident with significant medical needs developed new pressure ulcers and did not receive the prescribed silver alginate wound treatment, instead receiving calcium alginate for an extended period. During a dressing change, an LPN and the ADON failed to follow infection control protocols, including not using required PPE and reusing contaminated instruments, contrary to facility policy.
Two residents with colostomies did not consistently receive ostomy care as ordered by their physicians, as documented in the TAR and confirmed by the ADON. Both residents were cognitively intact and had care plans specifying the need for regular ostomy care, but records showed multiple missed care opportunities.
Two residents experienced medication administration errors, including late administration, incorrect dosages, and wrong medication forms, resulting in a medication error rate of 26.9%. Nursing staff acknowledged the errors, which occurred despite facility policy requiring timely and accurate medication administration.
The facility failed to implement a comprehensive pressure ulcer prevention program for two residents, resulting in the development of Stage II pressure ulcers. Both residents were at risk due to impaired mobility and incontinence, but care plans were not adequately followed. Incontinence care was not provided every two hours, and required pressure-relieving devices were not in place. Staff shortages contributed to the inability to provide necessary care, as confirmed by staff interviews and observations.
The facility failed to maintain sanitary conditions in food storage and preparation, affecting all residents receiving food. Expired and undated food items were found, and a staff member did not follow proper hand hygiene when changing gloves during food preparation. The dishwasher also failed to reach the required rinse temperature.
The facility failed to maintain a clean and safe environment, with issues such as discolored tile and grout, rusty air vents, torn walls, and sticky floors. A resident's room was particularly unkempt, with soiled bedding, cluttered window sills, and flies present. Staff confirmed the lack of maintenance and cleaning, noting the absence of a maintenance person for over a month and the facility's quarterly exterminator contract not addressing flies.
The facility failed to ensure proper documentation of advanced directives for two residents. One resident lacked an order for code status upon admission, while another had conflicting code status orders in electronic and paper records. The DON confirmed these discrepancies, which violate the facility's policy requiring clear display of advanced directives in medical records.
A facility failed to accurately document a resident's psychiatric diagnoses in the PASRR, despite the resident having major depressive disorder and unspecified psychosis. The PASRR did not reflect these conditions, although the resident's care plan and MDS indicated active diagnoses and antidepressant use. The DON confirmed the oversight, and the facility's policy required a review for unrecognized serious mental illness, which was not conducted.
The facility failed to develop comprehensive care plans for three residents, affecting their diagnoses, medications, and ADLs. A resident with dementia, depression, hallucinations, insomnia, and diabetes lacked care plans for these conditions and medications. Another resident with cerebral infarction and heart disease had no care plans for anticoagulation and bleeding risks. A third resident with dementia and other conditions lacked an ADL care plan. The facility's policy required care plans within seven days of the MDS assessment, which was not followed.
A resident with dementia and Alzheimer's disease did not receive consistent assistance with bathing, shaving, and oral care, despite requiring substantial help. The resident experienced gaps of up to ten days between showers, was often unshaven, and lacked access to oral care supplies. Staff interviews revealed that personal hygiene supplies were out of reach, and there was no follow-up after shower refusals. The facility's policy did not address handling refusals, leading to inadequate care.
A resident with a history of malnutrition and anxiety did not receive the required level of activity engagement as per her care plan, due to staffing challenges and inadequate scheduling. The resident's participation in activities was minimal, and she was often observed in her room without engagement. Interviews revealed that the Activity Director was the sole staff member for activities and was sometimes reassigned to other duties, leading to incomplete activity schedules.
A facility failed to implement pressure ulcer prevention interventions for a resident with known pressure ulcers. Despite physician's orders to use Prevalon boots to alleviate pressure, observations revealed the boots were not in place, and the resident's heels were not offloaded. An LPN confirmed the resident did not have the boots on and acknowledged signing off the treatment record inaccurately. The boots were later retrieved and applied after obtaining the resident's consent.
The facility failed to implement fall prevention interventions for three residents at risk for falls. A resident with dementia was found without non-skid socks, another with a femur fracture lacked fall mats and reminders, and a third with a history of falls did not have Dycem under her wheelchair cushion as ordered. Staff were unaware of these deficiencies, leading to inadequate supervision and increased fall risk.
A resident with dementia and anxiety disorder experienced inadequate pain management following a fall. Despite complaints of hip pain and signs of distress, the facility failed to implement a comprehensive care plan or document pain assessments and medication effectiveness. The resident was eventually sent to the hospital, where fractures were discovered, highlighting the facility's failure to manage the resident's pain appropriately.
A facility failed to perform AIMS assessments for a resident on antipsychotic medication, Seroquel, to monitor for side effects like extrapyramidal symptoms or tardive dyskinesia. The resident's medical record showed no evidence of these assessments since the medication's initiation, which the DON confirmed should occur at specific intervals. This oversight affected the monitoring of the resident's condition.
The facility failed to maintain adequate staffing levels in the Memory Lane secure unit, leaving one STNA to care for ten residents while the nurse administered medication in the assisted living area. This resulted in insufficient support for residents, some of whom were fall risks and required two-person assistance. The lack of communication and coordination among staff further exacerbated the issue, leading to non-compliance with staffing standards.
The facility failed to ensure a clean, safe, and homelike environment for 25 residents. Observations revealed missing toilet paper holders, paint and drywall damage, and a mouse trap in the Memory Care Unit. On the first floor, there were coffee spills, cracked linoleum, clogged sinks, and a urine odor. Maintenance and nursing staff confirmed these issues, with maintenance identifying a plumbing problem causing the sink clog.
The facility failed to ensure proper discharge procedures for two residents, leading to deficiencies in the discharge process. One resident was discharged against medical advice due to communication issues, and the other was transferred without complete documentation. The facility did not provide necessary discharge plans or transfer level of care documentation, and staff interviews revealed a lack of understanding and communication regarding the discharge process.
The facility failed to complete discharge summaries for three residents, each with complex medical histories, who were transferred to other nursing facilities. The records lacked necessary discharge documentation, including recapitulations of their stays and discharge plans of care. Interviews with staff confirmed these deficiencies.
The facility failed to administer prescribed medications and monitor two residents with edema and congestive heart failure. One resident did not receive Lasix and had no documentation of Neosporin application, while another lacked daily weight and intake/output records. The DON confirmed these lapses, which were noted as continued non-compliance.
The facility failed to provide timely and ordered pressure ulcer care for two residents. One resident with a Stage 1 pressure ulcer on the coccyx did not receive the prescribed daily treatment, as confirmed by the TAR and staff interviews. Another resident with an unstageable pressure ulcer on the right heel also did not receive the ordered treatment, as verified by the DON. This issue was part of ongoing non-compliance.
The facility failed to provide physician-ordered nutritional supplements to two residents with identified nutritional needs. One resident with severe protein-calorie malnutrition did not receive Healthshakes as recommended, and the DON had not communicated the dietician's recommendations to the physician. Another resident with a history of severe sepsis and malnutrition did not receive a Health Shake as ordered. This issue was part of a continued non-compliance from a previous survey.
A facility failed to maintain respiratory equipment in a sanitary manner for a resident with COPD. The nebulizer machine and mask were improperly stored in the dining room, and the mask was not changed as ordered. Staff interviews confirmed the oversight, and the treatment sheet showed missed changes. Facility policy on nebulizer care was not followed.
A facility failed to maintain a medication error rate of five percent or less, resulting in a 7.69 percent error rate. An LPN administered respiratory medications to a resident with COPD without adhering to the required one-minute interval between puffs, as per manufacturer guidelines and facility policy. The LPN was unaware of this requirement, contributing to the non-compliance.
The facility failed to obtain ordered lab tests for three residents, affecting their medical management. A resident with Alzheimer's and COPD did not receive scheduled lab tests, confirmed by the DON. Another resident with dementia and kidney failure also missed regular lab tests. Additionally, a resident with hemophilia and diabetes lacked Lipid testing since admission, as verified by the DON.
Failure to Ensure Competent IV Therapy Administration by Agency LPN
Penalty
Summary
The deficiency involves the facility’s failure to ensure that an IV medication was administered by a competent licensed nurse and to verify and document IV therapy competencies for an agency LPN. A resident was admitted with a postoperative wound infection, a PICC line placed in the right upper arm for long-term IV antibiotic therapy, and multiple comorbidities including diabetes, liver disease, hypertension, anemia, depression, and a history of stroke. The resident had an order for IV cefepime 2 g in 100 ml normal saline to be given three times daily via the PICC line. On observation, the PICC line had a flesh-colored bandage wrapped around the base, obscuring the insertion site, and the external catheter had a purple open-ended hub labeled “5 ml” with no needleless connector/valve attached. During administration of IV cefepime, the LPN cleaned the open end of the external PICC with an alcohol swab, flushed with normal saline, and then attached the IV tubing directly to the open end of the PICC line without a needleless connector device. When questioned, the LPN stated that PICC lines she worked with never had valves and that this was how PICC lines are, despite reporting that she had IV therapy training and certification. Licensure review showed the LPN had been licensed less than a year and, per the Ohio Board of Nursing, IV certification is no longer listed on LPN licenses for those licensed after a certain date, making IV training and competency verification the employer’s responsibility. The Human Resource Director reported she did not maintain personnel files, licensure checks, or competency records for agency staff, and the interim DON reported having no education or competency documentation for the LPN other than IV training provided after the issue was identified, stating that the agency would have competency records. The Administrator reported that one staffing agency only verified licensure and did not check competencies, and that another agency provided only a self-assessment skills checklist on which the LPN rated her IV therapy skills as limited and requiring supervision. The facility’s contract with that agency specified that the facility was responsible for orientation, education, training, and competency of agency staff.
Failure to Provide Comprehensive Suprapubic Catheter Care Resulting in Sepsis and Hospitalization
Penalty
Summary
A deficiency occurred when facility staff failed to develop and implement comprehensive and individualized care and interventions for a resident with a suprapubic catheter. The resident, who had a history of neurogenic bladder, diabetes, hypertension, and other chronic conditions, had a physician order for suprapubic catheter care every shift and monthly catheter changes. Despite these orders, there was no evidence that a care plan was developed at the time of catheter placement, and documentation showed repeated missed catheter care and tubing checks across several months. Staff interviews revealed that catheter care was not consistently performed due to staffing shortages, and some staff were unaware of or misunderstood the physician's orders regarding catheter changes, with some believing the order referred only to the catheter bag rather than the catheter itself. The resident's medical records indicated that catheter care and monthly changes were not documented as completed on multiple occasions, and there was no documentation of the resident refusing care or of the physician being notified about missed catheter changes. Additionally, there was no monitoring or documentation of urinary output or urine appearance prior to the resident's acute change in condition. Staff interviews confirmed that the suprapubic catheter had not been changed as ordered, and some staff admitted to not having received training on how to perform the procedure. The resident's care plan addressing the suprapubic catheter was not initiated until several months after placement, and interventions to monitor for complications were not implemented in a timely manner. As a result of these failures, the resident developed a severe urinary tract infection that progressed to sepsis and acute kidney injury, requiring hospitalization and intensive care. Hospital records documented grossly purulent urine, obstructive kidney stones, and the need for surgical intervention, including catheter exchange and stent placement. The lack of adherence to physician orders, inadequate documentation, and insufficient staff knowledge and training directly contributed to the resident's acute medical deterioration.
Removal Plan
- Resident #05 was transferred to the hospital and remained in the hospital.
- An audit of all current residents was completed by the DON for any residents with a suprapubic catheter. No other residents noted with a suprapubic catheter. Resident #09 was identified to have an order for an indwelling urinary catheter (Foley). Resident #09 was seen by the Nurse Practitioner.
- An investigation was completed by the DON of why this error occurred in order to implement corrective actions.
- RDCO #1022 reviewed facility policies including the Physician Order policy, Catheter Care policy, Suprapubic Catheter Replacement and Suprapubic Care procedures to ensure they were comprehensive, and no changes were needed prior to staff education.
- RDCO #1022 provided education to the DON on Physician Orders policy, Suprapubic Cath Care and Suprapubic Cath Replacement procedures.
- Education was provided in person or via phone to all current licensed nurses by the Director of Nursing (DON) and Assistant Director of Nursing (ADON). The education included following physician orders regarding catheters including catheter care (video was given on steps for suprapubic catheter replacement), along with the suprapubic catheter care and replacement procedure. In addition, staff were educated if they were unable to complete this task for the day as ordered, they were to report to the DON/ADON and they would assist on how to get the task completed. The DON followed up with the nurses after the education to ensure there were no unanswered questions related to the education.
- All current Certified Nurses Assistants (CNAs) were educated by the DON on catheter care for Foley catheters using the facility Catheter Care policy. A video was provided on how to do catheter care. The CNA staff were educated if they were unable to complete this task as ordered for the day they were to report to the DON/ADON and they would assist in how to get the task completed. The DON followed up with CNAs after the education to ensure there were no unanswered questions related to the education.
- The Medical Director was notified by the DON of the Immediate Jeopardy (IJ) concern involving Resident #05. An Ad-hoc Quality Assessment and Performance Improvement (QAPI) meeting was held with Medical Director, DON, Administrator, and RDCO #1022. The IJ was reviewed, the reason for the IJ, and the facility abatement plan.
- The Administrator provided contracted staffing agencies education related to catheter care. Education would be added for the staff to review prior to picking up a shift. The DON/designee would ensure agency staff reviewed education by contacting them once they had arrived at the facility and getting a verbal acknowledgement they have reviewed.
- The facility implemented a plan for all new staff to be verbally educated on Physician Order policy, Catheter Care policy, Suprapubic Catheter Replacement and Suprapubic Care procedures, what to do if you do not know how to change a catheter, following physician orders by the DON/designee during new hire orientation.
- The DON/ADON would review physician orders daily and would ensure if there were any new suprapubic catheter orders that the care and changing orders were in place and being followed. The DON/ADON would review residents with suprapubic catheters and would review catheter orders to ensure they were accurately documented when completed by going in and checking if the care and or catheter had been changed per order.
Failure to Ensure Timely Payment of Essential Services and Vendor Bills
Penalty
Summary
The facility failed to ensure timely payment of bills and invoices, resulting in multiple overdue accounts and shut-off notices for essential services such as water and electricity. Review of financial records and interviews revealed that invoices from the State Fire Marshal, local hardware store, and utility companies were not paid on time, with some accounts receiving final collection notices and threats of service interruption. The business office manager consistently forwarded overdue bills and shut-off notices to corporate accounts payable, but payments were often delayed or only partially made, leaving outstanding balances. Staff interviews confirmed that the facility was experiencing financial difficulties, with some supplies delayed and concerns expressed about payroll and the overall financial health of the facility. The medical director reported not being paid for several months, and the State Fire Marshal's office confirmed outstanding survey fees dating back to the previous year. The corporate representative acknowledged that some utility accounts exceeded autopay limits and that bills were sometimes only paid after shut-off notices were received, citing cash flow issues and the need to avoid bounced checks. The facility assessment indicated that all 35 residents were clinically complex, with multiple chronic or comorbid conditions, making uninterrupted services critical to their care. Despite the absence of actual service shut-offs at the time of the investigation, the ongoing risk of interruption due to unpaid bills was evident. The administrator's job description included responsibilities for financial oversight, but the system in place failed to ensure timely payment of essential services, potentially affecting all residents.
Failure to Assess and Meet Resident Activity Needs
Penalty
Summary
The facility failed to assess and meet the activity needs of all 35 residents, as evidenced by record review, observation, interviews, and review of the activity calendar and job descriptions. The activity calendar showed repetitive and limited activities, such as beverage cart and sit and chat, with only one main activity per day, and little to no evening programming. Observations and staff interviews confirmed that beverage cart and sit and chat were not considered meaningful activities by staff or residents, and that activities were often not conducted as scheduled. Residents and staff reported dissatisfaction with the lack of variety, frequency, and engagement in the activities provided, with some residents expressing boredom and a desire for more options. The memory care unit was particularly affected, with no specialized programming or activities provided for its residents. Observations revealed long periods with no activities, and staff confirmed that activity assessments had not been completed for memory care residents. Residents in this unit were often left without stimulation or opportunities to participate in group activities, and staff noted that when memory care residents were able to leave the unit for activities such as church, their mood improved significantly. However, such opportunities were rare, and the activity staff did not regularly provide or invite memory care residents to participate in activities. One resident with a history of major depression, anxiety disorder, and alcohol dependence in remission was specifically noted to have a care plan that included goals and interventions for activity participation, but reported that there were not enough activities to meet his needs. The activity director confirmed that she was the only member of the activity department, with limited time and resources to provide a variety of activities, and that the activity room was not accessible to residents outside of her working hours. The job description for the activity director outlined responsibilities for providing a comprehensive activity program, but these were not being met, as evidenced by the lack of assessments, limited programming, and resident and staff dissatisfaction.
Failure to Provide Sufficient Nursing Staff to Meet Resident Needs
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents, as evidenced by multiple staff and resident interviews, observations, and review of facility records. Staff reported frequent instances where Certified Nursing Assistants (CNAs) were left alone on the floor, especially during weekends and night shifts, resulting in delayed or missed care such as bathing, oral care, feeding assistance, and incontinence care. Staff also described situations where tasks requiring two staff members, such as Hoyer lift transfers, were performed by a single staff member due to inadequate staffing. Observations confirmed that call lights often went unanswered for extended periods, and residents expressed frustration with long wait times for assistance, sometimes exceeding an hour. Residents reported feeling unsafe, particularly during night shifts, and described incidents where they were not assisted with mobility aids, leading to fear of falls and actual accidents. Several residents stated that their personal care preferences, such as timely showers and the ability to choose their clothing, were not being met due to staff rushing through care. Staff interviews further revealed that the lack of adequate staffing led to poor quality and untimely care, with some residents not receiving regular incontinence care, turning, or repositioning as required. Staff also reported that nurses were often pulled away from medication passes to assist with resident care, causing further delays. A review of the facility's assessment tool indicated that the number of full-time and part-time nursing staff employed was insufficient to meet the needs of the current resident population, particularly those who were fully dependent on staff for activities of daily living (ADLs) such as dressing, bathing, transferring, and toileting. The Director of Nursing and Facility Administrator confirmed that, based on the facility assessment, the current staffing levels were not adequate to provide timely and quality care to residents. The deficiency was substantiated through direct observation, staff and resident interviews, and review of facility documentation.
Failure to Provide Specialized Memory Care Services and Activities
Penalty
Summary
The facility failed to provide specialized memory care services as advertised for all residents residing on the memory care unit. Record review showed that multiple residents with diagnoses such as dementia, Alzheimer's disease, depression, and other cognitive impairments were admitted to the unit. Despite facility brochures and fliers promoting a specialized memory care program, interviews with staff and observations revealed that no specific memory care program or specialized activities were implemented. The activities provided to memory care residents were the same as those offered to the rest of the facility, and there was no separate activity calendar or tailored programming for the memory care unit. Observations on the memory care unit showed a lack of engagement and stimulation for residents, with minimal activities occurring and residents often left sitting in common areas or in their rooms without interaction. Staff interviews confirmed that the activity director was unable to provide activities for the memory care unit due to other responsibilities, and activity assessments for these residents were not completed until after they were requested by surveyors. The only activities listed, such as beverage cart and sit and chat, were not consistently provided, and staff did not consider them meaningful activities. Residents were not routinely invited to participate in facility-wide activities, and the activity room was locked when the activity director was not present. Staffing on the memory care unit was consistently reported as inadequate, with only one aide assigned per shift, leading to periods when residents were left unsupervised while staff attended to individual care needs. Staff and family interviews expressed concerns about resident safety and the lack of engagement, stimulation, and supervision. Families reported not being informed about the benefits of memory care and expressed expectations for more specialized activities and higher staffing levels. The facility's own policies and job descriptions outlined requirements for individualized activity programming and assessments, which were not met for the memory care residents.
Failure to Administer Facility Resources and Maintain Adequate Dietary Staffing
Penalty
Summary
The facility failed to administer its operations in a manner that enabled effective and efficient use of resources, impacting all 35 residents. Multiple invoices and shut-off notices from utility companies and the Fire Marshal's office were overdue, with some accounts at risk of service interruption. The Business Office Manager consistently forwarded these notices to corporate accounts payable, but payments were often delayed or only partially made. Staff interviews revealed concerns about delayed supplies, financial instability, and lack of responsiveness from administration and corporate leadership. The Medical Director also experienced delayed payments, and the Fire Marshal's office confirmed outstanding bills dating back to the previous year. Administrative staff, including the Administrator, were frequently absent or inaccessible, with several staff members reporting that the Administrator was rarely present and did not engage with staff or residents. Concerns raised by staff were often ignored, and there was a general perception that administration and corporate did not prioritize the needs of the residents or the facility. The Administrator's job description outlined responsibilities for budgeting, financial oversight, and ensuring quality care, but these duties were not fulfilled as evidenced by the ongoing financial issues and lack of timely bill payments. Additionally, the facility failed to employ sufficient dietary staff as outlined in its facility assessment. The dietary department was consistently understaffed, with the Dietary Director and other staff members required to cover multiple roles and avoid overtime, leading to incomplete kitchen tasks and delays in meal and snack preparation. The facility assessment called for more dietary staff than were actually employed, and the short staffing resulted in CNAs having to leave resident care duties to retrieve snacks. Training for dietary staff was also inadequate, with planned training sessions not occurring and the Dietary Director lacking sufficient support. These deficiencies were confirmed by staff interviews and review of staffing schedules.
Inaccurate Facility Assessment Leads to Inadequate Staffing for Resident Care
Penalty
Summary
The facility failed to conduct an accurate and thorough facility-wide assessment to determine the necessary resources required to care for residents competently during both routine operations and emergencies, including nights and weekends. Review of resident data revealed that the number of residents dependent on staff for activities of daily living (ADLs) such as toileting, dressing, bathing, and transferring significantly exceeded the facility's stated capacity in its assessment. Specifically, there were 15 residents dependent on staff for toileting, 14 for dressing, 14 for bathing, and 9 for transferring, while the facility assessment only accounted for the ability to care for five residents in each of these categories. Additionally, the assessment outlined staffing requirements that were not met, including the need for four full-time RNs, four full-time LPNs, and fourteen full-time CNAs, while actual staffing levels were lower in several categories. Interviews with the Director of Nursing (DON), Facility Administrator, and Dietary Director confirmed discrepancies between the facility assessment and actual staffing levels, including insufficient numbers of direct care and dietary staff to meet the needs of the current resident population. The DON and Facility Administrator acknowledged that the facility-wide assessment was not completed accurately, resulting in inadequate staffing to provide timely and quality care for residents. This deficiency was identified during a complaint investigation and had the potential to affect all residents in the facility.
Failure to Follow Physician Orders and Provide Comprehensive Resident-Centered Care
Penalty
Summary
The facility failed to provide comprehensive, resident-centered care as evidenced by multiple deficiencies in following physician orders, documenting care, and notifying providers of significant changes in residents' conditions. For several residents, there were repeated lapses in the administration and documentation of prescribed treatments, such as wound care and nutritional supplements. For example, one resident with multiple comorbidities including diabetes and skin breakdown did not consistently receive ordered wound treatments or nutritional supplements, and there was no documentation of provider notification when these treatments were missed. Additionally, this resident received insulin outside of the prescribed sliding scale without appropriate physician orders or notification when blood glucose levels exceeded the threshold requiring provider contact. Other residents experienced similar failures in care. One resident with a history of stroke and impaired mobility had orders for weekly skin checks, but there were multiple periods where no documentation of these assessments was found. Another resident, at risk for pressure ulcers and with significant medical complexity, also did not have weekly skin checks documented as ordered. In the case of a resident with congestive heart failure, there was a significant, rapid weight gain over several days, but the physician was not notified in a timely manner as required by facility protocol and physician orders. Staff interviews confirmed a lack of awareness of the resident's diagnoses and a failure to conduct thorough record reviews, contributing to the missed notifications. Additionally, a resident on anticoagulant therapy did not have weekly skin assessments completed for an extended period, and significant bruising was observed but not documented or monitored as required by the care plan. This resident also experienced interruptions in receiving a prescribed protein supplement due to supply issues, with no evidence that the provider was notified or alternative options were considered. These deficiencies were confirmed through record reviews, staff interviews, and direct observations, affecting multiple residents and demonstrating a pattern of non-compliance with physician orders and care protocols.
Failure to Implement Fall Interventions and Secure Hazardous Chemicals
Penalty
Summary
The facility failed to implement and maintain fall prevention interventions and post-fall assessments for two residents. One resident, with diagnoses including dementia, insomnia, and a history of falls, was care planned to have a floor mat at bedside as a fall prevention measure. Observation revealed that the floor mat was not present in the resident's room, and this was confirmed by an LPN, indicating the intervention was not in place as required by the care plan. Another resident, with multiple diagnoses including cerebral infarction, diabetes, and cognitive impairment, experienced an unwitnessed fall and was transported to the hospital. Review of the medical record showed that no post-fall assessment was documented after the resident returned from the hospital, a fact confirmed by the DON several hours after the incident. Additionally, the facility failed to ensure hazardous chemicals were properly stored and inaccessible to residents on the memory care unit. Observation found that cabinets behind the nurses station were left unlocked and unattended, containing items such as nail polish, nail polish remover, medication disposal compounds, bleach, disinfectant wipes, stainless steel cleaner, and needles. An LPN confirmed that all residents on the unit wandered and had access to these chemicals while staff were occupied in a resident's room. Review of the MSDS for these chemicals indicated potential for irritation, toxicity, and other health hazards upon exposure. These deficiencies affected multiple residents, including those with cognitive impairments and histories of wandering, and were identified through observation, interviews, record reviews, and policy and MSDS reviews. The facility's failure to implement care planned interventions, complete required assessments, and secure hazardous materials resulted in non-compliance with safety and accident prevention standards.
Incomplete Discharge Documentation and Instructions
Penalty
Summary
The facility failed to provide comprehensive discharge instructions and did not ensure that documentation of a resident's discharge was present in the medical record. Specifically, a resident with multiple diagnoses, including cerebral infarction, type 2 diabetes mellitus, cognitive communication deficit, chronic kidney disease, hypertension, hyperlipidemia, heart failure, gastro-esophageal reflux disease, hyperkalemia, and insomnia, was discharged to their home. Review of the multidisciplinary discharge summary showed that discharge instructions were incomplete, with no evidence of education regarding diet or activities provided to the resident or their representative. Additionally, there was no documentation of a discharge note for the resident's discharge on the specified date. The Director of Nursing confirmed the incomplete documentation during an interview.
Failure to Complete Baseline Care Plans Within 48 Hours of Admission
Penalty
Summary
The facility failed to ensure that baseline care plans were completed within 48 hours of admission for two residents. For one resident admitted with chronic obstructive pulmonary disease, congestive heart failure, and metabolic encephalopathy, only the dietary care plan was initiated within the required timeframe, while the remainder of the care plan was not completed until several days later. The care conference for this resident occurred after admission, but there was no evidence of a baseline care plan being established within 48 hours as required. Another resident admitted with multiple diagnoses, including cerebral infarction, type 2 diabetes mellitus, chronic kidney disease, and heart failure, also did not have a complete baseline care plan within 48 hours. Only a nutrition/hydration risk care plan was initiated, with no other care plans documented. Additionally, the care conference summary for this resident lacked signatures from the resident, family, or representative, indicating incomplete involvement. Interviews with facility leadership confirmed that the care plans for both residents were not completed fully or in a timely manner, contrary to facility policy.
Failure to Provide Scheduled Showers According to Resident Preferences
Penalty
Summary
The facility failed to provide showers to residents according to their preferences and established shower schedules. Two residents with significant cognitive and physical impairments, including diagnoses such as Alzheimer's disease, dementia, and mobility issues, were identified as being dependent on staff for bathing. Documentation showed that both residents missed multiple scheduled showers over several months, despite care plans indicating their need for staff assistance and the use of mechanical lifts or supervision for bathing. The facility's own bathing policy stated that residents could choose the frequency and timing of their baths or showers. Interviews with staff and the Director of Nursing confirmed that the missed showers were not documented as being provided at alternative times, and in one case, staff reported that a resident's behavioral challenges led to skipped showers and changes. The lack of adherence to the shower schedule and resident preferences was verified through review of shower sheets and staff interviews, demonstrating a failure to meet the residents' needs for assistance with activities of daily living as outlined in their care plans and facility policy.
Oxygen Therapy Administered Without Physician Order
Penalty
Summary
A deficiency occurred when a resident with chronic obstructive pulmonary disease, congestive heart failure, and metabolic encephalopathy was admitted to the facility by ambulance with oxygen in place at 2 liters per minute. Nursing documentation and observation confirmed the resident continued to receive oxygen therapy via nasal cannula and oxygen concentrator. However, review of the resident's medical record revealed there was no physician order for oxygen therapy at any point during the resident's stay. Both the Administrator and Director of Nursing confirmed that an order should have been in place for the administration of oxygen, and facility policy requires a physician order for oxygen except in emergencies.
Failure to Provide Timely and Appropriate Pain Management
Penalty
Summary
A resident with multiple serious diagnoses, including lung and brain cancer, chronic pain, and heart failure, was admitted to the facility and had physician orders for Tramadol and acetaminophen to manage pain. Despite these orders, there was a delay in obtaining the Tramadol, with the medication not being delivered to the facility until seven days after it was ordered. During this period, the resident consistently reported moderate to severe pain, with pain ratings ranging from four to six out of ten on several occasions. There was no documentation that alternative pain relief medications or methods were provided to the resident while experiencing pain during the delay in receiving the prescribed Tramadol. The resident reported being told by nursing staff that the facility was out of her pain medication and that efforts were being made to obtain it. The Director of Nursing confirmed the delay in medication delivery and the lack of documentation for alternative pain management interventions. Facility policy requires pain management to be based on professional standards, the care plan, and resident choices, but these standards were not met in this instance.
Failure to Provide Medically-Related Social Services for Psychosocial Well-Being
Penalty
Summary
The facility failed to provide medically-related social services to support a resident's psychosocial well-being, specifically for a resident with a history of major depression, anxiety disorder, and alcohol dependence in remission. The resident was identified as being at risk for psychosocial issues due to social isolation, depression, and physical limitations, and his care plan included interventions such as access to psychiatric services and opportunities for social engagement. Despite these identified needs, the resident was unable to attend Alcoholics Anonymous (AA) meetings, which he considered his primary source of social interaction and support, after the facility's transportation van broke down. Interviews revealed that the resident missed multiple AA meetings due to the lack of transportation, and no alternative arrangements were made to support his psychosocial needs during this period. The resident reported not being aware of the facility's social worker and stated that no one had offered him additional support while he was unable to attend AA. The social worker acknowledged not following up with the resident or providing in-house services to address his needs during the transportation disruption. Other staff members confirmed the importance of AA meetings to the resident's well-being and noted a decline in his mood when he was unable to attend. The facility's social services job description outlined responsibilities for addressing residents' emotional adjustment and ensuring appropriate psychosocial interventions, but these were not fulfilled in this case. The lack of timely and appropriate social services intervention resulted in the resident not receiving the support necessary to maintain his highest possible quality of life, as required by facility policy and regulatory standards.
Failure to Provide Timely Pharmaceutical Services and Medication Administration
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of two residents by not ensuring timely receipt and administration of prescribed medications. One resident, with multiple diagnoses including hemiplegia, GERD, anxiety, depression, COPD, and others, had a physician's order for Debrox Otic Solution for ear wax removal. Documentation showed that over a four-day period, the medication was not available and was not administered as ordered. Progress notes repeatedly indicated the facility was awaiting the medication from the pharmacy, and there was no evidence that the physician was notified about the unavailability or missed doses. Interviews with nursing staff and the DON confirmed the medication was not received or administered, and the physician was not informed. Another resident, with diagnoses including lung cancer, COPD, diabetes, brain cancer, chronic pain, and heart failure, had an order for Tramadol for pain management. The medication was ordered from the pharmacy several days after the physician's order and was not delivered for seven days. The resident reported being in pain and not receiving the medication, and staff interviews confirmed ongoing issues with timely receipt of both prescription and OTC medications from the pharmacy. Facility staff described frequent delays and the need to purchase OTC medications from outside sources due to inconsistent pharmacy deliveries. The facility's policy required medications to be administered according to orders and within required time frames, which was not followed in these cases.
Failure to Provide Palatable and Appetizing Food to Residents
Penalty
Summary
Surveyors found that the facility failed to provide palatable, appetizing, and safe food to residents, specifically affecting two individuals reviewed for food quality. One resident with severe cognitive impairment, multiple chronic conditions, and a mechanically altered, pureed diet was observed receiving pureed meals that were stringy, lumpy, watery, and lacked flavor. The dietary staff confirmed during preparation that the pureed sugar snap peas, breaded fish, and roasted potatoes were not palatable, with issues in both texture and taste. The resident had a documented history of significant weight loss and was at risk for malnutrition, with care plans and orders specifying the need for appropriate diet preparation. Another resident, with diagnoses including dementia and mild protein-calorie malnutrition, was observed eating a lunch meal that was reported to have no flavor. The resident expressed dissatisfaction, stating the meal tasted as if they "might as well eat dirt." Both observations and interviews confirmed that the food provided was not palatable or appetizing, directly contravening the requirement to ensure residents receive nutritive, palatable food and drink.
Failure to Provide Food in Appropriate Texture for Residents
Penalty
Summary
The facility failed to provide food prepared in a form designed to meet the individual needs of two residents. One resident, with diagnoses including type 2 diabetes, hypertension, GERD, and cognitive impairment, was ordered a low concentrated sweets diet with mechanical soft texture. Despite no documentation of refusal of the modified diet, this resident was observed being served a whole hot dog, which did not meet the mechanical soft texture requirement. The error was only corrected after staff intervention at the time of service. Another resident, with severe cognitive impairment and multiple chronic conditions, was ordered a pureed texture diet. During meal preparation, staff were observed pureeing food items for this resident, but the resulting pureed foods did not achieve a smooth consistency as required. The pureed peas were stringy and lacked flavor, the breaded fish was watery and lumpy, and the potatoes were lumpy and flavorless. These issues were confirmed by dietary staff and the dietary director, and were not in accordance with the facility's policy for texture and consistency modified diets.
Failure to Accurately Document and Perform Suprapubic Catheter Changes
Penalty
Summary
The facility failed to ensure the accuracy of resident records and documentation for a resident with an indwelling suprapubic catheter. The resident, who had multiple diagnoses including neuromuscular bladder dysfunction and was dependent on staff for activities of daily living, had physician orders for monthly suprapubic catheter changes. Documentation in the treatment administration records indicated that the catheter was changed as ordered each month by various LPNs. However, interviews with the LPNs revealed that none of them had actually performed the catheter change, and some believed the documentation referred only to changing the catheter bag, not the catheter itself. One LPN stated they had no training on how to perform the procedure and were unaware of any such order. Further review showed that the resident's physician was not notified that the catheter changes were not being performed as ordered. The Director of Nursing confirmed that the catheter exchange was documented as completed when it had not been done. The deficiency was identified through record review, staff interviews, and communication with the resident's power of attorney, who also confirmed through messages with staff that the catheter had not been changed as required.
Catheter Bag Found on Floor—Infection Control Lapse
Penalty
Summary
The facility failed to maintain proper infection control practices when a resident's catheter bag was repeatedly observed lying on the floor. The resident involved had a history of quadriplegia, pure hypercholesterolemia, and neuromuscular dysfunction of the bladder, and was admitted with an indwelling catheter in place per physician order. Despite a care plan indicating severely impaired cognition and frequent bladder incontinence, observations on multiple occasions showed the catheter bag on the floor while the resident was resting in bed. This was confirmed by an LPN during an interview, indicating a lapse in infection prevention and control protocols for catheter care.
Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
During a wound care procedure for a resident with quadriplegia, diabetes mellitus, neurogenic bladder, and peripheral vascular disease, staff failed to follow appropriate infection control practices. The resident had an unstageable right hip pressure ulcer and an indwelling urinary catheter, with physician orders for daily wound treatments and enhanced barrier precautions (EBP), which require the use of gown and gloves during high-contact care. Observation revealed that both the LPN and the Assistant Director of Nursing entered the resident's room without donning gowns, despite EBP signage and supplies being available. The LPN performed the wound care using improper technique, including using the same gauze to clean multiple areas of the wound, handling bandage scissors without cleaning them between uses, and placing potentially contaminated scissors back with clean supplies. Additionally, when a dressing fell onto the bed, it was discarded, but the scissors were again used without cleaning before cutting a new dressing. Interviews with both the LPN and the ADON confirmed that the wound care was not completed as ordered and that EBP protocols were not followed. Policy reviews indicated that the facility's procedures required the use of gloves and gowns for such care, as well as proper hand hygiene and equipment cleaning. The failure to implement these infection control measures was observed directly and verified by staff, constituting a deficiency in the facility's infection prevention and control program.
Medication and Treatment Carts Left Unlocked and Unattended on Memory Care Unit
Penalty
Summary
The facility failed to maintain a safe environment free from accident hazards when medication and treatment carts were left unlocked and unattended on the locked memory care unit. During an observation, both carts were found unsupervised and unlocked at the nurses' station, with no staff present in the immediate area. The only staff member on the unit at the time, a CNA, was serving breakfast trays in the dining room, while the LPN was downstairs administering medications. This left the medication and treatment carts accessible and out of view of any staff. Medical record reviews confirmed that seven residents on the memory care unit were severely impaired in daily decision-making, ambulatory, and capable of independently moving throughout the unit. Interviews with staff verified that these residents wandered the unit and could open the drawers of the carts. Facility policy required that medication carts be locked when out of sight or unattended, a standard not met during the observed incident.
Incomplete MDS Assessment Components for Resident
Penalty
Summary
The facility failed to complete all required components of comprehensive assessments for one resident. Medical record review showed that a resident with multiple diagnoses, including quadriplegia, chronic pain, diabetes mellitus, neurogenic bladder, major depressive disorder, and peripheral vascular disease, was admitted to the facility. The annual Minimum Data Set (MDS) 3.0 assessment for this resident did not include the required Cognitive Pattern: Brief Interview for Mental Status and Pain Assessment interview. Additionally, the quarterly MDS assessment for the same resident was missing the required Pain Assessment interview. These omissions were confirmed during an interview with the Assistant Director of Nursing.
Failure to Develop Comprehensive Care and Discharge Plans
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for two residents, as required. For one resident admitted with hypertension, a pancreatic disorder, and a colostomy, the medical record showed that although the resident was cognitively intact and had a goal to return to the community, there was no active discharge plan, no referrals, and the local contact agency was unknown. The resident was routinely assessed for pain and received Tylenol for mild to moderate pain, but there was no evidence of a comprehensive pain care plan or a discharge care plan documented in the record. Similarly, another resident admitted with cirrhosis of the liver, diabetes mellitus, diverticulitis, and a colostomy was also cognitively intact and had a goal to return to the community. However, there was no active discharge plan, no referrals, and the local contact agency was unknown. The medical record did not contain evidence that a discharge plan of care had been developed for this resident. These findings were confirmed by interview with the Assistant Director of Nursing.
Failure to Provide Proper Pressure Ulcer Care and Infection Control
Penalty
Summary
A resident with multiple complex medical conditions, including quadriplegia, diabetes mellitus, and peripheral vascular disease, was admitted without skin impairments and later assessed as being at moderate risk for skin breakdown. Despite this, the resident developed three new facility-acquired pressure ulcers, including an unstageable pressure ulcer on the right hip. The prescribed treatment for this ulcer was to use a silver alginate dressing, which provides both autolytic debridement and antimicrobial action, but the resident was instead treated with calcium alginate, which lacks antimicrobial properties, for nearly two weeks. This discrepancy was not identified until a survey was conducted. During direct observation of a dressing change, an LPN and the ADON failed to follow proper infection control protocols, including not donning required personal protective equipment and not adhering to enhanced barrier precautions. The LPN also used unclean bandage scissors to cut dressings, reused contaminated instruments, and did not follow the wound care policy for dressing removal and hand hygiene. The ADON confirmed that the treatment was not completed as ordered and that infection control practices were not properly implemented. Facility policies required consistent treatment protocols and individualized care, which were not followed in this instance.
Failure to Provide Ordered Colostomy Care
Penalty
Summary
The facility failed to provide colostomy care as ordered for two residents who required such services. One resident, admitted with diagnoses including hypertension, pancreatic disorder, and a colostomy, had physician orders for colostomy care to be provided once per shift. Review of the Treatment Administration Records (TAR) showed that colostomy care was documented as completed on only 18 of 35 opportunities in February, 53 of 62 in March, and 24 of 30 in April. The resident's care plan also specified that the ostomy appliance should be changed as ordered. Another resident, admitted with diagnoses including cirrhosis of the liver, diabetes mellitus, diverticulitis, and a colostomy, had orders for ostomy care every shift. The TAR for April indicated that ostomy care was provided on 28 of 30 opportunities. Both residents were assessed as cognitively intact for daily decision-making. During an interview, the Assistant Director of Nursing confirmed that ostomy care was not completed as ordered for these residents.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, as evidenced by seven errors out of 26 observed medication administration opportunities, resulting in an error rate of 26.9%. For one resident with chronic atrial fibrillation, cerebrovascular disease, hypertension, congestive heart failure, and diabetes mellitus, a registered nurse administered prescribed morning medications outside the required timeframe. The nurse acknowledged administering the medications late, citing unfamiliarity with the hallway and being behind schedule. For another resident with dementia, diabetes mellitus, hypertension, anxiety disorder, and major depressive disorder, an LPN prepared and initially administered incorrect dosages of buspar and Effexor, and provided enteric coated aspirin instead of the ordered chewable form. The LPN confirmed the errors after being questioned and corrected the dosages, and later obtained the correct form of aspirin from the supply cabinet. Facility policy required medications to be administered as ordered and within a specific timeframe, which was not followed in these instances.
Inadequate Pressure Ulcer Prevention and Care
Penalty
Summary
The facility failed to develop and implement a comprehensive and individualized pressure ulcer prevention program for two residents, leading to the development of pressure ulcers. Resident #13, who was admitted with diagnoses including hyperlipidemia, hypertension, and altered mental status, was identified as being at moderate risk for developing pressure ulcers. Despite this, the resident's care plan did not adequately address the risk, and the resident developed a Stage II pressure ulcer on the coccyx. The facility's records showed insufficient documentation of incontinence care, which was not provided every two hours as required, contributing to the skin breakdown. Similarly, Resident #22, admitted with rheumatoid arthritis, muscle weakness, and altered mental status, was also at risk for skin integrity issues due to impaired mobility and incontinence. The resident's care plan included interventions for turning and repositioning, but these were not consistently implemented. The resident developed a Stage II pressure ulcer on the right buttock, and there was a lack of documentation regarding the care provided and the condition of the ulcer. The facility's failure to provide adequate incontinence care and pressure-relieving devices, as ordered, contributed to the development of the pressure ulcer. Interviews with staff revealed concerns about inadequate staffing levels, which impacted the ability to provide necessary care, including regular incontinence checks and repositioning. Observations confirmed that the required pressure-relieving mattresses were not in place for both residents, further indicating a lack of adherence to physician orders and facility policies. The facility's policies on incontinence management and pressure injury risk assessment were not effectively implemented, leading to the deficiencies noted in the report.
Food Storage and Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure that food was stored and served in a sanitary manner, potentially affecting all 33 residents who receive food from the facility. During an initial tour of the kitchen, expired and undated food items were found in both the walk-in and standing refrigerators, as well as in the dry storage area. Specifically, expired cream, Dijon mustard, and chili powder were noted, along with undated leftovers, coleslaw, fruit, salad, and dessert. Additionally, the dishwasher was unable to reach the required rinse temperature of 180 degrees, which was confirmed by the Dietary Supervisor, who noted this was the first occurrence of such an issue. Further observations revealed improper hand hygiene practices by a staff member during food preparation. The staff member was observed changing gloves multiple times without washing hands in between, which was confirmed during an interview. The facility's policies on food safety and hand washing, dated 2021, were reviewed and indicated that food should be stored to prevent contamination and that hands should be washed to prevent cross-contamination during food preparation. These policies were not adhered to, leading to the identified deficiencies.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a clean and safe environment for its residents, as evidenced by several observations and interviews. The floors, walls, air vents, and rooms were not properly maintained, leading to unsanitary conditions. Specific issues included discolored and dirty tile and grout around toilets, rusty air vents, torn walls, and sticky floors. Additionally, Resident #32's room was found to be particularly unkempt, with soiled bedding, cluttered window sills, and multiple meal trays left in the room. Flies were observed in the room, and staff confirmed the presence of flies and the sticky condition of the floors. Interviews with staff revealed that the facility had not had a maintenance person for over a month, and maintenance issues were not being promptly addressed. The staff also noted that the floors had been sticky for years, possibly due to excessive soap use, and that they had reported this issue previously. The facility had a quarterly contract with an exterminator, but there was no indication of treatment for flies. The lack of timely maintenance and cleaning contributed to the unsanitary conditions observed in the facility, affecting the residents' right to a safe and comfortable environment.
Inconsistent Documentation of Advanced Directives
Penalty
Summary
The facility failed to ensure that Resident #186 had an order in place for advanced directives upon admission. Resident #186, who was admitted with multiple diagnoses including a displaced bimalleolar fracture, muscle weakness, and severe intellectual disabilities, did not have a documented code status in either the physical or electronic medical records. This oversight was confirmed by the Director of Nursing (DON) during an interview, who acknowledged that an order for code status should have been established upon the resident's admission. The facility's policy on advanced directives, dated December 2016, mandates that residents be provided with information about their rights to accept or refuse medical interventions and to formulate advanced directives, which should be prominently displayed in their medical records. Additionally, the facility failed to maintain consistent documentation of Resident #7's advanced directives across different record formats. Resident #7, admitted with severe sepsis, major depressive disorder, and congestive heart failure, had conflicting code status orders in their electronic and paper medical records. The electronic health record indicated a Full Code status, while the paper chart listed a Do Not Resuscitate Comfort Care (DNR-CC) status. The DON confirmed the discrepancy and emphasized that the records should match to avoid confusion regarding the resident's care in emergencies. The facility's policy requires that information about advanced directives be clearly displayed in the medical record.
Inaccurate PASRR Documentation for Resident with Psychiatric Diagnoses
Penalty
Summary
The facility failed to ensure the accuracy of the Preadmission Screening and Resident Review (PASRR) for a resident diagnosed with major depressive disorder and unspecified psychosis. The medical record review, staff interview, and facility policy review revealed that the PASRR documentation for the resident, dated 05/24/19, did not indicate these psychiatric diagnoses in section D, which is meant for serious mental disorders. The resident's care plan included plans for depression and psychosis, and the Minimum Data Set (MDS) indicated active diagnoses of depression and psychotic disorder, along with the administration of antidepressant medication. The Director of Nursing confirmed that the PASRR documentation did not reflect the resident's psychiatric diagnoses and that a resident review had not been completed in light of these diagnoses. The facility's policy, updated in January 2023, stated that if a resident was admitted with a negative level I PASRR result and later showed evidence of a serious mental illness, a resident review should be conducted. This policy was not followed, leading to the deficiency noted in the report.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to ensure comprehensive care plans were developed for residents to address their specific diagnoses, medications, and activities of daily living (ADLs). This deficiency affected three residents. Resident #5, who was admitted with diagnoses including dementia, major depressive disorder, hallucinations, insomnia, and diabetes mellitus, did not have a comprehensive care plan addressing these conditions or the use of psychotropic medications and insulin. The facility's Registered Nurse confirmed the care plans were incomplete and noted that the care planning process was being managed by an off-site MDS nurse and the facility's nurse managers. Resident #4, admitted with cerebral infarction, atherosclerotic heart disease, hypertension, and hyperlipidemia, lacked care plans for anticoagulation medications and the associated risk of bruising and bleeding. The Director of Nursing verified the absence of these care plans. Additionally, Resident #33, with diagnoses including dementia, hypothyroidism, anxiety disorder, and insomnia, did not have a care plan for ADLs despite requiring various levels of assistance. The Director of Nursing confirmed the lack of an ADL care plan. The facility's policy required individualized comprehensive care plans to be developed within seven days of the MDS assessment, but this was not adhered to.
Failure to Assist Resident with Personal Hygiene
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living for Resident #32, who was dependent on staff for bathing, shaving, and oral care. The resident, who had multiple diagnoses including dementia, Alzheimer's disease, and muscle weakness, required substantial to maximum assistance for personal hygiene tasks. Despite a care plan indicating the need for total assistance with bathing, the resident did not consistently receive showers or bed baths as scheduled, with gaps of up to ten days between showers. Observations and interviews revealed that Resident #32 was often left unshaven and without proper oral care supplies. The resident was found in a state of undress and with wet clothing, indicating a lack of assistance with toileting. Staff interviews confirmed that the resident's personal hygiene supplies were stored out of reach, and there was no consistent follow-up after the resident refused showers. The facility's Director of Nursing acknowledged the lack of a clear policy on handling shower refusals and confirmed the lapses in providing scheduled showers. The facility's bathing policy allowed residents to choose the frequency and timing of their baths, but it did not specify procedures for handling refusals or ensuring consistent care. This lack of guidance contributed to the failure to provide necessary assistance to Resident #32, resulting in inadequate personal hygiene care over an extended period.
Failure to Provide Adequate Resident Activities
Penalty
Summary
The facility failed to ensure that activities were available for resident participation, specifically affecting one resident. This resident had a medical history that included mild protein calorie malnutrition, anxiety, and alcohol dependence, among other conditions. The resident's care plan indicated a need for participation in activities three to five times weekly, including music, group activities, and religious services. However, a review of the activity participation calendar for October and November 2024 showed that the resident did not meet this requirement, participating in only a few activities such as arts and crafts, religious services, and special events. The resident was often observed in her room with no activities or entertainment, such as music or television, indicating a lack of engagement in planned activities. Interviews with the resident's family and facility staff revealed further issues. The family member noted that the resident had poor vision and rarely participated in activities, while the Activity Director mentioned staffing challenges since the onset of COVID-19, which affected the ability to conduct activities. The Activity Director also noted that she was the only activity staff member and was sometimes pulled to work in other areas, leading to scheduled activities not being completed. The facility's policy required daily activities, including weekends, but the lack of adequate staffing and resources resulted in the resident not receiving the necessary engagement as outlined in her care plan.
Failure to Implement Pressure Ulcer Prevention Interventions
Penalty
Summary
The facility failed to implement skin prevention interventions for a resident with a known pressure ulcer as per the plan of care. The resident, who was admitted with an unstageable pressure ulcer and other medical conditions such as reduced mobility and dementia, was identified as having two Stage II pressure ulcers and two deep tissue injuries. Despite having physician's orders to apply Prevalon boots to her feet to alleviate pressure and promote healing, observations on two consecutive days revealed that the resident's heels were not offloaded, and the Prevalon boots were not in place as ordered. An LPN confirmed that the resident did not have the Prevalon boots on and acknowledged that the resident was supposed to have them to help alleviate pressure off her heels. The LPN admitted that the resident did not like to wear the boots and would kick them off, and that the boots were not found in the resident's room. Despite this, the treatment administration record was signed off to reflect that the boots were being used as ordered. The LPN retrieved a pair of Prevalon boots from the storage closet and applied them to the resident after obtaining her consent.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to implement fall prevention interventions for residents at risk for falls, affecting three residents. Resident #5, who had a history of mild dementia and required assistance with transfers, was found on the floor without non-skid footwear, which was part of her care plan. Despite the intervention being communicated to staff, observations revealed that the resident was not wearing non-skid socks on multiple occasions, and staff were unaware of the resident's fall risk status. Resident #28, with a history of a femur fracture and impaired mobility, was also not provided with the necessary fall prevention measures. Observations showed that the resident did not have fall mats at her bedside, was not wearing non-skid socks, and lacked a sign to remind her to call for assistance, all of which were part of her care plan. The LPN confirmed the absence of these interventions and was unaware of the requirement for fall mats. Resident #11, who had a history of falls and was at risk due to multiple fractures and dementia, was observed without the required Dycem under her wheelchair cushion. Although Dycem was found between the lift pad and the cushion, it was not placed as ordered. The LPN verified the absence of Dycem under the cushion, indicating a failure to adhere to the prescribed fall prevention measures.
Inadequate Pain Management After Resident Fall
Penalty
Summary
The facility failed to adequately assess, monitor, and manage the pain of a resident, identified as Resident #33, following a fall. Resident #33, who had diagnoses including dementia and anxiety disorder, was admitted to the facility with no initial reports of pain. However, after a fall on October 21, 2024, where she hit her head, Resident #33 began to exhibit signs of pain, particularly in her right hip. Despite these complaints, the facility did not have a comprehensive care plan related to pain management for her, and there was a lack of documentation regarding pain assessments or the effectiveness of administered pain medication. On October 22, 2024, Resident #33 underwent a mobile x-ray due to complaints of pain with movement, but the results showed no acute skeletal injuries. Despite this, the resident continued to express pain, particularly during movement, and was noted to be screaming in pain during transfers and when touched on her hip. The facility's staff, including LPNs and STNAs, observed these behaviors but did not consistently administer pain medication or document the resident's pain levels and responses to medication. The situation escalated when Resident #33 was sent to the emergency room on October 24, 2024, due to excruciating pain in her right hip. A CT scan at the hospital revealed a fracture in the right femur and a sacral fracture, which had not been identified by the initial in-house x-rays. Interviews with facility staff, including the Director of Nursing, confirmed that there was a failure to administer pain medication promptly and to document pain assessments and interventions effectively, leading to inadequate pain management for Resident #33.
Failure to Conduct AIMS Assessments for Resident on Antipsychotic Medication
Penalty
Summary
The facility failed to conduct Abnormal Involuntary Movement Scale (AIMS) assessments for a resident receiving antipsychotic medication, which is necessary to monitor for side effects associated with such medication use. This deficiency was identified during a review of the medical records of a resident who was prescribed Seroquel for hallucinations. The resident's medical record lacked evidence of any AIMS assessment being completed since the initiation of the antipsychotic medication, which is crucial for establishing a baseline and monitoring for any development or worsening of abnormal involuntary movements. The Director of Nursing (DON) confirmed that residents on antipsychotic medications should have AIMS assessments conducted to monitor for side effects like extrapyramidal symptoms or tardive dyskinesia. The DON stated that these assessments should be performed upon initiation of the medication, then at 30, 60, and 90 days, and subsequently on a quarterly basis or after any dosage change. The absence of these assessments for the resident in question indicates a failure to adhere to these monitoring protocols.
Inadequate Staffing in Memory Care Unit
Penalty
Summary
The facility failed to ensure adequate staffing levels to meet the needs of all residents, particularly in the Memory Lane secure unit. Observations and interviews revealed that there was only one State Tested Nursing Assistant (STNA) available to care for ten residents on the unit, as the nurse was administering medication in the connected assisted living area. This left the STNA responsible for providing morning care, assisting residents with activities of daily living, and serving breakfast without additional support. The situation was exacerbated by the fact that some residents were identified as fall risks and required two-person assistance, yet were left unattended in the dining room. Interviews with staff indicated that there was a lack of communication and coordination regarding staffing coverage when the nurse was away from the secure unit. An aide from the first floor was supposed to assist on the second floor during these times, but this did not consistently occur due to the busy morning schedule on the first floor. The Director of Nursing and the Administrator acknowledged the staffing challenges and the need for additional staff to ensure adequate coverage, especially during shift changes and when the nurse was occupied with duties in the assisted living area. The facility's assessment, updated in July 2024, outlined the staffing requirements based on the resident population and their needs. However, the report highlighted that the facility did not meet these staffing levels, particularly during night shifts and when agency aides called off. The deficiency was noted as part of a complaint investigation, indicating non-compliance with the required staffing standards to ensure resident safety and care.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, safe, and homelike environment, affecting 25 out of 33 residents. Observations in the second-floor Memory Care Unit revealed missing toilet paper holders in several rooms, paint damage on door frames, missing air conditioner covers, drywall damage, and a mouse trap under a heating unit. Interviews with maintenance staff and nursing personnel confirmed these issues, with maintenance acknowledging the presence of a mouse trap and the need for repairs. On the first floor, the surveyors observed coffee spills, dirty and cracked linoleum, damaged wallpaper, and clogged sinks. The hallway had a noticeable urine odor, and several door frames and thresholds were damaged, posing potential tripping hazards. Maintenance staff confirmed the flooring issues and explained that the sink clog was due to a plumbing issue originating from the second floor. The Director of Nursing verified the observations of soiled floors, damaged paint, and standing water.
Deficiencies in Discharge Process for Two Residents
Penalty
Summary
The facility failed to ensure proper discharge procedures for two residents, leading to deficiencies in the discharge process. Resident #36, who had multiple medical conditions including dementia and hypertension, was discharged to another nursing facility without a proper discharge plan or necessary documentation. The resident's daughter, who was also the power of attorney, insisted on transferring her mother against medical advice (AMA) due to communication issues with the facility. The facility staff did not provide the receiving facility with the required Minimum Data Set (MDS) assessment or transfer level of care documentation, and there was no evidence of a discharge plan of care or social service notes in the resident's medical record. Similarly, Resident #34, who had a history of chronic systolic congestive heart failure and other serious health conditions, was transferred to another nursing facility without a complete discharge order or necessary documentation. The receiving facility did not receive the required transfer level of care documentation, and there were no social service notes or discharge plan of care in the resident's medical record. The facility's staff, including the Admissions/Social Services Staff and the Business Office Manager, were unable to provide the necessary documentation due to a lack of knowledge and communication. Interviews with facility staff revealed a lack of understanding and communication regarding the discharge process, contributing to the deficiencies. The Admissions/Social Services Staff admitted to not knowing how to complete a transfer level of care and failed to document the pending discharges in the residents' medical records. The Director of Nursing confirmed that the facility did not have the necessary discharge information for both residents, highlighting a systemic issue in the facility's discharge process.
Failure to Complete Discharge Summaries for Residents
Penalty
Summary
The facility failed to ensure a discharge summary, including a recapitulation of the resident's stay, was completed for three residents. Resident #36, who had multiple diagnoses including dementia and hypertension, was discharged to another nursing facility without a discharge summary or plan of care. The resident's medical record lacked a Discharge Planning form, and the discharge was marked as Against Medical Advice (AMA) without proper documentation. Interviews with staff confirmed the absence of necessary discharge documentation. Similarly, Resident #34, with a history of chronic heart failure and diabetes, was discharged without a discharge order or a comprehensive discharge summary. The medical record only included minimal information, such as vital signs and the resident's condition, but lacked a discharge plan of care. Resident #35, who had conditions like COPD and dementia, was transferred to another facility after a fall and subsequent emergency room visit. The record did not contain a physician discharge recapitulation. Interviews with the DON confirmed the lack of interdisciplinary or physician discharge summaries for these residents.
Failure to Administer Medications and Monitor Residents with Edema
Penalty
Summary
The facility failed to provide appropriate treatment and care for two residents with edema and congestive heart failure. Resident #21, who was admitted with multiple diagnoses including congestive heart failure and edema, did not receive the prescribed Lasix medication on a specific date, and there was no documentation of Neosporin application for skin lesions as ordered. Additionally, the resident was observed without the prescribed TED hose and Kerlix dressing, which were part of the treatment plan for edema and skin lesions. The Director of Nursing confirmed these lapses in care and documentation. Resident #32, also diagnosed with congestive heart failure, did not have daily weights or intake and output measurements recorded as ordered by the physician. These assessments are crucial for monitoring the resident's condition, yet there was no evidence of compliance on specific dates. The Director of Nursing verified that these essential monitoring tasks were not completed as required. These deficiencies were identified during a complaint investigation and were noted as continued non-compliance from a previous survey.
Failure to Provide Timely Pressure Ulcer Care
Penalty
Summary
The facility failed to provide comprehensive pressure ulcer care timely and as ordered for two residents. Resident #26, admitted with multiple diagnoses including metabolic encephalopathy and severe protein calorie malnutrition, had a Stage 1 pressure ulcer on the coccyx. The physician ordered daily cleansing and dressing of the ulcer, along with skin prep for the heels to prevent breakdown. However, the Treatment Administration Record (TAR) showed that the treatment scheduled for 08/25/24 was not completed. Interviews with the resident and RN confirmed the lapse in care, and the facility's policy on pressure injury treatment was not adhered to. Resident #14, with a history of a fractured right femur, type 2 diabetes, and an unstageable pressure ulcer, also did not receive the ordered treatment for a right heel pressure ulcer. The physician's orders included cleansing and applying specific dressings daily, but the TAR indicated the treatment was not completed as ordered on 08/25/24. Interviews with the resident and the Director of Nursing verified the non-compliance with the treatment orders. This deficiency was part of a continued non-compliance issue from a previous survey.
Failure to Provide Physician-Ordered Nutritional Supplements
Penalty
Summary
The facility failed to provide physician-ordered nutritional supplements to residents with identified nutritional needs, affecting two residents. Resident #26, admitted with multiple diagnoses including severe protein-calorie malnutrition, was recommended to receive Healthshakes twice a day and weekly weights. However, the resident did not receive the supplements as there were no physician orders for them, and the Director of Nursing (DON) had not communicated the dietician's recommendations to the physician. Additionally, the resident's Medication Administration Record (MAR) showed that the Healthshake was not provided as ordered. Resident #32, with a history of severe sepsis, malnutrition, and other health issues, had a physician order for a Health Shake between breakfast and lunch. However, the Treatment Administration Record (TAR) indicated that the supplement was not provided on a specific date. The DON confirmed that the health shake was not administered as ordered. This deficiency was part of a continued non-compliance issue from a previous survey.
Improper Maintenance of Respiratory Equipment
Penalty
Summary
The facility failed to maintain respiratory equipment in a sanitary manner for a resident with multiple diagnoses, including COPD and Alzheimer's disease. The resident had a physician's order for Albuterol nebulizer treatment every six hours as needed, with instructions to change the nebulizer set weekly and as needed for soiling. However, observations revealed that the nebulizer machine and mask were left on a heater in the dining room, with the mask not stored in a sanitary bag. The mask was dated over a week prior and had not been changed as per the treatment order. Interviews with staff confirmed the improper storage and maintenance of the nebulizer equipment. The treatment sheet showed that the nebulizer set was not signed off as changed on two specified dates. The facility's policy required cleaning and proper storage of nebulizer equipment, which was not adhered to in this case. This deficiency was identified during an investigation under a specific complaint number.
Medication Error Rate Exceeds Acceptable Limit
Penalty
Summary
The facility failed to maintain a medication error rate of five percent or less, resulting in a 7.69 percent error rate during a medication administration observation. This deficiency was identified when a Licensed Practical Nurse (LPN) administered medications to a resident with chronic obstructive pulmonary disease (COPD). The LPN did not adhere to the manufacturer's guidelines and the facility's policy regarding the administration of metered-dose inhalers. Specifically, the LPN failed to wait the required one minute between puffs of the inhalers, as instructed by both the Ventolin and Combivent manufacturer guidelines and the facility's policy. During the observation, the LPN administered two respiratory medications to the resident. The first medication, Ventolin HFA Aerosol Solution, was given without the required one-minute interval between puffs. Similarly, the second medication, Combivent Respimat Inhalation Aerosol Solution, was also administered without the necessary waiting period. The LPN acknowledged during an interview that she was unaware of the need to wait one minute between puffs, although she knew to wait ten minutes between different types of inhalers. This oversight contributed to the facility's non-compliance with the medication error rate standard.
Failure to Obtain Ordered Laboratory Tests
Penalty
Summary
The facility failed to ensure that laboratory tests were obtained as ordered for three residents, affecting their medical management. Resident #19, admitted with multiple diagnoses including Alzheimer's disease and COPD, had physician orders for various lab tests every three months and every six months. However, there was no evidence of a baseline Hemoglobin A1C and Lipid Level, and the last set of tests was drawn in May 2024, with no tests conducted in August 2024 as required. The Director of Nursing (DON) confirmed that the laboratory tests were not completed as ordered. Similarly, Resident #21, with a complex medical history including dementia and acute kidney failure, had physician orders for regular lab tests every three and six months. The medical record showed no evidence that these tests were completed as ordered. The DON verified the omission of these tests. Additionally, Resident #3, with a history of hemophilia and type 2 diabetes, had orders for specific lab tests every six months, but there was no evidence of Lipid testing since admission. The DON confirmed the lack of laboratory testing for Lipids for this resident. This deficiency was investigated under Complaint Number OH00156671.
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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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
