The Convalarium Of Dublin
Inspection history, citations, penalties and survey trends for this long-term care facility in Dublin, Ohio.
- Location
- 6430 Post Rd, Dublin, Ohio 43016
- CMS Provider Number
- 365717
- Inspections on file
- 40
- Latest survey
- January 15, 2026
- Citations (last 12 mo.)
- 21
Citation history
Health deficiencies cited at The Convalarium Of Dublin during CMS and state inspections, most recent first.
Surveyors found that staff failed to follow infection control protocols for both shared equipment and isolation precautions. An LPN checked a resident’s blood glucose using a shared glucometer and cleaned it only with an alcohol wipe, despite facility policy requiring a low-level disinfectant wipe and the regional nurse’s acknowledgment that alcohol wipes would not prevent bloodborne illnesses. In a separate case, a resident on contact isolation for C. diff had a posted sign instructing staff to wear gloves and a gown upon room entry, yet a respiratory therapist entered without any PPE and a CNA performed incontinence care without a gown, later admitting she needed to read the door sign to know what PPE was required.
A resident with significant neurologic and functional impairments, including hemiplegia, aphasia, vascular dementia, and ADL deficits, was care planned to require assistance with meal set up and clean up. After a meal, the resident was observed in bed with food (corn) on their shirt, indicating they had not been cleaned up as required. The resident reported being unaware of the food on their clothing and expressed upset about not being cleaned after the meal. An LPN confirmed the presence of food on the resident and the resident’s distress. Facility policy on dignity required staff to groom residents as they wish to be groomed and to promote resident independence, which was not followed in this situation.
A resident with severe cognitive impairment, total dependence for ADLs, and multiple complex medical conditions was admitted with moisture-associated dermatitis to the coccyx. Although the care plan identified risk for skin breakdown and called for wound assessment and treatment per facility protocol, staff did not complete ongoing skin assessments for several weeks and did not obtain treatment orders for the coccyx dermatitis until well after admission. The wound nurse confirmed the lack of documented assessments and delayed treatment orders, and the DON stated that staff were expected to chart and treat skin issues until resolution, in contrast to the facility’s wound care policy requiring wound measurement and treatment as indicated.
A resident with multiple comorbidities, including Alzheimer’s disease, diabetes, COPD, schizophrenia, peripheral vascular disease, and a history of a heel pressure ulcer, was assessed as cognitively impaired and needing assistance with self-care and mobility, and had a physician order to wear Prevalon boots on both feet at all times except during hygiene care. Over multiple observations on consecutive days, the resident was repeatedly seen without the ordered boots in place, and an RN confirmed the resident had not been wearing them during his shift. This failure to follow the physician’s order for pressure ulcer prevention devices resulted in a cited deficiency related to pressure ulcer care and prevention.
A resident with multiple comorbidities and moderately impaired cognition, care planned as a fall risk and requiring assistance with toileting transfers, developed increasing right shoulder pain that interfered with therapy and was later confirmed by x-ray as a displaced scapular fracture. Documentation included a risk assessment stating the resident walked into a door post while going to the bathroom and an NP note indicating the resident ran into a door jamb, but the assessment was kept outside the medical record, lacked follow-up details, and did not specify whether staff were assisting. The incident was not entered on the incident/accident log, the medical record contained no clear description of how the injury occurred, and staff interviews yielded no recollection of the event, while the resident and family reported the injury occurred during a toilet transfer with staff assistance. Facility leadership acknowledged that the event was not thoroughly investigated and that staff statements and complete documentation of the cause of the injury were lacking.
A resident with multiple complex conditions, including CHF, DMII, morbid obesity, and chronic respiratory failure, who was cognitively intact but dependent on staff for several ADLs and used a wheelchair, was transported to the wrong location for a scheduled PET scan. Appointment documentation from a cardiology visit listed one testing site and time, while the physician order in the facility record listed a different site and date, resulting in the resident being taken to the incorrect testing center and missing the scan. The resident and spouse later contacted the facility from the wrong location and ultimately chose to walk back rather than wait for arranged transportation, contrary to the facility’s transportation policy that requires arranging and ensuring transport to and from outside appointments.
A resident with multiple chronic conditions and dementia reported missing dentures, which were later found broken in a toilet. The care plan directed staff to monitor for oral/dental problems and to coordinate dental care and transportation, and the guardian reportedly agreed to arrange for the resident to be seen by a dentist. However, over the following months there was no documentation of any dental visits or of attempts to contact the guardian regarding dental care, despite the requirement for a completed dental consent form. The SSD confirmed the lack of documentation of guardian contact and was unaware of any policy on the frequency of guardian contact to resolve such issues.
A facility failed to provide adequate PPE, specifically eye protection, for staff caring for a COVID-19 positive resident. Additionally, a resident exposed to COVID-19 refused isolation and frequently mingled in common areas without a mask. The facility did not notify residents or their representatives about the COVID-19 case, and mask-wearing was not enforced among residents, increasing the risk of virus spread.
The facility failed to maintain sanitary conditions in food storage and preparation areas, affecting 55 residents. Unlabeled and undated food containers were found in the refrigerator, and significant ice build-up was observed in the freezer. Additionally, ceiling vents over a food preparation area were covered in a brown and black fuzzy substance, all confirmed by the Dietary Manager.
The facility failed to educate and offer influenza vaccinations to residents as required, affecting five residents. Medical records showed that these residents either did not receive the flu vaccination since admission or were not offered it in the current year. Additionally, there was no documentation of education on the risks and benefits of the vaccination. The facility's policy required offering the vaccine and providing education, but this was not followed, as confirmed by the DON.
The facility failed to educate and offer COVID-19 vaccinations to residents, affecting several individuals. Despite previous vaccinations, some residents were not educated or offered the vaccine upon admission, and refusals were not documented. The DON confirmed these deficiencies, and a related policy was not provided during the survey.
The facility failed to follow a resident's DNR-CCA order, performing CPR without verifying the code status, which was accessible. Additionally, the facility did not adhere to physician orders for weight monitoring of another resident, missing several checks and failing to notify the MD of significant weight gains. The DON confirmed these deficiencies.
A resident with multiple stage four pressure ulcers did not receive proper wound monitoring in accordance with facility policy. Despite the requirement for weekly assessments, the resident's wounds were not measured upon readmission on two occasions, and there was a twenty-eight-day gap without visualization or measurement by a wound specialist. Staff interviews confirmed the deficiency, although no adverse outcomes occurred, the potential for harm was present.
A resident with acute and chronic respiratory failure was found with a pill cup containing eight tablets on the nightstand while asleep with a bipap. The medications were left by the night shift nurse from the 6:00 A.M. medication pass. An LPN confirmed the oversight, which violated the facility's medication storage policy.
A facility failed to maintain a medication error rate below five percent, resulting in an eight percent error rate. An LPN administered incorrect doses of Tylenol and Morphine to a resident, deviating from the physician's orders. The LPN acknowledged the error, indicating a possible change in the resident's medication order. The facility's policy requires correct medication preparation and administration, which was not followed.
Two residents in the facility did not receive their prescribed insulin doses on multiple occasions, and there was no documentation explaining the missed doses. One resident reported that the insulin was not administered due to a lack of stock. The facility's policy requires timely medication administration and proper documentation, which was not followed.
A facility failed to store a catheter bag properly, as it was found on the floor under a resident's bed, contrary to policy. Additionally, another resident with a peg tube did not have Enhanced Barrier Precautions (EBP) in place, lacking necessary signage and PPE, until surveyor intervention. These deficiencies were confirmed by staff interviews.
A resident with Parkinson's disease and vascular dementia experienced a fall in a LTC facility. Although the physician was notified promptly, the resident's spouse, who was the POA, was informed about 15 hours later. This delay in family notification was against the facility's policy, which requires immediate communication with the resident's legal representative or family member after such incidents.
A facility failed to complete physician-ordered lab tests for a resident with Alzheimer's, diabetes, and dementia. Despite orders for HbA1c and BMP tests every six months, these were not conducted over a specified period. The facility's policy requires nurses to execute such orders, but this was not followed, as confirmed by the Administrator and DON. This deficiency was found during a complaint investigation.
An LPN failed to perform hand hygiene during medication administration for two residents under enhanced barrier precautions. The LPN did not clean hands before and after preparing and administering medications, contrary to facility policy and signage requirements. This was confirmed during an interview and noted during a complaint investigation.
The facility failed to conduct pre-employment background checks for two STNAs and an OT, as required by policy, potentially affecting all 81 residents. Employee files lacked evidence of completed checks, confirmed by interviews with the Administrator and HR. This deficiency was investigated under a specific complaint number.
The facility failed to conduct performance evaluations for two STNAs, affecting all residents. STNAs hired over a year apart lacked documented evaluations, confirmed by the Administrator and HR. This deficiency was identified during a complaint investigation, with the facility census at 81.
The facility failed to document the required 12 hours of training for two STNAs, as confirmed by HR. This deficiency, affecting the entire resident population, was identified through personnel file reviews and staff interviews.
The facility did not follow the prepared lunch menu, substituting mixed vegetables for cauliflower and omitting garlic toast without a substitute. The Dietary Manager confirmed the lack of cauliflower and the oversight regarding the garlic toast.
The facility failed to ensure meals were served within a 14-hour window, resulting in a 15-hour gap between dinner and breakfast. The Dietary Manager confirmed the lack of substantial snacks during this period. Residents expressed dissatisfaction with the long interval and insufficient snack distribution, with some not receiving snacks at all. This issue was investigated under a specific complaint.
The facility failed to provide scheduled showers for two residents, despite their medical needs and care plans indicating the necessity for assistance with ADLs. One resident received only one shower over two weeks, while another received one shower in a month. Both residents confirmed not refusing care, and the DON verified the lack of documentation for the scheduled showers.
Failure to Properly Disinfect Shared Glucometer and Use PPE for Contact Precautions
Penalty
Summary
The deficiency involves failures in the facility’s infection prevention and control practices related to shared glucometer disinfection and use of personal protective equipment (PPE) for residents on isolation precautions. For one resident with multiple diagnoses including diabetes, hepatic encephalopathy, cirrhosis, and chronic viral hepatitis B and C, an LPN was observed checking the resident’s blood glucose using a shared facility glucometer and then cleaning the device only with an alcohol wipe. The LPN confirmed this was the method used to cleanse the glucometer. Review of the facility’s Shared Glucometer Cleaning Protocol showed that staff were required to use a fresh approved low-level disinfectant wipe each time the glucometer was used, and the Regional Nurse confirmed that cleaning a shared glucometer with an alcohol wipe would not prevent blood illnesses such as hepatitis. The deficiency also includes failure to follow required PPE use for a resident on contact isolation precautions for Clostridioides difficile (C. diff). This resident had diagnoses including atrial fibrillation, COPD, diabetes, dysphagia, and cognitive communication deficit, and was ordered contact isolation precautions. A sign on the resident’s door instructed staff to don gloves and a gown before room entry. A respiratory therapist was observed entering the room without any PPE, and a CNA was later observed performing incontinence care for the same resident without wearing a gown, with her scrub top visible. The CNA acknowledged that PPE should be worn in the room and had to read the sign after exiting to determine what PPE was required and for which resident. The unit manager confirmed the resident had been on contact isolation for C. diff and that contact precautions required the use of appropriate PPE, including gown and gloves upon entering the resident environment, as outlined in the facility’s Standard Precautions policy.
Failure to Provide Post-Meal Clean-Up Compromising Resident Dignity
Penalty
Summary
The deficiency involves the facility’s failure to provide post-meal care necessary to maintain a resident’s dignity. Resident #32, admitted on 03/22/23, had multiple diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side, morbid obesity due to excess calories, aphasia following cerebrovascular disease, cerebral infarction due to occlusion or stenosis of the right middle cerebral artery, major depressive disorder, anxiety, bipolar disorder, vascular dementia, hyperlipidemia, chronic kidney disease, and lack of coordination. The resident’s care plan, last revised on 11/03/25, identified a risk for ADL performance deficits related to generalized weakness, decreased strength and endurance, decreased activity tolerance, impaired mobility, and incontinence related to a cerebrovascular accident. The care plan specified that the resident required increased assistance with ADL performance and was able to eat with set up and clean up assistance. On 01/05/26 at 3:46 P.M., surveyor observation revealed Resident #32 resting in bed watching television with corn on his shirt from lunch, indicating that post-meal clean up assistance had not been provided. During an interview at the time of observation, the resident stated he was not aware of the corn on his shirt and expressed upset that he had not been cleaned up after lunch. At 3:48 P.M., an interview with LPN #604 confirmed that the resident had corn on him and that he was upset about not being cleaned up from lunch. Review of the facility’s “Dignity” policy, last revised 8/25, showed that staff were expected to groom residents as they wish to be groomed and to promote resident independence, which was not followed in this instance.
Failure to Timely Assess and Treat Non-Pressure Skin Condition
Penalty
Summary
The deficiency involves the facility’s failure to timely assess and implement treatment for a non-pressure skin condition in one resident. The resident was admitted with multiple serious diagnoses, including respiratory failure with hypoxia, cerebral edema, protein-calorie malnutrition, cerebral infarction, metabolic encephalopathy, hypokalemia, convulsions, paroxysmal atrial fibrillation, peripheral vascular disease, and pneumonia. An MDS assessment documented that the resident had severe cognitive impairment and was fully dependent on staff for all ADLs. The resident’s care plan, last revised on 11/19/25, identified risk for skin alteration related to generalized weakness, decreased strength and endurance, decreased activity tolerance, impaired mobility, impaired cognition, and incontinence, with interventions to administer treatments as ordered, monitor effectiveness, and assess and record wound healing, including measurements of length, width, and depth, following facility protocol. Despite these identified risks and care plan interventions, the admission assessment documented that the resident was admitted with moisture-associated dermatitis to the coccyx, and the facility did not perform any skin assessments from 09/02/25 through 09/29/25. Additionally, there were no treatment orders in place for the coccyx moisture-associated dermatitis until 09/25/25. Wound Nurse #586 confirmed the absence of documented skin assessments during this period and the lack of treatment orders for the dermatitis until that later date. The DON confirmed the expectation that staff should chart and treat skin issues until they are resolved. Facility policy on wound care, last revised 8/25, required staff to measure wounds, including length, width, and depth, and apply treatments as indicated. This non-compliance was investigated under multiple complaint numbers as cited in the report.
Failure to Implement Ordered Pressure Ulcer Prevention Devices
Penalty
Summary
Surveyors identified a deficiency in pressure ulcer prevention when a resident with Alzheimer’s disease, diabetes mellitus, COPD, schizophrenia, and peripheral vascular disease, who had a history of a right heel pressure ulcer and was care planned as at risk for additional skin breakdown due to immobility, was not provided ordered pressure-relieving devices. The resident’s quarterly MDS showed moderately impaired cognition with a BIMS score of 08 and a need for assistance with self-care and mobility. Physician orders dated 09/17/24 directed that the resident wear Prevalon boots on both feet at all times except during hygiene care. However, during random observations over two days, from the morning of 01/07/26 through the evening of 01/08/26, the resident was repeatedly observed without the Prevalon boots in place, and an RN confirmed the resident had not been wearing the boots that day and did not have them on at the start of his shift. This failure to implement the ordered pressure ulcer preventative intervention constituted the cited deficiency, which was investigated under multiple complaint numbers.
Failure to Thoroughly Investigate and Document Resident Shoulder Fracture Incident
Penalty
Summary
The deficiency involves the facility’s failure to complete a thorough investigation into a resident accident with injury, specifically a displaced scapular fracture, and to adequately document the circumstances of the incident. The resident was admitted with multiple serious diagnoses, including respiratory failure with hypoxia, sepsis, heart failure, heart disease, a displaced scapula fracture, cognitive communication deficit, and muscle weakness. An MDS assessment showed moderately impaired cognition and a need for supervision and touching assistance, and the care plan identified the resident as at risk for falls with interventions such as anticipating needs, ensuring call light access, appropriate footwear, and PT evaluation. Occupational therapy documented that the resident required contact guard assistance for toileting transfers and had requested a higher toilet. Over several days, progress notes and therapy notes documented new and increasing right shoulder and upper arm pain, with pain scores ranging from two to eight out of ten, interfering with therapy. On one date, the resident complained of right shoulder pain, the NP was notified, and a stat x-ray of the right shoulder was ordered along with an ice pack and a lidocaine 4% patch. The radiology report showed a displaced fracture of the scapula with degenerative changes, and the result was reviewed by the medical provider. An occupational therapy note recorded that the family requested a bedside commode over the toilet due to the resident recently injuring her right shoulder during a transfer. A risk assessment documented that the resident reported walking into a door post while going into the bathroom, with a pain level of six, but the assessment was marked privileged and confidential, not part of the medical record, and did not include follow-up on the injury, the x-ray results, the timing of the injury, or whether staff were assisting at the time. The medical record, including progress notes, contained no details on how the fracture occurred, and the incident/accident log had no entry for any fall or injury for this resident. The NP note stated the resident ran into a door jamb two days prior, but there was no corroborating detail in the record. Interviews with nursing and CNA staff who worked with the resident during the relevant period yielded no recollection of the resident or the incident. The resident’s family member reported that the resident fractured her shoulder after a toilet transfer with staff assistance and that both the resident and family informed management, who allegedly told them the resident had just bumped into the wall. The DON and Regional Nurse stated the resident was alert and oriented, referenced unnamed staff who said the resident bumped into the wall, and asserted it was not an unknown injury, but they could not state whether staff were present when the injury occurred, confirmed the event was not on the incident log, and acknowledged that staff statements were not obtained and there was no evidence in the medical record related to the cause of the fall or explanation for the discrepancy between the family’s account and facility documentation.
Failure to Provide Accurate Transportation for Outside PET Scan Appointment
Penalty
Summary
The facility failed to ensure adequate transportation was provided for an outside radiology appointment for Resident #96. The resident, admitted on 10/03/24, had diagnoses including acute chronic systolic heart failure, type II diabetes mellitus, morbid obesity, chronic respiratory failure, and major depression bipolar disorder. An MDS assessment dated [DATE] showed she was cognitively intact but dependent on staff for toileting, bathing, footwear, and turning in bed, and she used a wheelchair for mobility. Nursing progress notes confirmed multiple outside appointments, including a PET scan scheduled for 04/03/25. The after-visit summary from a cardiology appointment on 04/03/25 documented a PET scan scheduled at a testing location in Columbus, Ohio at 2:00 P.M., but the physician order in the medical record listed the PET scan for 04/16/25 at a different testing location in [NAME], Ohio at 1:30 P.M. A concern form completed by the Administrator documented that on 04/03/25 the resident was taken to the wrong testing center for the PET scan, causing the test to be missed and requiring rescheduling. A written statement by the Administrator dated 04/16/25 confirmed a transportation mistake was made for the 04/03/25 appointment and that the resident and her spouse contacted the facility to arrange pick-up from the incorrect location. During an interview, the Administrator confirmed the resident was taken to the wrong location and that Administrator Assistant #596 worked with the resident to ensure her return to the facility, but the resident and her spouse did not wait for transportation and decided to walk back to the facility. Review of the facility’s Transportation policy dated 08/24 showed the facility was responsible for arranging and ensuring transportation to and from outside appointments based on information received from the resident, family, transportation company, or doctor’s office. This failure affected one of three residents reviewed for transportation to outside appointments, with a facility census of 80, and was investigated under Complaint Numbers 2572222, 1376015 (OH00165472), and 1376014 (OH00165055).
Failure to Coordinate and Document Timely Dental Services for a Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely provision and coordination of dental services for a resident who required dentures. The resident, admitted with multiple medical diagnoses including COPD, hemiplegia, CHF, major depressive disorder, anxiety disorder, dementia, hallucinations, and muscle weakness, reported via a concern form that his dentures were missing. The concern form documented that the dentures were later found broken and lodged in a toilet, and that the resident’s guardian was notified and indicated they would contact the dental company for the resident to be seen by a dentist. The resident’s care plan, dated shortly after this event, directed staff to monitor and notify the medical provider as needed for oral/dental problems and stated that the facility would coordinate arrangements for dental care and transportation as needed or ordered. Despite these care plan directives and the identified need for dental services, review of progress notes from early November through early January showed no documentation of any dental visits for the resident and no documentation of attempts to contact the guardian regarding dental care. In an interview, the Social Service Director confirmed that there were no documented guardian contact attempts in the medical record during this period and stated that the guardian was required to complete a dental consent form for the resident to receive dental care at the facility. The Social Service Director reported that the guardian was last contacted in mid-November and given information on the consent form but acknowledged that this contact was not documented and that there were no further contacts with the guardian through early January. The Social Service Director also stated they were unaware of any facility policy specifying how many times a guardian should be contacted to resolve resident issues.
Inadequate PPE and Isolation Protocols for COVID-19
Penalty
Summary
The facility failed to ensure proper personal protective equipment (PPE) was available for staff providing care for a resident with a confirmed COVID-19 infection. Specifically, the PPE bin outside the room of the COVID-19 positive resident did not contain eye protection, which is required according to CDC guidelines for healthcare personnel entering the room of a patient with suspected or confirmed SARS-CoV-2 infection. This oversight was confirmed by an LPN during an observation. Additionally, the facility did not adhere to appropriate isolation protocols for a resident who had been exposed to COVID-19. The exposed resident initially agreed to move to a private room for isolation but later refused to stay there, demanding to return to the shared room with the COVID-19 positive resident. Despite being educated about the risks, the resident did not believe they would contract the virus and frequently left the room to socialize in common areas without wearing a mask, as confirmed by multiple staff and resident interviews. The facility also failed to notify residents and their representatives about the presence of a COVID-19 positive case within the facility, although a sign was placed on the entrance doors for the public. The Director of Nursing confirmed that while employees were required to wear surgical masks during an outbreak, residents were not required to wear masks. This lack of communication and enforcement of mask-wearing among residents potentially increased the risk of virus transmission within the facility.
Sanitation Deficiencies in Food Storage and Preparation
Penalty
Summary
The facility failed to maintain sanitary conditions in food storage and preparation areas, which had the potential to affect 55 residents who consumed food prepared by the facility. During an observation of the kitchen's walk-in refrigerator, it was found that containers of de-stemmed grapes, shredded lettuce, and diced yellow fruit were unlabeled and undated. The Dietary Manager confirmed the issue and was unable to verify when these food items were initially opened, indicating a lapse in following the facility's food storage policy. Further observations revealed significant ice and frost build-up in the walk-in freezer, with ice accumulation on food boxes and the freezer door frame. Additionally, two ceiling vents over a food preparation area were covered in a brown and black fuzzy substance. These conditions were confirmed by the Dietary Manager, highlighting a failure to adhere to the facility's policy that requires food to be stored in clean, dry areas free from contaminants, with proper labeling and dating to prevent contamination or cross-contamination.
Failure to Educate and Offer Influenza Vaccinations
Penalty
Summary
The facility failed to educate residents on the risks and benefits of influenza vaccinations and did not offer the vaccinations as required. This deficiency affected five residents who were reviewed for immunizations. The medical records of these residents showed that they either did not receive the flu vaccination since their admission or there was no evidence of being offered the vaccination in the current year. Additionally, there was no documentation of education provided to the residents or their representatives regarding the risks and benefits of the flu vaccination. The review of the facility's policy on Influenza and Pneumococcal Disease Prevention revealed that it required offering the seasonal influenza vaccine to all residents and providing education on the benefits and potential side effects before offering the immunization. However, the facility did not adhere to this policy, as confirmed by the Director of Nursing (DON), who acknowledged the deficiencies in vaccination practices. The DON confirmed that consents from residents had not been obtained, and the facility was not in compliance with its vaccination policy.
Deficiency in COVID-19 Vaccination Education and Offering
Penalty
Summary
The facility failed to educate residents and their representatives on the risks and benefits of the COVID-19 vaccination and did not offer the vaccine to eligible residents as required. This deficiency was identified through a review of medical records, immunization records, staff interviews, and facility policy review. Five residents were specifically affected by this oversight. For instance, Resident #42, admitted with multiple medical diagnoses, had received COVID-19 vaccinations previously but was not educated or offered the vaccine upon admission. Similarly, Resident #44 refused a COVID-19 booster, but there was no documentation of education or offer of the vaccine in the medical record. Other residents, such as Resident #61, had no evidence of receiving or refusing the COVID-19 vaccination, nor was there documentation of education or an offer being made. Resident #72 also refused a booster without a documented date or evidence of education and offer. Resident #89, despite having received previous vaccinations, was not educated or offered the vaccine upon admission. The Director of Nursing confirmed these findings and acknowledged the deficiencies in vaccination processes. Additionally, a facility policy related to COVID-19 vaccination was requested but not provided during the survey.
Failure to Follow Code Status and Weight Monitoring Orders
Penalty
Summary
The facility failed to adhere to the code status orders for a resident with a Do Not Resuscitate (DNR) Comfort Care Arrest (CCA) status. Despite the resident being unresponsive, staff initiated Cardiopulmonary Resuscitation (CPR) without verifying the code status, which was accessible both electronically and in hard copy at the nurse's station. The error was realized only after paramedics arrived, at which point CPR was ceased, and the resident subsequently expired. Interviews with the Registered Nurses and the Director of Nursing confirmed the oversight in checking the code status before performing CPR. Additionally, the facility did not follow physician orders regarding weight monitoring for another resident. The orders required daily and weekly weight checks with specific parameters for notifying the medical director of significant weight gains. However, there were instances of weight gains outside the set parameters without notification to the medical director, and numerous dates where weight checks were not documented. The Director of Nursing confirmed the lapses in following the weight monitoring orders and the lack of documentation for missed checks or resident refusals.
Failure in Wound Monitoring for Resident with Pressure Ulcers
Penalty
Summary
The facility failed to provide proper wound monitoring for a resident with multiple stage four pressure ulcers. The resident, who had a history of chronic respiratory failure, protein calorie malnutrition, paraplegia, and other serious conditions, was admitted with these ulcers already present. Despite the facility's policy requiring a complete skin check upon admission and readmission, the resident's wounds were not measured upon readmission on two occasions. Additionally, there was a significant gap in wound monitoring, as the wounds were not visualized or measured by a wound specialist for twenty-eight days. Interviews with staff, including a registered nurse and the Director of Nursing, confirmed the lack of wound assessments during this period. The facility's policy expected weekly assessments by a wound nurse or specialist, which were not conducted. Although the resident did not suffer any adverse outcomes from this lapse, the potential for harm was present due to the extended period without proper wound monitoring.
Medication Left at Bedside
Penalty
Summary
The facility failed to ensure medications were not left at the bedside, affecting one resident. Resident #55, who was admitted with acute and chronic respiratory failure, was observed asleep with a bipap on his face. A pill cup containing eight tablets was found on the nightstand beside the bed. There was no nurse present in the room at the time, and a certified nurse aide entered with the resident's breakfast tray. The resident attempted to take the pills, stating they were from the night before. A surveyor intervened and asked the resident to wait for a nurse to verify the medications. An interview with LPN #187 confirmed that the medications were left by the night shift nurse from the 6:00 A.M. medication pass. The facility's medication storage policy, which was undated, stated that medication should be stored in a manner that ensures the safety of the residents.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent, resulting in an eight percent error rate. This deficiency was identified during an observation of medication administration for a resident. The resident had physician orders for Tylenol 325 mg, two tablets every six hours for general discomfort, and Morphine Sulfate oral solution 20 mg per 5 ml, to be administered 0.5 mg by mouth four times a day and 0.5 ml every two hours for pain and shortness of breath. However, during the medication administration, the resident was given Tylenol 500 mg, two tablets, and 0.75 mg of Morphine, which did not align with the physician's orders. The LPN responsible for administering the medication explained that the resident received 0.5 mg of Morphine as a routine medication and an additional 0.25 mg as needed, totaling 0.75 mg, which was reportedly written by hospice. Upon verification, the LPN acknowledged that the medications given were not the correct doses as ordered by the physician, suggesting that the order might have been changed from what the resident was previously receiving. The facility's policy on medication dispensing requires that all medications be prepared and administered in accordance with the correct medication name and dose, which was not adhered to in this instance.
Failure to Administer Insulin and Document Missed Doses
Penalty
Summary
The facility failed to prevent significant medication errors affecting two residents. Resident #44, who has chronic obstructive pulmonary disease, morbid obesity, type two diabetes mellitus with diabetic polyneuropathy, and unspecified protein-calorie malnutrition, did not receive prescribed insulin on multiple occasions. The medical record showed that insulin was not administered on specific dates, and there was no documentation explaining the missed doses. The Director of Nursing confirmed the lack of documentation for the missed insulin doses. Resident #23, diagnosed with type two diabetes mellitus, morbid obesity, and other conditions, also experienced missed insulin doses. The resident did not receive Levemir insulin on two occasions, and there was no documentation explaining these omissions. An interview with the resident revealed that the insulin was not administered due to a lack of stock, as reported by an agency nurse. The Director of Nursing confirmed the absence of documentation for the missed doses, and the facility's policy requires timely medication administration and proper documentation.
Infection Control Deficiencies in Catheter and EBP Management
Penalty
Summary
The facility failed to ensure catheter bags were stored in a sanitary manner, which was observed in the case of a resident with an indwelling catheter. The resident, who had diagnoses including Parkinsonism and neuromuscular dysfunction of the bladder, was observed with his catheter bag laying flat against the floor under his bed. This was confirmed by an LPN, and it was noted that the facility's policy required the catheter to be secured and checked to ensure proper drainage, which was not adhered to in this instance. Additionally, the facility did not implement Enhanced Barrier Precautions (EBP) for a resident with a peg tube, despite the need for such precautions due to the presence of an opening. The resident, who had a history of malignant neoplasms and required assistance with ADLs, reported that staff typically wore masks and gloves but not gowns. There was no signage or PPE available near the resident's room, and EBP was only ordered after surveyor intervention. This oversight was confirmed by both an agency RN and the Director of Nursing.
Delayed Family Notification After Resident Fall
Penalty
Summary
The facility failed to notify the family of a resident, identified as Resident #21, in a timely manner following a fall. Resident #21, who was cognitively intact and had a diagnosis of Parkinson's disease, muscle weakness, and vascular dementia, experienced a fall while exiting the restroom. The incident report indicated that the resident's physician was notified shortly after the fall, but the resident's spouse, who was the Power of Attorney (POA) for healthcare, was not informed until approximately 15 hours later. This delay in notification was confirmed through interviews with facility staff, including Registered Nurses and the facility's administration. The facility's policy on Notification of Change requires that the resident's legal representative or an interested family member be informed immediately when an accident occurs that results in injury or has the potential for requiring physician intervention. However, the policy was not followed in this instance, as evidenced by the lack of timely communication with the resident's family. The deficiency was identified during a complaint investigation and was confirmed by staff interviews and a review of the facility's policy and the resident's medical records.
Failure to Execute Physician-Ordered Lab Tests
Penalty
Summary
The facility failed to ensure timely completion of physician-ordered laboratory services for a resident diagnosed with Alzheimer's disease, diabetes mellitus, and dementia. The resident had orders for a hemoglobin A1C (HbA1c) and a basal metabolic panel (BMP) to be conducted every six months due to their diabetes diagnosis. Despite these orders being documented on 07/18/24 and reiterated on 08/09/24, the laboratory tests were not completed from 07/18/24 to 09/11/24. This oversight was confirmed during an interview with the Administrator and Director of Nursing, who acknowledged that the laboratory company was not contacted to perform the necessary tests. The facility's policy, dated 06/09/22, states that the nurse who receives a physician's order is responsible for executing it, including contacting laboratory services. However, this procedure was not followed, resulting in the failure to conduct the required laboratory tests for the resident. This deficiency was identified during a complaint investigation, highlighting a lapse in the facility's adherence to its own policies regarding the execution of physician orders.
Failure to Perform Hand Hygiene During Medication Administration
Penalty
Summary
The facility failed to adhere to proper hand hygiene protocols during medication administration for residents under enhanced barrier precautions. On the specified date, an LPN was observed preparing and administering medications to two residents without performing hand hygiene before and after the process. The LPN did not wear gloves while preparing medications and failed to clean hands upon entering and exiting the residents' rooms, which were marked with enhanced barrier precaution signs. The deficiency was confirmed during an interview with the LPN, who acknowledged not performing hand hygiene as required. The facility's policy on Infection Control- Isolation/Precautions mandates hand hygiene before and after resident contact and after contact with objects in the resident's room. The signage from the United States Department of Health and Human Services also requires hand cleaning before entering and upon leaving the room. This incident was identified during a complaint investigation.
Failure to Conduct Pre-Employment Background Checks
Penalty
Summary
The facility failed to ensure that background checks for staff were completed prior to employment, affecting three employees: two State Tested Nursing Assistants (STNAs) and one Occupational Therapist (OT). The employee files for STNA #230, STNA #122, and OT #356 lacked documented evidence of completed background checks, and these individuals were not listed on the Bureau of Criminal Investigation (BCI) background check log. This oversight had the potential to affect all 81 residents residing in the facility. Interviews with the Administrator and HR personnel confirmed the absence of background checks in the employee files. HR #366 acknowledged that background checks were supposed to be conducted on the same day as orientation, but this was not done for the mentioned employees. The facility's policy, dated October 2023, mandates checking the Ohio Nurse Aide Registry, applicable licensing and certification authorities, and conducting criminal background checks in accordance with Ohio law and facility policy before hiring new employees. This deficiency was investigated under Complaint Number OH00155375.
Lack of Performance Evaluations for STNAs
Penalty
Summary
The facility failed to ensure that performance evaluations were completed for State tested Nursing Assistants (STNAs), specifically affecting two employees whose files were reviewed. STNA #122, hired on 07/29/22, and STNA #230, hired on 07/28/23, both lacked documented evidence of having undergone performance evaluations since their respective hire dates. This deficiency was confirmed through interviews with the Administrator and Human Resources, who verified the absence of performance evaluations for these STNAs. The issue was identified during an investigation under Complaint Number OH00155375, with the potential to impact all residents in the facility, which had a census of 81.
Deficiency in STNA Training Documentation
Penalty
Summary
The facility failed to ensure that State tested Nursing Assistants (STNAs) received the required minimum of 12 hours of training to maintain their competence. This deficiency was identified through a review of personnel files and staff interviews. Specifically, the personnel files of two STNAs, hired on different dates, lacked documented evidence of the required training. This issue was confirmed during an interview with a Human Resources representative, who verified the absence of documentation for the training. The deficiency was noted to have the potential to affect all residents in the facility, which had a census of 81 at the time of the report. This noncompliance was investigated under Complaint Number OH00155375.
Failure to Follow Prepared Menu
Penalty
Summary
The facility failed to adhere to the prepared lunch menu on 07/30/24, which was intended to include chicken Parmesan, cauliflower, garlic toast, and tiramisu for dessert. During an observation at 11:56 A.M., lunch trays for Unit One were seen leaving the kitchen with a test tray on an open cart. The last lunch tray was delivered to a resident at 12:46 P.M., and the test tray was removed. Upon inspection, it was noted that the resident's tray contained mixed vegetables instead of cauliflower, and there was no garlic bread or substitute provided. An interview with Dietary Manager (DM) #140 at 2:06 P.M. confirmed that there was no cauliflower available, leading to the substitution with mixed vegetables. Additionally, DM #140 acknowledged the omission of garlic toast and the failure to provide a substitute. This deficiency was identified during an investigation under Complaint Number OH00156101.
Failure to Provide Timely Meals and Snacks
Penalty
Summary
The facility failed to ensure that no more than 14 hours elapsed between the evening meal and breakfast, which had the potential to affect all residents receiving food from the kitchen. The evening meal was served at different times across units, with the earliest at 4:50 P.M. and the latest at 5:30 P.M., while breakfast was served starting at 7:50 A.M. and ending at 8:30 A.M., resulting in a 15-hour gap between meals. Interviews with the Dietary Manager confirmed the 15-hour interval and the lack of substantial snacks being offered during this period. Additionally, interviews with three residents revealed dissatisfaction with the long interval between supper and breakfast, as well as insufficient snack distribution. Two residents reported not receiving a snack the previous night, indicating a failure to provide suitable and nourishing alternatives for those who wished to eat outside of scheduled meal times. This deficiency was investigated under Complaint Number OH00156101.
Failure to Provide Scheduled Showers for Residents
Penalty
Summary
The facility failed to provide scheduled showers or baths for two residents, which was identified through record reviews, resident interviews, and staff interviews. Resident #25, who was admitted with diagnoses including diabetes, hyperkalemia, hyperglycemia, pressure ulcer wounds, and obesity, was found to have received only one shower over a two-week period despite being scheduled for at least two showers weekly. The resident confirmed not refusing any bathing care and had requested showers on scheduled days. The Director of Nursing (DON) verified the lack of documentation for showers and confirmed the resident's schedule. Similarly, Resident #68, with diagnoses including atrial fibrillation, diabetes, obesity, and COPD, was documented to have received only one shower in a month. The resident's care plan indicated a need for assistance with activities of daily living (ADLs), yet there was no documentation of showers or refusals except for one noted refusal. The resident confirmed receiving only one shower and not refusing any care. The DON acknowledged the lack of documentation and confirmed the requirement for STNAs to document care provided.
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Surveyors found that multiple hazardous storage areas, including a closet near medical records, a beauty salon used to store chemical cases, a supply room in one nursing station, a room leading to a smoking area, a housekeeping room near therapy, and a lobby storage room, lacked required self-closing or automatic-closing doors. These conditions did not comply with NFPA 101 requirements for hazardous area enclosure and had the potential to affect all residents and staff in an emergency.
Surveyors found that the facility did not conduct fire drills on every shift each quarter and did not vary drill conditions as required by NFPA 101. Record review showed that one shift lacked a documented drill for an entire quarter, and the pattern of drill times and dates did not demonstrate varied conditions. The Maintenance Director confirmed the incomplete and noncompliant fire drill schedule, which affected all residents and staff emergency preparedness.
Surveyors found that the facility did not maintain clear egress corridors as required by NFPA 101, with a TV/video cart plugged into a corridor outlet and multiple unsecured chairs placed in the hallway near resident rooms and the secured unit dining room, including directly in front of a fire extinguisher. These items projected about 29 inches into an approximately eight-foot-wide corridor and were located in front of the handrail, potentially affecting 28 residents and staff’s ability to assist in an emergency. The Maintenance Director confirmed these corridor obstructions during the survey.
A resident with intact cognition receiving Medicare Part A skilled services for metabolic encephalopathy had services discontinued while benefit days remained, but the facility did not issue the required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN). The Social Services Director later confirmed that no SNF ABN was provided and reported she believed only a Notice of Medicare Non-Coverage (NOMNC) was needed when all skilled services were stopped. This practice conflicted with the facility’s written policy, which required SNF ABNs to be issued when extended care items or services were initiated, reduced, or terminated due to expected non-coverage by Medicare.
Surveyors identified that the facility exceeded the acceptable medication error rate when two residents with type 2 DM received insulin doses that were not administered according to orders or manufacturer instructions. In two separate observations, an LPN administered Novolog and another LPN administered insulin glargine and insulin lispro without priming the insulin pens, and the insulin lispro and Novolog were given after the residents had already consumed a significant portion of their breakfast meals, despite orders for administration before meals. Manufacturer information for both insulin products required priming before each injection to ensure accurate dosing, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and specified time frames.
The facility failed to maintain accurate and complete crash cart audits for multiple full-code residents. Surveyors, accompanied by the DON, found that daily crash cart checks did not include verification of supply expiration dates, and that an extension cord documented as present on several audit dates was not actually in the cart. Audit logs also conflicted with the cart’s contents by indicating that required items such as eye protection, saline, and clear plastic were present when they were not. These findings were inconsistent with the facility’s policy requiring the crash cart to be checked every 24 hours and after each use, with prompt replacement of equipment and supplies.
A resident with chronic respiratory failure on supplemental O2, COPD, and cognitive risk factors was repeatedly documented as non-compliant with the smoking policy, including going out to smoke outside designated times and retaining cigarettes and lighters provided by family. Despite prior assessments identifying this resident as unsafe to smoke without supervision, a later assessment classified the resident as safe to smoke independently without documented rationale or care plan update. The resident subsequently went outside alone with an O2 nasal cannula in place, lit a cigarette, and sustained facial burns when the cannula ignited, as observed by staff and confirmed by EMS and ED records. In a separate case, another cognitively impaired resident with a history of falls had a care-planned intervention for non-skid strips in front of a recliner, but observation and staff confirmation showed the strips were not present, despite remaining on the active fall-risk care plan.
Multiple dependent residents did not receive scheduled showers, bed baths, or shaving as outlined in their care plans and the facility’s routine care policy. One resident recovering from spinal surgery missed numerous scheduled showers over several months. Another resident who relied on staff for self-care repeatedly requested shaving but was not shaved, and visible facial hair was observed after a recent shower. A resident with chronic respiratory failure and a tracheostomy, requiring substantial/maximal assist with personal hygiene, had no documented showers for an extended period and was observed with long facial hair, which staff acknowledged should be removed during bathing or as needed. A cognitively impaired resident with ESRD and CHF, scheduled for twice-weekly showers, had multiple undocumented or missed showers and reported not getting showers despite asking aides who said they lacked time. Another cognitively intact resident with hemiplegia and multiple comorbidities, also scheduled for twice-weekly showers, had several dates where documentation showed no shower/bath/bed bath provided or no entry at all, and she reported feeling unclean and unimportant when her showers were missed.
A resident with an indwelling urinary catheter for urinary retention, and care plan interventions requiring the drainage bag to be properly secured with a dignity cover, was observed seated in a chair with the catheter drainage bag uncovered and containing visible dark yellow urine that could be seen from the hallway. Later, an LPN confirmed the catheter bag was lying directly on the floor without a dignity cover. This situation occurred despite facility policy requiring care to be provided in a manner that respects and enhances each resident’s dignity and personal privacy.
A cognitively intact resident with chronic orthopedic pain had a PRN oxycodone order, but multiple doses were signed out on the narcotic log by an RN without corresponding entries on the MAR or documented pain assessments. A CNA/med tech reported frequent problems with this RN’s narcotic counts and documentation, describing erratic behavior when handling narcotic keys. The resident reported taking oxycodone only once or twice daily and otherwise using Tylenol, which conflicted with the number of oxycodone doses signed out. The facility’s investigation found it was inconclusive whether narcotics were misappropriated or whether there was a failure of documentation, but confirmed there was no evidence that all signed-out doses were administered.
Failure to Maintain Self-Closing Doors for Multiple Hazardous Storage Areas
Penalty
Summary
Surveyors identified a deficiency related to hazardous area protection and door requirements under NFPA 101, 2012 Edition. During facility tours, they observed that multiple hazardous storage areas did not have self-closing or automatic-closing doors as required for hazardous areas such as combustible storage and chemical storage. These areas included a closet next to medical records, a beauty salon being used to store cases of chemicals, a supply room in Station #2, and the room leading to the smoking area in Station #3. On a subsequent tour, surveyors observed additional hazardous areas without self-closing doors. The housekeeping room across from therapy and the lobby storage room were both noted to lack self-closing door mechanisms. The facility census at the time was 59 residents, and the surveyors stated that this deficient practice had the potential to affect all residents and staff's ability to assist in an emergency. The Maintenance Director verified these findings at the time they were observed.
Plan Of Correction
K 0321 This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be admissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as its allegation of substantial compliance as of 06/12/2026 K-0321 Doors with Self-Closing Devices Corrective action for resident/s: 1. The closet door next to medical records was lacking a self-closing door on 5/19/2026. Maintenance director to add self-closing device to closet door next to medical records on or before 06/12/2026 in accordance with applicable code. 2. The beauty salon had chemicals stored in it on 5/19/2026. Maintenance director moved chemicals from beauty salon on 05/20/2026 in accordance with applicable code. 3. The supply room on station 2 was lacking a self-closing door on 5/19/2026. Maintenance director to add self-closing door to supply room on station 2 on or before 06/12/2026 in accordance with applicable code. 4. The room to the smoking area on station 3 was lacking a self-closing door on 5/19/2026. Maintenance director to add a self-closing door to the smoking are on station 3 on or before 06/12/2026 in accordance with applicable code. 4. The housekeeping room across from therapy was lacking a self-closing door on 5/19/2026. Maintenance director to add a self-closing door to the housekeeping room across from therapy gym on or before 06/12/2026 in accordance with applicable code. 5. The lobby storage room was lacking a self-closing door on 5/19/2026. Maintenance director to add a self-closing door to the lobby storage room on or before 06/12/2026 in accordance with applicable code. Identification of other residents who may be affected: LNHA and Maintenance director/designee completed a full facility audit for doors with self-closing devices on 05/26/2026. Any corrective action, including, doors identified as needing self-closures will be added on or before 06/09/2026 in accordance with applicable code. Measures for systemic change: LNHA educated Maintenance Director on 05/26/2026 regarding NFPA 101-2012 sections 19.3.2.1 and 19.3.5.9 specifically regarding doors with self-closing devices. How Corrective Action will be monitored Ongoing "Doors with Self-Closing device audit" to be completed weekly x 2 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 06/12/2026
Failure to Conduct Required Quarterly Fire Drills on All Shifts
Penalty
Summary
The facility failed to conduct fire drills in accordance with NFPA 101, 2012 Edition, sections 19.7.1 through 19.7.1.8, specifically by not holding drills every shift each quarter and not varying drill conditions as required. Record review on 06/09/25 at approximately 10:32 A.M. showed there was no fire drill conducted for the first shift during the third quarter. The documented first-shift fire drills occurred on 01/30/26 at 2:42 P.M., 04/30/26 at 1:51 P.M., and 10/31/25 at 10:58 A.M., indicating a missed quarter. Second-shift fire drills were recorded on 02/26/26 at 5:20 P.M., 06/03/25 at 4:35 P.M., 08/29/25 at 3:46 P.M., and 11/25/25 at 5:09 P.M., and third-shift drills on 02/28/26 at 11:47 P.M., 05/30/25 at 12:18 A.M., 07/22/25 at 11:34 P.M., 09/26/25 at 11:40 P.M., and 12/15/25 at 5:17 A.M. The surveyor determined that drills were not conducted under varied conditions and that the required quarterly drill on each shift was not consistently performed. The Maintenance Director confirmed these findings at the time they were identified, and the deficiency had the potential to affect all 59 residents and staff response in an emergency. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency related to facility-wide emergency preparedness practices and documentation of fire drills.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 05/29/2026 K-0712 Fire Drills Corrective action for resident/s: There were no records of a fire drill for the first shift of the third quarter of 2025. First shift fire drill completed on 5/24/2026 by maintenance director/designee with no findings or corrective action necessary. Identification of other residents who may be affected: On 5/26/2026 Maintenance director/designee completed 100% audit of the scheduled fire drills to ensure a drill is scheduled quarterly each shift with no findings or corrective action necessary. Measures for systemic change: LNHA educated Maintenance Director on 05/26/2026 regarding NFPA 101-2012 section 19.7.1.4 through 19.7.1.7. specifically including fire drill frequency requirements. How Corrective Action will be monitored Ongoing "Fire Drill Audit" to be completed weekly x 2 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 05/29/2026
Obstructed Egress Corridors Due to Equipment and Chairs
Penalty
Summary
The facility failed to maintain required clear egress widths in corridors in accordance with NFPA 101, 2012 Edition, sections 19.2.3.4 through 19.2.3.5 and 7.3.2 through 7.3.2.3, creating projections into the egress corridor that exceeded allowable limits. Surveyors observed that on one day in Station #3, a cart with a television and video equipment was plugged into an outlet in the corridor by room 38, and five activity room chairs were placed in the corridor near the secured unit dining room directly in front of a fire extinguisher. On the following day, surveyors again observed chairs in the Station #3 corridor, with four by room 35 and four by the activities room, and the same television cart still in the corridor; the chairs were not secured. The corridor was approximately eight feet wide, and the projections extended approximately 29 inches into the corridor in front of the handrail. These conditions had the potential to affect 28 residents in the facility and the staff’s ability to assist in an emergency, and the Maintenance Director confirmed the observations at the time of discovery. No specific resident medical histories or conditions were described in the report, only that 28 residents were potentially affected and the facility census was 59.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be subsequent remedial measures and should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 05/29/2026 K-0232 Clear path of egress Corrective action for resident/s: 1. On 05/18/2026 station 3 had a cart with a television parked in the corridor by room 38 that exceeded allowable limits. Maintenance director/designee moved the TV cart into the activity room, out to the corridor on 05/18/2026 in accordance with applicable code. 2. On 5/18/2026 station 3 had 5 chairs in the corridor near the dining room directly in front of the fire extinguisher. Maintenance director/designee moved the chairs into the dining room, out of the corridor on 5/18/2026 in accordance with applicable code. 3. On 5/19/2026 station 3 had 4 chairs by the activity room and 4 by room 35. In addition, the TV cart was in the corridor. The maintenance director/designee moved the chairs and TV cart into the dining room, out of the corridor on 5/19/2026 in accordance with applicable code. Identification of other residents who may be affected: Maintenance director/designee completed a 100% facility audit for clear paths of egress on 5/26/26 with no findings or corrective action necessary. Measures for systemic change: Maintenance Director/designee educated staff on 5/26/2026 regarding NFPA 101-2012 section 19.2.3.4 and 19.2.3.5 specifically including maintaining a clear path of egress. How Corrective Action will be monitored Ongoing "Path of Egress Audit" to be completed weekly x 2 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 05/29/2026
Failure to Issue Required SNF ABN When Discontinuing Medicare Part A Services
Penalty
Summary
The deficiency involves the facility’s failure to issue a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) when Medicare Part A services were discontinued for a resident who still had available benefit days. The resident was admitted with a diagnosis of metabolic encephalopathy and had intact cognition per the Minimum Data Set assessment. The facility’s own SNF Beneficiary Notification Review documented that Medicare Part A skilled services began on 02/11/26 and the last covered day was 03/11/26, and that the facility initiated discharge from Medicare Part A services before the resident’s benefit days were exhausted. Despite this, no SNF ABN was provided to the resident or the resident’s representative. During interviews, the Social Services Director stated that the SNF ABN was issued hours prior to the last covered day but, upon reviewing her files, confirmed that no SNF ABN had actually been issued for this resident. She further explained that she believed an SNF ABN was only required if one skilled service remained and that if all skilled services were being discontinued, only the Notice of Medicare Non-Coverage (NOMNC) needed to be issued. The Administrator, however, stated that a resident should always receive both a SNF ABN and a NOMNC when Medicare Part A services are discontinued and benefit days remain. Review of the facility’s written policy dated 03/28/23 showed that the facility was required to issue SNF ABNs for initiation, reduction, or termination of extended care items or services when Medicare payment was not expected, which did not occur in this case.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as its allegation of substantial compliance as of 05/29/2026 F-0582 Corrective action for resident/s: On 5/14/26 Resident #34 was informed of rights and responsibilities related to Advanced Beneficiary Notice and voiced understanding of information for future reference by administrator. Identification of other residents who may be affected: Any resident receiving skilled services from nursing or therapy services. The Administrator audited all residents who were discharged from skilled services in the past 30 days to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary Notice on 5/29/26. No non-compliance was noted. Measures for systemic change: On 5/14/2026 Business Office Manager, Director of Rehab, Minimum Data Set nurse, Director of Nursing and Social Services Director were educated on proper procedure of issuing of Notice Of Medicare Non Coverage and Advanced Beneficiary Notice by administrator. All upcoming discharges from skilled services will be reviewed weekly at Utilization Review meeting to ensure notices will be delivered timely. How Corrective Action will be monitored: Administrator or designee to complete audits of all residents being discharged from skilled services to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 5/29/26
Insulin Administration Errors and Failure to Prime Insulin Pens
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5%, with surveyors identifying 3 errors out of 28 medication administration opportunities, resulting in a 10.71% error rate. For one resident with type 2 diabetes mellitus and moderate cognitive impairment, the physician’s order directed Novolog insulin 10 units via subcutaneous pen-injector to be given before meals. During an observed medication pass, the LPN administered 10 units of Novolog insulin without priming the pen and did so after the resident had already consumed approximately 50% of the breakfast meal. The LPN later confirmed she did not prime the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer instructions for the Novolog FlexPen specified that an air shot (priming) must be performed before each injection to ensure proper dosing. Another resident, also diagnosed with type 2 diabetes mellitus and with intact cognition, had orders for insulin glargine 35 units subcutaneously twice daily and insulin lispro 20 units subcutaneously before meals, plus 12 units subcutaneously if blood glucose was between 251 mg/dL and 300 mg/dL. During an observed medication administration, an LPN administered 35 units of insulin glargine and 32 units of insulin lispro without priming the insulin pens and after the resident had consumed approximately 90% of the breakfast meal, despite orders for insulin lispro to be given before meals. The LPN later stated she could not remember if she had primed the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer information for insulin lispro stated that the pen must be primed before each injection to confirm insulin delivery and remove air, and that failure to prime could result in too much or too little insulin. The DON confirmed the expectation that insulin be administered as ordered, including priming each pen with two units before dialing the prescribed dose, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and required time frames.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 5/29/2026. F-0759 Corrective action for resident/s: Residents #21 and #22 were assessed and evaluated by nurse and Director of Nursing 5/14/26. Resident #21 and #22 both denied any adverse effects and none were noted upon assessment by the Director of Nursing on 5/14/2026. Notification made to physician on 5/14/2026. LPN # 2 competency Eval on insulin administration with the Director of Nursing completed 5/14/2026. Identification of other residents who may be affected: Diabetic residents on assignment of LPN #2/station 2 have the potential to be affected and were assessed by the DON/Designee on 5/14/26 and found to be within normal limits. Measures for systemic change: All Nurses were educated by the Director of Nursing on the steps for Insulin administration per competency, diabetes clinical protocol policy, Medication and treatment orders policy, administering medications policy, and Obtaining fingerstick Glucose Level policy On 5/14/2026. How Corrective Action will be monitored: Director of Nursing and Assistant Director of Nursing will complete insulin administration audits on 5 nurses. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance: 5/29/2026
Inaccurate Crash Cart Audits and Missing Emergency Equipment
Penalty
Summary
The facility failed to ensure accurate and complete crash cart audits for residents requiring basic life support, affecting eighteen of thirty-five residents who were designated as full code. During an observation of the crash cart with the DON, surveyors found that the daily audit documentation for the month did not include verification of expiration dates for crash cart supplies. Review of the crash cart audit logs showed that an extension cord was documented as being in the cart on multiple dates, but the extension cord was not present in the cart at the time of inspection. Additionally, the audit documentation indicated that required items, including eye protection, saline, and clear plastic, were not present in the crash cart, yet they were documented as being in the cart. The facility’s undated “Emergency Crash Cart” policy stated that the crash cart is to be checked every 24 hours and after every use, and that equipment and supplies are to be noted and replaced promptly, but the observed documentation and contents of the cart did not match these requirements. This deficiency was verified with the DON at the time of the survey and was cited under the requirement that personnel provide basic life support, including CPR, to residents requiring emergency care, subject to physician orders and advance directives, and was investigated under Complaint Number 2687380.
Plan Of Correction
Cridersville Care Center Provider Number:366171 Survey Type: Complaint Survey Survey Date: 04/29/26 This Plan of Correction (PoC) outlines the actions completed by the facility with regards to the deficiency citation. This Plan of correction does not constitute any admission of guilt or liability by the facility and is submitted only in response to the regulatory requirements. Please accept the following as the facility's credible allegation of compliance as of 4/30/26. F678 CPR All Full Code residents #18 have the potential to be affected by the alleged deficiency. On 4/27/26 the DON/ADON re-stocked the crash cart per the inventory sheet for all missing items. Crash cart inventory sheet updated and new one will go into effect on 5/1/26. All licensed nursing staff provided with training related to crash cart inventory being a daily audit review using inventory sheet on 4/27/26 per DON/designee. The DON/designee will conduct clinical rounds and conduct a random audit of crash cart three times per week for 4 (four) weeks to ensure compliance. The results of the audit will be documented. The facility conducted an Ad-Hoc QAPI meeting on 4/27/26 and discussed the alleged deficiency and corrective actions. Date when corrective action will be completed: 4/30/26
Unsafe Smoking Practices with Oxygen and Missed Fall-Prevention Interventions
Penalty
Summary
The deficiency involves the facility’s failure to provide a safe smoking environment, adequate supervision, and appropriate implementation of its smoking policy for a resident who used oxygen and smoked, as well as failure to implement fall-prevention interventions as care planned for another resident. One resident had multiple relevant diagnoses, including chronic respiratory failure with hypoxia, COPD, end-stage renal disease, dependence on supplemental oxygen, diabetes, and necrotizing fasciitis. Her care plans identified impaired visual function, risk for respiratory complications related to a history of smoking, and risk for cognitive decline, with interventions including use of oxygen per order and observation for understanding. A smoking-related care plan created earlier documented that she wished to use smoking products, had been assessed as safe to smoke "with supervision," and was non-compliant with the smoking policy, with family continuing to provide smoking supplies despite education and a verbal warning for non-compliance. Smoking assessments and progress notes showed a pattern of non-compliance and inconsistent classification of this resident’s smoking safety. Multiple smoking observation/assessments completed earlier in March documented that she had no cognitive loss, visual deficits, or dexterity problems but was unsafe to smoke without supervision because she did not return smoking materials and did not follow designated smoke times. Progress notes described her going out to smoke multiple times by herself or with family, including sneaking out next door with a cigarette and going out multiple times in one evening, with staff documenting that she was "reeducated" and that family brought in cigarettes and lighters which she did not return to staff. Despite this history, a smoking assessment completed after a three-day hospital stay assessed her as safe to smoke without supervision, with no documentation explaining how this conclusion was reached or evidence that her care plan was updated accordingly. On the day of the incident, the resident reported she had cigarettes and a lighter on her person after returning from dialysis and stated she "could not find a nurse" and went outside to smoke, saying she "guessed" she forgot she had her oxygen on. A CNA observed her outside and saw a flame coming through the resident’s oxygen nasal cannula tubing, turned off the oxygen tank, removed the tubing, and patted out sparks on the resident’s shirt sleeve. The resident’s face and hands appeared black in color, and EMS documented first-degree burns to the head and face, with the resident stating she lit a cigarette with her nasal cannula on, causing the burn. The hospital record described her face as black from smoke and her lips and mouth as "burnt and charred," with a recommendation for intubation that she refused. The facility’s incident report recorded that she went outside with oxygen on to smoke without notifying staff, that staff witnessed the occurrence as she walked through the dining room door to the courtyard, and that she stated she thought she had turned her oxygen off. The facility’s smoking policy required interdisciplinary evaluation to determine safe versus unsafe smokers, staff maintenance of all smoking paraphernalia for both safe and unsafe smokers, and progressive consequences for policy violations. A separate deficiency involved another resident at risk for falls whose care plan included use of non-skid strips on the floor in front of her recliner as a fall-prevention intervention. This resident had severe cognitive impairment, used a walker and wheelchair, required supervision or touching assistance for transfers and ambulation, and had experienced two or more falls without injury since the prior assessment. The fall-risk care plan, initiated at admission, specified non-skid strips in front of the recliner beginning in November. However, nursing staff interviewed were not familiar with all of the resident’s fall-prevention interventions without checking the record, and observation of the room showed two recliners with no non-skid strips on the floor in front of them. An LPN confirmed that the non-skid strips were not present despite the intervention remaining active in the care plan, and moving the recliners did not reveal any strips. The facility’s fall management policy required identification of hazards and risk factors, implementation of interventions to minimize falls and injuries, and development and implementation of a care plan based on interdisciplinary evaluation, with interventions related to identified risk factors.
Plan Of Correction
Smoking: On 03/21/26 at 3:16 P.M. 911 response was activated for Resident #11 and Medical Director #601 was notified by Registered Nurse (RN) #322. On 03/21/26 at 3:18 P.M. on-call Nurse/Social Services #423 immediately notified the Administrator and Director of Nursing (DON) #304 of the incident involving Resident #11. On 03/21/26 at 3:22 P.M. Emergency Medical Services (EMS) arrived onsite. At 3:30 P.M. Resident #11 was transported to the emergency room. On 03/21/26 at 3:30 P.M. RN #322 completed a smoking re-assessment of Resident #11 assessing the resident to be an unsafe smoker requiring supervision due to failure to remove oxygen prior to entering designated smoking area. On 03/21/26 from 3:38 P.M. through 7:57 P.M. Licensed Practical Nurse (LPN) #337, #336, #335, #338; RN #334, and DON #304 re-assessed residents (who smoke). This included Resident #22, Resident #3, Resident #47, Resident #50, Resident #60, Resident #150, Resident #86, and Resident #10 to determine smoking safety (via smoking assessment). Each resident was re-educated regarding the facility smoking policy and staff verified there were no smoking materials on their person. The residents' smoking materials would be maintained by facility staff and distributed per policy. On 03/21/26 at 4:30 P.M. DON #304 responded to facility and an Ad Hoc (not scheduled) Quality Assurance (QA) meeting was held via telephone with the Administrator, DON #304 and Medical Director #601 to review investigative findings and plan of action. A root cause analysis was completed and determined Resident #11 had smoking materials on her person (believed to be obtained from family without staff knowledge) and failed to remove her oxygen. The QA team discussed a corrective action plan. On 03/21/26 from 5:00 P.M through 03/22/26 at 3:00 P.M. 26 RNs, 13 LPNs, one medical technician (MT), 54 Certified Nursing Assistants (CNA) four activities staff, one central supply staff, 11 dietary staff, 12 housekeeping staff, three laundry staff, one medical records staff, two social designees, two maintenance staff, nine administrative staff, and 19 therapy staff (158 staff at the time of the incident) were provided education regarding the facility smoking policy by DON #304 and the Administrator. This was completed via 1:1, small group in-services or via phone. Newly hired staff would receive education during general orientation regarding the facility's smoking policy. On 03/21/26 at 5:00 P.M. DON #304 completed an audit of all residents who smoke (Resident #22, Resident #3, Resident #47, Resident #50, Resident #60, Resident #150, Resident #86, and Resident #10) to verify smoking evaluations and plans of care accurately reflected the residents' smoking safety needs. The residents were educated on the facility smoking policy, and smoking materials were to be maintained at the nurses' station. An audit was completed which included verification of required safety measures present in designated smoking areas, including an ash can, fire extinguisher, fire blanket, ash trays and no oxygen signs. There were no identified concerns or changes made because of the audits. On 03/21/26 at 8:55 P.M. Resident #11 returned from the ED. LPN #332 verbally educated the resident regarding the facility smoking policy which included the need for supervision, a smoking apron (to be worn) and the facility smoke times. LPN #332 verified no smoking materials were on the resident's person or in her room at this time. On 03/23/26 at 11:00 A.M. the Interdisciplinary Team (IDT) (Administrator, DON #304, Medical Director #601, RN #302, Social Services #427, Social Services #423, DON #300, and Maintenance #436) met in-person to review the plan of action with DON #304/designee to complete weekly monitoring of residents who smoke and designated smoking areas weekly for four weeks with Housekeeping responsible to complete the cleaning. Housekeeping staff were responsible for cleaning ashtrays and the designated smoking area daily. Audits to be reviewed and any further actions required to be directed by the Quality Assurance and Performance Improvement (QAPI) Committee during scheduled meetings. The IDT also reviewed all current smoking assessments and care plans for residents who smoke. Resident #50 required a change in supervision levels with smoking due to cognition levels and her plan of care as well as Resident #11's plan of care was updated to reflect supervision/safety. On 03/23/26 from 3:45 P.M. to 8:55 P.M. Social Services #423 re-educated residents who smoke (Resident #22, Resident #3, Resident #47, Resident #50, Resident #60, Resident #150, Resident #86, Resident #10) and responsible parties, if applicable regarding the facility smoking policy and supervision levels. On 03/23/26 at12:13 P.M. Social Services #427 contacted Resident #11's family member (#602) to schedule a care conference. Family member #602 and Family Member #603 were not available to meet until 03/27/26. On 03/23/26 at 1:00 P.M. staff education related to smoking areas, removal of oxygen prior to entering smoking area and maintaining smoking materials at the nurses' station for residents who smoke was initiated by DON #304 and the Administrator via 1:1, small group in-services or via phone call. Education was completed for all 158 staff by 03/24/26 at 1:00 P.M. Newly hired staff would be educated during general orientation regarding the facility's smoking policy. The facility does not utilize agency staff. On 03/27/26 at 11:00 A.M. a care conference was held with Resident #11 and Family Members #602 and #603, the Administrator, Social Services #423 and Social Services #427. The facility smoking policy was reviewed. The resident and family were informed an involuntary discharge would be initiated should the resident exhibit non-compliance moving forward and supervision would be increased beyond the two-hour standard of care to monitor more closely for non-compliance with the facility smoking policy. Family Member #602 stated he educated his siblings as well. On 04/10/26 at 2:00 P.M. DON #304 initiated education with 26 RNs and 13 LPNs (100% of nurses educated) regarding completion of the smoking evaluation via 1:1, small group in-services, or phone. The education was completed by 6:00 P.M. on 04/10/26. A new resident who smokes must remain supervised until the interdisciplinary team (IDT) reviews and determines smoking safety, at which time the care plan is developed and resident and family education is provided. The communication through the staff would be the care plan. Newly hired staff receive education during general orientation regarding the facility's smoking policy and completion of smoking evaluation via Point Click Care (PCC). On 04/10/26 at 4:29 P.M. DON #304 initiated an order in PCC for the nurse to verify, each shift, that Resident #11's smoking materials were maintained at the nurses' station. On 04/13/26 at 5:30 P.M. DON #304 initiated orders in PCC for nurses to verify, each shift, that all residents who smoke would have smoking materials maintained at the nurses' station. An updated list of smokers included: Resident #60, Resident #50, Resident #11, Resident #86, Resident #113, and Resident #151. On 04/13/26 at 5:45 P.M. DON #304 initiated questionnaires for staff regarding the smoking policy with re-education provided as needed via 1:1 and small group in-services for staff currently in the facility with all staff to be questioned/educated prior to working their next scheduled shift. Falls: On 4/9/26, Maintenance Director placed non-skid strips on the floor in front of Resident #12's recliner. Like Residents are identified as residents who have had a fall within the facility. Utilizing the Fall Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, an audit of falls and appropriate interventions for the past 30 days will be completed by the Director of Nursing or designee to ensure fall interventions are in place per plan of care. This audit along with identified corrections will be completed on or F 0689 before 5/13/26. The Director of Nursing or designee will re-educate licensed nurses and STNA/CNAs on the Fall Management Policy to include fall interventions to be in place per the care plan. This education will be completed on or before 5/13/26. Utilizing the Fall Management Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, the Director of Nursing or designee will complete an audit of new admissions, new readmissions and residents who experience a fall within the last 7 days, weekly for four weeks, beginning 5/14/26 to ensure fall safety interventions are in place per plan of care. Current fall interventions found to not be in place will be corrected with all intervention in place per plan of care. Negative findings to be addressed immediately and negative trends or system wide issues will be reported to the QAPI committee, and the action plan will be adjusted as needed.
Removal Plan
- Activated 911 response for Resident #11 and notified the Medical Director.
- On-call Nurse/Social Services immediately notified the Administrator and DON of the incident.
- EMS arrived onsite and Resident #11 was transported to the emergency room.
- Completed a smoking re-assessment of Resident #11, determining the resident was an unsafe smoker requiring supervision due to failure to remove oxygen prior to entering the designated smoking area.
- Re-assessed all residents who smoke (Residents #22, #3, #47, #50, #60, #150, #86, and #10) to determine smoking safety via smoking assessment.
- Re-educated residents who smoke regarding the facility smoking policy and verified there were no smoking materials on their person.
- Implemented that smoking materials would be maintained by facility staff and distributed per policy.
- Held an ad hoc QA meeting to review investigative findings and plan of action.
- Completed a root cause analysis determining Resident #11 had smoking materials on her person and failed to remove oxygen.
- Developed a corrective action plan.
- Provided facility-wide education to staff on the facility smoking policy.
- Implemented that newly hired staff would receive smoking policy education during orientation.
- Completed an audit of all residents who smoke to verify smoking evaluations and plans of care accurately reflected smoking safety needs.
- Ensured smoking materials were maintained at the nurses’ station.
- Audited designated smoking areas for required safety measures (ash can, fire extinguisher, fire blanket, ash trays, and no-oxygen signs).
- Provided verbal education to Resident #11 on smoking policy (supervision, smoking apron, smoke times).
- Verified no smoking materials were on Resident #11’s person or in her room.
- Conducted an in-person IDT meeting to implement weekly monitoring of residents who smoke and designated smoking areas weekly for four weeks.
- Assigned housekeeping to clean ashtrays and the designated smoking area daily.
- Directed audits to be reviewed by QAPI.
- Reviewed all current smoking assessments and care plans for residents who smoke.
- Updated Resident #50’s supervision level.
- Updated Resident #11’s plan of care to reflect supervision/safety.
- Re-educated residents who smoke and responsible parties (as applicable) regarding the facility smoking policy and supervision levels.
- Contacted Resident #11’s family to schedule a care conference.
- Initiated additional staff education regarding smoking areas, removal of oxygen prior to entering smoking area, and maintaining smoking materials at the nurses’ station.
- Held a care conference with Resident #11 and family to review smoking policy.
- Informed resident/family that involuntary discharge would be initiated for future non-compliance.
- Increased supervision beyond the two-hour standard of care to monitor more closely for non-compliance.
- Provided education to all nurses regarding completion of the smoking evaluation.
- Implemented that new residents who smoke must remain supervised until IDT review determines smoking safety and care plan/education are completed.
- Entered an order in PCC for nursing to verify each shift that Resident #11’s smoking materials were maintained at the nurses’ station.
- Entered orders in PCC for nursing to verify each shift that all residents who smoke have smoking materials maintained at the nurses’ station.
- Initiated staff questionnaires regarding the smoking policy with re-education as needed.
- Required all staff to be questioned/educated prior to working their next scheduled shift.
Failure to Provide Scheduled Bathing and Shaving Assistance for Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide scheduled and needed bathing and shaving assistance to multiple dependent residents in accordance with their care plans, preferences, and the facility’s routine care policy. One resident with spinal stenosis and recent L2–L5 decompression fixation fusion was care planned for substantial/maximal assistance with shower/bath and toileting hygiene and was scheduled for showers on Tuesdays and Fridays. Electronic documentation from early January through early April showed this resident did not receive a shower or bed bath on 11 identified scheduled days, and the DON confirmed these missed bathing events. Another resident with dysphagia and developmental issues, who required assistance with self-care and mobility, reported that she asked staff to shave her but they did not, which bothered her. During an observation following a recent shower, she stated she had not been shaved and that the hair "itched"; small gray hairs were visible on her chin. A CNA confirmed the presence of gray chin hairs and acknowledged the resident needed shaving, stating it would be addressed with the next scheduled shower. A further resident with chronic respiratory failure, tracheostomy status, heart failure, moderate intellectual disabilities, anxiety, depression, and PTSD required substantial/maximal assistance with personal hygiene and had a care plan for assistance with self-care, including personal hygiene. Her shower schedule called for showers on Monday and Thursday nights, with complete shaves for men and women. Review of documentation showed her last recorded shower/bath was nearly a year earlier, with no indication of additional personal hygiene or facial hair removal on that date. Observations on two separate days showed long white hairs on her chin and jaw line, which a CNA later confirmed, stating facial hair removal should occur with baths/showers or as needed. A resident with end stage renal disease, respiratory failure, hyperlipidemia, and congestive heart failure, who had impaired cognition and required partial/moderate assistance with bathing and personal hygiene, was scheduled for showers on Wednesdays and Saturdays. Review of shower documentation from admission through early April revealed no showers provided or refusals documented on at least ten scheduled shower days. In interviews, this resident reported not receiving scheduled showers, was unsure of his shower days, and stated he could use a good scrub down, adding that he had asked aides who told him they did not have time. A CNA explained that shower days appear on shower sheets and in the computer and that CNAs are supposed to document daily, with nurses checking the documentation; the DON verified the resident had not received showers per schedule or preference. Another resident with a fracture of the lower end of the left humerus, hemiplegia and hemiparesis after cerebral infarction, rheumatoid arthritis, hypertensive heart disease, urinary retention, and osteoarthritis was care planned as non–weight bearing to the left upper extremity and requiring substantial/maximal assistance with showering/bathing. Her electronic record showed she was scheduled for showers on Wednesdays and Saturdays. The shower task question "did the resident receive a shower/bath/bed bath?" was documented as "no" on three dates, indicating no shower/bath/bed bath was completed, and left unanswered on three additional dates. The DON confirmed that one missed shower was due to an outside appointment, that on two dates the "no" response meant no bathing of any type occurred, and that on three dates there was no documentation at all. The resident, who was cognitively intact, reported that missing showers made her feel unimportant compared to others and that she did not feel clean when her shower was missed. Facility policy on routine resident care stated that showers, tub baths, and shampoos are to be scheduled according to person-centered care or state guidelines, with additional showers given upon request, but the documented and observed care did not reflect consistent provision of scheduled bathing and shaving for these residents.
Plan Of Correction
1. Resident #5 received a shower by the STNA on 4/13/26. Resident #8 received a shower by the STNA on 4/8/26. Resident #9 received a shower and had their chin shaved by the STNA on 4/14/26. Resident #70 received a shower by the STNA on 4/13/26. Resident #76 received a shower and had their chin shaved by the STNA on 4/15/26. 2. Like residents are identified as residents who need assistance with showering and shaving. Utilizing the Shower Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, an audit of like residents will be completed by the Director of Nursing or designee to ensure that showers and resident shaving are completed. This audit along with identified corrections will be completed on or before 5/13/26. 3. The Director of Nursing or designee will re-educate licensed nurses and STNA's on the Routine Resident Care Policy to include bathing and shaving residents. This education will be completed on or before 5/13/26. 4. Utilizing the Shower Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, the Director of Nursing or designee will complete an audit of 4-6 residents weekly for four weeks, beginning 5/14/26 to ensure that showers and resident shaving are completed. Noncompliance found during audits will be addressed and assistance with showers and/or shaving provided. Negative findings to be addressed immediately and negative trends or system wide issues will be reported to the QAPI committee, and the action plan will be adjusted as needed.
Uncovered Urinary Catheter Drainage Bag Compromises Resident Dignity
Penalty
Summary
The facility failed to maintain a resident’s right to privacy and dignity related to management of an indwelling urinary catheter. A resident admitted with malignant neoplasm of the esophagus and type II diabetes mellitus had a care plan identifying risk for urinary tract infection and catheter-related trauma due to an indwelling catheter for urinary retention. The care plan interventions included ensuring the catheter tubing was secured and the drainage bag was properly secured with a dignity cover in place. Physician orders directed that the resident’s 16 French indwelling urinary catheter be changed every 30 days and as needed, and the comprehensive MDS documented that the resident had an indwelling catheter and was cognitively intact. During observation, the resident was seen seated in a chair with the urinary catheter drainage bag hanging from the chair without a dignity cover, and dark yellow urine was visible in the bag from the hallway. In a later observation and interview, an LPN confirmed that the catheter bag was lying directly on the floor and did not have a dignity cover. Attempts to interview the resident to confirm cognitive status were unsuccessful, as the resident was unable to answer screening questions. Review of the facility’s “Resident Dignity & Personal Privacy” policy stated that the facility should provide care in a manner that respects and enhances each resident’s dignity, individuality, and right to personal property, which was not followed in this instance when the catheter drainage bag was left uncovered and visible.
Plan Of Correction
The Laurels of Athens wishes to have this plan of correction submitted as our written allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission to nor agreement with, either the existence of, or the scope and severity of, any of the cited deficiencies or conclusions set forth in the statement of deficiencies. This plan is prepared and/or executed to ensure continuing compliance with regulatory requirements. Our alleged date of compliance is 5/13/2026. 1. On 4/6/26, Resident #92's catheter bag was removed from the floor, the bag changed and covered for dignity by the licensed nurse. Resident #92 discharged from the facility on 4/11/26. 2. Like Residents are identified as residents who utilize urinary catheters. An audit will be completed by the Director of Nursing or designee for like residents utilizing the Urinary Catheter Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC to ensure catheter bags are covered for dignity and not laying directly on the floor. This audit along with identified corrections will be completed on or before 5/13/26. 3. The Director of Nursing or designee will re-educate licensed nurses on the Indwelling Urinary Catheter Policy as well as Resident Dignity & Personal Privacy Policy to include privacy covers are in place for urinary catheters and that the catheter is not laying on the floor. This education will be completed on or before 5/13/26. 4. Utilizing the Urinary Catheter Audit Tool which was created on 4/20/26 by the Director of Nursing for purpose of this POC, the Director of Nursing or designee will complete an audit of all residents with catheters weekly for four weeks, beginning 5/14/26 to ensure catheter bags are covered for dignity and not laying directly on the floor. Any catheters found to be touching the floor or uncovered will be removed from the floor, the bag changed and covered for dignity. Negative findings to be addressed immediately and negative trends or system wide issues will be reported to the QAPI committee, and the action plan will be adjusted as needed.
Failure to Prevent Possible Misappropriation and Poor Documentation of PRN Narcotics
Penalty
Summary
The deficiency involves failure to prevent potential misappropriation of a resident’s narcotic medication and failure to ensure accurate documentation of controlled substance administration. A cognitively intact resident with chronic pain related to an internal orthopedic device and left knee pain had an order for oxycodone 5 mg PO every four hours PRN for pain and a care plan directing staff to administer medications as ordered and observe for effectiveness and side effects. The resident’s MDS showed she rated her pain as 7/10 and received opioid medication. However, review of the February MAR and the narcotic log revealed multiple discrepancies between narcotic sign-outs and documented administration. On several occasions, oxycodone doses were signed out on the narcotic log by an RN without corresponding documentation on the MAR. Specifically, oxycodone was signed out on one evening at 9:30 p.m. with no MAR entry, and again on a subsequent night at 1:30 a.m. and 5:30 a.m. with no MAR entries for those times. Another dose was signed out at 9:00 p.m. while the MAR reflected administration at 10:16 p.m., and a later dose at 5:30 a.m. was documented on both the narcotic log and MAR. There was also no documentation of pain assessments before or after PRN opioid administration. These documentation gaps meant there was no evidence that all narcotic doses signed out were actually administered to the resident. Staff interviews further highlighted concerns about the handling of narcotics. A CNA/med tech reported frequently taking the narcotic keys from the RN and described the RN’s behavior as erratic, with repeated problems involving incorrect narcotic counts and missing documentation on both the MAR and narcotic log. The resident stated she did not receive oxycodone more than once or twice a day, preferring to take Tylenol the rest of the time, which conflicted with the number of oxycodone doses signed out. When questioned, the RN gave inconsistent explanations about how often she pulled and administered PRN narcotics and acknowledged struggling with the new system, while also suggesting the resident may have received PRN tizanidine instead of remembering oxycodone. The facility’s investigation concluded that evidence was inconclusive as to whether misappropriation occurred or whether the issue was solely lack of documentation, but confirmed there was no evidence the resident received all doses signed out on the narcotic log.
Plan Of Correction
1. Resident #99 had a Self-Reported Incident submitted and investigated via the EIDC on 3/2/26. The investigation was inconclusive as we could not prove that misappropriation occurred. On 2/24/26, Resident #99 was interviewed and pain assessed by Director of Nursing and resident had no ill effects related to the inconsistent documentation in the medical record as it relates to her controlled substance pain medication. 2. Like Residents are identified as residents who utilize controlled substance PRN pain medications. An audit will be completed by the Director of Nursing or designee for like residents utilizing the Controlled Substance Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC to ensure PRN controlled substance pain medications that are signed off the control sheet are documented in the resident medical record as well. This audit along with identified corrections will be completed on or before 5/13/26. 3. The Director of Nursing or designee will re-educate licensed nurses on the Controlled Substances Policy to include appropriate documentation of controlled substances. In addition, the licensed nurses will be re-educated by the Director of Nursing or designee on the Abuse Prohibition Policy to include misappropriation of resident property. This education will be completed on or before 5/13/26. 4. Utilizing the Controlled Substance Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, the Director of Nursing or designee will complete an audit three controlled substance sheets from each of the nine medication carts for a total of twenty-seven sheets weekly for four weeks, beginning 5/14/26 to ensure PRN controlled substance pain medications that are signed off the control sheet are documented in the resident medical record as well. Inconsistencies noted from the audit will be investigated for misappropriation. Negative findings to be addressed immediately and negative trends or system wide issues will be reported to the QAPI committee, and the action plan will be adjusted as needed.
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