The Laurels Of Heath
Inspection history, citations, penalties and survey trends for this long-term care facility in Heath, Ohio.
- Location
- 717 South 30th Street, Heath, Ohio 43056
- CMS Provider Number
- 365466
- Inspections on file
- 47
- Latest survey
- January 29, 2026
- Citations (last 12 mo.)
- 27
Citation history
Health deficiencies cited at The Laurels Of Heath during CMS and state inspections, most recent first.
A cognitively intact, fully ADL-dependent resident with multiple chronic conditions had a photo of their naked back taken without consent by a CNA using a personal cell phone during a bed bath. Staff interviews confirmed that personal phones were not permitted in resident care areas and that only the wound nurse, using a facility phone, was authorized to take resident photos for clinical purposes. An LPN reported that the CNA showed her the image, and another LPN reported that the image was then sent to another nurse and subsequently to the resident’s parent. The resident first learned of the photo when a parent contacted and texted the image, and the resident expressed being upset that no permission had been requested. Review of facility policies and CMS guidance showed that this conduct violated resident rights to privacy and confidentiality.
A cognitively intact, fully ADL-dependent resident reported feeling violated after learning that a CNA had taken a picture of the resident’s naked back during care using a personal cell phone, without consent, and that the image was shared with family. Staff interviews confirmed that personal cell phone use and taking resident photos were prohibited except by the wound nurse using a facility device, yet a CNA took the photo and an LPN subsequently sent it to the resident’s parent. The ADON and Administrator were informed of the incident, but no formal investigation could be found, and the Administrator, viewing the matter as a HIPAA issue rather than abuse, did not report the allegation to the State Agency as required by facility policy and CMS guidance.
A cognitively intact resident who was dependent on staff for all ADLs reported that a CNA took a picture of the resident’s naked back with a personal cell phone during a shower, without consent. Staff interviews showed that the CNA sent the image to an LPN, who then sent it to the resident’s parent, despite facility policy prohibiting personal cell phone use in care areas and limiting resident photography to the wound nurse using a facility phone. Although an LPN reported the incident to the ADON, the Administrator did not conduct or ensure a formal, thorough investigation, did not interview the involved CNA or LPN, did not verify deletion of the image from personal devices, and did not report the incident to the State Agency, despite CMS guidance and facility policy requiring investigation and reporting of such allegations.
A resident with multiple complex medical conditions experienced a change in condition and was assessed by an LPN, during which a CNA witnessed the LPN make an inappropriate comment with sexual innuendo. The CNA reported the incident to the unit manager and provided a written statement, but the DON did not receive the statement, did not investigate, and did not report the allegation to the State survey agency as required by facility policy.
A resident with cognitive and medical conditions experienced a change in condition and, during assessment, an LPN allegedly made an inappropriate comment with sexual innuendo in the presence of a CNA. The CNA reported the incident and provided a written statement, but management did not investigate or report the allegation as required by policy, and the LPN was not suspended pending investigation.
A resident with chronic pain and opioid dependence was given a crushed extended-release Morphine tablet and double the prescribed dose of Lyrica by an LPN, despite clear labeling that the Morphine should not be crushed. The error was discovered after the resident became confused and sedated, requiring Narcan administration and hospital evaluation.
Surveyors found that opened multi-use vials of Tuberculin solution in multiple medication storage rooms were not labeled with the date of first use, contrary to manufacturer guidelines. Staff confirmed the omission and removed the vials from use. This practice had the potential to affect all residents, as all new admissions receive TB testing.
The facility did not monitor or address recurring infection patterns, including multiple cases of UTIs, skin, fungal, osteomyelitis, and respiratory infections across several units. Despite documentation of these trends, there was no evidence of staff education, monitoring, or auditing to prevent further spread, as confirmed by an RN interview.
Surveyors found that several residents were living in rooms with unclean conditions, including stained window blinds, cobwebs, dirty floors, soiled bed linens, exposed drywall, and uncovered fluorescent light fixtures. Despite cleaning schedules indicating these rooms had been cleaned, the Maintenance Director confirmed the deficiencies, which were documented under complaint investigations.
A resident with ALS and dysphagia was kept on a pureed diet without supporting medical assessments, despite repeatedly expressing a desire to return to a regular diet. The facility did not offer alternative food options or document informed refusal, and staff confirmed that only pureed food was provided until further swallow studies were completed, failing to support the resident's right to self-determination.
A resident with cognitive impairment and multiple medical conditions, who required staff assistance for ADLs, was observed with noticeable facial hair on multiple occasions. Staff confirmed that shaving assistance should have been provided according to the care plan, but this was not done, resulting in a failure to meet the resident's personal hygiene needs.
The facility failed to properly assess and document dietary needs, obtain accurate and timely weights, and notify physicians of significant weight changes for several residents. One resident was placed on a pureed diet without a documented swallow study or medical assessment, refused the diet, and was not offered a risk agreement. Another resident experienced delays in obtaining an accurate weight after an initial discrepancy, and a third resident's daily weights and required physician notifications for weight changes were not consistently completed or documented.
Multiple residents were observed with house flies present in their rooms, including flies on bed covers and windowsills, and one resident was seen swatting at flies near her face. Staff confirmed that flies were a persistent issue throughout the facility. Pest control records showed ongoing fly activity linked to poor sanitation in resident bathrooms, with recommendations for regular cleaning and sanitizing not adequately implemented.
Two residents were administered psychotropic medications without appropriate diagnoses or proper justification for not attempting gradual dose reductions. One resident received an antipsychotic for anxiety without a documented psychiatric diagnosis, while another continued on multiple psychotropic drugs despite pharmacy recommendations for dose reduction, with provider denials lacking clear clinical contraindication.
A resident with multiple psychiatric and neurological conditions, who preferred independent activities such as watching TV and movies in his room, did not have access to a TV for an extended period after a room change. Despite staff attempts to offer alternative activities, the resident's documented preferences were not met, and there was no evidence that his preferred activities were facilitated.
A resident with bilateral hand contractures and multiple psychiatric diagnoses did not receive a recommended splint and brace program after discharge from OT. Despite OT recommendations for bilateral hand splints and ROM exercises, there were no physician orders or restorative program in place, and staff confirmed that no such interventions were implemented.
A resident with dementia and a history of falls experienced multiple unwitnessed falls due to not wearing non-skid footwear, despite repeated education and care plan interventions. Facility staff confirmed ongoing non-compliance and did not implement new or alternative interventions, resulting in continued falls over an extended period.
Two residents did not receive timely dental care, including follow-up for dentures after tooth removal and assistance with denture replacement after loss. One resident, cognitively intact, was not offered further dental appointments after an initial cancellation, while another with dementia had not been seen by a dentist or assisted with lost dentures, despite care plans requiring such interventions.
A resident with multiple diagnoses and a recent fall was discharged from OT with a recommendation for a restorative program focused on ADLs, including personal hygiene, dressing, and grooming. While a restorative ambulation program was implemented following PT recommendations, the ADLs restorative program was not initiated, as confirmed by staff interviews and record review.
Surveyors found that several areas, including bathrooms and resident rooms, had loose toilet rails, broken or missing tiles, dirty sinks, odors, sticky floors, and damaged furniture. Nursing staff confirmed these issues, which affected six residents and compromised the safety and cleanliness of the environment.
Surveyors found that three residents, each with significant cognitive or physical impairments, did not have their call bells within reach as required by facility policy. In each case, staff confirmed the call bells were not accessible, despite the residents' ability to use them if properly positioned.
A resident with paraplegia and other medical conditions repeatedly requested assistance from the social worker to transfer to another facility closer to a preferred location. Despite these requests and the resident's intact cognition, there was no evidence that the social worker made any attempts to contact other facilities or document follow-up actions, instead relying on the resident's mother to find a new placement.
Surveyors found that three residents with significant cognitive and physical impairments did not have water or beverages accessible in their rooms. Staff, including CNAs and an LPN, confirmed the absence of water and only provided it after residents requested it. The facility lacked a policy for providing ice water, contributing to the deficiency in maintaining resident hydration.
A resident with severe cognitive impairment and a history of exit seeking eloped from the facility after her wanderguard was not in place and staff failed to verify her whereabouts for several hours. Multiple staff assumed she was in her usual locations, and a headcount was not performed when first notified by a local store. The resident was later found by police at the store, having been missing for an extended period.
A resident's $1,000.00 cash, secured in the facility's safe, was missing when the POA came to collect belongings. The BOM claimed the money was returned to the resident, but no documentation was found to support this. The facility's policy required funds to be held in a trust account, and the lack of proper records led to the deficiency.
A facility failed to routinely clean CPAP equipment for a resident with sleep apnea, despite having a physician's order for CPAP use. The resident, who required assistance with daily activities and used a wheelchair, did not have orders for cleaning the CPAP mask and tubing. Interviews revealed that nurses were responsible for cleaning the equipment for residents not on the ventilator unit, but this was not done, contrary to facility policy.
The facility failed to properly store resident food in the Unit 3 refrigerator, affecting 40 residents. Observations revealed unlabeled and undated food, spillage, and pools of liquid surrounding food items. An STNA confirmed these findings, which were contrary to the facility's updated Refrigerator and Freezer Maintenance policy.
A resident with Alzheimer's dementia and other conditions required supervision for eating. During meal assistance, an STNA stood while feeding the resident, contrary to the facility's protocol that requires staff to sit, make eye contact, and converse with residents. This was noted as a deficiency in a complaint investigation.
A facility failed to accurately document wound care treatment orders for a resident with complex medical conditions. The wound NP's progress notes indicated orders for treatments like 3% acetic acid, ace bandages, and 1/2 strength Dakin's solution, which were not reflected in the resident's medical records. Interviews revealed the facility never received these orders, and the NP admitted to possible inaccuracies due to distractions.
A resident contracted Legionella due to the facility's failure to implement a comprehensive water management program. Despite having measures like water temperature checks, the facility did not conduct a Legionella risk assessment or identify potential growth areas. The resident, with a complex medical history, became lethargic and tested positive for Legionella after hospital transfer. The deficiency was noted during a complaint investigation.
Unauthorized Photograph of Resident Violates Privacy and Dignity
Penalty
Summary
A resident’s right to privacy and dignity was violated when a CNA took a photograph of the resident’s naked back without consent while providing a bed bath. The resident had been admitted with multiple diagnoses including paraplegia, seizure disorder, severe protein-calorie malnutrition, hypertension, insomnia, amaurosis fugax, dilated cardiomyopathy, and anxiety disorder. A quarterly MDS showed the resident had a BIMS score of 15, indicating intact cognition, and was dependent on staff for all ADLs, including showering, bathing, and repositioning in bed. The resident later reported that no one had asked permission to take the picture and that he was upset when he learned of it. Staff interviews confirmed that the CNA used a personal cell phone to take the picture in a resident care area, contrary to facility policy. CNA #233 admitted taking the picture of the resident’s naked back without the resident’s knowledge during a bed bath. Another CNA stated that staff were not to be on their cell phones in patient care areas and that no pictures were to be taken with personal cell phones. A different CNA reported that only the wound nurse should take resident pictures, and only with a facility phone for wound measurement purposes. These statements aligned with written facility policies that prohibited use of personal electronic devices in resident areas and strictly prohibited taking pictures or videos in any resident area using personal cell phones. Further interviews revealed that the photograph was shared beyond its original capture. An LPN reported that the CNA showed her the picture of the resident’s back on the CNA’s personal cell phone when the LPN returned to the unit. Another LPN stated that the CNA told her she had taken a picture of the resident’s back and that the picture was sent to another LPN, who then sent it to the resident’s mother. The resident reported that he first became aware of the picture when his father called and then texted him the image of his naked back, at which point he expressed that he was not happy the picture had been taken without his permission. The ADON acknowledged that a CNA had taken a picture of the resident’s back and that it was sent to a nurse who then sent it to the resident’s parents, and noted that the resident was upset because he was cognitively intact and able to make his own decisions. Review of facility policies and a CMS memorandum confirmed that taking photographs of a resident without consent violates resident rights to privacy and confidentiality.
Failure to Report Allegation of Abuse Involving Unauthorized Resident Photograph
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of abuse to the State Agency after staff took and shared an unauthorized photograph of a resident’s naked back. The resident, admitted with diagnoses including paraplegia, seizure disorder, severe protein-calorie malnutrition, hypertension, insomnia, amaurosis fugax, dilated cardiomyopathy, and anxiety disorder, had a BIMS score of 15, indicating intact cognition, and was dependent on staff for all ADLs, including showering and repositioning in bed. During a shower, a CNA took a picture of the resident’s naked back on a personal cell phone without the resident’s consent. Multiple staff interviews confirmed that facility policy prohibited staff from using personal cell phones in resident care areas and from taking resident photographs, except by the wound nurse using a facility phone for clinical purposes. An LPN reported that she was shown the picture of the resident’s back on the CNA’s personal phone and later informed the resident that the CNA had taken the picture; the resident stated he did not like that the picture had been taken without asking him first. Another LPN reported that the CNA told her she had taken the picture and that it had been sent to another LPN, who then sent it to the resident’s mother. The resident later reported learning of the picture only when his father called and then texted him the image, and he stated he was upset, had not given permission, and felt violated because he did not know who had seen the picture. The ADON acknowledged that a CNA had taken a picture of the resident’s back and that the image was sent to a nurse who then sent it to the resident’s parents, and confirmed that staff cell phone use in direct care areas was prohibited. The Administrator stated she was notified of the incident within two hours and notified corporate, but she could not locate a formal investigation and indicated that an LPN had done interviews at the time. The Administrator further stated she did not believe there was intent to do harm, considered the incident a HIPAA violation rather than abuse, and therefore did not submit a report to the State Agency. This inaction occurred despite facility policy and CMS guidance requiring that all allegations of abuse, including those involving unauthorized photographs, be thoroughly investigated and reported to appropriate state agencies.
Failure to Investigate Unauthorized Resident Photograph and Privacy Violation
Penalty
Summary
The deficiency involves the facility’s failure to conduct a thorough investigation after being informed that staff took a photograph of a resident without consent. Resident #42, who was cognitively intact with a BIMS score of 15 and dependent on staff for all ADLs including bathing and repositioning, reported that a CNA took a picture of his naked back without his permission. The resident stated he first learned of the picture when his father called and then texted him the image, and he reported feeling violated because no one had asked his permission and he did not know who had seen the picture. Staff interviews confirmed that facility policy prohibited staff from using personal cell phones in resident care areas and from taking resident photographs, except by the wound nurse using a facility phone for clinical purposes. On the date of the incident, CNA #233 took a picture of Resident #42’s naked back while giving him a shower, without asking for consent. LPN #500 stated that when she returned to the unit, CNA #233 showed her the picture on a personal cell phone. LPN #500 then went to the resident’s room, referenced the picture, and informed the resident that the CNA had taken a picture of his back; the resident told her he did not like that the picture had been taken without asking him first. LPN #500 acknowledged that she did not report the incident to management. LPN #15 reported that CNA #233 told her she had taken a picture of the resident’s back and sent it to LPN #500, who then sent the picture to the resident’s mother. LPN #15 stated she notified the ADON immediately but did not speak with the resident about the picture until the following day, when the resident again expressed that he was not happy the picture had been taken without his permission. The ADON and Administrator confirmed that a CNA had taken a picture of the resident’s back and that the picture was sent to the nurse on the unit and then to the resident’s parents. The Administrator stated she was notified within two hours and notified corporate, but she did not speak with CNA #233 or the resident about the picture. Both the Administrator and ADON verified they did not interview CNA #233 or LPN #500 about the incident and did not verify that the picture had been deleted from their personal cell phones. The Administrator could not locate a formal investigation and stated that LPN #15 had done the interviews at the time. The Administrator further stated she did not believe there was intent to do harm, did not consider the incident abuse, and did not submit a report to the State Agency, characterizing it instead as a HIPAA violation. Facility policy and CMS guidance cited in the report require that all allegations of abuse, including unauthorized photographs, be thoroughly investigated and reported, which did not occur in this case.
Failure to Report Alleged Verbal/Emotional Abuse to State Agency
Penalty
Summary
The facility failed to ensure that an allegation of verbal/emotional abuse involving a resident was reported to the State survey agency as required. The incident involved a resident with multiple diagnoses, including metabolic encephalopathy, bipolar disorder, malignant neoplasm of the uterus, adult failure to thrive, and depression. On the day of the incident, the resident experienced a significant change in condition and was found unresponsive, leading to her transfer to the hospital for evaluation and treatment of sepsis and acute kidney injury. During the assessment of the resident's change in condition, a CNA witnessed an LPN make an inappropriate comment with sexual innuendo while checking the resident's hand grasp strength. The CNA felt uncomfortable with the comment and reported it to the unit manager, who instructed her to provide a written statement. The CNA completed the statement and left it in the unit manager's office as directed. The unit manager confirmed receiving the report and informed the DON about the situation, acknowledging that the comment could be considered verbal/emotional abuse if it had occurred. Despite the report being made, the DON did not receive the written statement and did not initiate an investigation or report the allegation to the State survey agency. The DON stated that she did not initially interpret the incident as potential abuse, partly due to the resident's unresponsiveness at the time. The facility's abuse prohibition policy requires immediate reporting and investigation of all abuse allegations, regardless of the resident's ability to comprehend. However, no self-reporting incident was submitted, and the required procedures for handling abuse allegations were not followed.
Failure to Investigate and Report Alleged Verbal/Emotional Abuse
Penalty
Summary
The facility failed to investigate an allegation of potential verbal/emotional abuse when it was reported to management staff. A resident with multiple diagnoses, including metabolic encephalopathy and bipolar disorder, experienced a change in condition and was assessed by an LPN. During the assessment, a CNA present in the room overheard the LPN make an inappropriate comment with sexual innuendo, which made the CNA uncomfortable. The CNA reported the incident to the unit manager and provided a written statement as instructed. Despite the CNA's report and written statement, the Director of Nursing (DON) was not made aware of the specific nature of the alleged inappropriate comment until later, and neither the DON nor the Administrator received the written statement. The unit manager confirmed being informed of the incident and acknowledged the comment could be considered verbal/emotional abuse. However, no statement was obtained from the resident, who had been transferred to the hospital, nor from the LPN involved. The LPN was not suspended pending investigation, and no self-reporting incident (SRI) was submitted as required by facility policy. The facility's abuse prohibition policy requires immediate reporting and investigation of all allegations of abuse, including verbal abuse, regardless of the resident's ability to comprehend. The policy also mandates suspension of the accused employee and timely notification of state or federal agencies. In this case, the facility did not initiate an investigation or report the allegation, resulting in non-compliance with regulatory requirements.
Crushed Extended-Release Morphine and Double Dose of Lyrica Result in Harm
Penalty
Summary
A significant medication error occurred when a nurse crushed and administered an extended-release Morphine (MS Contin) tablet to a resident, despite clear labeling and pharmacy instructions indicating the medication should not be crushed, chewed, or split. The nurse also administered double the prescribed dose of Lyrica, giving the resident 300 mg instead of the ordered 150 mg. The nurse was not aware that the Morphine ER tablet should not be crushed and had not previously worked with the resident since the medication was ordered. The error was discovered after the resident exhibited confusion, sedation, and hallucinations, prompting further assessment by the unit manager and notification of the physician's assistant. The resident involved had a history of chronic pain syndrome, opioid dependence, low back pain, and other medical conditions. He was cognitively intact and had no communication issues according to his most recent assessment. The resident had recently returned from the hospital with new orders for MS Contin and a re-instated order for Lyrica. The medication administration record and staff interviews confirmed that the resident received his scheduled doses of both medications on the morning of the incident, but the Morphine ER was crushed and the Lyrica dose was doubled in error. The error was identified after the resident's wife questioned the administration of crushed medications and the resident's change in condition. The nurse involved admitted to crushing all of the resident's medications and was unaware of the specific instructions for the Morphine ER. The facility's medication administration policy required nurses to check a "Do Not Crush" list and follow physician orders, but the nurse failed to do so. The incident resulted in the resident requiring Narcan administration to reverse the effects of opioid overdose and an evaluation at the emergency department.
Failure to Label Opened Multi-Use Tuberculin Vials
Penalty
Summary
Surveyors observed that multi-use vials of Tuberculin (TB) solution (Tubersol) stored in medication refrigerators across three separate medication storage rooms were opened but not labeled with the date they were first accessed. In each instance, the vials were found without any indication on the vial or packaging to reflect when they had been opened, despite the manufacturer’s guidelines requiring that opened vials be discarded after 30 days of use. The expiration date on all vials was noted to be 04/2026, but there was no way to determine how long the vials had been in use. Interviews with staff, including a medication technician and two unit managers, confirmed the absence of open dates on the vials and acknowledged that the vials should not have been in use without proper labeling. The staff members removed and discarded the vials upon discovery. The facility’s practice of not labeling opened multi-use vials of Tuberculin solution had the potential to affect all 112 residents, as all new admissions receive a two-step TB test upon admission.
Failure to Monitor and Address Infection Patterns
Penalty
Summary
The facility failed to properly monitor and address patterns and trends of known infections, as evidenced by a review of infection control logs from June to August 2025. During this period, multiple infections were documented, including urinary tract infections, skin infections, fungal infections, osteomyelitis, and respiratory infections, with several instances of the same type of infection occurring in the same units. Despite these documented patterns and trends, there was no evidence that the facility took action to address them, such as staff education, monitoring, or auditing of care practices. An interview with a registered nurse confirmed that no interventions or educational efforts had been implemented in response to these infection trends, and the facility's infection control documentation lacked any indication of efforts to reduce the likelihood of infection spread among the 112 residents.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
Surveyors observed multiple instances where the facility failed to maintain a clean and homelike environment for its residents. One resident was found lying in bed with window blinds in the room displaying several dark brown stains. Another resident's room had cobwebs in the corners and windowsill, a dirty floor with stains along the baseboard and under furniture, and bed sheets that were soiled with dark brown stains. In a separate room, a resident was seen sitting in a wheelchair near an empty bed, with the wall behind the bed deeply scratched and exposing dry wall material over a large area. Additionally, another room was noted to have an uncovered over-bed light fixture, exposing fluorescent bulbs, with no bed located under the fixture. A review of the housekeeping cleaning schedules indicated that the rooms with cleanliness issues had been marked as cleaned by staff. The Maintenance Director confirmed the unclean conditions, the exposed drywall, and the exposed light bulbs during an interview. The facility's housekeeping policy was reviewed and stated its purpose was to promote a sanitary environment. These findings were documented as part of an investigation under specific complaint numbers.
Failure to Honor Resident Choice in Diet Texture
Penalty
Summary
A resident with multiple complex medical diagnoses, including ALS, dysphagia, and recent dental procedures, was admitted to the facility and subsequently placed on a pureed texture diet. The hospital discharge summary recommended a soft diet for an unspecified number of days following a dental procedure, but did not indicate a need for a long-term downgrade in diet texture. Despite this, the facility maintained a pureed diet order for the resident without documentation of appropriate medical tests or assessments, such as a modified barium swallow study, to justify the continued restriction. The resident, who was cognitively intact, repeatedly expressed dissatisfaction with the pureed diet and requested to revert to a regular texture diet, but there was no evidence that the facility offered this option or documented informed refusal with acknowledgment of risks. Interviews with the resident confirmed that he refused facility meals due to the pureed diet and had to purchase his own food, as no alternatives were provided. Staff interviews, including those with the dietitian, SLP, and LPN, confirmed that the resident was only offered pureed food and that changes to the diet order were contingent on further swallow studies, which had not been completed. The facility failed to honor the resident's right to self-determination and choice regarding diet texture, as required, by not facilitating or documenting the resident's informed choice to assume risk and select a different diet texture.
Failure to Provide Personal Hygiene Assistance for Dependent Resident
Penalty
Summary
A resident with diagnoses including heart disease, depression, seizures, and intellectual disabilities was admitted on 07/11/23 and had impaired cognition, as evidenced by a BIMS score of 7 out of 15. The resident's quarterly MDS assessment indicated a need for moderate to dependent assistance with activities of daily living (ADLs), including personal hygiene and shaving. The care plan dated 06/06/24 specified that staff assistance was required for personal hygiene tasks. Observations on two consecutive days revealed the resident had noticeable facial hair on the upper lip and chin while resting in bed and during breakfast. Staff interviews confirmed that the resident should have been offered shaving assistance during showers and as needed when facial hair was visible. The unit manager acknowledged that the resident, who participates in activities and spends time in common areas, had not received the necessary personal hygiene assistance as outlined in her care plan.
Failure to Properly Assess, Document, and Communicate Nutrition and Weight Management Needs
Penalty
Summary
The facility failed to properly assess and manage the nutritional needs and dietary orders for multiple residents, resulting in deficiencies related to food and fluid provision. For one resident with complex medical conditions including ALS, heart failure, diabetes, and dysphagia, the facility changed his diet order from regular to pureed texture without documented evidence of a swallow study or a medical assessment confirming the necessity of this change. Despite the resident's repeated refusals of the pureed diet and his requests for a risk agreement to acknowledge his preference for a regular diet, the facility did not provide such documentation or allow him to sign a risk agreement. The resident continued to refuse facility meals and medications, and there was no evidence that his medications were modified to accommodate his dietary order, as they were administered whole with thin liquids, contrary to typical practice for a pureed diet order. Another resident was admitted with multiple chronic conditions and had discrepancies in her initial weight documentation. The initial weight recorded was later deemed inaccurate, but a re-weight was not obtained until 11 days later, despite the facility's policy and the dietitian's expectation that re-weights should be completed within 72 hours of a request. This delay in obtaining an accurate weight hindered the dietitian's ability to perform an accurate nutritional assessment and monitor the resident's nutritional status as intended. A third resident, also with significant medical issues, had physician orders for daily weights and for the physician to be notified of weight gains exceeding three pounds over two days. The facility failed to document weights on several required days and did not notify the physician of multiple instances where the resident's weight increased by more than three pounds in the specified timeframe. These failures were confirmed by facility staff interviews and were not in accordance with the facility's own weight management policy, which required regular monitoring and timely notification of significant weight changes.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by multiple observations of house flies in several resident rooms. On multiple occasions, flies were seen on windowsills, bed covers, and flying around residents, with one resident observed swatting at flies near her face while awaiting meal service. Residents reported persistent fly presence in their rooms, and staff confirmed that flies were a recurring issue throughout the facility, particularly in certain rooms. Review of pest control records indicated that the facility had been treated for fly activity in both the kitchen and resident rooms. The pest control company identified poor sanitation in resident bathrooms, specifically the presence of urine and fecal matter, as a contributing factor to the fly problem and recommended regular cleaning and sanitizing. The facility's pest control policy required frequent treatments and prompt reporting of pest issues, but monitoring and sanitation practices were not sufficient to prevent ongoing fly activity.
Failure to Ensure Appropriate Use and Dose Reduction of Psychotropic Medications
Penalty
Summary
The facility failed to ensure that residents receiving psychotropic medications had appropriate diagnoses and that proper justification was provided for not attempting gradual dose reductions. For one resident, olanzapine, an antipsychotic medication, was ordered for anxiety upon admission without a documented psychiatric diagnosis. The DON and ADON confirmed that the medication was continued from the hospital without an appropriate diagnosis, and there was no documentation to justify its use. Facility policy required that the prescribing practitioner and interdisciplinary team determine if continuing such medication was justified when no clear indication was present, but this was not followed. For another resident, multiple psychotropic medications were prescribed, including hydroxyzine, trazodone, and buspirone. Pharmacy recommendations to gradually reduce the dose of hydroxyzine were made on two occasions, but the provider denied these requests, citing reasons such as scheduled surgery and shoulder pain. There was no evidence that further attempts at gradual dose reduction were made, nor was there documentation of clinical contraindication as required by facility policy. The facility's failure to ensure appropriate diagnoses and to attempt or justify not attempting gradual dose reductions for psychotropic medications resulted in noncompliance with their own policies.
Failure to Provide Meaningful Activities per Resident Preference
Penalty
Summary
The facility failed to provide meaningful activities according to the preferences of a resident with multiple psychiatric and neurological diagnoses, including Parkinson's disease with dyskinesia, bipolar disorder, obsessive-compulsive disorder, unspecified psychosis, suicidal ideations, schizophrenia, and visual and auditory hallucinations. The resident was cognitively intact and had a documented preference for independent activities, such as watching TV and movies, listening to music, spending time outside, and taking naps, primarily in his room during the afternoon and evening. Despite these documented preferences, there was no evidence that the resident had access to a TV or that the activity of watching TV/movies was completed for thirty days. Observations confirmed the absence of a TV in the resident's room, and the resident reported that his TV had not been reinstalled after a room change. Staff interviews revealed that the activity staff communicated daily activity options to the resident and attempted to provide in-room activities, but the resident declined or returned these items. The Activities Director confirmed the resident's preference for solitude and independent activities, as well as the lack of a TV in the new room following a room move. The deficiency was identified through observation, medical record review, census review, and interviews, demonstrating a failure to meet the resident's individualized activity needs as outlined in his care plan.
Failure to Implement Splint/Brace Program for Resident with Hand Contractures
Penalty
Summary
The facility failed to implement a splint and brace program for a resident with bilateral hand contractures, as identified through medical record review, observation, staff interviews, and facility policy review. The resident had a history of bipolar disorder, anxiety, depression, suicidal behavior, and contractures, and was dependent on staff for care, bathing, and transfers. Occupational therapy (OT) had previously recommended the use of bilateral hand splints, passive range of motion (PROM) exercises for the left hand, active range of motion (AROM) exercises for the right hand, and verbal cues for self-feeding. However, there were no physician orders in place for the use of splints or for a restorative program involving PROM and AROM exercises. Observation revealed that the resident was not using splints, and interviews with the Therapy Director and Assistant Director of Nursing confirmed that no restorative program had been implemented following OT discharge. The OT had not written orders or completed an evaluation for the implementation of a splint and ROM restorative program, and the nursing restorative staff did not have a program to follow. Facility policy indicated that properly used splints and braces can enhance mobility and protect extremities, but this was not carried out for the resident in question.
Failure to Address Repeated Non-Compliance with Fall Interventions
Penalty
Summary
The facility failed to implement appropriate interventions and adequately address repeated non-compliance with fall prevention measures for a resident with a history of falls and impaired cognition. The resident, who had diagnoses including dementia, diabetes, anxiety disorder, and glaucoma, was identified as being at risk for falls and required assistance with activities of daily living. The care plan included interventions such as keeping the call light within reach and ensuring the resident wore non-skid footwear when out of bed. Despite these interventions, the resident experienced multiple unwitnessed falls over several months, many of which were attributed to not wearing non-skid footwear. Fall investigations repeatedly documented that the resident was non-compliant with wearing non-skid footwear, and staff educated the resident on this intervention multiple times. However, the facility did not implement alternative or additional interventions to address the resident's ongoing non-compliance. Interviews with facility staff confirmed the resident's repeated non-compliance and the lack of new or modified interventions, despite the resident having numerous falls over an extended period. The facility's policy required review and modification of care plans following falls, but the interventions remained unchanged and ineffective.
Failure to Provide Timely Dental Services and Denture Replacement
Penalty
Summary
The facility failed to provide or offer timely dental services to residents as needed, affecting two of four residents reviewed for dental care. One resident, who was cognitively intact and had all natural teeth removed following a medical procedure, did not receive follow-up for denture impressions or appointments after an initial cancellation due to insurance issues. Despite care plan interventions requiring coordination of dental care and follow-up, there was no evidence that further dental appointments were discussed or scheduled, and the resident confirmed he had not been approached about dentures, which made eating more challenging for him. Another resident, who had dementia and required assistance with self-care, lost her dentures at an unknown time and had not received assistance from the facility in obtaining a replacement. The care plan for this resident included staff observation for oral/dental issues and making dental appointments as needed, but the DON confirmed the resident had not been seen by a dentist for an extended period and was unaware of the missing dentures until the time of the interview.
Failure to Implement Recommended ADLs Restorative Program After OT Discharge
Penalty
Summary
The facility failed to implement a recommended restorative program for activities of daily living (ADLs) for a resident following discharge from occupational therapy (OT) services. The resident, who had diagnoses including orthopedic care, left femur fracture, high blood pressure, spinal stenosis, and dementia, was readmitted after a fall incident. Upon readmission, therapy evaluations were recommended, and both physical therapy (PT) and OT assessments were completed. The PT evaluation resulted in a restorative program for ambulation, which was implemented and documented as being followed daily. However, although the OT evaluation recommended a restorative program for ADLs such as personal hygiene, dressing, and grooming, this program was not implemented. Staff interviews confirmed that the resident never participated in an ADLs restorative program, and the Assistant Director of Nursing acknowledged that the evaluation for the ADLs program was not reviewed or acted upon after it was completed and locked by OT. This omission resulted in the resident not receiving the specialized rehabilitative services as required.
Environmental Maintenance Deficiencies Affecting Resident Safety and Comfort
Penalty
Summary
Surveyors observed that the facility failed to maintain essential environmental features in resident rooms and bathrooms, including toilet rails, thresholds, walls, floors, and dressers. Multiple bathrooms had handrails attached to toilets that were loose and moved several inches when touched, compromising their stability. Broken and missing tiles were noted on bathroom walls, and some thresholds had damaged or missing linoleum tiles. Additional observations included dirty and rust-colored sinks, milky pink toilet water, incontinence odors, and heavily scraped door frames with paint removed. In one case, a community shower room had molding off the wall and broken floor tiles at the threshold. Resident rooms were also found with sticky floors, puddles of liquid, urinals on the floor, and damaged furniture such as dresser drawers. Black grout and discoloration were observed around bathtubs and wall tiles. These findings were confirmed through interviews with nursing staff, including RNs, LPNs, and CNAs, who verified the presence of loose toilet rails, damaged fixtures, dirty conditions, and odors in the affected areas. The deficiencies affected six residents out of 117 in the facility.
Failure to Ensure Call Bells Within Reach for Multiple Residents
Penalty
Summary
The facility failed to ensure that call bells were within reach for three out of six residents observed during the survey. For one resident with Alzheimer's disease, dementia, and severely impaired cognition, the call bell was not present on the correct side of the bed and was instead plugged in on the opposite side, hanging on the floor and out of sight. A Licensed Practical Nurse confirmed that the resident, who was able to activate a call bell, did not have one within reach at the time of observation. Another resident, admitted with multiple diagnoses including traumatic brain injury, muscle weakness, and cognitive impairment, was found in bed without the call bell in reach; it was draped across a bedside table drawer, out of the resident's reach. Certified Nurse Aides verified that the resident could activate the call bell if it were accessible, but it was not positioned appropriately. A third resident, with a history of cerebral infarction, dementia, and legal blindness, was observed sitting in a recliner with the call light activated but lying on the floor, detached from the wall and out of reach. Staff confirmed the call light was not accessible to the resident. Review of facility policy indicated that call lights are to be placed within reach, but this was not followed in these cases.
Failure to Provide Social Services for Resident Transfer Requests
Penalty
Summary
The facility failed to ensure that medically-related social services were provided to assist a resident in achieving the highest possible quality of life, specifically by not supporting the resident's repeated requests to transfer to another facility. The resident, who had diagnoses including paraplegia, unspecified protein-calorie malnutrition, generalized anxiety, and chronic respiratory failure, was cognitively intact and had clearly expressed his desire to move closer to a specific location during multiple care conferences. Documentation showed that the resident's preference to transfer was discussed on several occasions, with the social worker assigned to assist in finding a suitable facility. Despite these documented requests, there was no evidence in the medical record that the social worker made any attempts to contact facilities in the desired area over an extended period. Interviews confirmed that the social worker was aware of the resident's wishes but relied on the resident's mother to identify a new facility, even though the resident was his own responsible party. The social worker also acknowledged that there was no documentation of follow-up actions taken to facilitate the transfer, which was a required responsibility according to the job description.
Failure to Provide Drinking Water to Residents
Penalty
Summary
The facility failed to ensure that residents received drinking water consistent with their needs and preferences, resulting in three out of five observed residents not having water or beverages available to them. One resident with severe cognitive impairment and multiple diagnoses, including Alzheimer's disease and dysphasia, was observed in bed without water in reach. An LPN confirmed the absence of water and provided it only after the resident requested cold water. Another resident, admitted for surgical aftercare and with significant physical and cognitive impairments, was also found in bed without water accessible. A CNA verified the lack of water, found an empty cup across the room, and provided ice water only after the resident expressed a preference for it. The resident's assigned CNA stated that water is typically passed once a day unless requested. A third resident, with a complex medical history including cerebral infarction, COPD, diabetes, and legal blindness, was observed sitting in a recliner without water or fluids at bedside. The overbed table was dirty and cluttered with food remnants. A CNA confirmed the absence of water or fluids in reach after being prompted by the surveyor. The facility did not have an ice water policy in place at the time of the survey. These observations and staff interviews demonstrate a failure to provide adequate hydration opportunities for residents as required.
Failure to Prevent Elopement Due to Inadequate Supervision and Wanderguard Monitoring
Penalty
Summary
A resident with diagnoses including COPD, cachexia, panic disorder, depression, dementia, and mild cognitive impairment, and who was assessed as having severely impaired cognition, eloped from the facility for an extended period. The resident was identified as being at risk for exit seeking and elopement, with interventions in place such as a wanderguard device attached to her wheelchair, regular checks of the device, and supervision as needed. Despite these interventions, documentation showed that on the day of the incident, the day shift did not mark that the wanderguard was in place, and the resident was last seen at 9:00 A.M. by staff. The resident was later found at a local store by police, having been missing for several hours, and her wanderguard was not in place when she was located. Interviews with staff revealed that multiple CNAs and a medication technician had seen the resident earlier in the day, but no one had direct knowledge of her whereabouts after the morning. Staff assumed the resident was in her usual locations within the facility, such as the dining room or activity areas, and did not verify her presence during lunch when her tray was left untouched. The facility did not have cameras near the front door, and staff did not initiate a headcount when first notified by the store about a woman in a wheelchair, as they did not immediately recognize the resident was missing. The resident had a history of removing her wanderguard, but staff believed the device had been effective since it was moved to her wheelchair. The facility's elopement policy required rounds at specific times and procedures for missing residents, but these were not followed effectively on the day of the incident. Staff did not perform timely checks or a headcount, and the absence of the resident went unnoticed for several hours. The resident was ultimately found safe, but the failure to ensure the wanderguard was in place and to provide adequate supervision led to the elopement event.
Misappropriation of Resident's Funds Due to Inadequate Documentation
Penalty
Summary
The facility failed to ensure the timely return of a resident's money, leading to a misappropriation incident. A resident, who had been admitted with various medical conditions including metabolic encephalopathy and COPD, had $1,000.00 cash secured in the facility's safe by the Business Office Manager (BOM) and witnessed by other staff members. However, when the resident's power of attorney (POA) came to collect the resident's belongings after the resident's passing, the money was missing from the safe. The BOM claimed that the resident had requested the return of the money and that a new letter was completed to indicate the return, which the resident allegedly signed. However, no such letter was found in the facility's records, and the receptionist had no recollection of receiving it. The original letter, which was supposed to confirm the securing of the money, was the only document found, and it did not provide evidence of the money's return. The facility's investigation revealed that the BOM was no longer employed there, and the Administrator was unable to confirm the return of the money due to the lack of documentation. The facility's policy prohibited keeping resident funds outside of a trust account, and the absence of proper receipts or records contributed to the deficiency.
Failure to Clean CPAP Equipment Routinely
Penalty
Summary
The facility failed to ensure that respiratory equipment used for sleep apnea, specifically the CPAP mask and tubing, was cleaned routinely for a resident. This deficiency affected one resident who was diagnosed with conditions including unspecified dementia, spina bifida, sleep apnea, depression, and anxiety. The resident required assistance with activities of daily living due to bilateral lower extremity impairment and used a wheelchair for mobility. The resident also used oxygen therapy and a CPAP machine for breathing assistance while sleeping. Despite having a physician's order for the use of CPAP every bedtime and as needed, there were no orders for the routine cleaning of the CPAP facemask and tubing. Interviews with facility staff revealed inconsistencies in the responsibility for cleaning respiratory equipment. It was noted that if a resident resided on the ventilator unit, the respiratory technician was responsible for cleaning the equipment. However, for residents not on the ventilator unit, such as the affected resident, the nurses were responsible for daily cleaning. The facility's policy indicated that oxygen equipment should be cleaned regularly, yet this was not adhered to, as confirmed by the Regional Registered Nurse. This deficiency was investigated under a specific complaint number, indicating non-compliance with the facility's policies and procedures.
Improper Food Storage in Unit 3 Refrigerator
Penalty
Summary
The facility failed to properly store resident food in the Unit 3 refrigerator, which had the potential to affect all 40 residents on J Hall and K Hall. During an observation, it was noted that the refrigerator contained a container of unlabeled and undated food. There was spillage on the walls and floors of the refrigerator, with a pool of orange liquid and a soaked rag on the bottom right. On the left side, the bottom drawer contained a pool of clear liquid, with a soggy undated sandwich floating in it, along with a health shake and a milk carton, both of which were soft and wet to the touch. An interview with an STNA confirmed the presence of unlabeled and undated food, as well as the spillage and pools of liquid surrounding the resident food. The facility's policy on Refrigerator and Freezer Maintenance, updated recently, requires that food be removed and surfaces cleaned with detergent and a sanitizing solution, which was not adhered to in this instance.
Failure to Provide Dignity in Dining for a Resident
Penalty
Summary
The facility failed to provide dignity in dining for a resident during meal assistance. The resident, who was admitted with Alzheimer's dementia, heart failure, and glaucoma, was on a regular diet with pureed texture and thin liquids. According to the Minimum Data Set (MDS) assessment, the resident required supervision or touch assistance for eating. Observations revealed that the resident did not immediately begin feeding herself and was seen using a fork to eat ice cream. During this time, a State tested Nursing Assistant (STNA) was observed standing while feeding the resident, which is against the facility's protocol. The facility's guidelines for dignity in dining require nursing staff to sit with residents, make eye contact, and converse with them while assisting with meals. However, the STNA confirmed standing while feeding the resident, which was a deviation from the expected practice. This incident was part of a complaint investigation and was documented as a deficiency under Complaint Number OH00158242.
Inaccurate Documentation of Wound Care Orders
Penalty
Summary
The facility failed to ensure accurate documentation of wound care treatment orders for a resident with multiple complex medical conditions, including tracheostomy, quadriplegia, and dependence on a respirator. The wound nurse practitioner's (NP) progress notes indicated new treatment orders that were not reflected in the resident's medical records. Specifically, there was no evidence of orders for 3% acetic acid to cleanse a wound, ace bandages for venous ulcers, or 1/2 strength Dakin's solution for cleansing various wounds. Interviews with the Director of Nursing (DON) and Wound Licensed Practical Nurse (WLPN) revealed that the facility never received these orders, and the NP admitted to possible inaccuracies in documentation due to distractions. The NP's progress notes also showed discrepancies in the treatment of the resident's sacrum wound, where the order was changed from 1/2 strength Dakin's solution to a house wound cleanser without proper documentation. The NP acknowledged that she might have documented inaccurately and relied on the staff's entries into the electronic medical record. These documentation errors were identified during a closed medical record review and interviews, highlighting a lack of compliance with professional standards for maintaining accurate medical records.
Failure to Implement Effective Water Management Program
Penalty
Summary
The facility failed to implement a comprehensive and effective water management program to identify areas at risk for Legionella growth, which resulted in a resident contracting Legionella. The resident, who was cognitively intact, had a complex medical history including quadriplegia, dependence on a respirator, and chronic bronchitis, among other conditions. A change in the resident's condition was noted when they became lethargic, leading to their transfer to the hospital where they tested positive for Legionella. Interviews with facility staff revealed that the facility had not completed a Legionella risk assessment prior to the resident's positive test. Although the facility had measures such as checking water temperatures and conducting visual inspections, these were deemed insufficient as they had not identified potential areas for Legionella growth. The facility's water management program, which was supposed to include a risk assessment and control measures, was not fully implemented. The facility's water management program outlined the need for a team to manage the program, describe the building's water systems, and identify areas where Legionella could grow. However, these steps were not completed, and the facility did not conduct water cultures for Legionella as part of routine program validation. The deficiency was identified during a complaint investigation, highlighting the facility's non-compliance with its own water management policy.
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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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