The Merriman
Inspection history, citations, penalties and survey trends for this long-term care facility in Akron, Ohio.
- Location
- 209 Merriman Rd, Akron, Ohio 44303
- CMS Provider Number
- 365859
- Inspections on file
- 42
- Latest survey
- January 27, 2026
- Citations (last 12 mo.)
- 21 (1 serious)
Citation history
Health deficiencies cited at The Merriman during CMS and state inspections, most recent first.
Surveyors found that the facility did not provide adequate and appropriate eating utensils with resident meal trays. Observations showed meal trays being passed with only a spoon, sometimes plastic, and no additional utensils or napkins, with brown paper towels substituted instead. Dietary staff reported an ongoing shortage of metal silverware, napkins, and sometimes juice cups, and stated that plastic utensils were used for about half of all trays over several months. Several cognitively intact residents on various diets, some needing set-up assistance and others independent with eating, reported frequently receiving only a spoon, receiving plastic utensils for many meals, or occasionally receiving no utensils at all, and these reports were confirmed by concurrent observation of their lunch trays. Facility policy required that meals be served using reusable dishes and flatware, and administration acknowledged residents should receive appropriate silverware for all meals.
Two residents experienced neglect when staff failed to identify, treat, and communicate about worsening wounds, resulting in severe sepsis and amputation. In both cases, staff did not perform or document required skin assessments, failed to notify physicians, and did not follow up on external reports of wounds. Additionally, two other residents were subjected to verbal abuse by staff, with delayed investigation and lack of intervention by other staff members.
The facility did not complete required background checks, Nurse Aide Registry reviews, abuse registry checks, or reference checks for multiple staff members before hiring. Personnel files lacked evidence of these checks, and the background check log was incomplete. The HR Director and Administrator confirmed these omissions, and some staff had disciplinary actions or were involved in incidents without proper pre-employment screening.
The facility failed to provide proper wound care and physician oversight for two residents, resulting in hospitalization and severe outcomes, and did not conduct required background checks for multiple staff members. Investigations into abuse, neglect, and misappropriation were incomplete, and the facility did not maintain a safe environment, with ongoing issues of illicit drug use among residents and no effective policy to address it. These deficiencies demonstrated significant breakdowns in administrative oversight and had the potential to affect all residents.
A glass door used by families and ambulances was found broken with shattered glass for approximately two weeks. The DON and Administrator were aware of the issue, and although repair quotes were obtained, the door remained unrepaired with no documented follow-up, contrary to facility policy requiring prompt resolution of such concerns.
Multiple residents with substance use disorders engaged in ongoing illicit drug and alcohol use within the facility, including use of methamphetamine, cocaine, marijuana, and alcohol. Despite repeated positive drug screens, observed drug paraphernalia, and admissions of use, the facility did not implement specific interventions or update care plans to address illicit substance use. Staff and administrators confirmed that drug access was a common problem and that the facility lacked effective policies and actions to address substance abuse.
A resident with bilateral leg amputations and limited mobility was unable to reach the call light to request assistance, as it was not within reach and the resident could not self-propel the wheelchair. The resident had to call out for help until a CNA responded. Facility policy required call lights to be accessible at all times, but this was not followed in this instance.
A resident with multiple chronic conditions and intact cognition experienced unauthorized charges on their bank account totaling nearly $4,000. The facility identified the fraudulent activity but failed to conduct required interviews with staff or other residents as part of its investigation, resulting in an incomplete response to the misappropriation.
The facility did not complete and report the results of investigations into allegations of physical abuse and misappropriation involving two residents within the required five business days. In both cases, the investigations exceeded the mandated timeframe without documented extenuating circumstances, contrary to facility policy.
The facility did not conduct thorough investigations into allegations of abuse, neglect, and misappropriation involving three residents. In each case, required interviews with staff or key witnesses were not completed, and assessments or documentation were missing or incomplete, despite facility policy requiring comprehensive investigations.
A resident with multiple medical and behavioral health diagnoses was discharged on an emergency basis without proper documentation, including a discharge summary, recapitulation of stay, or a signed physician's order. The discharge was based on unsubstantiated allegations and lacked required signatures and supporting evidence, contrary to facility policy.
A resident with multiple sclerosis and a stage IV pressure ulcer did not receive wound care as ordered when staff failed to replace a dressing that had come off during incontinence care. The missing dressing was not reported or addressed by staff, resulting in the resident being left without the required wound treatment.
A resident with severe cognitive impairment and orders for supervised smoking with a smoking apron was repeatedly observed smoking unsupervised and without the required protective equipment. Facility staff confirmed the resident was to be supervised and that safety protocols, including use of a smoking apron and staff presence, were not followed as outlined in the care plan and facility policy.
A resident with an indwelling Foley catheter did not receive timely or documented catheter care for ten days following hospital readmission. Medical records and progress notes lacked evidence of catheter care, and no physician's orders were in place until ten days after the resident's return. The DON confirmed the absence of orders and documentation, and the resident reported delays in incontinence care.
A resident admitted with fractures and post-surgical pain did not receive prescribed pain assessments or oxycodone for over two days due to failures in medication ordering and staff follow-up. The resident experienced significant pain, and staff interviews confirmed the delay was caused by lack of communication and adherence to the facility's pain management policy.
The facility failed to ensure physician oversight of wound care, resulting in two residents with significant wounds not receiving timely medical assessment or treatment. In both cases, wounds were documented by staff but not reported to a physician, and no wound treatments were initiated. The nurse practitioner involved was not wound certified, and the medical director was not informed of the residents' conditions. Both residents required hospital transfers for severe wound-related complications.
A medication error occurred when an LPN administered another resident's narcotic medication, Tramadol, to a resident who did not have an order for it. The error happened after the LPN mixed up medication cups while attempting to give medications in the hallway, failing to follow facility policy requiring verification of resident identity and proper medication administration.
A resident who required assistance with oral medication administration was found with an antibiotic pill left in a cup at the bedside after being told it was no longer needed. A CNA confirmed that medications should not be left with residents and that nurses are responsible for observing medication administration. Facility policy required timely administration and proper documentation, but these procedures were not followed in this instance.
A resident with chronic wounds and orders for Enhanced Barrier Precautions (EBP) received wound care from an LPN who failed to don a gown as required by facility policy and posted signage. Although gloves were used and PPE was available nearby, the LPN acknowledged not wearing a gown during the high-contact care activity, resulting in a breach of infection control protocols.
Dietary staff were found not wearing required hair restraints in the food preparation area, and several food items in the kitchen cooler were undated and unmarked. The dietary supervisor confirmed these issues, which were not in accordance with facility policies on food safety and sanitation.
The facility did not ensure that required discharge documentation and communication were completed for two residents, resulting in missing information in medical records and failure to relay important details, such as follow-up appointments, to receiving facilities. This occurred during a period of social worker turnover, with discharge planning responsibilities shared among staff.
The facility failed to provide sufficient dietary staff, resulting in delayed meal service for all residents. Observations and interviews revealed that meals were consistently late, with breakfast and lunch not served on time due to staffing shortages. The Dietary Manager acknowledged the issue and attributed it to insufficient staffing, although new hires had not yet started.
The facility's kitchen was found to have multiple sanitation issues, including dirty floors, equipment with food debris, and improperly stored food items. These conditions were confirmed by dietary staff, who cited short staffing as a reason for inadequate cleaning. The facility's policies on food storage and sanitation were not followed, potentially affecting all 53 residents receiving meals.
The facility failed to maintain clean and sanitary bathing and shower rooms for residents. Observations revealed a toilet with feces and no water, dirty floors, missing tiles, a leaking shower, and black substances on the walls. Used gloves and a dirty towel were also found. A housekeeper confirmed these conditions, and facility policies indicated that bathrooms and floors should be cleaned daily.
The facility failed to provide the correct serving size of mechanical soft meat to six residents on a mechanical soft diet. The menu required a #6 scoop for the Salisbury steak, but a #10 scoop was used instead, providing less than the prescribed amount. This error was confirmed by the Dietary Manager.
A resident's dignity was compromised due to wearing sweatpants that were too large, causing them to fall and expose his legs and brief in view of others. Despite being aware of the issue, facility staff did not provide a solution, citing the lack of a guardian or family to provide clothing and an inability to find appropriately fitting pants.
The facility failed to create person-centered care plans for residents with PTSD, specifically for two residents whose care plans lacked identification of specific triggers. Interviews with staff revealed a lack of awareness regarding these triggers, despite the facility's policy on trauma-informed care. This deficiency highlights a gap in staff training and communication regarding the needs of residents with PTSD.
A resident with a history of stroke and contracture was not wearing a prescribed hand splint as ordered, with the last documented application on January 12. Observations and interviews revealed staff were unaware of the splint's status, and it was found unused on the resident's dresser. The facility's policy required nursing staff to supervise the use of adaptive equipment.
Two residents in a LTC facility were found to be at risk due to inadequate supervision and enforcement of smoking policies. One resident, with schizophrenia, was observed smoking without a protective apron, resulting in burn holes in his clothing. Another resident, using oxygen, had smoking paraphernalia in his room, violating the facility's no-smoking policy. The facility's failure to conduct thorough assessments and enforce safety measures led to these deficiencies.
The facility failed to maintain clean and properly labeled respiratory care equipment for two residents. One resident had blood-stained BiPAP head straps that were not replaced, and another had unlabeled oxygen tubing, contrary to facility policy. Staff were unsure of the procedures, highlighting a need for policy review and training.
The facility failed to properly label and store insulin medications for three residents with type two diabetes mellitus. Insulin pens were found opened but not dated, and some lacked resident labels, contrary to facility policy and pharmacy guidelines. A nurse confirmed the oversight during an interview.
A resident with severe malnutrition and dysphagia was served mechanical soft Salisbury steak instead of the prescribed pureed meat. The Dietary Manager confirmed the error, noting that diet orders were being checked but had not yet been updated for this resident.
A resident with morbid obesity and poly osteoarthritis fell and sustained bilateral distal femur fractures while receiving incontinence care due to the facility's failure to provide a king bariatric bed. Despite the presence of three staff members, the resident slid off the queen bed, highlighting the need for a larger bed to prevent such incidents.
The facility failed to consistently monitor and record food temperatures, affecting meal palatability and safety for all residents. Observations showed missing temperature logs, and milk was served above the required temperature. Residents expressed dissatisfaction with the food quality, describing it as cold and institutional grade. The Dietary Director confirmed the inconsistencies, and a resident's daughter brought a refrigerator due to food inconsistency.
The facility failed to adhere to meal plans and resident preferences, affecting multiple residents. A resident with cellulitis did not receive the prescribed mighty shake and other items during lunch. Another resident with multiple sclerosis did not receive preferred yogurt and fruit, and the serving size of French toast sticks was incorrect. A third resident with alcoholic cirrhosis was missing bread and applesauce cake, while a resident with severe malnutrition did not receive a mighty shake or hot water for tea. The facility's policy to provide a diet meeting residents' needs was not followed.
Two residents in an LTC facility did not receive their prescribed mighty shake nutritional supplements as ordered, leading to a deficiency. One resident, with conditions including cellulitis and muscle spasm, and another with severe protein-calorie malnutrition, were both observed to have meal trays missing the supplements. This was confirmed by the DON, despite facility policy requiring adherence to dietary needs.
A resident's Acamprosate Calcium medication was not administered as ordered due to an error in prescription cancellation by the pharmacy, resulting in the facility not receiving the medication. The resident, with a history of alcoholic dependence, was supposed to receive the medication three times daily, but it was only administered twice over a ten-day period. The facility's policy on medication administration was not adhered to, and there was no documentation to justify the missed doses.
The facility exceeded the acceptable medication error rate, reaching 7.69% due to errors in administering medications to two residents. One resident received an incorrect dosage of vitamin D3, while another did not receive their prescribed omeprazole. These errors were confirmed by the LPNs involved, indicating non-compliance with the facility's medication administration policy.
A facility failed to maintain a sanitary kitchen, affecting nearly all residents. The Kitchen Manager was absent due to poor performance, leaving the cook in charge. Observations revealed grease build-up, dirty floors, and improper knife storage. Staff confirmed a lack of cleaning supplies and supervision, with floors uncleaned for months. The dishwashing area had a leaking pipe, and the meal service area was cluttered. Cleaning checklists were not completed, contributing to unsanitary conditions.
Failure to Provide Adequate and Appropriate Eating Utensils for Meals
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate and appropriate eating utensils and special eating equipment to residents during meals, as required by facility policy. Surveyor observations on the morning of 01/22/26 showed CNAs passing breakfast trays that contained only a metal spoon, with no additional silverware or utensils present or offered. Later that morning, a dietary aide was observed transporting 15–20 meal trays on an open cart, each tray containing only a plastic spoon placed on a folded brown paper towel next to the covered plate. Interviews with dietary staff revealed there was an ongoing shortage of metal silverware, resulting in plastic utensils being used for at least half of the residents’ trays for each meal. Staff also reported the kitchen had been out of napkins since 01/20/26 and was using folded brown paper towels from a hand towel dispenser instead, and that the facility sometimes ran out of juice cups. One dietary aide stated there had been a shortage of silverware and utensils for at least six months. Review of the facility’s policy titled "Use of Disposable Dishes/Flatware" indicated that resident meals were to be served using reusable dishes and flatware. Multiple residents with varying diagnoses and functional statuses reported and demonstrated that they frequently did not receive appropriate utensils with their meals. Cognitively intact residents on regular, mechanical soft, carbohydrate-controlled, or no concentrated sweets diets, some requiring set-up assistance and others independent with eating, stated they often received only a spoon, sometimes plastic utensils, and at times no utensils at all. Examples included residents reporting receiving only a spoon to eat meat or salad, receiving plastic utensils for about half of their meals, and occasionally having to eat with their fingers. During each of these interviews at lunchtime on 01/22/26, observations confirmed that the residents’ trays contained only a metal spoon. The administrator later confirmed that residents should receive appropriate silverware for all meals, consistent with facility policy. This deficiency represents non-compliance investigated under Complaint Number 2693876.
Failure to Prevent Neglect and Abuse Due to Inadequate Skin Management and Staff Conduct
Penalty
Summary
The facility failed to develop and implement a comprehensive and individualized skin management program, resulting in neglect of two residents with significant medical needs. One resident, who was severely cognitively impaired and dependent on staff for care, developed a worsening wound on the left lateral foot. Despite care plan interventions for skin breakdown prevention, weekly wound reports documented the wound's decline without evidence of physician notification or wound treatments being implemented. The wound nurse only worked one day per week, did not notify the physician, and did not add treatment orders to the treatment administration record. The resident's wound deteriorated to the point of severe sepsis, requiring hospital transfer and resulting in the resident not returning to the facility. Another resident, with end stage renal disease, diabetes, and a history of amputation, developed a right heel ulcer that was first identified by the dialysis center. The dialysis center attempted to communicate the finding to the facility multiple times without success. Facility staff continued to document no new skin issues in weekly assessments, and the physician was not made aware of the ulcer. The ulcer progressed to wet gangrene and necrotizing infection, ultimately requiring an above-the-knee amputation after hospital transfer. Interviews revealed that nursing staff were unaware of the wound, had not performed or documented required skin assessments, and failed to communicate changes in the resident's condition. Additionally, the facility failed to protect two other residents from verbal abuse by staff. In one case, a CNA was verbally aggressive and threatened a resident during an argument, as corroborated by multiple witness statements. The facility's investigation into the incident was delayed, and staff failed to intervene appropriately during the altercation. These deficiencies affected four residents and were substantiated through medical record review, interviews, and facility policy review.
Removal Plan
- Resident #46 was transferred to the hospital and did not return to the facility.
- Resident #20 was transferred to the hospital for emergent treatment. The resident returned to the facility. Upon return, Resident #20 was re-assessed for pressure injury risk with a Braden scale, a skin assessment was completed, pressure reducing device were ordered and implemented and weekly skin assessments and wound care chart audits were implemented.
- The Director of Nursing (DON) and Assistant Director of Nursing (ADON) #504 completed assessments on all residents.
- Regional Nurse #566 educated the DON and ADON #504 on wound identification, staging and dressing changes.
- The facility initiated a plan for the DON/designee to audit 100% of skin assessments, weekly wound reports, and dialysis communication logs for eight weeks. Inaccurate findings would be reported to the facility Quality Assessment and Performance Improvement (QAPI) committee. Audits would be reviewed in monthly QAPI meetings to assess processes and performance of staff through proper identification and compliance.
- Regional Nurse #566, the DON and ADON #504 initiated education for all nurses on accurate wound documentation, wound documentation process and wound rounding expectations.
- ADON #504 contacted the dialysis center to verify processes for return communication for residents with wounds or new orders.
- The facility implemented a Monthly Dialysis Foot Check form. This form would be sent to the Dialysis Center monthly by the DON/designee for communication when they do monthly skin checks.
- Regional Nurse #566, the DON and ADON #504 completed additional education and competencies for all licensed nurses related to wound identification and staging.
- The DON and ADON #504 completed in-service education for Certified Nursing Assistant (CNA) staff on early reporting of skin changes.
- All full time and part time licensed nurses were evaluated for competencies and completed return demonstrations for wound assessment and documentation (for a simulated wound). Competencies were completed by the DON and ADON #504. Licensed staff off or who worked as needed (PRN) would have competencies evaluated before their next shift on the floor.
- The DON revised the facility Resident Return admission Checklist to include wound verification and order reconciliation for all returning residents. Education on the new form was provided to licensed nurses by the DON and ADON #504. The checklist would also be reviewed by the DON or ADON #504 upon admission. These would be monitored during any new admission or readmissions to facility. New staff would also be educated by the nurse training them on this form.
- The DON and ADON #504 provided education for all nursing and CNA staff on proper wound care and to alert nurse if a resident dressing had come off or needed replaced.
- The facility implemented staff training on the facility Abuse, Neglect & Misappropriation policy.
- The Administrator sent a message out to all staff on the definition of neglect. Receptionist #808 was calling each staff person to educate, offer time for questions and express understanding.
- The facility implemented a plan to randomly ask three staff members per week for four weeks about the definition of neglect.
- A root cause analysis was conducted related to the incidents of neglect. The facility identified the root cause of neglect for Resident #46 and Resident #20 was the facility's failure to provide ordered wound care and monitor wound status. There were no systems to verify treatment completion, escalate concerns, or ensure nursing accountability.
- The facility implemented a plan for the Administrator or designee to complete audits for three residents three times per week for four weeks then monthly for two months to identify potential areas of neglect to include showers, medication administration and wound care.
Failure to Complete Pre-Employment Background and Registry Checks for Staff
Penalty
Summary
The facility failed to conduct required background checks, Nurse Aide Registry (NAR) reviews, abuse registry checks, and reference checks for multiple employees prior to hire. Personnel files for several staff members, including CNAs, LPNs, and an activities assistant, lacked evidence of these checks. In some cases, the background check log did not include the employees, indicating that no background check was completed. The facility also failed to maintain a complete and accurate background check log, with some logs missing information for staff hired prior to certain years. Interviews with the Human Resources (HR) Director confirmed that reference checks were not completed prior to hire, and that the facility's practice was to proceed with hiring after two unsuccessful attempts to contact references. The HR Director also confirmed that there was no evidence of NAR or abuse registry checks for several employees. In one instance, a background check found in a personnel file did not belong to the employee in question. The HR Director stated that missing documentation was due to previous HR management and changes in facility ownership, resulting in lost files and incomplete records. The Administrator and Regional Director of Operations (RDO) demonstrated a lack of understanding regarding the difference between the abuse registry and the NAR, with the Administrator stating she thought they were the same. The RDO confirmed that, in the past, reference checks were considered complete after two documented attempts, regardless of whether references were actually obtained. Several employees had disciplinary actions or were involved in self-reported incidents, but there was no evidence that required pre-employment checks were completed for them. This deficiency was identified during a complaint investigation and had the potential to affect all residents in the facility.
Breakdown in Administrative Oversight, Wound Care, Staff Vetting, and Resident Safety
Penalty
Summary
The facility failed to administer its operations in a manner that ensured effective and efficient use of resources to protect resident safety and prevent neglect. Specifically, there were significant lapses in wound care and physician oversight for two residents, resulting in one resident being hospitalized with severe sepsis due to a worsening foot wound and another resident requiring hospitalization and an above-the-knee amputation after a diabetic ulcer was not identified or treated. The facility lacked a systematic and comprehensive skin management program, which contributed to these incidents of neglect and actual harm. Additionally, the facility did not conduct required pre-employment criminal background checks, Nurse Aide Registry (NAR) checks, abuse registry checks, or personal and professional background checks for multiple staff members, including CNAs, LPNs, and other personnel. The Human Resources Director confirmed the absence of these checks and the lack of an accurate background check log. One CNA, who had been involved in multiple self-reported incidents (SRIs) for abuse allegations and had several disciplinary actions, was among those for whom no background checks were completed. These failures in staff vetting increased the risk to all residents. The facility also failed to thoroughly investigate allegations of abuse, neglect, and misappropriation. In several cases, investigations were incomplete, with missing staff interviews, lack of resident assessments, and conflicting or uncollected witness statements. Furthermore, the facility did not maintain a safe environment, as evidenced by multiple incidents of illicit drug use and possession among residents, with staff and contracted behavioral health specialists reporting ongoing substance abuse issues that were not addressed by administration. The facility lacked a policy for handling confirmed illicit substance use among residents, and there was no evidence that these or other concerns were addressed through the facility's quality assurance or QAPI program.
Failure to Repair Broken Glass Door in Timely Manner
Penalty
Summary
A glass door leading outside from the nursing unit was observed to be broken, with shattered glass covering the bottom half of the door. The DON confirmed the door had been in this condition for approximately two weeks. The Administrator stated that the door was used by families and ambulances, acknowledged awareness of the issue, and indicated that although quotes for repair had been obtained, the door had not yet been fixed. Review of a work request form showed a request to repair the broken glass was made, and calls for repair quotes were documented, but there was no follow-up information available. Facility policy requires that concerns be reported and addressed promptly to maintain a safe, clean, and comfortable environment, but this was not followed in this instance.
Failure to Provide Safe Environment and Effective Substance Abuse Program
Penalty
Summary
The facility failed to provide a safe environment free from drugs and alcohol and did not have an effective substance abuse program, as evidenced by multiple residents engaging in ongoing illicit drug and alcohol use while residing in the facility. Several residents with histories of substance use disorders, including opioid dependence, cocaine abuse, and alcohol abuse, were repeatedly found to be using illicit substances such as methamphetamine, cocaine, marijuana, and alcohol. Despite positive drug screens, observed drug paraphernalia, and admissions of ongoing use, the facility did not implement specific interventions to prevent or reduce illicit drug use, nor did it update care plans to address these issues. Staff interviews confirmed that drug access was a common problem and that the facility was not taking adequate action to address it. In one case, a resident with a history of opioid dependence and major depressive disorder tested positive for multiple illicit substances on several occasions, including methamphetamine, cocaine, and marijuana, without corresponding prescriptions. The resident's care plan lacked interventions specific to illicit drug use, and staff reported finding drug paraphernalia in the resident's room. The facility's behavioral health specialists stated that their recommendations for interventions were not implemented, and the administrator confirmed there was no policy addressing confirmed illicit substance use among residents. The facility's only response to suspected drug use was to notify the physician, as per their outdated policy. Other residents were also involved in incidents of drug use and related behaviors. Two residents sharing a room were found with an unknown visitor in possession of drugs, and one was observed performing sexual acts in exchange for substances. The facility failed to follow its own abuse and exploitation policies in response to this incident. Another resident with a history of alcohol and cocaine abuse was repeatedly found intoxicated, involved in altercations, and observed using marijuana in the facility, with no documented follow-up or interventions by staff. Interviews with staff and administrators confirmed a lack of cohesive care and policy regarding substance abuse, and that the facility had not taken effective steps to address the ongoing drug problem.
Failure to Ensure Call Light Accessibility for Non-Ambulatory Resident
Penalty
Summary
A deficiency was identified when a resident with significant mobility impairments, including bilateral leg amputations and use of a manual wheelchair, was found unable to access their call light. The resident, who was cognitively intact and required varying levels of assistance for activities of daily living, expressed a desire to lie down but could not reach the call light to request help. Observation confirmed that the call light was not within reach, and the resident was unable to self-propel the wheelchair due to the placement of the wheels and his physical limitations. During the incident, the resident resorted to yelling for staff assistance, at which point a CNA entered the room to provide help. The CNA confirmed that the resident could not independently move the wheelchair and that the call light was not accessible at the time. Facility policy required that call lights remain within reach of residents at all times, and alternative call systems should be provided if traditional call lights were not usable. This failure to ensure call light accessibility was found during a complaint investigation and affected one of several residents identified as unable to self-ambulate.
Failure to Protect Resident from Misappropriation of Funds
Penalty
Summary
A resident with diagnoses including heart failure, hypertension, diabetes, and depression, and with intact cognition, experienced unauthorized charges totaling $3,941.66 on their bank account. The charges were discovered by the Business Office Manager (BOM) after the resident was unable to access funds at a store. The BOM reviewed the resident's bank statements and identified multiple unapproved transactions related to DoorDash and Lyft, which the resident did not make. The BOM reported the incident to the police, cancelled the resident's debit card, and contacted the bank, which was able to reverse only three months of the fraudulent charges, although the activity had been ongoing for approximately six months. The facility's investigation into the misappropriation was incomplete, as there were no interviews conducted with staff or other residents who may have been involved or had knowledge of the incident. The Administrator confirmed that neither staff nor residents were interviewed regarding the missing funds and stated that the case was referred to the Attorney General's office. The facility ultimately unsubstantiated the self-reported incident, citing a lack of evidence identifying who took the resident's money, despite the facility's policy requiring interviews with the resident, the accused, and all witnesses during such investigations.
Failure to Timely Complete and Report Abuse and Misappropriation Investigations
Penalty
Summary
The facility failed to complete and report the results of investigations into allegations of abuse and misappropriation to the State agency within the required five business days. In one instance, a cognitively intact resident with diagnoses including depression, alcohol abuse, and kidney failure was involved in a physical altercation with another resident, resulting in an investigation that was completed in six business days. In another case, a cognitively intact resident with chronic medical conditions such as COPD, diabetes, and malnutrition reported missing personal items, including a wallet, ID, debit card, and cash. The investigation into this misappropriation allegation was completed in eight business days. The Administrator confirmed that neither investigation was completed and reported within the mandated timeframe, and there was no documentation of extenuating circumstances to justify the delays. Facility policy requires that such investigations be completed within five days unless special circumstances are present, but no such circumstances were identified or documented for these cases. This deficiency was identified during a complaint investigation and affected two of four residents reviewed for self-reported incidents.
Failure to Conduct Thorough Investigations of Abuse, Neglect, and Misappropriation Allegations
Penalty
Summary
The facility failed to thoroughly investigate allegations of abuse, neglect, and misappropriation involving three residents. In one case, a resident with depression, anxiety, cognitive communication deficit, and dementia reported $353 missing. The facility's investigation included interviews with other residents but did not include any staff interviews, contrary to facility policy. The administrator confirmed that staff were not interviewed and acknowledged the investigation was not thorough. In another instance, a cognitively intact resident involved in an altercation with another resident was not assessed, and vital signs were not obtained. The investigation contained conflicting witness statements, and a key witness, the therapist who initially reported the incident, was not interviewed. In a third case, a resident reported missing personal items, including a wallet and $500. The investigation did not confirm if all staff were interviewed due to uncertainty about when the items went missing, and there was no personal inventory to verify ownership of the wallet. The administrator confirmed the investigation was incomplete. Facility policy required interviews with all relevant parties, but this was not consistently followed.
Failure to Document and Complete Appropriate Resident Discharge
Penalty
Summary
The facility failed to provide evidence of an appropriate discharge for a resident, including the completion of a discharge summary or recapitulation of stay, and did not document the details of the discharge in the medical record. The resident, who had multiple diagnoses such as osteomyelitis of vertebrae, asthma, substance abuse, anxiety, bipolar disorder, hypertension, depression, and muscle weakness, was cognitively intact at the time of discharge. The discharge was executed with less than 30 days' notice, citing an emergency due to alleged endangerment of safety in the facility. The discharge location was a local hotel, and the discharge notice was not signed by the resident or facility staff. Review of the facility's investigation revealed a lack of written statements from residents or staff, with the only evidence being hearsay reported by the Administrator. The resident denied the allegations of illicit drug distribution. There was no documentation in the medical record regarding the need for immediate discharge, no discharge summary, and no signed physician's order for the discharge. A verbal order was claimed to have been received but was not signed by the medical director. The facility's policy required a discharge order and a summary of information to ensure continuity of care, but these steps were not followed in this case.
Failure to Complete Ordered Pressure Ulcer Treatment
Penalty
Summary
A deficiency occurred when staff failed to ensure that pressure ulcer treatments were completed as ordered for a resident with multiple sclerosis and a stage IV pressure ulcer of the penis. The physician's order required nightly cleansing, application of Skin Prep and collagen filler, and covering the wound with an ABD pad. Record review showed the treatment was performed on one date, but during observation the following morning, the wound dressing was not in place. The resident reported that the dressing had come off during incontinence care the previous night and had not been replaced. An LPN confirmed that there was no dressing in place at the time of observation. Further review and interviews revealed that staff did not notice or report the missing dressing during incontinence care, despite the dressing being found in the resident's brief. The facility's policy required consistent treatment protocols for pressure injuries to aid healing, but this protocol was not followed. The deficiency was identified during a complaint investigation and affected one of three residents reviewed for pressure ulcers.
Failure to Provide Required Supervision and Safety Equipment During Resident Smoking
Penalty
Summary
A deficiency was identified when a resident with severe cognitive impairment and a history of schizophrenia, muscle weakness, and hypertension was not provided with adequate supervision while smoking, as required by physician orders and the care plan. The resident had orders for supervised smoking with a smoking apron due to an increased risk of injury, including dropping ashes on themselves and being unable to safely light or extinguish tobacco products. Despite these orders and care plan interventions, observations revealed the resident was left unsupervised in the designated smoking area on multiple occasions and was not wearing the required smoking apron. Additionally, the resident was seen picking up and smoking a discarded cigarette from another resident, further demonstrating a lack of supervision and adherence to safety protocols. Interviews with facility staff, including the Administrator, DON, and ADON, confirmed that the resident was supposed to be a supervised smoker and that the smoking apron was not being used as intended. The facility's smoking policy required staff or volunteer supervision during designated smoking times and that all smoking materials be kept in a secure area for supervised smokers. However, these procedures were not followed, resulting in unsupervised smoking and the absence of required protective equipment for the resident.
Failure to Provide Timely Foley Catheter Care and Documentation
Penalty
Summary
The facility failed to provide timely and documented Foley catheter care for a resident who returned from the hospital with an indwelling catheter. Medical record review showed that after the resident's return, there was no evidence of catheter care being provided or documented for a period of ten days. Progress notes repeatedly indicated the catheter was intact, but did not mention any catheter care. The treatment administration records and physician's orders also lacked any orders or documentation for Foley catheter care during this period. Catheter care orders were not initiated until ten days after the resident's return, despite the resident's care plan identifying risks associated with the indwelling catheter, such as infection and skin decline, but not specifying interventions for catheter care. Interviews with the DON confirmed the absence of catheter care orders and documentation during this time. The resident reported that incontinence care was not provided in a timely manner. The deficiency was identified during a review of activities of daily living for three residents, with this resident being affected. The facility census at the time was 45.
Failure to Provide Timely Pain Management
Penalty
Summary
The facility failed to provide timely and appropriate pain management for a resident admitted with multiple medical conditions, including spondylolisthesis, lumbar region, and compression fractures. Upon admission, the resident had physician orders for pain assessment every shift and for 10 mg oxycodone to be administered every four hours as needed for pain. However, the resident did not receive a pain assessment or the prescribed pain medication for approximately two and a half days after admission. The medication was not available in the facility until 7:28 P.M. on the third day, and the first dose was administered at 7:44 P.M. the same day. Documentation confirmed that the resident experienced significant pain during this period, with a pain rating of six out of ten, and reported being unable to get out of bed due to pain following surgery and internal stitches. Interviews with facility staff, including the DON and ADON, revealed that the delay in pain management was due to failures in ordering and following up on the resident's pain medication. Staff did not complete the required pain assessments, and there was a lack of communication and accountability regarding the ordering and administration of the prescribed oxycodone. The facility's own pain management policy, which required assessment and collaboration with the physician to manage pain, was not implemented in this case. The resident reported that staff blamed each other for the delay, and the facility's investigation confirmed the medication was not ordered or available as required.
Failure to Ensure Physician Oversight of Wound Care
Penalty
Summary
The facility failed to ensure that wound care for residents was overseen by a physician, resulting in a lack of appropriate medical oversight and treatment for residents with significant wounds. In one case, a resident with multiple comorbidities, including diabetes and cognitive impairment, developed a worsening wound on the left foot. Despite weekly wound reports documenting the decline of the wound, there was no evidence that a physician was notified or that wound treatments were initiated. The wound nurse only measured the wound and did not assess it or communicate with the physician, and the nurse practitioner involved was not wound certified. The resident was eventually transferred to the hospital with severe sepsis due to the untreated wound, and the hospital expressed concerns about the extent of the wounds. Another resident with end stage renal disease, diabetes, and a history of amputation developed an ulcer on the right heel, which was identified by the dialysis center but not documented or reported by facility staff in weekly skin assessments. The dialysis center attempted to notify the facility about the ulcer, but there was no evidence of follow-up or physician notification. The resident's condition deteriorated, and upon eventual hospital transfer, was found to have a necrotizing soft tissue infection requiring emergency above-the-knee amputation. The physician confirmed he was not made aware of the wound until after the resident was hospitalized. Interviews with facility staff and review of facility policy revealed that there was no physician oversight of wound care, and the nurse practitioner providing wound care was not wound certified nor supervised by a wound certified provider. The medical director was not informed of the residents' wounds and did not oversee wound care. Facility leadership confirmed they were unaware that wound care was not being overseen by a physician, contrary to facility policy requiring the medical director to oversee the medical care of all residents.
Medication Error Due to Improper Administration Practices
Penalty
Summary
A medication error occurred when a Licensed Practical Nurse (LPN) administered the wrong medication to a resident with diagnoses including schizophrenia, hypertension, and a history of falls. The LPN had two different residents' medications in cups at the top of the medication cart. While attempting to administer medication in the hallway, the LPN knocked over the cups, replaced the medications, and then gave the resident the medications. After administration, the LPN realized that the resident had received another resident's narcotic medication, Tramadol, which was not ordered for him. Review of the resident's medical record confirmed there was no physician's order for Tramadol for this resident. The facility's policy required staff to verify resident identity and administer medications according to orders, which was not followed in this instance. The Director of Nursing confirmed the medication error and stated that staff are not permitted to pre-pour multiple residents' medications at one time.
Improper Medication Storage at Bedside
Penalty
Summary
A deficiency occurred when a medication was found improperly stored at a resident's bedside. The resident, who had a history of a left foot fracture, difficulty walking, and muscle weakness, was assessed as cognitively intact but required assistance with oral medication administration. During an observation, a clear plastic cup containing a white pill, identified as an antibiotic, was found at the resident's bedside. The resident confirmed that he had been told he no longer needed the medication and therefore did not take it. A certified nurse aide confirmed the presence of the pill and acknowledged that nurses were responsible for observing residents taking their medications and that medications should not be left with residents. Facility policy required medications to be administered within one hour of the prescribed time and documented as refused if not taken, with self-administration only permitted if the resident was deemed capable by the physician and care team. The incident was identified during a complaint investigation and involved a failure to ensure medications were properly stored and administered according to policy.
Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
A deficiency was identified when a Licensed Practical Nurse (LPN) failed to follow proper infection control practices during wound care for a resident with chronic venous ulcers and other medical conditions, including congestive heart failure and diabetes mellitus. The resident had a physician's order and care plan in place for Enhanced Barrier Precautions (EBP) due to open wounds, which required the use of gowns and gloves during high-contact care activities such as wound care. Signage outside the resident's room indicated the need for EBP, and personal protective equipment (PPE) was available in a cart down the hall. During an observation of wound care, the LPN cleansed her hands and donned gloves but did not put on a gown as required by the EBP protocol. When questioned, the LPN confirmed that the resident was on EBP and acknowledged that she had not donned a gown prior to providing wound care. Review of the facility's policy confirmed that EBP, including the use of gowns, was indicated for residents with wounds. This failure to adhere to established infection control procedures constituted a deficiency as documented in the report.
Failure to Label Food and Use Hair Restraints in Kitchen
Penalty
Summary
Surveyors observed that dietary staff in the kitchen failed to wear required hair restraints while in the food preparation area, as both a cook and a dietary aide were not wearing hair coverings at the time of inspection. Additionally, a review of the kitchen cooler revealed multiple food items, including a pan of hamburgers in broth, a bucket of meatballs, and a pan of hamloaf, that were undated and unmarked. The dietary supervisor confirmed these observations. Facility policies reviewed indicated that proper labeling and dating of food, as well as the use of hair restraints, are required for food safety and sanitation.
Failure to Document and Communicate Required Discharge Information
Penalty
Summary
The facility failed to ensure that resident medical records contained all required discharge information and that appropriate information was communicated to the receiving facility for two residents reviewed for discharge planning. For one resident with diagnoses including aftercare following major joint replacement, dementia, and osteoarthritis, the medical record lacked documentation indicating the resident was being discharged or specifying the receiving facility. Additionally, a scheduled follow-up medical appointment was not communicated to the receiving facility, resulting in a missed appointment. The discharge summary only generically referenced transfer to another nursing home, and the resident signed the summary without clear documentation of the discharge plan. For another resident with chronic obstructive pulmonary disorder, sleep apnea, and diabetes, the medical record similarly lacked documentation regarding the discharge or the destination facility. The discharge summary again only referenced transfer to an unnamed nursing home. Interviews with the Administrator and DON revealed that during a period of social worker turnover, discharge planning responsibilities were shared among staff, leading to gaps in documentation and communication. The facility's discharge policy required providing an appropriate summary of information at discharge, which was not met in these cases.
Insufficient Dietary Staffing Leads to Delayed Meal Service
Penalty
Summary
The facility failed to ensure sufficient dietary staff for timely meal service, affecting all residents who received meals from the kitchen. Observations during the initial tour of the kitchen revealed that breakfast trays were being plated late, with only three staff members present. Interviews with dietary staff confirmed that the kitchen was short-staffed, leading to delays in meal service. Residents reported that meals were consistently late, with one resident specifically noting that breakfast had not been received by 10:35 A.M., despite being scheduled for 8:00 A.M. Further observations showed that by 12:58 P.M., no meal carts were present in the nursing unit and dining areas, indicating that lunch had not been served on time. A CNA confirmed that lunch had not been delivered yet. The Dietary Manager acknowledged receiving complaints about late meals and attributed the issue to insufficient staffing. Although new staff had been hired, they had not yet started working, leaving the facility unable to meet the scheduled meal times.
Sanitation Deficiencies in Kitchen Affecting Meal Service
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, which had the potential to affect all 53 residents receiving meals. During an initial tour of the kitchen, several sanitation concerns were observed. The floor of the small storage room was dirty with dirt stains and debris under the storage racks. The stove had a heavy build-up of stains and food debris, and the prep table across from the stove had moderate food debris and stains. The robotcoup, a blender used to mechanically alter food, had various dried food debris and stains. Additionally, a fan next to the robotcoup had a moderate amount of dust on the blades and cover. The floor where the steamer and plate warmer were located had dirt stains, crumbs, and debris, and the small silver counter/stand the mixer sat on had food crumbs and stains. Further observations revealed that Walk-in cooler #1 had debris, a cracked egg with dried yolk, an old onion, and debris under the racks. Unlabeled and undated food items were found in the cooler. Both walk-in freezers had food crumbs and debris on the floor. The dry storage area had over 15 boxes of food items stored directly on the floor. The ice machine had dried, sticky stains on top, and there were dirty towels on the three-compartment sink. A cart next to the steam table had plates and insulated bottoms with crumbs and stains. The dish machine area had dirt stains, debris, and standing water under the machine. Dietary staff confirmed these findings and attributed them to short staffing, which hindered proper cleaning. The facility's policies on food storage and sanitation were not adhered to, as evidenced by the conditions observed.
Deficiency in Maintaining Clean Bathing and Shower Rooms
Penalty
Summary
The facility failed to maintain clean and sanitary bathing and shower rooms for residents, excluding 20 residents identified as not using these facilities. During an observation, the toilet in the bathing room was found to have no water and contained feces, with no signage indicating it was out of use. The floor was dirty with dirt buildup around the edges. In the shower room, missing tiles, a leaking shower, and a black substance on the wall were noted, along with black/brown grout. Used gloves, a dirty towel on an old chair, and gritty dirt buildup were also observed. A housekeeper confirmed these conditions, and a review of facility policies revealed that bathrooms and floors should be cleaned daily and maintained in a clean, safe, and sanitary manner.
Incorrect Serving Size for Mechanical Soft Diet
Penalty
Summary
The facility failed to ensure the correct serving size of mechanical soft meat was provided to six residents who were on a mechanical soft diet. The menu for the lunch meal on January 22, 2025, included Salisbury steak, mashed potatoes, and lima beans. According to the menu/diet spreadsheet, the mechanical soft diet required a #6 scoop, which provides 5.33 ounces of ground Salisbury steak. However, during the lunch tray line service, the dietary staff used a #10 scoop, which only provided 3.20 ounces. This discrepancy was confirmed by the Dietary Manager, who verified that the incorrect scoop was used, affecting six residents who had physician orders for a mechanical soft diet.
Resident's Dignity Compromised by Ill-Fitting Clothing
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident #5, had properly sized clothing, which compromised his right to dignity. Resident #5, who was cognitively intact but experienced hallucinations and delusions, was observed multiple times with sweatpants that were too large, causing them to fall to his ankles and expose his legs and disposable brief. This occurred in various locations, including his room, the hallway, and the outside smoking area, where other residents and staff could see him. Despite being aware of the issue, the facility staff, including CNAs and the Assistant Director of Nursing, acknowledged the problem but did not provide a solution, citing the lack of a guardian or family to provide clothing and an inability to find appropriately fitting pants. The facility's policy on Resident Rights, revised in December 2016, states that residents have the right to a dignified existence. However, the facility did not uphold this policy for Resident #5, as evidenced by the repeated observations of his ill-fitting clothing and the staff's failure to address the issue adequately. Interviews with staff confirmed the ongoing problem, yet no effective action was taken to ensure Resident #5 had clothing that maintained his dignity.
Failure to Develop Person-Centered Care Plans for PTSD Residents
Penalty
Summary
The facility failed to develop person-centered care plans for residents with Post Traumatic Stress Disorder (PTSD), specifically for Resident #10 and Resident #29. Both residents had pertinent diagnoses including PTSD, and their care plans lacked identification of specific triggers that could lead to re-traumatization. Resident #29's care plan mentioned a history of trauma but did not list any specific triggers, despite the resident's admission that large crowds caused anxiety. Similarly, Resident #10's care plan did not address PTSD or identify triggers, even though the resident reported that big groups of people and aggressive communication were triggers. Interviews with facility staff, including a Certified Nursing Assistant, a Registered Nurse, an Activity Aide, and the Social Services Director, revealed a lack of awareness regarding the specific PTSD triggers for Residents #10 and #29. The staff were either unaware of the residents' triggers or did not believe they had the ability to inquire about them. This lack of knowledge and communication among staff members contributed to the deficiency in providing appropriate care for residents with PTSD. The facility's policy on Trauma Informed Care, which was revised in March 2019, stated that nursing staff would be trained on trauma assessment and identifying triggers. However, the deficiency indicates that this training was not effectively implemented, as evidenced by the staff's lack of awareness and the absence of specific triggers in the care plans for the affected residents. The facility's failure to adhere to its own policy and adequately address the needs of residents with PTSD led to the identified deficiency.
Failure to Ensure Resident Wore Hand Splint as Ordered
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident #21, wore a hand splint according to the physician's order. Resident #21, who has a history of chronic pain, hemiplegia, hemiparesis following a stroke, and anxiety disorder, was prescribed a left resting hand splint to be worn in the morning and removed in the evening. The medical record indicated that the resident had been receiving occupational therapy to address increased assist needs and worsening left upper extremity tone due to a contracture. Despite the discharge recommendation to continue using the splint, documentation revealed that the splint was not applied on multiple occasions, and the last recorded application was on January 12, 2025. Observations and interviews conducted on January 21 and 22, 2025, confirmed that Resident #21 was not wearing the splint, and staff members, including CNAs and therapy personnel, were unaware of the reasons for this lapse. The splint was found on top of the resident's dresser, indicating it was not in use. The Director of Nursing confirmed the lack of documentation regarding the splint's application, which was supposed to be recorded by the aides. The facility's policy on adaptive equipment, revised in January 2024, stated that the use of such equipment should be supervised by nursing staff to help residents maintain their physical well-being.
Smoking Hazards and Inadequate Supervision in LTC Facility
Penalty
Summary
The facility failed to ensure that two residents, identified as Resident #5 and Resident #29, were free from potential accident hazards related to smoking. Resident #5, who was admitted with diagnoses including schizophrenia and generalized muscle weakness, was observed smoking without wearing a smoking apron, despite having multiple burn holes in his clothing. The Assistant Director of Nursing (ADON) had assessed Resident #5 as a safe independent smoker without thoroughly inspecting his clothing for burn holes, which was a requirement of the smoking assessment. This oversight led to Resident #5 continuing to smoke unsafely, as evidenced by his habit of throwing lit cigarette butts on the ground and the presence of burn holes in his clothing. Resident #29, who had diagnoses including chronic obstructive pulmonary disease and was on oxygen, was found to have smoking paraphernalia in his room, despite a facility policy that prohibited smoking in areas where oxygen was in use. An observation revealed the presence of a lighter, a metal pipe with soot, and a vape device in Resident #29's room, along with a sign indicating no smoking due to oxygen use. Resident #29 admitted to previously smoking in his room, which was a violation of the facility's smoking policy. The facility's smoking policy did not adequately address the risks associated with residents who smoked and used oxygen, contributing to the unsafe conditions. The facility's failure to enforce its smoking policy and ensure adequate supervision and safety measures for residents who smoke resulted in potential accident hazards. The lack of thorough assessments and supervision allowed unsafe smoking practices to continue, posing risks to the residents and the facility. The observations and interviews conducted during the survey highlighted these deficiencies, which affected the safety and well-being of the residents involved.
Deficiencies in Respiratory Care Equipment Maintenance
Penalty
Summary
The facility failed to maintain clean and sanitary conditions for respiratory care equipment for two residents. Resident #21, who has chronic obstructive pulmonary disease (COPD) and a cancer lesion, was observed with dirty and blood-stained head straps on his BiPAP machine. Despite having a growth on his head that bled, the straps were not replaced or cleaned, contrary to the physician's order to replace the BiPAP mask, headgear, and tubing every three months. The facility's policy did not address the cleanliness of the head straps, and the manufacturer's guide emphasized the importance of regular cleaning. Resident #34, also diagnosed with COPD, had oxygen tubing that was not labeled with the date of the last change, as required by the facility's policy. The tubing was supposed to be changed weekly, but the staff, including RN #500, were unsure of the policy details. The Director of Nursing confirmed the lack of labeling and acknowledged the need for staff training on the oxygen administration policy. The facility's policy required oxygen tubing and masks/cannulas to be changed weekly and as needed if soiled or contaminated.
Failure to Properly Label and Store Insulin Medications
Penalty
Summary
The facility failed to ensure that insulin medications were accurately labeled and stored according to professional principles, affecting three residents with type two diabetes mellitus. During an observation of medication cart #2, it was found that insulin pens for these residents were opened but not dated, and some did not have labels with the residents' names. This lack of proper labeling and dating could lead to the use of outdated medications, as the facility's policy requires medications to be dated when opened and discarded after 28 days. The medical records for the affected residents showed that they were prescribed various types of insulin, including Humalog, Fiasp, and Toujeo, which require specific storage conditions. The facility's policy and pharmacy guidelines mandate that these insulins be refrigerated until use and dated upon opening. However, the observation revealed that these guidelines were not followed, as confirmed by an interview with a registered nurse who acknowledged the oversight. This deficiency in medication management was identified during a survey, highlighting a failure in adhering to established protocols for medication storage and labeling.
Resident Served Incorrect Food Texture
Penalty
Summary
The facility failed to ensure that Resident #9 received food prepared in a form designed to meet their individual needs. Resident #9, who was diagnosed with severe protein-calorie malnutrition, dementia without behavioral disturbance, and oropharyngeal phase dysphagia, was identified as requiring a pureed food texture. However, during an observation of Resident #9's lunch meal, it was noted that the resident was served mechanical soft Salisbury steak instead of the prescribed pureed meat. The meal ticket on the lunch tray indicated that the resident should have received mechanical soft with pureed meat only. The Dietary Manager confirmed that Resident #9 was served the incorrect food texture and acknowledged that the diet orders were being checked against meal tickets but had not yet been updated for Resident #9.
Failure to Provide Appropriate Bed Size Leads to Resident Fall and Injury
Penalty
Summary
The facility failed to provide necessary interventions to prevent a fall with injury for a resident who was dependent on staff for incontinence care and personal hygiene. The resident, who had diagnoses including morbid obesity and poly osteoarthritis, required a king bariatric bed rather than the queen bed provided. This inadequacy was identified as the root cause of the fall that resulted in actual harm. On the day of the incident, the resident was being provided incontinence care by multiple staff members when she slid off the mattress and was assisted to the floor, resulting in bilateral distal femur fractures. The resident had been bedbound for four years and used a wheelchair for two of those years. The incident occurred despite the presence of three staff members, including two CNAs and an agency CNA, who were assisting with the resident's care. Interviews with staff revealed that the resident required maximum assistance with activities of daily living and typically needed three to four staff members to assist with rolling in bed. The facility's quality assurance program identified the need for a larger bed as the root cause of the fall, indicating a failure to implement an adequate fall prevention plan tailored to the resident's specific needs.
Inconsistent Food Temperature Monitoring and Resident Dissatisfaction
Penalty
Summary
The facility failed to ensure that food temperatures were consistently monitored and recorded, which affected the palatability and safety of meals served to all 55 residents. The Food Temperature Log forms from 12/15/24 to 01/06/25 showed numerous instances where temperatures were not recorded for breakfast, lunch, and dinner. Observations on 01/06/25 revealed that food temperatures were not documented, and the milk served was above the required temperature of 40 degrees Fahrenheit. Interviews with residents indicated dissatisfaction with the food quality, describing it as cold and institutional grade. The Dietary Director confirmed the inconsistencies in temperature checks and acknowledged the blank sections in the Food Temperature Logs. A resident's daughter expressed concerns about the inconsistency of the food, leading her to bring a refrigerator to the resident's room. The facility's Food and Nutrition Services policy, revised in 10/2017, mandates that each resident receives a nourishing, palatable, and well-balanced diet, considering their preferences, which was not adhered to in this instance.
Failure to Follow Meal Plans and Preferences
Penalty
Summary
The facility failed to ensure that the menus and meal plans were followed as planned, affecting several residents. Resident #9, who was admitted with conditions including cellulitis and peripheral vascular disease, did not receive the mighty shake, applesauce cake, or bread as per the menu and meal ticket during lunch. The Director of Nursing (DON) confirmed the discrepancy during an observation. Resident #13, diagnosed with multiple sclerosis and anxiety disorder, also experienced issues with meal delivery. The resident's breakfast and lunch trays did not include the preferred items such as yogurt, fruit, and cottage cheese as indicated on the meal ticket. The Dietary Director confirmed that the breakfast pizza was not delivered, and the substitute should have been scrambled eggs and toast. Additionally, the serving size of French toast sticks was incorrect. Resident #27, with diagnoses including alcoholic cirrhosis and anxiety, did not receive the correct portion size of French toast sticks and was missing bread and applesauce cake during lunch. Similarly, Resident #44, who had severe protein-calorie malnutrition, did not receive the mighty shake or hot water for tea as per the meal ticket. The facility's policy requires that each resident is provided with a diet that meets their nutritional and dietary needs, which was not adhered to in these cases.
Failure to Provide Prescribed Nutritional Supplements
Penalty
Summary
The facility failed to provide the prescribed nutritional supplements to two residents, leading to a deficiency in meeting their dietary needs. Resident #9, who was admitted with conditions including cellulitis, muscle spasm, and peripheral vascular disease, had a physician's order for a mighty shake supplement twice daily. However, during an observation on January 7, 2025, it was noted that Resident #9's meal tray did not include the mighty shake, as well as other items listed on the meal ticket. This was confirmed by the Director of Nursing during an interview. Similarly, Resident #44, who was admitted with diagnoses such as malignant neoplasm of the brain and severe protein-calorie malnutrition, was also prescribed a mighty shake twice daily. On January 6, 2025, an observation revealed that Resident #44's breakfast tray lacked the mighty shake, despite it being listed on the meal ticket. The facility's policy, revised in October 2017, mandates that each resident receives a diet that meets their nutritional and dietary needs, which was not adhered to in these cases. This deficiency was investigated under specific complaint numbers.
Failure to Administer Medication as Ordered
Penalty
Summary
The facility failed to ensure that a resident's medication, Acamprosate Calcium, was available and administered as ordered. The resident, who was admitted with diagnoses including alcoholic dependence, lumbar degenerative disc disease, anxiety, and depression, had a hospital discharge order to take Acamprosate Calcium 333 mg three times daily for 10 days. However, the medication was not administered as prescribed from 11/10/24 to 11/20/24, except for two instances. The medication administration records indicated that the medication was held or required nursing notes, but no documentation or validation was found in the nursing progress notes to justify this action. Interviews with the Director of Nursing and the Medical Director confirmed the medication was not administered as ordered, and there was no evidence in the medical record to explain why. A telephone interview with the pharmacy revealed that the prescriptions for the medication were canceled in error, resulting in the facility not receiving the medication. The facility's policy on administering medications, which requires medications to be administered safely, timely, and as prescribed, was not followed. This deficiency was investigated under specific complaint numbers.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate of 5% or less, resulting in a rate of 7.69% during the survey. This deficiency was identified through the observation of medication administration for two residents. Resident #27, who has diagnoses including alcoholic cirrhosis and anxiety, was prescribed vitamin D3 at a dosage of 2000 IU daily. However, during an observed medication administration, the resident received only 400 IU, which was confirmed as an error by the LPN responsible for the administration. Similarly, Resident #53, with diagnoses such as atherosclerotic heart disease and gastro-esophageal reflux disease, was prescribed omeprazole 20 mg daily. During the medication administration observation, the LPN ADON failed to administer the omeprazole as ordered. These errors were confirmed through interviews with the respective nursing staff. The facility's policy on administering medications, which mandates safe and timely administration as prescribed, was not adhered to, leading to the identified deficiency.
Unsanitary Kitchen Conditions in LTC Facility
Penalty
Summary
The facility failed to maintain a sanitary kitchen environment, which had the potential to affect all residents except one. The Director of Nursing confirmed that the Kitchen Manager was sent home due to poor work performance, leaving the cook in charge of supervising the kitchen staff. Observations revealed multiple sanitation issues, including dried liquid spills on storage shelving, sticky floors with grease build-up, and food particles under cooking equipment and preparation tables. Additionally, food carts were found with dirt, grease, and dried food, and knives were stored improperly with grease build-up underneath. Further inspection showed that the kitchen lacked proper cleaning supplies, as confirmed by a staff member, who stated that the floors had not been cleaned appropriately for five to six months. The staff member also reported that the evening shift lacked supervision to ensure daily cleaning duties were performed. The kitchen's dishwashing area had a leaking pipe with a tub collecting dark, odorous water, and the meal service area outside the kitchen was cluttered and dirty with dried food spills. Interviews with staff confirmed the absence of completed cleaning duties checklists, which were supposed to be filled out daily and submitted to the Kitchen Manager. The facility's cleaning duties checklists outlined specific tasks for both morning and evening shifts, including changing sanitization buckets, organizing food storage, and cleaning various kitchen areas. However, these tasks were not being completed or documented, contributing to the unsanitary conditions observed during the survey.
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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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