The Sanctuary At Tuttle Crossing
Inspection history, citations, penalties and survey trends for this long-term care facility in Dublin, Ohio.
- Location
- 4880 Tuttle Road, Dublin, Ohio 43017
- CMS Provider Number
- 366170
- Inspections on file
- 33
- Latest survey
- January 9, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at The Sanctuary At Tuttle Crossing during CMS and state inspections, most recent first.
Two residents with significant psychiatric and cognitive conditions were roommates when one cognitively intact resident physically struck or pushed the other severely cognitively impaired resident after accusing him of urinating on the toilet seat. Staff heard yelling and a loud noise, then found a resident on the floor partially outside the room, appearing fearful and confused, with a head injury and arm laceration, while the roommate stood over him yelling profanities and making threats. The aggressor admitted to staff and leadership that he had smacked or pushed the other resident, causing the fall. The injured resident was sent to the hospital, where imaging showed a falx SDH and acute traumatic C5–C6 fractures, and hospital records later documented cardiorespiratory arrest, acute hypoxic respiratory failure, suspected aspiration, dysphagia, advanced dementia, and acute traumatic fall-related injuries, culminating in the resident’s death. The facility failed to ensure the resident was free from abuse as required by its abuse, neglect, and exploitation policy.
The facility failed to timely report an allegation of abuse after a cognitively impaired resident with multiple psychiatric and neurologic diagnoses was found on the floor with a head injury while a roommate stood over him yelling and making threatening statements. An LPN notified the DON shortly after the incident, and the Administrator and DON were aware that the roommate had stated he smacked the resident, causing the fall. Despite this, the Administrator delayed reporting the allegation to the state until the following day, treating it initially as an unwitnessed fall, contrary to facility policy requiring immediate reporting of alleged abuse or events resulting in serious bodily injury.
Surveyors found that three residents with pressure ulcers did not receive timely or accurate wound care orders. In one case, a resident received the wrong treatment for 10 days due to staff confusion. Another resident had two conflicting wound care orders simultaneously, and a third resident experienced a delay in receiving any treatment orders after a wound assessment. The DON confirmed these lapses, which were not in accordance with facility policy requiring evidence-based wound care.
Surveyors found the kitchen had unsanitary conditions, including ice buildup with embedded food and hair in the freezer, mildew odor and black substance in the refrigerator, and dirt accumulation throughout. Food was served below the required holding temperature, with staff confirming the food was not hot enough. All residents received meals from this kitchen.
Staff failed to maintain the walk-in freezer at the required temperature, with repeated observations of temperatures above zero degrees Fahrenheit and significant ice buildup. Food items stored in the freezer, including meats and vegetables, were not kept at safe temperatures and continued to be served to residents. Staff interviews revealed a lack of knowledge about proper freezer standards, and facility records documented ongoing issues with the freezer's door seal and temperature control.
The facility did not ensure enhanced barrier precautions (EBP) were in place for several residents with chronic or open wounds. Multiple residents lacked EBP signage, care plan documentation, and readily available PPE outside their rooms. Staff confirmed the absence of EBP measures, and the DON acknowledged that EBP is necessary for residents with wounds, but these precautions were not implemented.
A resident with significant physical disabilities and no cognitive deficits was not provided with showers twice weekly or offered bed baths between scheduled showers, as required by facility policy. The resident also reported not receiving assistance with hair care. Documentation confirmed only four showers were given over several weeks, and staff interviews acknowledged the failure to meet established bathing protocols.
A resident with multiple medical conditions was not given a Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF-ABN) when therapy services were discontinued, even though skilled benefit days remained. The omission was confirmed by the Business Office Manager after review of the medical record.
A resident with quadriplegia and severe cognitive impairment did not receive therapy-recommended splinting devices due to the facility's failure to obtain physician orders and ensure application as directed. Despite therapy discharge summaries specifying the need for hand, knee, and ankle/foot splints, staff did not consistently offer or apply the devices, and the splints were found unused in the resident's room. Staff interviews confirmed the lack of orders and inconsistent communication between therapy and nursing regarding splinting schedules.
Staff failed to ensure that two residents who required mechanical lift transfers received assistance from two caregivers as required. In both cases, CNAs performed transfers alone using a Hoyer lift, contrary to facility policy and safety guidelines. The DON confirmed that single-staff transfers are not permitted, and the facility's safety guide specifies that two or more caregivers are needed for safe operation.
A resident with significant medical conditions requiring enteral nutrition did not receive several scheduled tube feedings as ordered by the physician due to a problem with the feeding pump. The resident, who was aware of her nutritional regimen, reported missing feedings and not being informed of the reason. The DON confirmed the missed feedings, and facility policy lacked specific guidance on following physician orders.
The facility did not ensure that a licensed pharmacist performed required monthly medication regimen reviews, including medical chart reviews, for two residents with complex medical and psychiatric conditions who were receiving multiple psychotropic and other medications. Pharmacy records and consultant pharmacist reports lacked documentation of these reviews for specific months, and the DON confirmed no additional documentation was available.
Surveyors identified significant medication errors, including a nurse administering insulin without priming the pen, missed doses of an antibiotic despite its availability, and multiple missed or improperly timed doses of an anticoagulant. These errors affected three residents and were confirmed through observation, record review, and staff interviews.
A resident who had agreed to receive dental services did not receive them in a timely manner because their signed consent was not properly filed, resulting in staff being unaware of the request and the resident not being scheduled for dental care.
A resident with multiple chronic conditions left the facility with his wife against medical advice, and staff failed to document the AMA discharge in the medical record as required by facility policy. The resident's wife signed the resident out only after being prompted, and interviews confirmed the lack of proper documentation.
A resident with multiple medical conditions and intact cognition was unable to activate the call light system in their room and bathroom despite repeated attempts. The malfunction was confirmed by both staff and direct observation, and the issue persisted over multiple checks. Facility policy requires immediate reporting and alternative solutions for call light failures, but the system remained nonfunctional during the survey.
The facility failed to maintain a clean and sanitary shower room, affecting several residents and potentially impacting others. Observations showed stained and loose flooring, with water bubbling from underneath, and missing tiles. Staff and residents reported that some residents refused to use the shower room due to its condition, describing it as filthy and smelly. The facility had started looking for contractors to address the issue but had no definite plans yet.
Resident-to-Resident Physical Abuse Resulting in Traumatic Injuries and Death
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from abuse by a roommate, resulting in actual physical harm. One resident (Resident #51), who had Parkinson’s disease, dementia with severe cognitive impairment, psychotic and mood disturbances, anxiety disorder, repeated falls, and major depressive disorder, shared a room with another resident (Resident #21) who had bipolar disorder, schizophrenia, hearing loss, dementia, psychotic and mood disturbances, and anxiety disorder, but was assessed as cognitively intact. Resident #51 used a walker and wheelchair and required setup assistance for some mobility tasks but was otherwise independent with certain bed mobility. The facility’s abuse policy defined abuse as the willful infliction of injury or intimidation with resulting physical harm, including resident-to-resident altercations. On the evening of the incident, staff heard Resident #51 yelling and a loud noise from the room shared by Residents #51 and #21. When staff entered, they found Resident #51 lying on the floor, with his head and torso outside the room and his legs inside, and Resident #21 standing over him, yelling profanities and making threatening statements such as, “touch me again and next time you won’t be able to stand back up,” and “I promise next time, you won’t get up.” Resident #51 appeared fearful and confused. A full body assessment revealed a raised, reddened area with a small amount of bleeding on the back of his head and a laceration on his right arm. The incident itself was unwitnessed by staff, but Resident #21 admitted to staff, the DON, and the Administrator that he had smacked or pushed Resident #51, causing him to fall, reportedly because he believed Resident #51 had urinated on the toilet seat. Resident #51 was sent to the hospital for evaluation following the incident. Hospital records documented that a CT scan of the head showed a small interhemispheric falx subdural hematoma, and imaging also revealed an acute traumatic fracture through bridging anterior osteophyte at C5–C6 extending through the body of C6, as well as an acute traumatic C6 vertebral body fracture. The hospital discharge diagnoses included cardiorespiratory arrest, acute hypoxic respiratory failure, suspected aspiration with significant oropharyngeal secretions, oropharyngeal dysphagia, advanced dementia, acute traumatic fall, acute traumatic C5–C6 osteophyte fracture, and acute traumatic C6 vertebral body fracture. Resident #51 later expired in the hospital. Law enforcement became involved after being contacted by Resident #51’s family and began collecting information about the incident between the two residents. The facility’s failure to ensure Resident #51 was free from abuse by another resident resulted in actual harm, including the documented head and cervical spine injuries.
Failure to Timely Report Allegation of Resident-to-Resident Abuse
Penalty
Summary
The deficiency involves the facility’s failure to timely report an allegation of abuse involving a resident with severe cognitive impairment. The resident, who had diagnoses including Parkinson’s disease, dementia, psychotic disturbance, mood disturbance, anxiety disorder, repeated falls, and major depressive disorder, was admitted on an unspecified date and had an MDS dated 12/02/25 showing severe cognitive impairment. On 12/12/25, staff heard the resident yelling and found him lying on the floor with his head and torso outside the room and his legs inside, while his roommate was present in the room, standing over him and yelling. A full body assessment documented a small amount of bleeding and a raised area on the scalp consistent with possible head impact, and the resident appeared fearful and confused during the assessment. EMS was contacted and the resident was transported to the hospital for evaluation of a head injury. Progress notes and the Facility Reported Incident (FRI) show that the event was identified as an allegation of physical abuse between the two residents, with staff reporting that the roommate was swearing loudly and threatening that if touched again, the resident would not be able to stand back up. The Administrator and DON confirmed they were notified of the incident on the night it occurred and were told that the roommate had stated he smacked the resident, causing him to fall. The Administrator confirmed that, during his interview, the roommate admitted to smacking the resident, but the Administrator reported the incident to the state the next day because he initially believed it was an unwitnessed fall, despite knowing of the admission of having smacked the resident. The facility’s Abuse, Neglect, and Exploitation policy required that all alleged violations involving abuse or resulting in serious bodily injury be reported immediately, but no later than two hours after the allegation is made. The delay in reporting this allegation of abuse constituted the cited deficiency.
Failure to Timely and Accurately Initiate Pressure Ulcer Treatment Orders
Penalty
Summary
The facility failed to ensure that pressure ulcer treatment orders were initiated, ordered, and implemented in a timely and accurate manner for three residents reviewed for pressure ulcer care. For one resident admitted with a stage 3 pressure ulcer, the facility did not initiate the wound physician's order for Hydrocolloid paste until 10 days after it was prescribed, instead providing only barrier cream during that period. The DON confirmed that both treatments were available in-house, but staff confusion regarding the correct product led to the delay in appropriate care. Another resident admitted with a stage 4 pressure ulcer had two overlapping and conflicting treatment orders for the same wound over a two-day period. The resident received orders for both a foam border dressing and Mesalt with gauze, resulting in a lack of clarity regarding which treatment should have been provided during that time. The DON verified the presence of these concurrent orders. A third resident with two stage 3 pressure ulcers did not have any treatment orders in place for two days following the wound physician's assessment and recommendation for Hydrocolloid paste. The DON confirmed that there was a gap between the wound assessment and the initiation of the appropriate treatment orders. Facility policy required evidence-based treatments in accordance with current standards of practice for all residents with pressure injuries, but this was not followed in these cases.
Unsanitary Kitchen Conditions and Improper Food Holding Temperatures
Penalty
Summary
Surveyors observed multiple failures in the facility's kitchen related to food storage, preparation, and sanitation. The freezer was found to be operating at temperatures above the recommended level, with built-up ice on the floor containing embedded pasta and a chunk of hair. The walk-in refrigerator emitted a strong mildew odor, had an unknown black substance along the walls, a pool of water accumulating around a lightbulb and dripping onto the floor, and dust buildup on the ceiling near the fan. Additional unsanitary conditions were noted, including a black substance behind the dishwashing sink, dirt buildup around the entrance door, black buildup behind and under the trash can, and dirt accumulation on floors and walls in corners and behind shelving. Staff interviews confirmed the lack of cleaning logs and acknowledged the unsanitary conditions. Further observations revealed that food tray temperatures at the end of one hall were below the required holding temperature, with chicken at 119°F, vegetables at 128°F, and stuffing at 137°F. When tasted, the food was warm but not hot, and staff confirmed that the food was not being held at or above the 135°F mark. All 49 residents in the facility received meals from this kitchen, indicating that the unsanitary conditions and improper food temperatures had the potential to affect the entire resident population.
Failure to Maintain Proper Freezer Temperatures for Food Storage
Penalty
Summary
The facility failed to store frozen foods at the appropriate temperatures to prevent spoilage, as evidenced by multiple observations of the walk-in freezer registering temperatures above the required standard. On several occasions, the freezer temperature was found to be between 7 and 20 degrees Fahrenheit, rather than at or below zero degrees Fahrenheit as required by facility policy. There was significant ice buildup on the internal thermometer, door frame, and floor, and a thick layer of frost was observed on the shelves and food items. Staff interviews confirmed the presence of these conditions and revealed a lack of knowledge regarding the correct freezer temperature. The freezer door seal was damaged, preventing the door from closing properly, which contributed to the temperature issues and ice accumulation. Review of facility records, including a sanitation audit and service logs, indicated that the problem with the freezer had been ongoing, with previous documentation of foods not being frozen solid and signs of freezer burn. The audit and service logs also noted the damaged gasket, kick plate, and frame, as well as the inability of the freezer to maintain proper temperatures. Despite these findings, food stored in the compromised freezer, such as chicken and vegetables, continued to be served to residents. The deficiency had the potential to affect all residents receiving food from the facility kitchen, except for one resident who did not eat food from the kitchen.
Failure to Implement Enhanced Barrier Precautions for Residents with Wounds
Penalty
Summary
The facility failed to implement and maintain enhanced barrier precautions (EBP) for residents with wounds, as required for infection prevention and control. Observations and record reviews revealed that multiple residents with chronic or open wounds did not have EBP signage or personal protective equipment (PPE) such as gowns and gloves available outside their rooms. In several cases, care plans and physician orders did not include EBP, and staff interviews confirmed the absence of these precautions. One resident with severe cognitive impairment and an unstageable pressure ulcer did not have EBP signage or PPE outside her room, and staff confirmed she was not under EBP. Another resident with a stage three pressure ulcer to the right heel also lacked a care plan for EBP, and there were no EBP orders or PPE available outside the room. A third resident with a stage four pressure ulcer of the sacral region similarly had no EBP care plan or orders, and staff confirmed the absence of EBP measures. Additionally, a resident with a left hip wound and a wound vacuum in place did not have EBP signage or PPE outside the room during multiple observations. Staff interviews indicated that PPE was stored at the nursing station rather than being immediately accessible near the resident's room. The Director of Nursing confirmed that EBP is necessary for residents with chronic wounds, but the required precautions were not in place for these residents.
Failure to Honor Resident Bathing Preferences and Facility Bathing Policy
Penalty
Summary
A deficiency was identified when a resident with diagnoses including cerebral infarction, acute respiratory failure with hypoxia, dysphasia, and bilateral paralysis, who had no cognitive deficits and required assistance for transfers and activities of daily living, was not provided with bathing opportunities in accordance with facility policy and her expressed preferences. The resident reported not receiving routine showers twice a week and not being offered bed baths between scheduled shower days. She also stated that staff would not assist with her hair care due to its length, requiring her to wait for her sister to visit for grooming. Review of the resident's medical record and facility documentation confirmed that only four showers were provided over a period of approximately three weeks, with no documentation available to verify additional showers or bed baths. Facility policy required that residents be offered showers at least twice weekly and bed baths daily, but this was not consistently documented or provided for the resident in question. Interviews with the DON and Regional Nurse confirmed the expectation for regular bathing and acknowledged the lack of compliance with facility protocols.
Failure to Provide SNF-ABN When Therapy Services Ended
Penalty
Summary
The facility failed to provide a Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNF-ABN) to a resident when therapy services were discontinued, despite the resident still having skilled benefit days remaining. The resident, who had diagnoses including anemia, atrial fibrillation, and hypertension, was admitted on 01/22/25 and received therapy services that ended on 02/16/25 due to admission to hospice care. Medical record review showed no evidence that the required SNF-ABN was given at the time therapy services ended. This was confirmed during an interview with the Business Office Manager, who acknowledged that the notice should have been provided but was not.
Failure to Implement and Order Therapy-Recommended Splinting Devices
Penalty
Summary
The facility failed to provide appropriate care to maintain or improve range of motion for a resident with significant physical and cognitive impairments. The resident, who had diagnoses including anoxic brain damage, metabolic encephalopathy, quadriplegia, and severe cognitive impairment, was dependent on staff for all mobility and activities of daily living. Occupational and physical therapy discharge summaries recommended the use of multiple splinting devices, including resting hand splints, knee braces, and ankle/foot braces, with specific schedules for their application. However, review of the resident's medical record revealed there were no physician orders in place for any of the recommended splints or braces. Observations showed the resident was not wearing any splints during multiple checks, and the devices were found stored in a box on the floor in the resident's room. Staff interviews confirmed the absence of current orders for splints and indicated that the resident was not routinely offered the devices, despite therapy recommendations and the resident's willingness to use them if offered. Communication between therapy and nursing staff was verbal, and the process for obtaining physician orders and ensuring implementation of splinting schedules was not followed, particularly after the resident's multiple hospitalizations.
Failure to Provide Adequate Assistance During Mechanical Lift Transfers
Penalty
Summary
Staff failed to provide adequate assistance during mechanical lift transfers for two residents who required such assistance. In one instance, a Certified Nurse Aide (CNA) was observed transferring a resident from a wheelchair to a bed using a Hoyer lift without the required second staff member present. The CNA confirmed during an interview that she performed the transfer alone and acknowledged that two staff members were needed for the procedure. In another case, a different CNA was seen exiting a resident's room with a Hoyer lift, and no other staff were observed. This CNA also admitted to transferring the resident alone, stating she believed it was safe and permitted to do so. The Director of Nursing (DON) confirmed that facility policy does not allow single-staff Hoyer lift transfers. Additionally, a review of the Patient Lift Safety Guide indicated that most lifts require two or more caregivers to operate safely. These observations and interviews demonstrate that the facility did not ensure residents who required mechanical lift assistance were provided with adequate supervision and assistance to prevent accidents.
Failure to Follow Physician Orders for Tube Feedings
Penalty
Summary
A resident with diagnoses including cerebral infarction, acute respiratory failure with hypoxia, dysphasia, and bilateral paralysis was admitted to the facility and required nutritional tube feedings as ordered by a physician. The physician's order specified Nutren 2.0 complete liquid nutrition, to be administered as a 250 mL bolus five times daily. However, on one day, the resident did not receive the scheduled enteral feedings at 8:00 A.M., 11:00 A.M., and 12:00 P.M., only receiving feedings later in the day at 5:00 P.M. and 9:00 P.M. The resident, who had no cognitive deficits and was aware of her feeding regimen, reported missing two feedings and expressed frustration at not being informed about the reason for the missed feedings. The Director of Nursing confirmed that the missed feedings were due to a problem with the resident's tube feeding pump. Review of facility policy indicated a general commitment to providing nutritional care but did not include a specific policy on following physician's orders. The deficiency was identified through medical record review, resident and staff interviews, and policy review, and it was determined that the facility failed to ensure physician orders for tube feedings were followed for this resident.
Failure to Complete Monthly Pharmacist Medication Regimen Reviews
Penalty
Summary
The facility failed to ensure that a licensed pharmacist conducted monthly medication regimen reviews, including a review of the medical chart, for at least two residents. For one resident with diagnoses such as senile degeneration of the brain, major depressive disorder, anxiety disorder, hypertension, hyperlipidemia, hypothyroidism, and sleep apnea, there was no documentation of a pharmacist's review of the medication regimen for the month of February 2025. This resident was receiving antipsychotic, antidepressant, antianxiety, and opioid medications, yet pharmacy records and consultant pharmacist recommendations did not reflect a monthly review or any recommendations for that period. The DON confirmed that no additional documentation was available to indicate the review had occurred. Another resident, admitted with conditions including intracerebral hemorrhage, schizoaffective disorder, anxiety, and hypertension, and who was severely cognitively impaired, also did not have documented pharmacist reviews for June 2024 and February 2025. This resident was receiving daily antipsychotic and antidepressant medications. Review of pharmacy progress notes and consultant pharmacist reports did not show evidence of the required monthly reviews or recommendations for the specified months. The DON confirmed the absence of documentation for these reviews. Facility policy requires that each resident's drug regimen be reviewed at least monthly by a licensed pharmacist, including a review of the medical chart.
Significant Medication Administration Errors Identified
Penalty
Summary
The facility failed to ensure residents were free from significant medication errors, as evidenced by multiple incidents involving improper medication administration. In one instance, a registered nurse administered insulin to a resident with diabetes mellitus type II without priming the insulin pen, contrary to manufacturer instructions and the user guide, which state that priming is necessary to remove air and ensure accurate dosing. The nurse confirmed during an interview that she did not prime the pen and was unaware of the requirement. Additionally, two other residents experienced missed doses of critical medications. One resident did not receive two scheduled doses of the antibiotic Keflex, despite the medication being available in the facility's emergency medication box. Another resident missed several scheduled doses of the anticoagulant Xarelto, and the medication was not administered with meals as ordered. The Director of Nursing confirmed the missed doses and the timing issue with meal administration. These failures were identified through observation, medical record review, staff interviews, and policy review.
Failure to Provide Timely Dental Services Due to Misfiled Documentation
Penalty
Summary
A deficiency occurred when a resident who had agreed to receive dental services was not provided with those services in a timely manner. The resident, admitted with diagnoses including cerebral infarction, alcohol dependence, intellectual disabilities, and hypertension, had a care plan identifying the potential for oral health problems and interventions that included coordinating dental care. Documentation showed the resident was made aware of available ancillary services and had signed to receive dental care. However, the signed document was not properly filed in the resident's record. As a result, when the facility prepared for the dentist's visit, staff were unaware that the resident had elected to receive dental services. The resident reported not having seen a dentist since admission and had been requesting to do so. Staff interviews confirmed the oversight was due to the misfiled paperwork, which led to the resident not being scheduled for dental care as intended.
Failure to Document Against Medical Advice (AMA) Discharge
Penalty
Summary
The facility failed to ensure proper documentation in the medical record for a resident who was discharged against medical advice (AMA). Specifically, a resident with chronic heart failure, muscle weakness, and chronic kidney disease was admitted and later left the facility with his wife without following the established sign-out procedures. The nurse was not notified prior to the resident's departure, and the resident's wife only signed the resident out in the front desk book after being prompted by a nurse aide. The medical director and DON were notified of the situation, but there was no documentation in the resident's medical record regarding the AMA discharge. Interviews confirmed that the resident's wife took him home with no intention of returning, citing dissatisfaction with the care provided. The business office manager verified that the medical record lacked any documentation of the AMA discharge, and a review of facility policy indicated that such documentation should have been entered by nursing and social services staff. This deficiency affected one of three residents reviewed for discharges.
Nonfunctional Call Light System in Resident Room
Penalty
Summary
A deficiency was identified when a resident's call light system failed to function properly in both the bathroom and bathing area. The resident, who had intact cognition and multiple medical diagnoses including metabolic encephalopathy, generalized anxiety disorder, delusional disorder, obstructive sleep apnea, chronic pain, epilepsy, and obesity, was unable to activate the call light despite multiple attempts. Observations confirmed that the call light did not activate when pressed, and the issue persisted over multiple checks. A nurse passing medications was notified of the malfunction, and a subsequent attempt by an LPN also confirmed the call light was not working at the bedside. The facility's policy requires staff to report any problems with the call light system immediately and to provide alternative solutions until the issue is resolved. Despite this policy, the resident's call light system remained nonfunctional during the period of observation, and the deficiency was confirmed through interviews and direct observation. The issue affected one of two residents reviewed for call lights, with a facility census of 58.
Unsanitary Shower Room Conditions
Penalty
Summary
The facility failed to maintain a shower room in a clean and sanitary manner, affecting three residents and potentially impacting 34 others who used the shower room on the 200 hall. Observations revealed that the floor of the shower room had large black stained areas covering nearly the entire floor, with a loose area surrounding the center floor drain that caused water to bubble up when stepped on. Additionally, a small portion of tile was missing from the half wall dividing the two shower areas. Interviews with staff and residents confirmed the poor condition of the shower room. A State Tested Nurse Aide (STNA) and a Licensed Practical Nurse (LPN) both noted that some residents refused to use the shower room due to its condition. Residents expressed their dissatisfaction, describing the room as filthy and smelly, with some refusing to use it until repairs were made. The facility had begun seeking contractors for repairs but had not yet secured any definite plans.
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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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