Urbana Health & Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Urbana, Ohio.
- Location
- 741 E Water Street, Urbana, Ohio 43078
- CMS Provider Number
- 365365
- Inspections on file
- 21
- Latest survey
- August 29, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Urbana Health & Rehabilitation Center during CMS and state inspections, most recent first.
Surveyors found that three residents' rooms had holes in the walls and torn wallpaper, with both residents and staff confirming the damage had not been addressed. Review of maintenance logs showed no documentation that these issues were identified or reported, despite facility procedures requiring staff to log such maintenance needs.
Residents repeatedly raised concerns during council meetings about delayed call light responses, staff rudeness, cold showers, and requests for additional smoking breaks, but these issues remained unresolved for several months. Residents also reported that their requests to meet without staff and have a resident take meeting minutes were not accommodated. Staff interviews confirmed that these concerns were not addressed in a timely manner, and the facility's required documentation and follow-up process was not effectively implemented.
During a medication pass, two residents received medications incorrectly: one was given the wrong formulation of a laxative by an LPN, and another received crushed extended-release Potassium Chloride from an RN, resulting in a medication error rate above 5%.
Several residents were served popcorn shrimp that was not properly prepared, resulting in a hard, white coating that was difficult to chew and unappetizing. The shrimp was cooked in an oven instead of a deep fryer, contrary to the product's requirements and facility policy, leading to multiple residents being unable to eat their meal.
Staff responsible for food preparation and service failed to maintain sanitary practices, including not covering a noncommunicable skin condition on the forearms, not keeping hair fully restrained, and not sanitizing hands after touching the face and hair. These actions resulted in unsanitary food handling and equipment use, affecting nearly all residents receiving food from the kitchen.
Staff failed to perform hand hygiene during both medication administration and meal tray delivery. A nurse used bare hands to pick up dropped medications from an unclean cart before administering them to a resident with severe cognitive impairment and multiple chronic conditions. Additionally, a dietary manager delivered meal trays to three residents without using hand sanitizer between rooms, despite facility policy requiring hand hygiene after contact with the patient environment.
Multiple residents experienced prolonged periods without functioning air conditioning, unclean and poorly maintained rooms, and uncomfortable common areas, including a cold shower room and broken dining chairs. Maintenance issues were not consistently addressed, and residents reported dissatisfaction with the cleanliness and comfort of their environment.
The facility did not honor a resident's request for a supervised smoking break and failed to timely address repeated requests from two residents for an additional scheduled smoke break, despite these concerns being raised in resident council meetings. Staff cited insufficient staffing as the reason for not providing the extra break, and facility records showed no follow-up or resolution of the residents' requests.
Staff failed to maintain dignity and respect for two residents, including one who was subjected to an inappropriate gesture by a CNA during care, and another who was not consulted before being given a clothing protector and was referred to disrespectfully as the "only true feed" in the dining room.
A resident with multiple chronic conditions and cognitive intactness reported being verbally abused by a CNA, who admitted to calling the resident an "ass" during a dispute over a roommate. The incident was reported to the DON, who allegedly attempted to downplay the situation. Facility policy prohibits such verbal abuse, but the resident was not asked for a formal statement, and the Administrator was unaware of the event.
A resident with multiple chronic conditions reported that a CNA called him an inappropriate name during a dispute, and although the incident was brought to the attention of the DON, it was not reported to the administrator or state agency as required by facility policy. The CNA admitted to the comment, and the DON addressed the matter informally without following mandated reporting procedures.
A resident reported being called an "ass" by a CNA and informed the DON, who attempted to downplay the incident and did not initiate a formal investigation or collect statements as required by facility policy. The Administrator was unaware of the event, and the facility failed to follow its procedures for investigating abuse allegations.
The facility did not complete required PASRR screenings for two residents who began receiving hospice care, despite significant changes in their medical status and care needs. Both residents had complex medical histories and were dependent on staff, but no PASRR documentation was found or completed at the time hospice services were initiated.
Two residents with complex medical conditions did not receive routine care conferences every three months as required. Medical record reviews and interviews confirmed that care conferences were not held according to schedule, and staff acknowledged being behind in completing them, contrary to facility policy.
Surveyors found unsecured hazardous chemicals in unlocked areas accessible to a resident with severe cognitive impairment and wandering behavior. Additionally, the facility did not honor a restricted liquid diet for a resident requiring hydration management.
A resident with multiple cardiac and renal diagnoses, who was cognitively intact and independent, received more fluids than prescribed on several occasions. Staff interviews and tray observations confirmed that the resident's physician-ordered fluid restriction was not consistently followed, with meal trays sometimes containing excess fluids.
A nurse crushed and administered an extended-release potassium chloride tablet to a resident with severe cognitive impairment and multiple cardiac conditions, despite facility policy and pharmacy guidance indicating this medication should not be crushed. The error was confirmed through staff interviews and review of facility documentation.
Surveyors found expired Folic Acid stock in the medication room and observed that a resident's prescribed Hydralazine dose was left unattended at the bedside, with staff confirming that medication administration was not always directly observed as required by policy.
A resident with a broken tooth and subsequent infection did not receive a timely follow-up dental appointment for root extraction. After an initial unsuccessful extraction and a referral for oral surgery, the resident was treated with antibiotics but was not scheduled for the necessary procedure. The scheduler left a message with the only Medicaid-accepting surgical clinic, but no further action was documented, leaving the resident to manage symptoms independently.
A resident with significant physical limitations was exposed to a swarm of flying insects in her room, which she was unable to remove herself. Staff and family confirmed the presence of the insects, and the resident was moved to another room. The facility was aware of the pest issue but had not resolved it by the time of the survey, resulting in a deficiency for not maintaining an effective pest control program.
The facility did not maintain documentation of annual 90-minute testing for seven emergency lights as required by NFPA 101, with a staff member confirming unawareness of the requirement. This deficiency had the potential to affect 46 residents.
The facility did not complete the required four-hour load bank test of its diesel generator within the mandated 36-month period and failed to properly document engine hours during monthly tests, as confirmed by the Maintenance Director. This lapse affected the reliability of the essential electrical system for all residents.
Surveyors found that two corridor doors would not latch despite multiple attempts, and a staff member was unaware of the regulatory requirements. This deficiency had the potential to affect 17 residents, as the doors did not meet NFPA 101 standards for smoke resistance and positive latching.
Surveyors found that two wires passed unsealed through a smoke barrier above the ceiling near a resident corridor, with the Maintenance Director confirming unawareness of the sealing requirement. This deficiency had the potential to affect five residents and did not comply with NFPA 101-2012 standards for smoke barrier construction.
Surveyors found that several fire/smoke barrier doors, including those near the DON office and in resident rooms, were unable to close properly during both routine checks and a fire alarm test. Staff confirmed they were unaware of the closure requirements for these doors, resulting in noncompliance with NFPA 101-2012 standards and potentially affecting multiple residents.
Surveyors observed numerous cigarette butts scattered in both the back of the facility and the employee smoking area, which was located near combustible materials. The required metal containers with self-closing covers for ash disposal were not present in the employee area, despite ashtrays being provided. Staff confirmed awareness of the issue, but no corrective action was taken prior to the survey.
Surveyors found that oxygen cylinders in a storage area were labeled as "full" and "partial/empty" without a clear definition for "partial," leading to possible misplacement of nearly full cylinders in the empty section. A staff member confirmed confusion about the requirements, and the issue had the potential to affect multiple residents.
Failure to Maintain Resident Rooms Free of Damage
Penalty
Summary
Surveyors identified that the facility failed to maintain resident rooms in a safe and homelike condition, as evidenced by the presence of holes in the drywall and torn wallpaper in the rooms of three residents. Observations revealed that one resident's room had two large holes and torn wallpaper on the wall beside the bed, which the resident confirmed had been present for a long time. Another resident's room had a large hole and torn wallpaper behind the bed, with the resident acknowledging the damage but unsure of its duration. A third resident's room also had a hole and torn wallpaper behind the bed, though the resident was unaware of the damage. Staff interviews confirmed the existence of these deficiencies in all three rooms. A review of the facility's maintenance work order log from June to August did not show any documentation that the holes or torn wallpaper in these rooms had been identified or reported. The facility's work order process requires staff to identify and log maintenance needs, but there was no evidence that this process was followed for the affected rooms. The deficiency was identified during a complaint investigation and affected three out of four residents reviewed for a homelike environment, with the facility census at 47.
Failure to Address and Resolve Resident Council Concerns in a Timely Manner
Penalty
Summary
The facility failed to address and resolve resident concerns raised during Resident Council meetings in a timely manner, as evidenced by repeated documentation of unresolved issues in the council minutes over several months. Concerns included call lights not being answered promptly, requests for an additional smoking break, cold showers in a specific wing, and staff speaking rudely to residents. These issues were consistently brought up in meetings from January through May, with no documented resolution or satisfactory response provided to the residents. Interviews with residents who held leadership roles in the Resident Council revealed ongoing dissatisfaction with the administration's handling of their complaints. The residents reported that their requests, such as having a resident take meeting minutes and meeting without staff present, were not accommodated. They also expressed frustration that their concerns about staff behavior, call light response times, and environmental issues like shower temperature had persisted for months without resolution. Staff interviews confirmed that the concerns raised by residents were not being resolved in a timely manner. The Activities Director acknowledged that resident training to take minutes had not been completed, and the Administrator confirmed that issues such as call light response, staff rudeness, and environmental complaints remained unresolved. The facility's policy required documentation and follow-up on resident concerns, but the process was not effectively implemented, as evidenced by the lack of resolution and ongoing resident dissatisfaction.
Plan Of Correction
maintain ongoing compliance LNHA will audit Resident Council Minutes and Concern forms weekly X4, then monthly x2 to ensure concerns are being resolved timely and appropriately. Results of the audits will be forwarded to the facility QAPI committee for further review and recommendation. F600 Urbana Health and Rehab wishes to point out to any person who reviews this document that we do not necessarily agree with the citations with which we were cited. However, the law requires us to prepare a plan of correction for the citations regardless of whether we agree with them or not. Thus, we have prepared such a plan as noted below. Please note though, that this plan does not constitute an admission that the citations are either legally or factually correct. This plan of correction is not meant to establish any standard of care, contract, obligation, or position, and Urbana Health and Rehab reserves all rights to raise all possible contentions and defenses in any civil or criminal action or proceeding. Please accept 07/30/25 as the facility's allegation of compliance date. The facility failed to ensure residents were safe from abuse, affecting one resident #24. Step 1 Resident #24 was assessed and no negative findings. Resident assessment completed on 6/11/25 by NP. STNA #240 was removed from duty and suspended, personnel file for STNA #240 was reviewed for background check, along with 5 other random staff personnel files, no concerns were identified. Audit completed on 6/6/25. Step 2 To identify other residents that have the potential to be affected, on 6/6/25 the Social Services initiated interviews of those residents able to be interviewed regarding abuse, completing the interviews on 6/6/25 with no negative findings. DON completed skin check on 6-6-25 for non-verbal and cognitively impaired resident with no negative findings. Step 3 To prevent this from recurring, NHA started in house
Medication Error Rate Exceeds 5% Due to Administration Errors
Penalty
Summary
The facility failed to maintain a medication error rate below five percent during a medication pass observation, resulting in a calculated error rate of 6.67%. Two residents were directly affected by medication administration errors. For one resident with a history of chronic obstructive pulmonary disease, osteoporosis, pneumonia, and paroxysmal atrial fibrillation, the LPN administered Senna Plus 8.6-50 mg instead of the ordered Sennoside 8.6 mg. The error was confirmed by the LPN during an interview. Another resident, diagnosed with chronic diastolic heart failure, depression, vascular dementia, paroxysmal atrial fibrillation, and hypertension, received Potassium Chloride ER 20 MEQ in crushed form, contrary to the extended-release medication's administration guidelines. The RN confirmed that the Potassium Chloride ER was crushed and administered in applesauce. Facility policy requires staff to verify correct medication, dose, route, and administration method for each resident, which was not followed in these instances.
Plan Of Correction
F759 Facility observed medication administration error rate of 6.75% affecting residents #43 and #15, when LPN administered Senna Plus to resident #43 instead of ordered Senna and RN crushed potassium chloride for resident #15. Step 1: The facility RN #204 immediately notified the PCP with no new orders on 6/4/25. Residents #43 was assessed by the facility DON with no negative findings and resident #15 was assessed by RN #204 without negative effects observed on 6/4/25. The LPN #257 and RN #204 were immediately educated by the facility DON on medication administration principles as well as medication error prevention. Completed on 6/5/25. Step 2: All residents have the potential to be affected by medication error rate of 6.75%. Step 3: To prevent this from recurring the DON or designee will educate licensed nursing personnel on principles of proper medication administration, including medications that can/cannot be crushed and medication error prevention as well as having updated medication administration competencies. Completed on 7/11/25. Step 4: To monitor and maintain ongoing compliance, the DON or designee will complete medication administration audits 2x per week x4 weeks then 2x per month x2 months. Audits will begin on 7/14/25. The results of the audits will be forwarded to the facility QAPI committee for further review and recommendations. F760 Facility failed to prevent significant medication administration error for resident #15, when RN #204 crushed potassium chloride for resident #15. Step 1: The facility RN #204 immediately notified the PCP; no new orders. The RN #204 assessed resident #15 without negative effects observed. The RN #204 was immediately educated by the DON on medication administration principles as well as medication error prevention with special focus on medications that cannot be crushed. Completed on 6/5/25. Step 2: This has the potential to affect residents that require medications being crushed. The DON will review medication lists for residents that require mechanically altered medications on 7/10/25. Step 3: To prevent this from recurring the DON or designee will educate licensed nursing personnel on principles of proper medication administration and medication error prevention with special focus on medications that cannot be crushed. Completed on 7/11/25. Step 4: To monitor and maintain ongoing compliance, the DON or designee will complete medication administration audits 2x per week x4 weeks then 2x per month x2 months. Audits will begin on 7/14/25. The results of the audits will be forwarded to the facility QAPI committee for further review and recommendations.
Unpalatable and Improperly Prepared Food Served to Residents
Penalty
Summary
The facility failed to prepare palatable food for residents on regular consistency textured diets, as evidenced by multiple observations and interviews. During a lunch meal, several residents received popcorn shrimp that had a white, hard coating and was not browned, making it difficult to chew. Residents who received the shrimp either struggled to eat it or removed it from their mouths due to its unappetizing texture and appearance. Interviews with these residents confirmed that the shrimp was unappetizing and difficult to chew, resulting in their inability to consume the meal. Further investigation revealed that the shrimp was prepared in an oven rather than a deep fryer, which was the appropriate method for this product. The cook confirmed that the facility did not have a deep fryer, leading to the shrimp remaining white and the coating becoming harder. The registered dietitian verified that the shrimp should have had a golden brown appearance and a coating that was easily chewed. Review of the facility's food production and safety policy indicated that foods are to be prepared by methods that maintain, develop, and enhance flavor, which was not followed in this instance.
Plan Of Correction
F804 Urbana Health and Rehab wishes to point out to any person who reviews this document that we do not necessarily agree with the citations with which we were cited. However, the law requires us to prepare a plan of correction for the citations regardless of whether we agree with them or not. Thus, we have prepared such a plan as noted below. Please note though, that this plan does not constitute an admission that the citations are either legally or factually correct. This plan of correction is not meant to establish any standard of care, contract, obligation, or position and Urbana Health and Rehab reserves all rights to raise all possible contentions and defenses in any civil or criminal action or proceeding. Please accept 07/30/25 as the facility's allegation of compliance date. The facility failed to provide residents on a regular diet with palatable food affecting residents 20, 39, 35, 5, 28, 2, 34, 12, 33, 198, 38, 8, 17, 27, 43, 29, 3, 13, 32, 22, 10, 26, 31, 25, 24, 7, 23, and 37. Step 1: Dietary Manager provided identified residents alternate menu items at their request. This was completed on 6/2/25. Step 2: Dietary Manager to audit current food supply to ensure we have ability to prepare the items properly for the best outcomes in taste and presentation. Audit completed to be by 6/30/25. Dietary manager will adjust weekly order to ensure menu items can be prepared by the kitchen appliances. Step 3: RRD to provide education on 6/18/25 to Dietary Manager to order alternative items when a specific way of preparation is unavailable at the facility. Step 4: To monitor and maintain ongoing compliance, RRD/Designee will audit menu and preparation process weekly X4, then monthly x2 to ensure that menu items are being prepared properly with the equipment Urbana kitchen has available. Results of the audits will be forwarded to the facility QAPI committee for further review and recommendation. --- F812 Urbana Health and Rehab wishes to point out to any person who reviews this document that we do not necessarily agree with the citations with which we were cited. However, the law requires us to prepare a plan of correction for the citations regardless of whether we agree with them or not. Thus, we have prepared such a plan as noted below. Please note though, that this plan does not constitute an admission that the citations are either legally or factually correct. This plan of correction is not meant to establish any standard of care, contract, obligation, or position and Urbana Health and Rehab reserves all rights to raise all possible contentions and defenses in any civil or criminal action or proceeding. Please accept 7/30/25 as the facility's allegation of compliance date. The facility failed to prepare food in a sanitary manner affecting 45 residents that received food from the facility kitchen. Observation 1: DM did not have arm coverings on while preparing food and she has a diagnosis of psoriasis. Observation 2: Cook #250 failed to wear gloves nor did she sanitize her hands after touching her face when reassembling the food processor. Step 1: Regional Dietitian educated DM on dress and personal hygiene and instructed to don a jacket and/or arm coverings, completed 6/4/25. Step 2: Regional Dietitian educated Cook #250 on handwashing in the kitchen, handling and storage of equipment and utensils, which included information on avoiding handling equipment that will come in contact with food, the drying of wet equipment, and the use of disposable gloves in the kitchen. Handwashing competencies.
Food Preparation and Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure food was prepared and served in a sanitary manner, affecting 45 residents who received food from the kitchen. Observations revealed that a diet manager with a noncommunicable skin condition on her forearms, characterized by white flakes and reddened skin, performed food preparation, service, and dishwashing duties without consistently covering the affected skin areas. Despite acknowledging the need to cover the flaky skin, the diet manager was observed multiple times with exposed forearms while handling food and washing dishes, and even when a jacket was worn, the sleeves were pushed up, leaving the skin exposed. Facility policy and state code require food employees to keep hands and exposed portions of arms clean and to wear protective coverings when necessary. Additionally, a cook was observed preparing pureed foods while engaging in unsanitary practices, such as rubbing her forehead and partially exposing her hair from under a hairnet during food preparation. The cook did not sanitize her hands after touching her face and hair, and she reassembled a food processor with her bare hands without ensuring the equipment was dry before use. The cook confirmed these actions during interviews. Facility policies require staff to avoid touching food-contact surfaces of cleaned equipment and to wear hair restraints that fully cover hair, but these standards were not followed during the observed food preparation processes.
Plan Of Correction
Completed 6/2/25 by Regional Dietitian. Step 2 The potential to affect all residents. Cognitive residents interviewed for adverse effects in last 30 days, non-verbal or cognitive impaired residents had medical records review with look back of 30 days, to be completed by 7/15/25. Step 3 All dietary staff to be educated by the RRD/designee on Facility policies "Food and Nutrition, Personnel and Training" and "Food and Nutrition, Sanitation and Infection Control" by 6/30/25. Step 4 To monitor and maintain ongoing compliance, RRD/designee will audit 1 dish washing process daily, weekly x4, then monthly x2 to ensure proper sanitation and infection control practices are being adhered to. Results of the audits will be forwarded to the facility QAPI committee for further review and recommendation.
Failure to Perform Hand Hygiene During Medication Pass and Meal Delivery
Penalty
Summary
Facility staff failed to perform proper hand hygiene during medication administration and meal tray delivery, resulting in a deficiency under infection prevention and control standards. During a medication pass, a registered nurse dropped several medications onto the top of a medication cart, which was not clean, and then used her bare, ungloved hand to pick up the medications and place them into a medication cup. The nurse then crushed the medications, mixed them with applesauce, and administered them to a resident with severe cognitive impairment and multiple chronic conditions, including heart failure and atrial fibrillation. Additionally, the dietary manager was observed delivering lunch trays to three different residents without performing hand hygiene between each delivery. The dietary manager entered each resident's room, removed the food tray lid, touched items on the tray and the food delivery cart, and exited the room without using the hand sanitizer dispensers that were available in each room. The dietary manager confirmed during an interview that she did not wash her hands or use hand sanitizer between meal tray deliveries, acknowledging awareness of the proper procedure but stating she did not often deliver trays. A review of the facility's hand hygiene policy indicated that employees are required to use alcohol-based hand rub or wash hands after touching a patient's environment. The observed failures to follow this policy during both medication administration and meal tray delivery directly contributed to the cited deficiency in infection prevention and control.
Plan Of Correction
F880 The facility failed to ensure proper infection control measures when: A) The RN #204 dropped medication for resident #15 on the medication cart during medication administration, then placed medication in a medication cup. B) The Dietary Manager #208 assisted with passing meal trays on the B-front hall without performing proper hand hygiene during tray pass for residents #98, #5, and #99. Step 1: The facility DON immediately educated A) the RN #204 on proper maintenance of infection control practices during medication administration and B) the Dietary Manager #208 on proper hand hygiene practices while passing meal trays. Hand Hygiene competencies were completed on both individuals as well. Completed on 6/10/25. Step 2: This has the potential to affect residents #15, #98, #5, #99; The DON will assess the identified residents #5 and #15 for potential effects on 7/10/25. Unable to assess #98 and #99 as these residents are not identified on the resident identifier list provided by the ODH Surveyors. Step 3: To prevent this from recurring, the DON or designee will educate A) licensed nurses on proper infection control principles during medication administration and B) staff that assist with meals on proper hand hygiene during the meal process. Completed on 7/11/25. Step 4: To monitor and maintain ongoing compliance, the DON or designee will audit A) maintenance of proper infection control practices during medication administration 2x per week x4 weeks then 2x per month x2 months and B) use of proper hand hygiene during tray pass 3x per week x4 weeks then monthly x2 months. Audits will begin 7/14/25. The results of the audits will be forwarded to the facility QAPI committee for further review and recommendations.
Failure to Maintain Safe, Sanitary, and Comfortable Environment
Penalty
Summary
The facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public, as required by regulation. Multiple residents experienced prolonged periods without functioning air conditioning in their rooms, despite documented work orders and repeated resident complaints. Residents dependent on oxygen and with significant medical conditions, such as heart failure and chronic respiratory issues, were observed in uncomfortably warm rooms, relying on fans for cooling. Maintenance staff confirmed that repairs were not completed due to unavailable parts and lack of assistance, and residents reported not seeing maintenance staff after initial contact. Environmental cleanliness and maintenance were also lacking throughout the facility. Several resident rooms were observed with dirty, sticky floors, rusted sinks, stained toilets, and built-up grime in corners and on fixtures. In some cases, furniture and call lights were damaged or inadequately repaired, and residents expressed dissatisfaction with the cleanliness and condition of their living spaces. The facility's A unit had widespread blackened buildup at room entryways and corners, and there was no written plan for floor replacement or deep cleaning. Resident council meeting minutes corroborated ongoing concerns about inadequate room cleaning. Common areas and shared facilities were similarly affected. The A unit shower room was repeatedly reported as uncomfortably cold by residents, with a measured temperature below the recommended range, a non-functioning wall heater, and significant dust and debris buildup on ceiling fans and louvers. Dining room chairs were found to be broken or worn, with exposed, unsealed wood surfaces, and at least one chair remained in use despite being identified as unsafe. Maintenance staff confirmed these issues and stated that some problems were not reported to them, resulting in delays or lack of repairs.
Plan Of Correction
F921 The facility failed to maintain a homelike environment for residents #3, #7, #8, #14, #29, #37, #38, #39, #198 directly and all 26 residents on A Wing when: A) 2 PTAC room units (HVAC) stopped working appropriately in residents #198 and #38 rooms. B) Resident #29 toilet dirty, sink rusted, and floors dirty/sticky. C) Resident #39 bed remote needing replaced, the floor was sticky, the light above the sink needed replaced, and the light cover was yellowed. Toilet caulking around toilet stained. D) Resident #8 sink rusted, light over sink yellowed, bathroom floor tiles stained, metal hinges on toilet seat dirty, gouges in bathroom doorway paint. E) Resident #3 floors with buildup in corners, gouges in drywall, tape on call light, bathroom floor with stains, toilet with yellowish stains, furniture in disrepair, unable to use over-the-bed light due to length of string, dust on lights/bulbs. F) Resident #37 toilet with yellowish stains and sticky floor. G) A Wing Shower Room 69 degree ambient temperature with non-functioning heater and fan louvers with build-up. H) All resident rooms on A Wing with buildup of blackened material at threshold to hallway. I) Resident #14 missing/damaged wallpaper near bed. J) One chair in main Dining Room with damaged armrest, remaining chairs with protective finish removed due to wear and in overall disrepair. Step 1: The facility immediately A) replaced the PTAC units in the rooms of both resident #198 and #38, in addition to placing order with contracted maintenance company BIS to assess, secure parts, and/or order additional units. Completed 6/5/25. B) The Maintenance Director audited resident rooms/bathrooms to identify a priority schedule for installation of new flooring, replacement of lighting units, toilets, and sinks. Completed on 7/10/25. C) The toilets in question were immediately cleaned. Completed on 6/10/25. D) DOM will create a schedule for installation of new flooring into non-priority rooms/areas as well as replacement of lighting units, sinks, and toilets. Completed on 7/10/25. The Maintenance Director has initiated repairs to identified areas noted above including the following measures: B) Resident #29 toilet cleaned 6/10/25, sink plan to replace, floors cleaned 6/10/25. C) Resident #39 bed remote needing replaced completed 6/10/25, the floor was sticky and cleaned 6/10/25, the light above the sink needed replaced and the light cover was yellowed both replaced 6/10/25, toilet caulking around toilet stained plan to replace. D) Resident #8 sink rusted plan to replace, light over sink yellowed replaced 6/10/25, bathroom floor tiles stained plan for new flooring, metal hinges on toilet seat dirty cleaned 6/10/25, gouges in bathroom doorway paint, plan to repaint. E) Resident #3 floors with buildup in corners cleaned 6/10/25, gouges in drywall repaired 6/4/25, tape on call light removed 7/10/25, bathroom floor with stains plan to replace, toilet with yellowish stains plan to replace, furniture in disrepair plan to replace, unable to use over-the-bed light due to length of string replaced 7/10/25, dust on lights/bulbs cleaned/dusted 7/10/25. F) Resident #37 toilet with yellowish stains plan to replace and sticky floor cleaned 6/10/25. G) A Wing Shower Room 69 degree ambient temperature with non-functioning heater and fan louvers with build-up corrected 6/4/25. H) All resident rooms on A Wing with buildup of blackened material at threshold to hallway, adhesive from new/replaced hallway flooring removed 7/10/25. I) Resident #14 missing/damaged wallpaper near bed, plan to remove paper and paint room. J) One chair in main Dining Room with damaged armrest removed from use, remaining chairs with protective finish removed due to wear and in overall disrepair, plan to replace all Dining Room chairs. Step 2: This has the potential to affect all residents. The DOM or designee will create a Master Deep Cleaning schedule for all resident rooms/bathrooms/shower rooms. The LNHA will place a request for capital funds to replace sinks, toilets, and furniture identified as in disrepair. Will be completed on 7/10/25. Step 3: To prevent this from recurring, the LNHA, DOM, or designee will educate staff on the work order process. The DOM will educate the environmental services staff on the Master deep cleaning schedule. The DON will educate STNA's on the need for cleaning toilets and floors throughout the day and night when soiled. Completed on 7/11/25. Step 4: To monitor and maintain ongoing compliance, the LNHA or designee will audit 5 rooms for repair/maintenance needs 5 times per week and complete work order notifications. The DON will audit 8 toilets weekly for 4 weeks then monthly for 2 months. The DOM will audit 6 HVAC vents weekly for 4 weeks then monthly for 2 months. Audits to begin on 7/14/25. The results of the audits will be forwarded to the facility QAPI committee for further review and recommendations.
Failure to Honor Resident Smoking Break Requests and Address Council Concerns
Penalty
Summary
The facility failed to honor a resident's request for a supervised smoking break and did not timely address or resolve requests for an additional smoke break for two other residents. One resident, who had diagnoses including neuromuscular dysfunction of the bladder, depression, and nicotine dependence, required staff supervision for smoking and assistance with transfers. This resident reported not receiving a requested smoke break after asking the Social Services staff, who communicated the request to management but did not ensure follow-through. The administrator was aware of the request but was occupied with another situation and assumed the need had been addressed. Additionally, two other residents, both cognitively intact and dependent on staff for transfers, had participated in resident council meetings where a request for an additional smoking break between the existing scheduled times was made. Despite repeated documentation of this request in council meetings, there was no evidence that the facility addressed or resolved the concern in subsequent meetings or in practice. The designated smoking times did not include a break between 4:00 P.M. and 9:00 P.M., as requested by the residents. Staff interviews confirmed that the facility was unable to provide the additional supervised smoking break due to staffing limitations, even though the responsibility for supervising smoking was shared among staff. The Activities Director indicated that a new staff member would be trained to assist with smoking supervision, but at the time of the survey, the additional break had not been implemented. Facility policies reviewed stated that residents have the right to a dignified existence and self-determination, but the facility did not ensure these rights were upheld regarding the residents' smoking requests.
Plan Of Correction
Urbana Health and Rehab wishes to point out to any person who reviews this document that we do not necessarily agree with the citations with which we were cited. However, the law requires us to prepare a plan of correction for the citations regardless of whether we agree with them or not. Thus, we have prepared such a plan as noted below. Please note though, that this plan does not constitute an admission that the citations are either legally or factually correct. This plan of correction is not meant to establish any standard of care, contract, obligation, or position, and Urbana Health and Rehab reserves all rights to raise all possible contentions and defenses in any civil or criminal action or proceeding. Please accept 7/30/25 as the facility's allegation of compliance date. F550 The facility failed to maintain the rights of residents by not providing extra smoke breaks to residents #24, #29, #35 when requested. Step 1: The facility immediately reviewed smoking policy and current smoking schedule, additional smoke added with adjustments of current times. Completed on 6/24/25. Step 2: To identify other residents that have the potential to be affected, IDT reviewed current in-house residents that smoke. Completed on 6/24/25. Step 3: To prevent this from recurring, the facility IDT will complete updated smoking assessments on current residents choosing to smoke, will have a meeting with the smokers to review the policy, updated smoking times, and have noted residents sign updated smoking contracts. Completed on 7/10/25. Step 4: To monitor and maintain ongoing compliance, the DON or designee will interview 3 smokers per week x4 weeks then monthly x2 months to ensure policy/smoking break compliance and verify new times are working as desired for residents. Audits will begin 7/14/25.
Failure to Provide Dignity and Respect to Residents
Penalty
Summary
Staff failed to provide dignity and respect to two residents. For one resident with neuromuscular bladder dysfunction, depression, and nicotine dependence, a CNA made an inappropriate gesture by lifting her own breasts over her shirt in front of the resident during care. The CNA admitted to making the gesture in an attempt to be funny, but the resident did not find it humorous and reported the incident occurred about a month prior to the interview. For another resident with severe cognitive impairment, memory problems, and total dependence for activities of daily living, staff did not interact with or ask the resident before placing a clothing protector on her in the dining room. Additionally, a CNA referred to the resident as the "only true feed" in the dining room, a term acknowledged by the CNA as disrespectful. Both staff members confirmed their actions during interviews. Facility policy requires residents to be treated with respect and dignity, but these actions did not meet that standard.
Plan Of Correction
F557 The facility failed to maintain the dignity of residents; A) a STNA #206 referred to residents requiring assistance with food and fluid intake as "Feeds," B) a STNA #222 applied a clothing protector on resident #21 prior to asking permission to do so and waiting for a reply, and, as well as C) a STNA #240 made an inappropriate gesture in regard to breasts in the presence of resident #22. Step 1: The facility DON immediately... A) Educated the STNA #206 on the inappropriateness of referring to residents in terms of needs, diagnoses or other identifiable qualifiers, emphasizing the importance of using more appropriate terminology such as "residents requiring assistance with..." on 6/3/25. B) Educated STNA #222 on the need to ask and wait for reply prior to applying items such as clothing protectors to residents and if resident is unable to reply or understand on 6/3/25, IDT to discuss with resident representative and ensure stated desires are care planned. Completed on 6/27/25. C) SRI opened and investigation initiated. Completed on 6/10/25. Step 2: To identify other residents that have the potential to be affected... A) DON or designee reviewed current residents that require assistance with oral intake. B) DON or designee reviewed current non-verbal and/or cognitively impaired residents that might use clothing protectors during meals. C) Resident interviews with interview-able residents and skin sweeps on non-interview-able residents completed with no negative findings (R/T SRI). Completed on 6/27/25. Step 3: To prevent this from recurring... A) DON or designee will educate staff on the inappropriateness of referring to residents in terms of needs, diagnoses or other identifiable qualifiers, emphasizing the importance of using more appropriate terminology such as "residents requiring assistance with..." Completed on 7/11/25. B) DON or designee will educate staff on asking residents permission and waiting for a response prior to applying a clothing protector and for non-verbal residents to verify use on care profile or care plan. Completed on 7/11/25, for non-verbal and/or residents that are unable to respond the DON or designee will contact the residents' responsible party to discuss use of clothing protectors during meals and update the residents' care plans and care profile with responsible party's desires related to the use of clothing protectors. Completed 6/27/25. C) LNHA educated current staff on the Abuse, Neglect, and Misappropriation Policy and Procedure. Completed on 6/7/25. STNA #240 was educated by the facility Staffing Coordinator on 6/16/25 prior to returning to work. Step 4: To monitor and maintain ongoing compliance... A) DON or designee will audit 5 staff members per week x4 weeks then monthly x2 months for appropriate responses. B) DON or designee will review new admissions for ability to determine desire for clothing protector use and if non-verbal or cognitively impaired will discuss with responsible party then update care plan and profile as indicated in addition to auditing 3 non-verbal/cognitively impaired residents weekly x4 weeks then monthly x2 months for clothing protector use in relationship to care planned desires. C) DON or designee will interview 3 residents per week x4 weeks then monthly x2 months to ensure appropriate staff behavior while providing care or in resident areas. Audits will begin 7/14/25. The results of the audits will be forwarded to the facility QAPI committee for further review and recommendations. F565 Urbana Health and Rehab wishes to point out to any person who reviews this document that we do not necessarily agree with the citations with which we were cited. However, the law requires us to prepare a plan of correction for the citations regardless of whether we agree with them or not. Thus, we have prepared such a plan as noted below. Please note though, that this plan does not constitute an admission that the citations are either legally or factually correct. This plan of correction is not meant to establish any standard of care, contract, obligation, or position and Urbana Health and Rehab reserves all rights to raise all possible contentions and defenses in any civil or criminal action or proceeding. Please accept 07/30/25 as the facility's allegation of compliance date. The facility failed to ensure that resident concerns were addressed in a timely manner or resolved affecting resident #24, #35, and #29. Step 1: Concerns that were not addressed for residents #24, #35, and #29 were written on Concern forms by NHA and given to appropriate manager for follow-up. This will be completed by 6/30/25. Step 2: Resident Council Minutes were audited back six months by NHA to ascertain any concerns not addressed on 6/30/25. Concern forms were completed and given to appropriate department manager for resolution. Step 3: LED, Life Enrichment staff, and all department managers will be educated by LNHA on proper follow-up of Resident Council concerns, i.e., proper documentation of the following: education provided, equipment needed, replacement of items, etc. This will be completed by 6/30/25. Step 4: To monitor and
Failure to Protect Resident from Verbal Abuse by CNA
Penalty
Summary
A deficiency occurred when a cognitively intact resident with multiple medical diagnoses, including coronary artery disease, heart failure, diabetes, and cerebrovascular accident, reported being verbally abused by a Certified Nursing Aide (CNA). The resident, who was independent in daily activities and served as the president of the resident council, stated that the CNA called him an "ass" after he requested that a disruptive roommate be moved. The resident reported this incident to the Director of Nursing (DON), who allegedly attempted to minimize the situation, possibly due to a personal relationship with the CNA. The resident expressed that he felt the comment was abusive and that he was not asked to provide a formal statement regarding the incident. Interviews with the CNA confirmed that she used the term "ass" when addressing the resident and acknowledged that it was disrespectful and a mistake. The DON and Administrator were interviewed, with the Administrator unaware of the incident and the DON describing the resident as being inappropriate with staff. The DON stated she spoke with both parties to resolve the matter. Facility policy clearly prohibits abuse, including verbal abuse defined as the use of disparaging or derogatory language toward residents. The report documents that the facility failed to ensure residents were protected from verbal abuse as required by policy and regulation.
Plan Of Correction
F600 Urbana Health and Rehab wishes to point out to any person who reviews this document that we do not necessarily agree with the citations with which we were cited. However, the law requires us to prepare a plan of correction for the citations regardless of whether we agree with them or not. Thus, we have prepared such a plan as noted below. Please note though, that this plan does not constitute an admission that the citations are either legally or factually correct. This plan of correction is not meant to establish any standard of care, contract, obligation, or position and Urbana Health and Rehab reserves all rights to raise all possible contentions and defenses in any civil or criminal action or proceeding. Please accept 07/30/25 as the facility's allegation of compliance date. The facility failed to ensure residents were safe from abuse, affecting one resident #24. Step 1: Resident #24 was assessed and no negative findings. Resident assessment completed on 6/11/25 by NP. STNA #240 was removed from duty and suspended, personnel file for STNA #240 was reviewed for background check, along with 5 other random staff personnel files, no concerns were identified. Audit completed on 6/6/25. Step 2: To identify other residents that have the potential to be affected, on 6/6/25 the Social Services initiated interviews of those residents able to be interviewed regarding abuse, completing the interviews on 6/6/25 with no negative findings. DON completed skin check on 6-6-25 for non-verbal and cognitively impaired resident with no negative findings. Step 3: To prevent this from recurring, NHA started in-house education with all staff regarding elements of abuse to include verbal abuse. Completed on 6/6/25. New hired staff will be educated on abuse policy during orientation. Step 4: To monitor and maintain ongoing compliance, the NHA/designee will interview 5 residents weekly x4 then monthly x2 to ensure there are no issues with abuse. The NHA/designee will conduct 5 staff interviews weekly x4 then monthly x2 to validate what to do if they witness or hear abuse. The results of the audits will be submitted to the QAPI committee for further review and recommendations. --- F609 Urbana Health and Rehab wishes to point out to any person who reviews this document that we do not necessarily agree with the citations with which we were cited. However, the law requires us to prepare a plan of correction for the citations regardless of whether we agree with them or not. Thus, we have prepared such a plan as noted below. Please note though, that this plan does not constitute an admission that the citations are either legally or factually correct. This plan of correction is not meant to establish any standard of care, contract, obligation, or position and Urbana Health and Rehab reserves all rights to raise all possible contentions and defenses in any civil or criminal action or proceeding. Please accept 07/30/25 as the facility's allegation of compliance date. The facility failed to ensure an allegation of abuse was reported to the state agency, affecting resident #24. Step 1: The incident was reported to ODH and investigated by NHA on 6/10/25. Resident #24 was assessed and no negative findings. Assessment completed on 6/11/25 by NP with no negative finding. Step 2: To identify other residents that have the potential to be affected, on 6/6/25 the Social Services initiated interviews of those residents able to be interviewed regarding abuse, completing the interviews on 6/6/25 with no negative findings. DON completed skin check on 6-6-25 for non-verbal and cognitively impaired resident with no negative findings. Step 3: RDCS educated NHA and DON on reporting of all allegations of abuse on 6-6-25. To prevent this from recurring, NHA started immediate in-house education with all staff.
Failure to Report Alleged Verbal Abuse to State Agency
Penalty
Summary
A deficiency occurred when the facility failed to ensure that an allegation of verbal abuse was reported to the state agency as required. A cognitively intact resident with multiple medical diagnoses, including coronary artery disease, heart failure, diabetes, and a history of cerebrovascular accident, reported that a CNA called him an "ass" during an interaction regarding another resident's disruptive behavior. The resident stated he reported the incident to the DON, who attempted to minimize the situation, allegedly due to a personal relationship with the CNA. The resident expressed dissatisfaction with the response and indicated that no one had asked him for a formal statement regarding the incident. Interviews with the CNA confirmed the use of the inappropriate term, and the CNA acknowledged it was disrespectful. The DON admitted to addressing the situation informally by speaking with both parties but did not report the incident to the administrator or the state agency. The administrator was unaware of the incident until the surveyor's inquiry. Review of facility policy confirmed that all such allegations should be immediately reported to the administrator and appropriate agencies, which did not occur in this case.
Plan Of Correction
including management team, regarding reporting of all allegations of abuse. Education will be completed by 6/6/25. New hired staff will be educated on abuse policy during orientation. Step 4 NHA/designee will monitor compliance of reporting to state agency allegation of Abuse, Neglect, Misappropriation weekly X4 then monthly x2. The results of the audits will be submitted to the QA committee for further review and recommendations.
Failure to Investigate Alleged Verbal Abuse
Penalty
Summary
A deficiency occurred when the facility failed to initiate an investigation into an allegation of abuse involving a resident with a history of coronary artery disease, heart failure, diabetes, cerebrovascular accident, and non-Alzheimer's dementia. The resident, who was cognitively intact and independent in daily activities, reported that a CNA called him an "ass" during an interaction about another resident's disruptive behavior. The resident stated he reported the incident to the DON, who attempted to minimize the situation, suggesting the CNA may not have meant anything by the comment. The resident expressed dissatisfaction with the response and noted that no one had asked him for a statement regarding the incident. Interviews with the CNA confirmed the use of the term and an apology was made to the resident. However, the Administrator was unaware of the incident, and the DON admitted to not initiating a formal investigation, not collecting statements from involved parties, and not documenting the event as required by facility policy. The facility's policy mandates that all allegations of abuse be thoroughly investigated, but this process was not followed in this case.
Plan Of Correction
F610 Urbana Health and Rehab wishes to point out to any person who reviews this document that we do not necessarily agree with the citations with which we were cited. However, the law requires us to prepare a plan of correction for the citations regardless of whether we agree with them or not. Thus, we have prepared such a plan as noted below. Please note though, that this plan does not constitute an admission that the citations are either legally or factually correct. This plan of correction is not meant to establish any standard of care, contract, obligation, or position, and Urbana Health and Rehab reserves all rights to raise all possible contentions and defenses in any civil or criminal action or proceeding. Please accept 7/30/25 as the facility's allegation of compliance date. The facility failed to follow Ohio Resident Abuse Policy and ensure an investigation was initiated for an allegation of abuse affecting resident #24. Step 1: Alleged perpetrator was suspended on 6/4/25 pending investigation results. Resident #24 was assessed and no negative findings. Assessment completed on 6/11/25 by NP with no negative findings. Step 2: To identify other residents that have the potential to be affected, on 6/6/25 the Social Services initiated interviews of those residents able to be interviewed regarding abuse, completing the interviews on 6/6/25 with no negative findings. DON completed skin checks on 6-6-25 for non-verbal and cognitively impaired resident with no negative findings. Step 3: RDCS educated NHA and DON on reporting of all allegations of abuse on 6-6-25. To prevent this from recurring, NHA started immediate in-house education with all staff regarding Abuse Policy and the investigation of all allegations of abuse. Education will be completed by 6/6/25. New hired staff will be educated on abuse policy during orientation. Step 4: NHA/designee will monitor compliance of investigating allegations of Abuse, Neglect, Misappropriation weekly X4 then monthly x2. The results of the audits will be submitted to the QAPI committee for further review and recommendations.
Failure to Complete PASRR for Residents Initiated on Hospice Services
Penalty
Summary
The facility failed to complete the required Preadmission Screening and Resident Review (PASRR) for two residents who began receiving hospice services. Both residents had significant medical histories, including dementia, anxiety, and other chronic conditions, and were dependent on staff for most or all activities of daily living. Despite these changes in their care needs, there was no evidence that a PASRR was completed or updated when hospice services were initiated for either resident. Record reviews confirmed that neither resident had a PASRR completed at the time of their significant change in status, specifically when they were admitted to hospice care. This was further verified through an interview with the Social Service Designee, who acknowledged the absence of PASRR documentation for both residents during this transition. The deficiency was identified during a review of residents receiving hospice services, affecting two out of two residents reviewed in this category.
Plan Of Correction
F644 Urbana Health and Rehab wishes to point out to any person who reviews this document that we do not necessarily agree with the citations with which we were cited. However, the law requires us to prepare a plan of correction for the citations regardless of whether we agree with them or not. Thus, we have prepared such a plan as noted below. Please note though, that this plan does not constitute an admission that the citations are either legally or factually correct. This plan of correction is not meant to establish any standard of care, contract, obligation, or position and Urbana Health and Rehab reserves all rights to raise all possible contentions and defenses in any civil or criminal action or proceeding. Please accept 7/30/25 as the facility's allegation of compliance date. The facility failed to ensure that PASRR were completed for residents #14 and #3 regarding significant changes in condition and hospice enrollment. Step 1: Social Services promptly completed PASRRs on residents #14 and #3 for their significant change in condition. Completed on 6/12/25. Step 2: Social Services to complete an audit on all residents in the last year who have significant changes and admitted to hospice services. Completed on 6/26/25. Step 3: LNHA to provide education to IDT on process of discussing residents with significant change and possible hospice admission at morning clinical meeting, weekly resident review, and weekly PASRR meeting. Education completed by 6/30/25. Step 4: To monitor and maintain ongoing compliance, LNHA will audit PASRR weekly log and MDS Sig Changes assessments weekly x4, then monthly x2 to ensure PASRRs are being completed for residents with Sig Changes and admissions to hospice. Results of the audits will be forwarded to the facility QAPI committee for further review and recommendation. --- F0657 Urbana Health and Rehab wishes to point out to any person who reviews this document that we do not necessarily agree with the citations with which we were cited. However, the law requires us to prepare a plan of correction for the citations regardless of whether we agree with them or not. Thus, we have prepared such a plan as noted below. Please note though, that this plan does not constitute an admission that the citations are either legally or factually correct. This plan of correction is not meant to establish any standard of care, contract, obligation, or position and Urbana Health and Rehab reserves all rights to raise all possible contentions and defenses in any civil or criminal action or proceeding. Please accept 07/30/25 as the facility's allegation of compliance date. The facility failed to ensure residents #29 and #39 received routine care conferences. Step 2: NHA will audit the care conference schedule and compare to Comprehensive assessments and make adjustments to the care conference schedule as necessary by 6/30/25. Step 3: Social Services will be educated by LNHA on process of scheduling care conferences timely in accordance with Comprehensive assessment schedule. Education completed by 6/30/25. Step 4: Administrator will monitor compliance by auditing Care Conference completion weekly x4 weeks, then monthly x2 months. The results of the audits will be submitted to the QAPI committee for further review.
Failure to Conduct Routine Care Conferences as Required
Penalty
Summary
The facility failed to ensure that routine care conferences were conducted for residents as required. Specifically, two residents with significant medical histories, including coronary artery disease, heart failure, hypertension, diabetes, and renal insufficiency, did not receive care conferences every three months. Medical record reviews showed gaps between documented care conferences and the required quarterly schedule. Both residents were found to be cognitively intact at the time of the deficiency, and interviews with them confirmed that they had not participated in care conferences every three months as expected. Further interviews with the Social Services Designee revealed an acknowledgment that care conferences were supposed to be completed every three months, but the process was behind schedule. Review of the facility's policy confirmed that care plans should be reviewed and revised at least with each comprehensive and quarterly assessment, in line with Resident Assessment Instrument (RAI) requirements. The deficiency was identified through medical record review, resident and staff interviews, and policy review, demonstrating a failure to follow established protocols for care plan review and resident participation.
Unsecured Hazardous Chemicals and Failure to Honor Restricted Liquid Diet
Penalty
Summary
The facility failed to maintain a safe environment free of unsecured hazardous chemicals, as evidenced by observations of unlocked storage areas containing potentially poisonous substances. Specifically, a shower room closet in one unit was found to be easily unlocked and contained a bottle labeled as a chemical cleaner with a warning to keep out of reach of children. In another unlocked shower room, a gallon-sized container with a nozzle sprayer and tubing, containing an unidentified clear liquid, was found on the floor without any labeling. The Maintenance Director confirmed that these chemicals should have been secured and properly labeled, and was unable to identify the contents of the unlabeled container. During the same period, a resident with severe cognitive impairment and a history of wandering was observed moving freely throughout the facility, including the areas where these unsecured chemicals were accessible. Additionally, the facility failed to honor a restricted liquid diet for a resident reviewed for hydration. The report notes that the facility did not ensure the resident received the appropriate diet as ordered, which is required to maintain proper hydration and health. The resident's medical record indicated the need for a restricted liquid diet, but this was not provided as specified during the survey period.
Plan Of Correction
F689 The facility failed to maintain an environment free from accident hazard when unsecured cleaning chemicals were observed in the B Wing Shower Room and in a closet outside of the A Wing Shower Room. Step 1: The facility DOM immediately removed the chemicals from the B Wing Shower Room and placed a lock on the closet outside of the A Wing Shower Room. Completed on 6/10/25. Step 2: This has the potential to affect 3 residents, #37, #14, and #4, who are known to wander throughout the facility. The facility DON assessed and identified residents with no negative findings. Completed on 6/11/25. Step 3: To prevent this from reoccurring, the DON or designee will educate staff on the need to keep chemicals in a secure location when not in use. Completed on 7/11/25. Step 4: To monitor and maintain ongoing compliance, the DON or designee will audit shower rooms and closets 3 times per week for 4 weeks, then monthly for 2 months, to ensure cleaning chemicals are secure. Audits will begin on 7/14/25. The results of the audits will be forwarded to the facility QAPI committee for further review and recommendations.
Failure to Adhere to Physician-Ordered Fluid Restriction
Penalty
Summary
The facility failed to ensure that a resident with a physician-ordered fluid restriction received the correct amount of fluids as prescribed. The resident, who had diagnoses including heart failure, coronary artery disease, peripheral vascular disease, and renal insufficiency, was cognitively intact and functionally independent. According to the physician's order, the resident was to receive a total of 1200 cc of fluids per 24 hours, with specific amounts allocated for each meal. However, observations revealed that the resident's meal trays contained more fluids than allowed, such as 480 cc at lunch and 600 cc at breakfast, exceeding the prescribed limits. Interviews with both the resident and facility staff confirmed that the fluid restriction was not consistently honored. The resident reported that meal trays sometimes included too many fluids, and both the dietary cook and a registered nurse acknowledged that the resident occasionally received more fluids than ordered. The dietary cook specifically admitted to placing 600 cc of fluids on a breakfast tray when only 360 cc should have been provided, demonstrating a failure to follow the fluid restriction order.
Plan Of Correction
F692 The facility failed to follow resident #198's fluid restriction as ordered and failed to document/care plan resident refusal/non-compliance. Step 1: The facility ADON immediately removed additional ice water at bedside and updated resident's fluid restriction order to include documentation if resident is non-compliant, and care plan updated for resident #198. Completed on 6/9/25. Step 2: To identify other residents that have the potential to be affected, DON or designee reviewed all residents with fluid restriction orders as well as their corresponding care plans for accuracy. Completed on 6/9/25. Step 3: To prevent this from recurring, the DON or designee will educate staff on fluid restrictions including orders, non-compliance, fluid breakdowns, and need for proper documentation. Completed on 7/11/25. Step 4: To monitor and maintain ongoing compliance, the DON or designee will audit fluid restriction orders, care plans, and documentation weekly x4 weeks then monthly x2 months. Audits will begin 7/14/25. The results of the audits will be forwarded to the facility QAPI committee for further review and recommendations.
Crushing of Extended-Release Potassium Tablet Results in Significant Medication Error
Penalty
Summary
A deficiency occurred when a registered nurse crushed and administered a potassium chloride extended-release 20 milliequivalent tablet to a resident with multiple diagnoses, including chronic diastolic heart failure, vascular dementia, and severe cognitive impairment. The resident had a physician's order to crush medications unless contraindicated, and a separate order for potassium chloride extended-release. During medication preparation, the nurse crushed all of the resident's medications, including the extended-release potassium tablet, and administered them in applesauce. Interviews with the nurse and the facility pharmacist confirmed that extended-release potassium chloride tablets should never be crushed. Facility documentation and policy also specified that this medication form was not to be crushed. The facility's medication administration policy required staff to follow proper procedures and referenced a list of medications that should not be crushed, which included potassium chloride extended-release tablets.
Expired Medications and Improper Medication Administration Observed
Penalty
Summary
Surveyors identified two deficiencies related to medication management. First, during an observation of the overstock medication room, seven unopened bottles of Folic Acid 400 mcg were found with an expiration date of 02/2025, indicating they were expired. This was confirmed by a registered nurse, and facility documentation showed that Folic Acid 400 mcg was kept as over-the-counter stock. Facility policy requires that expired medications be destroyed or returned according to pharmacy guidelines, but these expired bottles remained in storage. Second, a review of records and observation for a resident with diagnoses including diabetes, cerebral infarction, edema, and hypertension revealed that a dose of Hydralazine, prescribed for hypertension, was left in a pill cup on the resident's bedside table. The medication had been signed as administered by the night shift nurse, but the resident reported that nurses sometimes left medications at the bedside without observing ingestion, especially when she was sleepy. This was verified by a registered nurse, who acknowledged that medications should not be left at the bedside and that administration should be observed.
Plan Of Correction
F761 The facility failed to ensure proper storage and handling of medications when medications were observed at the bedside of resident #28. B) Failed to remove seven bottles of expired Folic Acid from the OTC medication storage cabinet. Step 1: The facility RN Supervisor immediately A) secured the medications noted at bedside of resident #28, notified the PCP with no new orders, and assessed the affected resident with no negative findings. The RN #241 responsible for not properly securing (leaving at bedside) said medications was educated and disciplined by the DON. Completed on 6/2/25. B) The facility DON removed the expired folic acid from storage and disposed of on 6/4/25. Step 2: This has the potential to affect all residents; current medications in stock were audited for expiration dates and proper storage/properly secured by the DON on 6/13/25 with no negative findings. Step 3: To prevent this from recurring, the DON or designee will educate licensed nurses and the Central Supply Designee on the proper policy and procedure for labeling, securing, storage, handling, and (for nurses) administration of medications and biologic agents. Completed on 7/11/25. Step 4: To monitor and maintain ongoing compliance, the DON or designee will audit medications for proper labeling, storage, and handling 2x per week x4 weeks then 2x per month x2 months. Audits will begin 7/14/25. The results of the audits will be forwarded to the facility QAPI committee for further review and recommendations.
Failure to Ensure Timely Dental Follow-Up for Broken Tooth
Penalty
Summary
A deficiency occurred when the facility failed to ensure a follow-up dental appointment was made for a resident who had a tooth broken off at the gum line. The resident, who had a history of stroke, coronary artery disease, heart failure, hypertension, and diabetes, was cognitively intact and independent in most activities of daily living except for transfers, for which a Hoyer lift was required. After an initial dental appointment where the dentist was unable to extract the root of the broken tooth, a referral for oral surgery was placed in the resident's chart. Subsequent documentation indicated the resident developed an infection at the site, was treated with antibiotics, and was to follow up with dentistry. Despite these events, the resident reported not having received any further information or scheduling for the necessary oral surgery to remove the root. The appointment scheduler stated that a message was left with the only surgical dental clinic accepting Medicaid, but the clinic's policy was to only return calls if an appointment could be scheduled. There was no evidence that further efforts were made to secure the required dental care, resulting in the resident continuing to experience issues with the broken tooth and self-managing symptoms with over-the-counter medication.
Plan Of Correction
F791 The facility failed to secure and follow up on an oral surgeon appointment for resident #29. Step 1: The facility ADON immediately assessed resident #29 with no negative effects noted. Completed on 6/13/25. Step 2: To identify other residents that have the potential to be affected, the DON or designee will audit resident medical records for residents seen by the facility dental provider (360 care) for any residents that might have had a referral for follow-up care with outside dental services. Completed on 6/27/25 with no negative findings. Resident #29 scheduled for oral surgeon consult at the Cleveland Dental Inst. 7/31/25 at 11am. Step 3: To prevent this from recurring, the facility DON will educate staff involved with resident appointments that if the facility scheduler or designee is unable to find dental services due to insurance being out of network for the resident, the facility will make arrangements to get the cost of dental services covered. Completed on 7/11/25. Step 4: To monitor and maintain ongoing compliance, the DON or designee will audit dental needs, including services and needed follow-up, weekly x4 weeks then monthly x2 months. Audits will begin 7/14/25. The results of the audits will be forwarded to the facility QAPI committee for further review and recommendations.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
A deficiency was identified when a resident with diagnoses including cerebral infarction, muscle weakness, dysphagia, and anxiety was not provided with a pest-free environment. The resident, who was dependent on staff for dressing and transfers and had intact cognition, reported experiencing a 'swarm of flying ants' coming from the ceiling near her window. The insects were observed in the resident's room by staff, and the resident was subsequently moved to another room. The presence of 10 to 20 winged black insects was confirmed by observation in the resident's previous room, and the issue was not present the day before the incident. Interviews with the resident, her family representative, and staff confirmed the presence of the insects and the impact on the resident, who was unable to remove the insects herself due to physical weakness. The family representative expressed concern that the facility did not manage the pest issue in a timely manner. The Maintenance Director acknowledged awareness of the pest problem and stated that pest control had been contacted, but extermination had not occurred by the time of the survey. The deficiency was cited under the requirement to maintain an effective pest control program to ensure the facility is free of pests and rodents.
Plan Of Correction
F925 The facility failed to maintain an effective pest control program when insects were observed in room B23 requiring that resident #11 be moved to another room on 6/2/25 at which time pest control was contacted. As of 6/5/25 pest control still had not arrived to exterminate. Step 1: The facility SSD and DOM immediately moved resident #11 from room B23 to room B21 on 6/2/25. The DOM called pest control initially on 6/1/25 and again on 6/9/25. The facility DOM checked all other rooms on 6/2/25 with no negative findings. Resident #11 was assessed by facility LPN on 6/1/25 and 6/3/25 with no negative effects. Step 2: This has the potential to affect all residents. Pest control reports they are scheduled to treat the facility on 7/2/25. Completed on 7/3/25. Step 3: To prevent this from reoccurring, the LNHA will educate current staff on reporting any pest control needs when observed. Completed on 7/11/25. Step 4: To maintain ongoing monitoring and compliance, the LNHA or designee will audit 5 random resident rooms for signs of pests weekly for 4 weeks, then monthly for 2 months. Audits begin 7/14/25. The results of the audits will be forwarded to the facility QAPI committee for further review and recommendations.
Failure to Maintain Required Emergency Lighting Documentation
Penalty
Summary
The facility failed to maintain emergency lighting in accordance with NFPA 101-2012 Edition, Section 19.2.9.1 and Section 7.9.3.1.1. During a review of the life safety documentation, it was found that there was no record of the required annual 90-minute test for seven emergency lights. This lack of documentation was discovered in the facility's life safety binder during a survey. An interview with a staff member confirmed that the required testing had not been performed, as the staff member was unaware of the specific requirements. The deficiency had the potential to affect 46 residents, as emergency lighting is necessary for safe egress in the event of a power failure. The report does not mention any specific incidents involving residents or their medical conditions at the time of the deficiency.
Plan Of Correction
K291 Urbana Health and Rehab wishes to point out to any person who reviews this document that we do not necessarily agree with the citations with which we were cited. However, the law requires us to prepare a plan of correction for the citations regardless of whether we agree with them or not. Thus, we have prepared such a plan as noted below. Please note though, that this plan does not constitute an admission that the citations are either legally or factually correct. This plan of correction is not meant to establish any standard of care, contract, obligation, or position, and Urbana Health and Rehab reserves all rights to raise all possible contentions and defenses in any civil or criminal action or proceeding. Please accept 07/30/25 as the facility's allegation of compliance date. The facility failed to complete the annual 90-minute emergency light test. Step 1: Director of Maintenance to complete the 90-minute test by (7/18/25). Step 2: Potential to affect all residents. Power outage on 4/29/25 for 1 hour, with no negative outcomes. The generator worked properly. Step 3: NHA educated Maintenance Director on NFPA 101 Emergency Lighting 90 Minute Annual Testing by 7/15/25. Step 4: NHA to monitor emergency lighting test logs for continued compliance weekly x4 then monthly x2. Results of the audits will be forwarded to the facility QAPI committee for further review and recommendation.
Failure to Complete Required Generator Load Bank Testing and Documentation
Penalty
Summary
The facility failed to maintain its diesel generator in accordance with NFPA 110-2010 requirements. During a review of the life safety documentation, it was found that the last four-hour load bank test of the generator had not been completed within the required 36-month interval, with the most recent test occurring several years prior. Additionally, the monthly test records did not document the engine hours as required, instead only noting the start and end times of the test. These findings were confirmed by the Maintenance Director, who was unaware of the specific requirements for generator testing and documentation. This deficiency had the potential to affect all 46 residents in the facility, as the generator is a critical component of the essential electrical system. The lack of proper testing and documentation means the facility could not ensure the generator's reliability in supplying emergency power within the required timeframe, as outlined by NFPA 110 standards. No specific resident medical histories or conditions were mentioned in relation to this deficiency.
Plan Of Correction
K918 Urbana Health and Rehab wishes to point out to any person who reviews this document that we do not necessarily agree with the citations with which we were cited. However, the law requires us to prepare a plan of correction for the citations regardless of whether we agree with them or not. Thus, we have prepared such a plan as noted below. Please note though, that this plan does not constitute an admission that the citations are either legally or factually correct. This plan of correction is not meant to establish any standard of care, contract, obligation, or position, and Urbana Health and Rehab reserves all rights to raise all possible contentions and defenses in any civil or criminal action or proceeding. Please accept 07/30/25 as the facility's allegation of compliance date. The facility failed to ensure that the 4-hour 36-month load test was completed on the generator and written record of maintenance and testing was logged incorrectly. Step 1: Facility Administrator obtained the 4-hour bank test documentation from 6/9/2023. Step 2: NHA audited the generator testing log for the time meter reading—start and end—ensuring that it would include hours of the engine, not the test start and end time. Maintenance Director corrected log entry for the month of July 2025. Step 3: NHA educated Maintenance Director on the correct way to log generator testing entries 7/15/25.
Failure of Corridor Doors to Latch as Required by NFPA 101
Penalty
Summary
During a facility tour, surveyors observed that the corridor doors to residents' rooms A-9 and B-12 would not latch despite three attempts to secure them. These doors are required by NFPA 101-2012 standards to resist the passage of smoke and be equipped with positive latching hardware. The failure of these doors to latch was confirmed through direct observation and staff interviews. The staff member interviewed at the time, identified as MD#1, acknowledged the issue and stated he was unaware of the specific requirements for corridor doors. The deficiency was noted to have the potential to affect 17 out of 46 residents, as the non-latching doors did not meet the regulatory standards for corridor openings, which are intended to prevent the spread of smoke and maintain fire safety within the facility.
Plan Of Correction
K363 Urbana Health and Rehab wishes to point out to any person who reviews this document that we do not necessarily agree with the citations with which we were cited. However, the law requires us to prepare a plan of correction for the citations regardless of whether we agree with them or not. Thus, we have prepared such a plan as noted below. Please note though, that this plan does not constitute an admission that the citations are either legally or factually correct. This plan of correction is not meant to establish any standard of care, contract, obligation, or position and Urbana Health and Rehab reserves all rights to raise all possible contentions and defenses in any civil or criminal action or proceeding. Please accept 07/30/25 as the facility's allegation of compliance date. The facility failed to ensure that resident room doors A9 and B12 would not latch. Step 1: Director of Maintenance fixed resident room doors A9 and B12 on 6/6/25. Step 2: Maintenance Director completed house audit to ensure that all resident doors latched properly when closed on 6/6/25, with no negative findings. Step 3: LNHA educated Director of Maintenance on corridor doors and safety to ensure proper functioning when closed on 7/15/25. Step 4: NHA/designee will audit corridor room doors to ensure ongoing compliance weekly x4 then monthly x2. The results of the audits will be submitted to the QAPI Committee for further review and recommendations. --- K0372 Urbana Health and Rehab wishes to point out to any person who reviews this document that we do not necessarily agree with the citations with which we were cited. However, the law requires us to prepare a plan of correction for the citations regardless of whether we agree with them or not. Thus, we have prepared such a plan as noted below. Please note though, that this plan does not constitute an admission that the citations are either legally or factually correct. This plan of correction is not meant to establish any standard of care, contract, obligation, or position and Urbana Health and Rehab reserves all rights to raise all possible contentions and defenses in any civil or criminal action or proceeding. Please accept 07/30/25 as the facility's allegation of compliance date. The facility failed to ensure smoke barrier in Rm #B9 would resist passage of smoke. Step 1: Penetrations in Rm#B9 were sealed to resist passage of smoke to prevent passage of smoke creating a sealed/contained smoke compartment on 6/6/25. Step 2: All resident rooms audited for penetrations by 7/15/25. Step 3: Maintenance Director educated by LNHA on the smoke barrier function of the ceiling and maintaining the integrity of the ceiling on 7/15/25. Step 4: To monitor and maintain compliance, LNHA/designee will audit smoke barriers for compliance weekly for X4, then monthly X2. Results of the audits will be forwarded to the facility QAPI committee for further review and recommendation.
Unsealed Wire Penetrations in Smoke Barrier
Penalty
Summary
During a facility tour, surveyors observed that one grey wire and one white wire were passing through a smoke wall without being properly sealed in the space between the drop ceiling and the building ceiling at the double corridor by room B-9. This unsealed penetration was found in an area that serves as a smoke barrier, which is required by NFPA 101-2012 to be constructed with a minimum 1/2-hour fire resistance rating and to restrict the transfer of smoke. The observation was made in the presence of the Maintenance Director, who confirmed the finding and stated he was unaware of the requirements for sealing such penetrations. The deficiency had the potential to affect five out of 46 residents in the facility. The report cites specific NFPA 101-2012 code sections that require all penetrations in smoke barriers, including those for wires, to be protected by a system or material capable of restricting smoke transfer. The failure to seal the wire penetrations in the smoke barrier constituted noncompliance with these requirements.
Plan Of Correction
K0372 Urbana Health and Rehab wishes to point out to any person who reviews this document that we do not necessarily agree with the citations with which we were cited. However, the law requires us to prepare a plan of correction for the citations regardless of whether we agree with them or not. Thus, we have prepared such a plan as noted below. Please note though, that this plan does not constitute an admission that the citations are either legally or factually correct. This plan of correction is not meant to establish any standard of care, contract, obligation, or position and Urbana Health and Rehab reserves all rights to raise all possible contentions and defenses in any civil or criminal action or proceeding. Please accept 07/30/25 as the facility's allegation of compliance date. The facility failed to ensure smoke barrier in Rm #B9 would resist passage of smoke. Step 1 Penetrations in Rm#B9 were sealed to resist passage of smoke to prevent passage of smoke creating a sealed/contained smoke compartment 6-6-25. Step 2 All resident rooms audited for penetrations by 7/15/25. Step 3 Maintenance Director educated by LNHA on the smoke barrier function of the ceiling and maintaining the integrity of the ceiling 7/15/25. Step 4 To monitor and maintain compliance, LNHA/designee will audit smoke barriers for compliance weekly for X4, then monthly X2. Results of the audits will be forwarded to the facility QAPI committee for further review and recommendation. K0374 Urbana Health and Rehab wishes to point out to any person who reviews this document that we do not necessarily agree with the citations with which we were cited. However, the law requires us to prepare a plan of correction for the citations regardless of whether we agree with them or not. Thus, we have prepared such a plan as noted below. Please note though, that this plan does not constitute an admission that the citations are either legally or factually correct. This plan of correction is not meant to establish any standard of care, contract, obligation, or position and Urbana Health and Rehab reserves all rights to raise all possible contentions and defenses in any civil or criminal action or proceeding. Please accept 07/30/25 as the facility's allegation of compliance date. The facility failed to maintain fire/smoke barrier doors by DON office and room R1. Fire/Smoke barrier door by A4 and A9 failed to close during test of fire alarm. Step 1 Maintenance Director repaired the doors by DON office and room R1 and A4 and A9 6-6-25. Step 2 Fire doors audits for compliance by Maintenance Director 6-6-25, no negative findings. Step 3 Maintenance Director educated by LNHA on the Fire/Smoke Barrier Doors by 7-15-25. Step 4 To monitor and maintain compliance, LNHA/designee will audit fire/smoke barriers doors for compliance weekly for X4, then monthly X2. Results of the audits will be forwarded to the facility QAPI committee for further review and recommendation.
Failure of Fire/Smoke Barrier Doors to Close as Required
Penalty
Summary
During a facility tour, surveyors observed that several fire/smoke barrier doors did not function as required by NFPA 101-2012 standards. Specifically, the double corridor fire/smoke barrier door near the Director of Nursing office and a resident room was unable to close. Additionally, fire/smoke barrier doors in two resident rooms failed to close correctly. When the fire alarm system was tested, these doors were also unable to close completely, indicating a persistent issue with the self-closing or automatic-closing mechanisms required for smoke barrier doors. Staff interviews confirmed the findings at the time of discovery. A staff member acknowledged being unaware of the specific requirements for fire/smoke barrier doors as outlined in the NFPA 101-2012 Edition. The observed deficiencies directly contravened the standards, which mandate that such doors must be self-closing or automatic-closing and able to close fully upon activation of the fire alarm or loss of power to the hold-open device. The report also notes a failure to maintain smoking areas in accordance with NFPA 101-2012 Edition, Section 19.7.4. However, the detailed findings and observations related to the smoking area deficiency are not fully included in the provided excerpt. The primary documented deficiency centers on the inability of fire/smoke barrier doors to close as required, potentially affecting 13 out of 46 residents in the facility.
Plan Of Correction
K741 Urbana Health and Rehab wishes to point out to any person who reviews this document that we do not necessarily agree with the citations with which we were cited. However, the law requires us to prepare a plan of correction for the citations regardless of whether we agree with them or not. Thus, we have prepared such a plan as noted below. Please note though, that this plan does not constitute an admission that the citations are either legally or factually correct. This plan of correction is not meant to establish any standard of care, contract, obligation, or position, and Urbana Health and Rehab reserves all rights to raise all possible contentions and defenses in any civil or criminal action or proceeding. Please accept 7/30/25 as the facility's allegation of compliance date. The facility failed to ensure safe smoking as evidenced by cigarette butts on the ground around staff smoking area, lining the emergency lane parking, yellow line on sidewalk, floor of employee smoking area, in front of storage area that stored combustible materials. Additionally, there were no self-closing metal containers into which ashtrays could be emptied. Step 1: Director of Maintenance cleaned the staff smoking area on 6-6-25. A 16 qt. covered, self-closing, metal receptacle was obtained for placement of cigarette butts and placed in the smoking area on 6/15/25. Step 2: Audit was completed by DON/ADON on designated smoking areas on 6-6-25 for compliance issues, with no negative findings. Step 3: All staff educated on NFPA 101 Smoking Regulations: safe smoking practices and the importance of proper disposal of used smoking materials.
Failure to Maintain Smoking Areas and Receptacles per NFPA 101
Penalty
Summary
The facility failed to maintain smoking areas in accordance with NFPA 101-2012, Section 19.7.4, as observed during a facility tour. Numerous cigarette butts, exceeding 50, were found scattered in the back of the facility along the emergency lane parking area and the yellow line on the sidewalk. Additionally, the employee smoking area, located in front of a storage area containing combustible materials such as chairs and shelving, had innumerable cigarette butts on the floor. The storage area did not contain metal containers with self-closing cover devices for emptying ashtrays, despite ashtrays being provided. Staff interviews confirmed awareness of the issue, with one staff member stating that action would only be taken if the issue was formally documented. The deficiency had the potential to affect 22 of 46 residents in the facility. The observations indicated that the facility did not comply with required smoking regulations, including the provision of appropriate receptacles and the maintenance of designated smoking areas free from fire hazards.
Plan Of Correction
K741 Urbana Health and Rehab wishes to point out to any person who reviews this document that we do not necessarily agree with the citations with which we were cited. However, the law requires us to prepare a plan of correction for the citations regardless of whether we agree with them or not. Thus, we have prepared such a plan as noted below. Please note though, that this plan does not constitute an admission that the citations are either legally or factually correct. This plan of correction is not meant to establish any standard of care, contract, obligation, or position, and Urbana Health and Rehab reserves all rights to raise all possible contentions and defenses in any civil or criminal action or proceeding. Please accept 7/30/25 as the facility's allegation of compliance date. The facility failed to ensure safe smoking as evidenced by cigarette butts on the ground around staff smoking area, lining the emergency lane parking, yellow line on sidewalk, floor of employee smoking area, in front of storage area that stored combustible materials. Additionally, there were no self-closing metal containers into which ashtrays could be emptied. Step 1: Director of Maintenance cleaned the staff smoking area on 6-6-25. A 16 qt. covered, self-closing, metal receptacle was obtained for placement of cigarette butts and placed in the smoking area on 6/15/25. Step 2: Audit was completed by DON/ADON on designated smoking areas on 6-6-25 for compliance issues, with no negative findings. Step 3: All staff were educated on NFPA 101 Smoking Regulations: safe smoking practices and the importance of proper disposal of used smoking materials in appropriate receptacles on 6-24-25. New hires are educated upon orientation. Step 4: To monitor and maintain ongoing compliance, the LNHA/designee will audit the staff smoking area weekly x4 then monthly x2. The results of the audits will be submitted to the QAPI committee for further review and recommendations.
Improper Segregation of Oxygen Cylinders Due to Undefined Signage
Penalty
Summary
During a facility tour, surveyors observed that the oxygen storage area near room A-13 contained two signs labeled "full" and "partial/empty" for cylinder segregation. However, the facility had not defined what constituted a "partial" cylinder, which created the potential for cylinders that were nearly full to be placed in the empty section. This lack of clear definition and segregation did not meet the requirements outlined in NFPA 99-2012 Edition, Section 11.6.5.2, which mandates that empty and full cylinders must be segregated if stored within the same enclosure. An interview with a medical staff member confirmed the finding, as the staff member was unaware of the specific requirements and found the signage confusing. The deficiency was identified as having the potential to affect eight out of 46 residents, but no specific details about the residents' medical history or conditions at the time of the deficiency were provided in the report.
Plan Of Correction
K923 Urbana Health and Rehab wishes to point out to any person who reviews this document that we do not necessarily agree with the citations with which we were cited. However, the law requires us to prepare a plan of correction for the citations regardless of whether we agree with them or not. Thus, we have prepared such a plan as noted below. Please note though, that this plan does not constitute an admission that the citations are either legally or factually correct. This plan of correction is not meant to establish any standard of care, contract, obligation, or position, and Urbana Health and Rehab reserves all rights to raise all possible contentions and defenses in any civil or criminal action or proceeding. Please accept 7/30/25 as the facility's allegation of compliance date. The facility failed to maintain oxygen storage signage near room A 13; empty oxygen bottles were labeled "partial/empty." Step 1: Maintenance Director corrected the signage on 6-6-25 with a sign that reads "Empty." Step 2: All residents that utilize oxygen were assessed for proper storage and placement of oxygen tanks by 7/15/25. Step 3: LNHA educated all clinical staff on appropriate signage for Oxygen room 7/15/25. New hires are educated upon orientation. Step 4: LNHA/designee to monitor for continued compliance will audit oxygen room signage weekly x4 then monthly x2. Results of the audits will be forwarded to the QAPI committee for further review and recommendations.
Latest citations in Ohio
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.
Surveyors found that the facility failed to document tray line food temperatures for multiple meals served from two dining room kitchenettes, despite having a “Trayline Taste & Temperature Log” and a policy requiring food to be stored, prepared, distributed, and served according to professional food safety standards. Review of logs showed repeated missing entries for breakfast, lunch, and dinner services in both the Harrison and McClellan dining areas, and the Senior Director of Culinary Services confirmed that temperatures had not been recorded for those meals, potentially affecting all residents receiving meals from those kitchenettes.
The facility failed to conduct and document required periodic care conferences for two residents, despite multiple comprehensive, quarterly, and significant change MDS assessments and a policy requiring periodic care conferences with resident and/or family participation. One resident with Parkinson’s disease, post-stroke hemiplegia, TIA, DMII, and depression had only two documented care conferences over a year, while another resident with aphasia, cerebrovascular disease, DMII, gait difficulty, coagulation defect, depression, and muscle weakness had no documented care conferences in the past year, aside from a declined invitation to the representative. The UCC confirmed that care conferences were expected to occur quarterly and that no additional documentation existed for either resident.
A resident with Alzheimer's disease and type II DM, who required extensive assistance with ADLs and was receiving scheduled Lantus and sliding-scale Humalog, experienced a severely elevated blood glucose level. The on-call provider was notified and ordered an additional dose of lispro insulin with a directive to recheck the blood glucose after administration. Nursing staff administered the extra insulin but did not document any follow-up blood glucose check, and the DON confirmed that this reevaluation was required by the facility's abnormal blood glucose policy and was not completed or documented.
A resident with Parkinson’s disease, dementia, and hypothyroidism was prescribed levothyroxine once daily along with other medications. A consultant pharmacist’s monthly drug regimen review recommended that levothyroxine be given in the morning on an empty stomach, 30–60 minutes before food, per manufacturer instructions. The medical record contained no documented physician response to this recommendation, and the MAR showed the drug scheduled for morning administration while the resident was observed eating breakfast and receiving the medication at the same time. An LPN confirmed administering levothyroxine during the meal, and the DON verified there was no documentation explaining whether or why the pharmacist’s recommendation was or was not followed, resulting in a failure to act on and document the identified irregularity.
A resident with severe cognitive impairment, multiple comorbidities, documented gait and balance abnormalities, and a high fall risk was care planned and assessed by therapy to require contact guard assistance and use of a gait belt for transfers and ambulation. While being assisted by a CNA from a recliner to the bathroom with a walker, the CNA did not apply a gait belt, even though the resident had a known tendency to lean backward when standing. As the CNA reached to open the bathroom door, the resident lost balance and fell backward, striking the back of the head, and was later found by an LPN without a gait belt in place, contrary to the facility’s gait belt policy and the resident’s assessed needs.
A resident with CKD stage five requiring peritoneal dialysis (PD) was admitted with pre-admission physician orders for three daily PD exchanges and monitoring for peritonitis (fever, abdominal pain, cloudy effluent), but these monitoring orders were not entered into the facility’s physician orders. The care plan referenced PD and general monitoring but did not specifically address peritonitis monitoring. Paper PD flowsheets showed incomplete and inconsistent documentation of exchanges and resident condition, including missing condition/comments for individual treatments and no record of one ordered PD exchange. The PD cycler flowsheet lacked effluent descriptions on multiple days. The PD nurse reported facility staff were expected to monitor effluent and symptoms, and the DON confirmed the absence of specific peritonitis monitoring orders, lack of an order for the PD cycler, and documentation gaps, despite a facility policy requiring ongoing assessment and monitoring for complications before, during, and after dialysis treatments.
A nurse was observed preparing multiple oral medications for a resident with depression, traumatic brain injury, anxiety, and impaired cognition by pushing tablets and capsules from unit-dose cards directly into her ungloved hand and then using her fingers to place them into a medication cup. In a follow-up interview, the RN confirmed this practice and acknowledged that the correct procedure is to dispense medications directly from the card into the cup, contrary to the facility’s medication administration policy requiring adherence to good nursing principles and practices.
A resident with Alzheimer’s disease, diabetes, anxiety, significant ADL dependence, and behavioral symptoms was observed seated in a chair positioned against the nursing station with a locked wheelchair placed directly in front, also against the nursing station, effectively restricting movement. An LPN confirmed both wheelchair wheels were locked and that it should not have been placed there, while a CNA stated she had positioned the wheelchair to prepare for lunch, was unable to complete the transfer, and left it in place, acknowledging this was wrong. This arrangement conflicted with the facility’s restraint policy, which prohibits physical restraints except when alternatives are ineffective for treating a medical symptom and defines restraints as devices adjacent to the body that cannot be easily removed and that restrict freedom of movement or access to the body.
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
Failure to Document Tray Line Food Temperatures in Dining Room Kitchenettes
Penalty
Summary
The deficiency involves the facility’s failure to document tray line food temperatures for meals served from the Harrison and McClellan Dining Room kitchenettes, as required by professional standards for food service safety and the facility’s own policy. Review of the “Trayline Taste & Temperature Log” (revised September 2018) showed missing temperature documentation for multiple meals from the Harrison Dining Room kitchenette, including dinner on 03/30/26 and 03/31/26, lunch and dinner on 04/01/26 and 04/02/26, dinner on 04/07/26, and lunch and dinner on 04/08/26 and 04/10/26. The Senior Director of Culinary Services confirmed during interview that tray line food temperatures were not documented on the log for these meals. Similarly, review of the same log for the McClellan Dining Room kitchenette revealed that tray line food temperatures were not documented for dinner on 04/01/26, breakfast and lunch on 04/02/26, and lunch and dinner on 04/07/26. The Senior Director of Culinary Services also verified these omissions during interview. The facility census at the time was 27 residents, and the governing “Food and Nutrition” policy, approved on 09/07/21, stated that the facility must store, prepare, distribute, and serve food in accordance with professional standards for food service safety.
Plan Of Correction
F812 The facility will continue to ensure food temperatures are completed before meals are served for all residents. To ensure compliance with this standard the following measures have been taken: 1. Immediately 4/15/26 culinary supervisor #224 was re-educated by Dietary Manager to this standard and policy "Food and Nutrition" which includes documentation of food temperatures. 2. All dietary staff have been re-educated to the standard and policy "Food and Nutrition" during the month of April 2026. 3. Audits of food temperature documentation to be completed by Dietary Manager 4 x per week for 4 weeks then weekly for 4 weeks. 4. Administrator to validate audits/compliance and provide additional training as needed. Administrator will present to QAPI committee for ongoing monitoring and further direction.
Failure to Conduct and Document Required Care Conferences
Penalty
Summary
The deficiency involves the facility’s failure to complete and document comprehensive care conferences at required intervals in accordance with care plan regulations and facility policy. For one resident with Parkinson’s disease with dyskinesia, cognitive communication deficit, hemiplegia and hemiparesis following cerebral infarction, transient cerebral ischemic attack, type II diabetes mellitus, and major depressive disorder, the record showed multiple MDS assessments over a one-year period, including annual, quarterly, and significant change assessments. However, only two care conferences were documented during the last 12 months, despite the expectation that care conferences be conducted quarterly with the resident and family when possible. The Unit Care Coordinator confirmed that no additional care conference documentation existed for this resident beyond the notes dated 04/21/25 and 01/02/26. A second resident, with diagnoses including aphasia following cerebrovascular disease, cerebral infarction, type II diabetes mellitus, unsteadiness on feet, difficulty in walking, coagulation defect, depression, and muscle weakness, also had multiple MDS assessments completed over the review period, including quarterly and annual assessments. The record contained a note that a care conference was offered to the resident’s representative, who declined to attend, but there was no documentation of any care conferences for the most recent 12 months. The Unit Care Coordinator confirmed that no other care conference documentation was available for this resident. Facility policy stated that periodic care conferences involving the resident, family, and the interdisciplinary team are part of the care planning process, but the required periodic care conferences and corresponding documentation were not completed for these two residents.
Plan Of Correction
THIS PLAN OF CORRECTION SERVES AS BERKELEY SQUARE'S CREDIBLE ALLEGATION OF SUBSTANTIAL COMPLIANCE AS OF June 1, 2026. Without admitting or denying the validity or existence of the alleged deficiencies, Berkeley Square provides the following Plan of Correction: F657 The facility will continue to document completion of care conferences at the required intervals for all residents, including residents #04 & #15. To ensure compliance with this standard the following measures have be taken: 1. The social service designee and the inter- disciplinary team were re-educated by the administrator to the facility policy "Care Conference" on 4/29/26 and verbalized understanding. 2. Care conferences for resident #04 and resident #15 were conducted on or before 4/29/2026 by the interdisciplinary team. 3. Review of all other residents was conducted by the social service designee to validate and ensure that care conference schedule is up to date with timely care conferences scheduled for them on 4/15/2026. Audits of care conferences to be completed weekly for four weeks and then monthly after that by the social service designee. Documentation of the care conference including any identified concerns in the medical record. Administrator to validate audits/compliance and provide additional training as needed. Administrator will present results of these audits to QAPI committee for ongoing monitoring and further direction.
Failure to Reevaluate Blood Glucose After Treatment for Hyperglycemia
Penalty
Summary
The facility failed to ensure that a resident with diabetes received treatment in accordance with professional standards of practice when nursing staff did not reevaluate the resident's blood glucose after treatment for severe hyperglycemia. The resident, admitted with diagnoses including Alzheimer's disease, type II diabetes mellitus, and depression, had physician orders for Humalog insulin on a sliding scale before meals, Lantus insulin 25 units daily, and lisinopril 5 mg daily. The resident required extensive assistance with activities of daily living, including transfers, toileting hygiene, eating, and bathing. On the evening in question, the resident's blood glucose was documented as 532 mg/dL, and the on-call provider was notified. The provider gave a new order to administer an additional 8 units of lispro (Humalog) and to recheck the blood glucose in 30 minutes. The electronic medication administration record showed that the blood glucose of 532 mg/dL was obtained at 9:00 p.m. and that the additional 8 units of lispro were administered at 9:21 p.m. However, there was no documentation in the resident's chart that the blood glucose was rechecked after the additional insulin was given. In an interview, the DON confirmed there was no evidence of reevaluation and verified that, according to the facility's "Abnormal Blood Glucose Procedure" policy, the resident should have been reevaluated and that the evaluation step should have been included in the progress note documentation.
Plan Of Correction
F684 The facility will continue to ensure all residents, including #03, receive treatment in accordance with professional standards of practice and reevaluated for hyperglycemia. To ensure compliance with this standard the following measures have been taken: 1. The director of nursing assessed resident #03, reviewed documentation and orders and found no ill effects immediately 4/16/26. 2. All licensed nurses were re-educated to facility policy "Blood Glucose Monitoring" by the Director of Nursing/designee in April 2026. 3. Audits of like-residents that require blood sugar checks to be completed by the director of nursing/designee two times a week for 4 weeks and then monthly after that to validate correct follow through when there is abnormally high blood glucose result. The Administrator will bring results of these audits to the QAPI committee for ongoing monitoring and further direction.
Failure to Act on Pharmacist Drug Regimen Recommendation for Thyroid Medication
Penalty
Summary
The deficiency involves the facility’s failure to ensure that pharmacy recommendations from the monthly drug regimen review were acted upon and documented for a resident. The resident was admitted with diagnoses including Parkinson’s disease, dementia, and hypothyroidism, and had current physician orders for levothyroxine 150 mcg once daily, buspirone 50 mg twice daily, and losartan 100 mg once daily. A medication regimen review dated 11/25/2025 included a consultant pharmacist recommendation that levothyroxine be administered consistently in the morning on an empty stomach, at least 30–60 minutes before food, per manufacturer instructions. There was no specific physician response in the medical record to this recommendation, and the facility’s policy stated that consulting pharmacist reviews are sent to nursing and addressed with the primary care provider or consulting specialist for review and follow-up. Review of the resident’s medication administration record for April 2026 showed levothyroxine scheduled for 9:00 a.m. On observation, the resident was seen eating breakfast in the dining area at 8:03 a.m., and an LPN reported administering the levothyroxine 150 mcg to the resident while the resident was in the dining area eating breakfast. The DON confirmed there was no evidence in the resident’s medical record explaining why the consultant pharmacist’s recommendation from 11/25/2025 was or was not acted upon. This lack of documented physician review and action on the pharmacist’s identified irregularity constituted noncompliance with the drug regimen review requirements.
Plan Of Correction
F756 The facility will continue to ensure the pharmacy recommendations from the monthly drug regimen review by a licensed pharmacist are acted upon for all residents, including #08. To ensure compliance with this standard the following measures have been taken: 1. Resident #08 was assessed by the registered nurse and med review completed by 4/28/26. After review of resident's drug regime's, it was discovered that resident #8 had 2 separate medication recommendations on the same form, to be reviewed by two separate practitioners, pharmacy has been instructed and agreed to separate meds on individual forms. 2. Licensed nurses re-educated to facility policy "Drug Regimen Review" by Director of nursing/designee in April 2026 and no later than 5/8/26. Licensed nurses are responsible for ensuring the reviews and recommendations are given to the physician for timely review. 3. Review of all other current residents Drug Regimen orders completed by Director of nursing/designee on 4/16/26 to ensure recommendations were followed up on/reviewed by the physician and address concerns if needed. 4. Audit of drug regime recommendations, pharmacy recommendations, and physician follow up to be completed weekly for four weeks by the Director of nursing/designee. Administrator will present results of these audits to the QAPI committee for ongoing monitoring and further direction.
Failure to Use Required Gait Belt During Ambulation Resulting in Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a required gait belt was used while assisting a high fall‑risk resident with ambulation, resulting in a fall with head injury. The resident had multiple diagnoses including metabolic encephalopathy, hypertension, osteoarthritis, muscle weakness, gait and mobility abnormalities, major depressive disorder, anxiety, and visual hallucinations. Admission and subsequent MDS and fall risk assessments documented that the resident was severely cognitively impaired, required moderate to maximal assistance with transfers and ambulation, could not independently come to a standing position, exhibited loss of balance while standing, used an assistive device, and had decreased muscle coordination. The resident had a history of falls prior to admission and was assessed as being at high, later moderate, risk for falls. The resident’s fall care plan identified her as at risk for falls and included interventions such as providing maximum to moderate assistance with transfers and walking short distances, use of a walker and wheelchair, and following the facility’s fall protocol. Therapy notes and care conference documentation indicated that the resident leaned backwards when standing, required contact guard to minimal assistance for bed mobility and transfers, and needed constant verbal cueing for safe sequencing during toilet transfers. The physical therapist confirmed that the resident was to use a gait belt with staff when ambulating, and the DON verified that therapy had assessed the resident as requiring contact guard assistance and a gait belt for ambulation and transfers. On the day of the incident, a CNA was assisting the resident from her recliner to the bathroom using a walker. The CNA walked beside the resident, providing guidance and support, and reported having a hand on the resident while assisting her. As they approached the bathroom door, the CNA reached for the doorknob to open it, and at that moment the resident began to lose her balance and fell backwards to the floor, striking the back of her head. The nurse who responded found the resident on her back at the foot of the bed with her feet near the bathroom, noted a red raised area on the back of the head, and documented that the resident was not wearing a gait belt and that the gait belt was on the dresser. In the facility’s investigative summary and in interviews, the CNA acknowledged that she did not have a gait belt on the resident while ambulating her, despite the resident’s assessed need for hands‑on assistance and gait belt use per facility policy and the resident’s care and therapy plans.
Failure to Implement PD Orders and Monitor Resident Receiving Peritoneal Dialysis
Penalty
Summary
The deficiency involves the facility’s failure to implement pre-admission physician orders for peritoneal dialysis (PD) and to provide ongoing monitoring for a resident with chronic kidney disease (CKD) stage five who required PD. Pre-admission orders dated 11/14/25 specified three daily PD exchanges at 6:00 A.M., 2:00 P.M., and 10:00 P.M., and directed staff to monitor for signs and symptoms of peritonitis, including fever, abdominal pain, and cloudy effluent. These monitoring orders were not entered into the facility’s physician orders. The resident’s care plan noted the need for PD and included general monitoring interventions (labs, signs of bleeding, bacteremia, septic shock, and significant vital sign changes), but did not specifically address the ordered monitoring for peritonitis. Review of PD documentation showed incomplete and inconsistent charting of treatments and resident condition. The paper peritoneal flowsheet had columns for time of PD and condition/comments, including instructions to call the nurse immediately for cloudy fluid, abdominal pain, or fever. However, the first entry on 11/15/26 at 2:00 P.M. only noted that the PD nurse completed the exchange, and the 10:00 P.M. entry that day had no condition/comment documentation. Subsequent days (11/16/25, 11/17/25, and 11/18/25) contained only one condition/comment entry per day rather than for each exchange, and there was no documentation that the 6:00 A.M. PD on 11/18/25 was completed. The PD cycler flowsheet starting 11/19/25 lacked any description of the effluent on multiple days. The PD nurse from the dialysis company stated facility staff were expected to monitor effluent for cloudiness and assess for abdominal pain and fever, and the DON confirmed there was no electronic physician order for peritonitis monitoring or for use of the PD cycler, that the paper charting did not allow for effluent description or symptom documentation for each treatment, and that PD was not documented at one ordered time. The facility’s dialysis policy required ongoing assessment and monitoring for complications before, during, and after treatments, which was not reflected in the documentation for this resident.
Improper Infection Control During Medication Administration
Penalty
Summary
Surveyors identified a deficiency in infection prevention and control related to medication administration for Resident #29. The resident was admitted on 02/28/14 with diagnoses including depression, traumatic brain injury, and anxiety, and had impaired cognition per a quarterly MDS assessment. During an observation on 03/25/26 at 6:58 A.M., RN #281 prepared the resident’s medications by removing an Amoxicillin-Pot Clavulanate tablet from the medication card and pushing it directly into her ungloved hand, then using her fingers to place the pill into a medication cup. The same process was observed for multiple other medications, including Escitalopram Oxalate, Furosemide, Sennosides, Lyrica, and Vitamin D, each being pushed from the card into the RN’s ungloved hand and then transferred by her fingers into the medication cup before administration to Resident #29. In a subsequent interview at 7:27 A.M. the same day, RN #281 confirmed she had placed each medication into her ungloved hands prior to administration and acknowledged that the proper procedure was to push the pills directly from the card into the medication cup. Review of the facility’s “Medication Administration – General guidelines” policy, revised 10/08/25, stated that medications are to be administered in accordance with good nursing principles and practices. This practice failure was cited as a deficiency under Complaint Number 2681777.
Improper Use of Wheelchair as a Physical Restraint
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to ensure a resident was free from physical restraints. Resident #7, admitted with diagnoses including Alzheimer’s disease, diabetes mellitus, and anxiety disorder, was documented on a recent MDS as rarely understood and dependent for ADLs except eating. The resident ambulated independently on the unit without an assistive device and had documented verbal and other behaviors occurring one to three days during the look-back period. The care plan noted the resident had potential to be physically aggressive, chase staff, throw objects, and be combative with care, with interventions such as offering choices, administering medications as ordered, and intervening early when agitation occurred. During an observation and interview, Resident #7 was found sitting in a chair with the right arm of the chair positioned against the nursing station and a wheelchair placed directly in front of him. The left arm of the wheelchair was also against the nursing station, and both wheelchair wheels were locked, creating a barrier that appeared to restrain the resident, who was sleeping with his knees touching the locked wheelchair. An LPN confirmed both wheelchair wheels were locked and that the wheelchair should not have been placed in front of the resident. A CNA reported she had placed the wheelchair there in preparation to get the resident up for lunch, was unable to transfer him, and left the wheelchair in that position, acknowledging it was wrong to keep it there. The facility’s physical restraint policy stated that physical restraints are not used except when alternatives are not appropriate or effective for treating a medical symptom and defined physical restraints as any device attached or adjacent to the body that the individual cannot easily remove and that restricts freedom of movement or access to the body.
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