Vista Center At The Ridge
Inspection history, citations, penalties and survey trends for this long-term care facility in Mineral Ridge, Ohio.
- Location
- 3379 Main Street, Mineral Ridge, Ohio 44440
- CMS Provider Number
- 365823
- Inspections on file
- 27
- Latest survey
- December 3, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Vista Center At The Ridge during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and multiple diagnoses was admitted with a DNRCC order, but during a medical emergency, an LPN found no Advance Directive information in the electronic record and a Full Code indicator in the physical chart, leading to the initiation of CPR. The DNRCC order had been signed and placed in the chart after a care conference, but no physician's order was entered and the code status was not updated in the system, resulting in the resident's wishes not being honored.
Surveyors found that the facility did not maintain a clean and sanitary environment, with multiple residents affected by unclean rooms, overflowing trash, food debris, stained linens, soiled bathroom fixtures, and pest presence. Staff interviews and cleaning schedules confirmed that housekeeping was not performed daily, and some staff used personal supplies to address ongoing messes, contrary to facility policy.
A resident with multiple medical conditions was discharged to a hotel without being provided a 30-day discharge notice or comprehensive discharge planning. The facility did not notify the Ombudsman or document coordination of discharge services, and there was no evidence the resident agreed to the discharge plan or was assisted in securing safe housing beyond a hotel arrangement.
The facility failed to label and date food items in the kitchen, potentially affecting 143 residents. During a kitchen tour, several undated and unlabeled items were found in the refrigerators, including a pork loin, hard-boiled eggs, ham, a Chef salad, and an unidentified substance. A staff member confirmed the items were unlabeled and undated, and the facility's policy requires all foods to be labeled and monitored.
The facility failed to document the offering and education of the COVID-19 vaccine to staff, affecting all 144 residents. Personnel records lacked documentation for several CNAs and an LPN, except for newly hired staff. Interviews confirmed the oversight, despite the facility's policy requiring such documentation.
Staff at the facility failed to adhere to PPE protocols during care for several residents, including those with indwelling devices and on droplet precautions. CNAs and RNs did not wear gowns or eye protection as required by Enhanced Barrier Precautions and droplet precautions, despite signage indicating the need for such measures. This non-compliance was observed across multiple residents, including those with tube feedings, urinary catheters, and intravenous therapy.
The facility failed to maintain a clean and safe environment, affecting residents and common areas. Furniture in the 200-hall was soiled and damaged, and Resident #63's room had persistent urine issues with no effective interventions. Resident #23's wheelchair was dirty, and the facility lacked a cleaning policy. The laundry room had excessive dust and debris, with unclear cleaning responsibilities. These deficiencies were confirmed by staff interviews and observations.
A facility failed to accurately document a resident's urinary catheter status. The resident was noted to have an indwelling catheter in the MDS assessment, but subsequent records and interviews indicated otherwise. Observations showed no catheter present, and staff confirmed its absence upon admission. The DON acknowledged the documentation inconsistencies.
A resident with chronic vascular ulcers did not have their daily wound dressing changes documented as completed on multiple occasions. Despite the presence of a nurse practitioner on some days, the facility failed to ensure proper documentation and adherence to treatment orders, affecting the resident's care.
Two residents in a LTC facility were found to have inadequate incontinence care and toileting assistance. One resident was left in a room with a strong urine odor and wet clothing, while another had multiple urine puddles and stained tiles in his room. Despite care plans requiring assistance, staff failed to provide timely care, and no toileting program was in place for the resident on diuretic therapy. Staff interviews confirmed the issues, and the facility's incontinence care policy was not followed.
The facility failed to follow its weight monitoring policy for two residents, resulting in unreported significant weight loss and missed weekly weigh-ins. One resident lost 8.7% of their weight in 30 days without physician notification or reweighing, while another resident's weekly weights were not recorded as ordered. These lapses were confirmed by the RD, indicating a breach in protocol.
A facility failed to administer oxygen as ordered and did not change the oxygen tubing weekly for a resident with COPD. The resident's oxygen was set at four liters per minute instead of the ordered three liters, and the tubing had not been changed since 01/23/25. An LPN confirmed these discrepancies, which affected the resident and potentially impacted four other residents receiving oxygen therapy.
The facility failed to complete accurate pre and post dialysis assessments for two residents requiring dialysis. One resident, moderately cognitively impaired, and another, cognitively intact, both had multiple instances of missing or incomplete assessments. Despite care plans requiring monitoring and communication with dialysis staff, these were not consistently documented, as confirmed by an LPN aware of the inconsistencies.
A facility failed to provide a trauma-informed care plan for a resident with PTSD, lacking documentation of triggers and interventions. Despite the facility's policy, staff were unaware of the resident's trauma history, and the care plan did not reflect necessary measures to prevent re-traumatization.
A facility failed to ensure pharmacist recommendations for a resident's medications were addressed by the physician. The resident, with multiple health conditions, was on Lasix and Hydroxyzine. The pharmacist recommended monitoring Lasix side effects and discontinuing Hydroxyzine, but the physician did not document actions or rationale, contrary to facility policy.
The facility failed to secure medications, affecting three residents. A resident with moderate cognitive impairment had multiple oral medications unsecured in their room. Another resident, cognitively intact, had unsecured nasal sprays and ophthalmic solutions. A third resident had unsecured nasal sprays on their bedside table. No orders or assessments for self-administration were present.
A facility failed to administer pneumococcal and Covid-19 vaccines to a resident with multiple health conditions, despite the resident's signed request for these vaccinations. The resident's medical record showed no provider orders for the vaccines, and the MDS assessment indicated the pneumococcal vaccine was not offered. An interview confirmed the resident had not received the Covid-19 vaccine, contrary to facility policy requiring vaccines to be offered upon admission.
A resident with dementia and Alzheimer's disease, assessed as high risk for falls, experienced multiple falls due to the facility's failure to implement physician-ordered interventions. Despite orders to keep a walker within reach and use a wheelchair, the resident was often found without these aids. Staff interviews revealed a lack of awareness and adherence to the care plan, leading to repeated falls and injuries.
The facility failed to ensure an effective pest control program, affecting 122 residents who eat meals from the kitchen. A resident reported flying ants, and a kitchen aide confirmed gnats in the kitchen despite using a green liquid in the mop water. Observations confirmed gnats around the food cart, dishwasher, and sink area. The maintenance director acknowledged the issue. The facility's Pest Control policy was not effectively implemented.
Failure to Honor and Document Resident's Advance Directive Code Status
Penalty
Summary
The facility failed to ensure that a resident's Advance Directive and code status were accurately documented and honored. The resident, who was severely cognitively impaired and had diagnoses including diabetes, dementia, muscle weakness, depression, and breast cancer, was admitted with a Do Not Resuscitate; Comfort Care (DNRCC) order according to her wishes and those of her son, who was her Power of Attorney. However, during a medical emergency when the resident was found unresponsive, the LPN checked the electronic record and found no information regarding Advance Directives. Upon reviewing the physical chart, the LPN found a yellow sheet indicating Full Code status and initiated CPR, also calling emergency services. The resident's son was notified and arrived after the resident had expired. It was only discovered days later that the resident was actually a DNRCC at the time of the incident. Further review revealed that after a care conference with the resident's son, the Social Service Designee faxed the DNRCC form to the nurse practitioner, who signed and placed it in the physical chart. The Social Service Designee also notified an RN to update the order, but there was no physician's order for the DNRCC in the resident's chart, nor was the code status updated in the electronic record. The facility's policy required that residents' Advance Directive wishes be honored and documented, with appropriate physician orders written for those choosing Advance Directives. This failure to accurately document and communicate the resident's code status led to the initiation of CPR against the resident's documented wishes.
Failure to Maintain Clean and Sanitary Resident Environment
Penalty
Summary
The facility failed to maintain a clean, safe, and sanitary environment for residents on the 400 unit, as evidenced by multiple observations and record reviews. Six residents, most with impaired cognition and psychiatric or neurological diagnoses, were directly affected. Observations included dried coffee stains, food and paper debris on the floors, overflowing trash, food stored improperly in dresser drawers, stained linens, and a heavily soiled pillow. Additionally, one room had a strong urine odor, a wet and rusted bathroom floor, and a toilet seat covered with dried feces. Another room had a significant presence of gnats around the sink and countertop. Interviews with staff revealed that housekeeping services were not provided daily on the unit, and a CNA reported bringing in personal cleaning supplies to address the ongoing mess. The housekeeping cleaning schedule showed missed cleaning days, and the facility's policy required maintaining a homelike environment. The Housekeeping Director confirmed the findings during the survey, and a housekeeper assigned to the unit was pulled from another area, indicating inconsistent cleaning practices.
Failure to Provide 30-Day Discharge Notice and Adequate Discharge Planning
Penalty
Summary
The facility failed to provide a 30-day discharge notice and appropriate discharge planning for a resident who was being discharged. The resident, who had diagnoses including morbid obesity, difficulty in walking, and epilepsy, was admitted from a hotel and was unable to return there due to eviction. The resident was cognitively intact and had no family involvement. During a care conference, it was noted that the resident was homeless and unable to secure alternative housing. The facility determined that the resident no longer required skilled nursing care or therapy and issued a Notice of Adverse Decision, denying continued stay. Social services assisted the resident in finding a hotel room and made arrangements for a primary care provider appointment and home health referral. However, there was no evidence in the medical record that a 30-day discharge notice was provided, that the Ombudsman was notified or involved in the discharge process, or that the resident was assisted in securing safe housing beyond the hotel arrangement. The resident was discharged to a hotel, and documentation did not confirm the resident's agreement to this discharge plan. Interviews with facility staff confirmed that the resident did not want to pay for continued stay and chose to be discharged to a hotel, but the Ombudsman was not notified, and there was no documentation of coordination with the Ombudsman or evidence of comprehensive discharge planning. The facility's policy required notification of the Ombudsman and a post-discharge plan of care, but these steps were not documented or completed for this resident.
Failure to Label and Date Food Items in Kitchen
Penalty
Summary
The facility failed to ensure that food items in the kitchen were labeled and dated appropriately, which could potentially affect 143 of the 144 residents who received meals from the facility kitchen. During an initial kitchen tour, it was observed that the main walk-in refrigerator contained a pork loin in a metal container that was undated and unlabeled. Additionally, the reach-in refrigerator had several items that were undated and unlabeled, including a metal container of 12 quartered hard-boiled eggs, a metal container of ham, a Chef salad, and a metal container of an unidentified gelatinous brown-green substance. An interview with a staff member confirmed that these items were unlabeled and undated, and the staff member was unaware of when they were placed in the refrigerators. The facility's policy on food storage requires all foods to be covered, labeled, and routinely monitored to ensure they are consumed by their use dates, frozen, or discarded as applicable.
Failure to Document COVID-19 Vaccine Education and Offering
Penalty
Summary
The facility failed to maintain proper documentation regarding the offering and education of the COVID-19 vaccine to its staff, which had the potential to affect all 144 residents. A review of personnel records for several CNAs and an LPN revealed no documentation that the facility had provided education or offered information and consent regarding the COVID-19 vaccine. Interviews with the Infection Control Preventionist and the Human Resources Manager confirmed that the facility did not maintain the necessary documentation for staff education and vaccine offering, except for newly employed staff hired within the last year. The facility's policy on COVID-19 vaccination, revised in December 2021, required that education on the benefits and potential side effects of the vaccine be provided before offering it to staff. The policy also stated that the refusal of the vaccine and the reason for refusal should be documented in the staff member's personnel file. However, the facility failed to adhere to this policy, as evidenced by the lack of documentation in the personnel files of existing staff members, except for those newly hired. This oversight in documentation and adherence to policy was verified through interviews with facility staff.
Failure to Adhere to PPE Protocols in Resident Care
Penalty
Summary
The facility failed to ensure that staff donned the appropriate personal protective equipment (PPE) when providing direct care to several residents, which was observed during a survey. For Resident #50, who was at risk for infection due to an ostomy and had orders for Enhanced Barrier Precautions (EBP) related to tube feedings, Certified Nursing Assistants (CNAs) entered the room and provided incontinence care wearing only gloves, without gowns, despite signage indicating the need for EBP. The CNAs admitted to not knowing where to find the gowns, as there was no supply cart with PPE outside the resident's room. Resident #16, who had an indwelling urinary catheter and was at risk for infection, also did not receive care with the appropriate PPE. A CNA assisted the resident with bathing and dressing, wearing only gloves and not a gown, as required by the EBP signage. The CNA acknowledged forgetting to wear a gown, which was located on a linen cart in the hallway. Similar deficiencies were noted for Resident #13, who was receiving intravenous therapy through a PICC line, and Resident #119, who had an enteral tube. In both cases, staff failed to wear gowns during high-contact care activities, despite EBP orders. Additionally, for Resident #36, who was on droplet precautions due to influenza A, staff did not wear the required eye protection and failed to change masks upon exiting the room, as indicated by the droplet precautions signage. These observations highlight a pattern of non-compliance with PPE protocols across multiple residents and care situations.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a clean and safe environment for its residents, as evidenced by several observations and interviews. In the 200-hall common area, furniture was found to be heavily soiled and damaged, with exposed metal and wood framing, and a large crack in the wall was noted. The Director of Nursing (DON) confirmed these findings during an interview. Additionally, Resident #63's room was in poor condition, with multiple puddles of urine, stained tiles, and a pervasive urine smell. The Registered Nurse (RN) and DON verified the room's condition, acknowledging that the room had been like this for some time and that housekeeping only cleaned once a day despite the ongoing issue. Resident #63, who has dementia and other medical conditions, was observed urinating in inappropriate places, contributing to the room's unsanitary state. The care plan for Resident #63 did not include interventions to prevent urination in inappropriate places, and there was no evidence of a toileting program in place. The Maintenance Director confirmed that the tiles and baseboards needed replacement due to urine damage. Furthermore, Resident #23's wheelchair was found to be dirty, with dried food and a brown/black substance on the seat and brakes. The facility lacked a policy or schedule for cleaning wheelchairs, as confirmed by the Administrator. The laundry room was also found to be in poor condition, with a thick coating of dust and debris behind the washing machines. The Laundry Aide and Maintenance Director had conflicting views on who was responsible for cleaning behind the machines, indicating a lack of clarity in cleaning responsibilities. Overall, the facility's failure to maintain cleanliness and address ongoing issues with resident care and the environment was evident in multiple areas, affecting the quality of care provided to the residents.
Inaccurate Documentation of Urinary Catheter Status
Penalty
Summary
The facility failed to ensure accurate documentation of a resident's bowel and bladder assessment, specifically regarding the presence of an indwelling urinary catheter. Resident #13, who was admitted with multiple diagnoses including acute cystitis, cognitive decline, and morbid obesity, was documented in the Minimum Data Set (MDS) admission assessment as having an indwelling urinary catheter. However, subsequent CNA documentation indicated frequent urinary incontinence with occasional continence, and there was no care plan or interventions for an indwelling catheter. Additionally, there were no physician orders to discontinue the catheter, and nursing progress notes lacked documentation of its presence or discontinuation. Observations and interviews further revealed inconsistencies in the documentation. An observation on February 3rd showed no catheter tubing or urine drainage bag, and interviews with the resident and CNAs confirmed that the resident did not have an indwelling urinary catheter upon admission. The Director of Nursing verified these findings, acknowledging the inconsistent documentation. The NSO guidelines emphasize the importance of accurate and complete documentation to prevent liability, highlighting the deficiency in maintaining a complete and accurate clinical record for Resident #13.
Failure to Document Wound Treatments as Ordered
Penalty
Summary
The facility failed to complete wound treatments as ordered by the physician for a resident with chronic left lower extremity vascular ulcers. The resident, who was admitted with diagnoses including disorders of veins, peripheral vascular disease, congestive heart failure, and diabetes mellitus type two, required daily wound dressing changes for their medial and lateral ulcers. However, the treatment administration record revealed that these dressing changes were not documented as completed on several occasions, specifically on 12/20/24, 01/09/25, 01/11/25, 01/12/25, 01/13/25, 01/19/25, and 01/23/25. Interviews with the wound nurse confirmed the lack of documentation for these dates, and it was noted that on some occasions, the nurse practitioner was present and would have completed the dressing changes, but they were not signed off. Additionally, there was no documented evidence that the dressing changes were completed as ordered on 12/20/24 and 01/11/25. A corrective action form was completed for instances in December 2024 when a nurse had signed off on treatments that were not done, indicating a pattern of failure to adhere to treatment orders.
Inadequate Incontinence Care and Toileting Assistance
Penalty
Summary
The facility failed to provide adequate incontinence care and toileting assistance for two residents, leading to significant deficiencies in their care. Resident #56, who was admitted with multiple diagnoses including bladder incontinence, was found in a room with a strong odor of urine. His care plan required assistance with toileting and incontinence care, but on the morning of the observation, he had not been checked by staff since the start of their shift. His room contained wet clothing and a strong urine odor, indicating a lack of timely incontinence care. Resident #63, diagnosed with dementia and other conditions, was also inadequately managed for incontinence. His care plan noted a risk for impaired skin integrity due to incontinence, but there were no interventions to prevent urination in inappropriate places. Observations revealed multiple puddles of urine in his room, stained tiles, and a pervasive urine smell. Despite being on diuretic therapy, there was no toileting program in place for him, and staff were not cleaning his room more than once a day, allowing urine to accumulate and seep under tiles. Interviews with staff, including CNAs, RNs, and housekeeping, confirmed the ongoing issues with incontinence care for both residents. Staff acknowledged the conditions in Resident #63's room and the lack of a toileting program. The facility's policy on incontinence care was not being followed, as it required care after each episode of incontinence, which was not happening. The Director of Nursing and Maintenance Director were unaware of the room's condition, highlighting a lack of oversight and communication within the facility.
Failure to Monitor and Document Weight Changes
Penalty
Summary
The facility failed to adhere to its policy regarding weight monitoring and physician notification for two residents, leading to deficiencies in nutritional care. Resident #36 experienced an 8.7% weight loss over 30 days, dropping from 322 pounds to 294 pounds. Despite this significant weight loss, there was no documented evidence that the physician was notified, nor was a reweigh conducted as per the facility's policy. The resident's care plan indicated a risk for nutritional status alteration, yet the necessary interventions, such as reweighing and physician notification, were not executed. The Registered Dietitian confirmed the absence of a reweigh, highlighting a lapse in following the dietary assessment note's recommendation. Similarly, Resident #37, who was at risk for nutritional and hydration alterations, did not have weekly weights obtained as ordered by the physician. The resident's weight record showed a decrease from 181 pounds to 174 pounds, a 3.86% weight loss, but lacked additional weekly weight records. The facility's policy required weekly weights for new admissions and reweighs for any significant weight variance, which were not followed. The Registered Dietitian confirmed the failure to obtain the required weekly weights, indicating a breach in the facility's weight monitoring protocol.
Oxygen Administration and Tubing Change Deficiency
Penalty
Summary
The facility failed to administer oxygen to Resident #128 as per the physician's orders and did not change the oxygen tubing as required. Resident #128, who was cognitively intact, had a medical history that included chronic obstructive pulmonary disease (COPD), kidney disease, and a history of stroke. The care plan for Resident #128 included interventions for altered breathing patterns due to COPD, which required oxygen administration according to the physician's orders. However, during an observation, it was noted that the oxygen was set at four liters per minute instead of the ordered three liters per minute, and the oxygen tubing had not been changed weekly as ordered, with the last change dated 01/23/25. The facility's policy on oxygen therapy stated that oxygen should be administered in accordance with the physician's orders and that tubing, nasal cannulas, and humidifiers should be changed as per the physician's orders. An interview with an LPN confirmed the discrepancies in the oxygen administration and the overdue tubing change. This deficiency affected Resident #128 and had the potential to impact four additional residents who were also receiving oxygen therapy.
Incomplete Dialysis Assessments for Residents
Penalty
Summary
The facility failed to ensure accurate and complete pre and post dialysis assessments for two residents who required dialysis services. Resident #37, who was moderately cognitively impaired and dependent on staff for various activities, had multiple instances where pre and post dialysis assessments were not completed on specified dates. Additionally, when assessments were completed, they often lacked necessary relevant information. The resident's care plan included interventions such as assisting with transfers to dialysis and monitoring the shunt for infection, but these were not adequately documented in the assessments. Similarly, Resident #83, who was cognitively intact but required assistance for daily activities, also had numerous dates where pre and post dialysis assessments were not completed. The resident's care plan outlined similar interventions as Resident #37, including monitoring the disease process and maintaining communication with dialysis staff. However, the assessments were either incomplete or missing, as confirmed by an LPN who acknowledged the inconsistencies. The facility's policy required nurses to obtain vital signs and assess the dialysis site, but these actions were not consistently documented.
Lack of Trauma-Informed Care Plan for Resident with PTSD
Penalty
Summary
The facility failed to provide an individualized care plan with interventions for a resident diagnosed with post-traumatic stress disorder (PTSD). This deficiency was identified during a review of the medical records and interviews with staff and the resident. The resident, who had a history of trauma and PTSD, did not have any triggers or interventions documented in their care plan to prevent re-traumatization. Despite the facility's policy on trauma-informed care, which requires the assessment and documentation of trauma-related triggers, the care plan lacked this critical information. Interviews with staff, including a Certified Nursing Assistant, a Registered Nurse, and the Director of Nursing, revealed a lack of awareness regarding the resident's past trauma and potential triggers. The Psychiatric Nurse Practitioner's progress note indicated the resident had a history of abuse and trauma, yet this information was not reflected in the care plan. The facility's failure to incorporate trauma-informed care practices into the resident's care plan affected the resident and had the potential to impact other residents diagnosed with PTSD.
Failure to Address Pharmacist Recommendations for Resident Medications
Penalty
Summary
The facility failed to ensure that pharmacist recommendations for a resident were addressed by the physician, affecting one of three residents reviewed for unnecessary medication. The resident, who was cognitively intact, had multiple diagnoses including hypertension, anxiety, malnutrition, muscle weakness, prostate disorder, depression, and diabetes. The resident required varying levels of assistance for daily activities. The physician's orders included Lasix and Hydroxyzine, with the latter being recommended for discontinuation by the pharmacist due to its unsuitability for elderly patients. The medication regimen review conducted by the pharmacist highlighted the need for monitoring potential side effects of Lasix and recommended discontinuing Hydroxyzine. However, there was no documented evidence that the physician addressed the recommendation for Lasix, and although the physician chose to continue Hydroxyzine, no rationale was provided for this decision. The Director of Nursing confirmed that the medication regimen reviews were not appropriately addressed by the physician, which was contrary to the facility's policy requiring physician action or documented rationale for rejecting pharmacist recommendations.
Medication Security Deficiency
Penalty
Summary
The facility failed to ensure that all medications were secured and stored in locked compartments, limiting access only to authorized personnel. This deficiency affected three residents on the 200-nursing unit. Resident #13, who had moderate cognitive impairment, was observed with multiple oral medications left unsecured in their room without a physician's order or assessment for self-medication. The medications included antidepressants, supplements, a hormone, a proton pump inhibitor, a schedule III pain medication, and others. A registered nurse confirmed the medications were left unattended. Resident #16, who was cognitively intact, had unsecured medications on a computer desk in their room, including nasal sprays and ophthalmic solutions. There was no provider order or assessment for self-administration of these medications. Similarly, Resident #95, with a history of respiratory failure and schizoaffective disorder, had unsecured nasal sprays on their bedside table without an order or assessment for self-administration. A medication technician confirmed the presence of these unsecured medications.
Failure to Administer Pneumococcal and Covid-19 Vaccines
Penalty
Summary
The facility failed to administer the pneumococcal and Covid-19 vaccines to Resident #125, who was admitted with diagnoses including malignant neoplasm of the stomach, bipolar disorder, and feeding difficulties with gastrostomy. Despite Resident #125's signed request for these vaccinations on 11/11/24, a review of the electronic medical record from 11/08/24 to 02/04/25 showed no provider orders for the vaccines. The Minimal Data Set (MDS) 3.0 assessment completed on 12/19/24 indicated that the pneumococcal vaccine was not offered, and the resident was not up to date with the vaccine. Additionally, there was no documentation regarding the Covid-19 vaccination status in the MDS assessment. An interview with Resident #125 on 02/04/25 confirmed that she had not received the Covid-19 vaccine and had requested the pneumonia vaccine upon admission. The facility's policy stated that residents would be offered the influenza and pneumococcal vaccines upon admission, with a physician order obtained at the time of consent, and that the Covid-19 vaccine would be offered per manufacturer guidelines via an authorized provider.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to maintain fall prevention interventions as ordered by the physician for a resident, leading to multiple falls. The resident, who was admitted with diagnoses including encephalopathy, dementia, and Alzheimer's disease, was assessed as high risk for falls. Despite this, the resident experienced falls on three separate occasions, with injuries noted after each incident. The care plan and physician orders specified that the resident should have a walker within reach and be redirected to a wheelchair until strength was regained, but these interventions were not consistently implemented. Observations revealed that the resident was often found sitting in a stationary chair without access to a walker or wheelchair, contrary to the care plan and physician orders. Staff interviews confirmed that the resident was supposed to use a walker for ambulation and sit in a wheelchair, yet these measures were not followed. The staff, including STNAs and a Medication Aid, failed to ensure the resident had the necessary mobility aids, and there was a lack of awareness among staff about the resident's required level of assistance. The Director of Nursing confirmed the resident's recent falls and the interventions that were supposed to be in place. However, observations showed that the resident continued to be seated in a stationary chair without the required mobility aids. The facility's policy on fall management was not effectively implemented, as evidenced by the repeated falls and the failure to adhere to the prescribed interventions for the resident.
Ineffective Pest Control Program
Penalty
Summary
The facility failed to ensure an effective pest control program, which had the potential to affect 122 out of 125 residents who eat meals from the kitchen. An interview with a resident revealed concerns about flying ants, while a kitchen aide confirmed the presence of gnats in the kitchen despite using a green liquid in the mop water to control them. Observations confirmed multiple gnats flying around the food cart, dishwasher, and sink area. The maintenance director acknowledged the gnat problem. The facility's undated Pest Control policy aimed to prevent and control pest infestations, but it was not effectively implemented. This deficiency was investigated under Complaint Number OH00152338.
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Surveyors found that multiple hazardous storage areas, including a closet near medical records, a beauty salon used to store chemical cases, a supply room in one nursing station, a room leading to a smoking area, a housekeeping room near therapy, and a lobby storage room, lacked required self-closing or automatic-closing doors. These conditions did not comply with NFPA 101 requirements for hazardous area enclosure and had the potential to affect all residents and staff in an emergency.
Surveyors found that the facility did not conduct fire drills on every shift each quarter and did not vary drill conditions as required by NFPA 101. Record review showed that one shift lacked a documented drill for an entire quarter, and the pattern of drill times and dates did not demonstrate varied conditions. The Maintenance Director confirmed the incomplete and noncompliant fire drill schedule, which affected all residents and staff emergency preparedness.
Surveyors found that the facility did not maintain clear egress corridors as required by NFPA 101, with a TV/video cart plugged into a corridor outlet and multiple unsecured chairs placed in the hallway near resident rooms and the secured unit dining room, including directly in front of a fire extinguisher. These items projected about 29 inches into an approximately eight-foot-wide corridor and were located in front of the handrail, potentially affecting 28 residents and staff’s ability to assist in an emergency. The Maintenance Director confirmed these corridor obstructions during the survey.
A resident with intact cognition receiving Medicare Part A skilled services for metabolic encephalopathy had services discontinued while benefit days remained, but the facility did not issue the required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN). The Social Services Director later confirmed that no SNF ABN was provided and reported she believed only a Notice of Medicare Non-Coverage (NOMNC) was needed when all skilled services were stopped. This practice conflicted with the facility’s written policy, which required SNF ABNs to be issued when extended care items or services were initiated, reduced, or terminated due to expected non-coverage by Medicare.
Surveyors identified that the facility exceeded the acceptable medication error rate when two residents with type 2 DM received insulin doses that were not administered according to orders or manufacturer instructions. In two separate observations, an LPN administered Novolog and another LPN administered insulin glargine and insulin lispro without priming the insulin pens, and the insulin lispro and Novolog were given after the residents had already consumed a significant portion of their breakfast meals, despite orders for administration before meals. Manufacturer information for both insulin products required priming before each injection to ensure accurate dosing, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and specified time frames.
The facility failed to maintain accurate and complete crash cart audits for multiple full-code residents. Surveyors, accompanied by the DON, found that daily crash cart checks did not include verification of supply expiration dates, and that an extension cord documented as present on several audit dates was not actually in the cart. Audit logs also conflicted with the cart’s contents by indicating that required items such as eye protection, saline, and clear plastic were present when they were not. These findings were inconsistent with the facility’s policy requiring the crash cart to be checked every 24 hours and after each use, with prompt replacement of equipment and supplies.
A resident with chronic respiratory failure on supplemental O2, COPD, and cognitive risk factors was repeatedly documented as non-compliant with the smoking policy, including going out to smoke outside designated times and retaining cigarettes and lighters provided by family. Despite prior assessments identifying this resident as unsafe to smoke without supervision, a later assessment classified the resident as safe to smoke independently without documented rationale or care plan update. The resident subsequently went outside alone with an O2 nasal cannula in place, lit a cigarette, and sustained facial burns when the cannula ignited, as observed by staff and confirmed by EMS and ED records. In a separate case, another cognitively impaired resident with a history of falls had a care-planned intervention for non-skid strips in front of a recliner, but observation and staff confirmation showed the strips were not present, despite remaining on the active fall-risk care plan.
Multiple dependent residents did not receive scheduled showers, bed baths, or shaving as outlined in their care plans and the facility’s routine care policy. One resident recovering from spinal surgery missed numerous scheduled showers over several months. Another resident who relied on staff for self-care repeatedly requested shaving but was not shaved, and visible facial hair was observed after a recent shower. A resident with chronic respiratory failure and a tracheostomy, requiring substantial/maximal assist with personal hygiene, had no documented showers for an extended period and was observed with long facial hair, which staff acknowledged should be removed during bathing or as needed. A cognitively impaired resident with ESRD and CHF, scheduled for twice-weekly showers, had multiple undocumented or missed showers and reported not getting showers despite asking aides who said they lacked time. Another cognitively intact resident with hemiplegia and multiple comorbidities, also scheduled for twice-weekly showers, had several dates where documentation showed no shower/bath/bed bath provided or no entry at all, and she reported feeling unclean and unimportant when her showers were missed.
A resident with an indwelling urinary catheter for urinary retention, and care plan interventions requiring the drainage bag to be properly secured with a dignity cover, was observed seated in a chair with the catheter drainage bag uncovered and containing visible dark yellow urine that could be seen from the hallway. Later, an LPN confirmed the catheter bag was lying directly on the floor without a dignity cover. This situation occurred despite facility policy requiring care to be provided in a manner that respects and enhances each resident’s dignity and personal privacy.
A cognitively intact resident with chronic orthopedic pain had a PRN oxycodone order, but multiple doses were signed out on the narcotic log by an RN without corresponding entries on the MAR or documented pain assessments. A CNA/med tech reported frequent problems with this RN’s narcotic counts and documentation, describing erratic behavior when handling narcotic keys. The resident reported taking oxycodone only once or twice daily and otherwise using Tylenol, which conflicted with the number of oxycodone doses signed out. The facility’s investigation found it was inconclusive whether narcotics were misappropriated or whether there was a failure of documentation, but confirmed there was no evidence that all signed-out doses were administered.
Failure to Maintain Self-Closing Doors for Multiple Hazardous Storage Areas
Penalty
Summary
Surveyors identified a deficiency related to hazardous area protection and door requirements under NFPA 101, 2012 Edition. During facility tours, they observed that multiple hazardous storage areas did not have self-closing or automatic-closing doors as required for hazardous areas such as combustible storage and chemical storage. These areas included a closet next to medical records, a beauty salon being used to store cases of chemicals, a supply room in Station #2, and the room leading to the smoking area in Station #3. On a subsequent tour, surveyors observed additional hazardous areas without self-closing doors. The housekeeping room across from therapy and the lobby storage room were both noted to lack self-closing door mechanisms. The facility census at the time was 59 residents, and the surveyors stated that this deficient practice had the potential to affect all residents and staff's ability to assist in an emergency. The Maintenance Director verified these findings at the time they were observed.
Plan Of Correction
K 0321 This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be admissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as its allegation of substantial compliance as of 06/12/2026 K-0321 Doors with Self-Closing Devices Corrective action for resident/s: 1. The closet door next to medical records was lacking a self-closing door on 5/19/2026. Maintenance director to add self-closing device to closet door next to medical records on or before 06/12/2026 in accordance with applicable code. 2. The beauty salon had chemicals stored in it on 5/19/2026. Maintenance director moved chemicals from beauty salon on 05/20/2026 in accordance with applicable code. 3. The supply room on station 2 was lacking a self-closing door on 5/19/2026. Maintenance director to add self-closing door to supply room on station 2 on or before 06/12/2026 in accordance with applicable code. 4. The room to the smoking area on station 3 was lacking a self-closing door on 5/19/2026. Maintenance director to add a self-closing door to the smoking are on station 3 on or before 06/12/2026 in accordance with applicable code. 4. The housekeeping room across from therapy was lacking a self-closing door on 5/19/2026. Maintenance director to add a self-closing door to the housekeeping room across from therapy gym on or before 06/12/2026 in accordance with applicable code. 5. The lobby storage room was lacking a self-closing door on 5/19/2026. Maintenance director to add a self-closing door to the lobby storage room on or before 06/12/2026 in accordance with applicable code. Identification of other residents who may be affected: LNHA and Maintenance director/designee completed a full facility audit for doors with self-closing devices on 05/26/2026. Any corrective action, including, doors identified as needing self-closures will be added on or before 06/09/2026 in accordance with applicable code. Measures for systemic change: LNHA educated Maintenance Director on 05/26/2026 regarding NFPA 101-2012 sections 19.3.2.1 and 19.3.5.9 specifically regarding doors with self-closing devices. How Corrective Action will be monitored Ongoing "Doors with Self-Closing device audit" to be completed weekly x 2 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 06/12/2026
Failure to Conduct Required Quarterly Fire Drills on All Shifts
Penalty
Summary
The facility failed to conduct fire drills in accordance with NFPA 101, 2012 Edition, sections 19.7.1 through 19.7.1.8, specifically by not holding drills every shift each quarter and not varying drill conditions as required. Record review on 06/09/25 at approximately 10:32 A.M. showed there was no fire drill conducted for the first shift during the third quarter. The documented first-shift fire drills occurred on 01/30/26 at 2:42 P.M., 04/30/26 at 1:51 P.M., and 10/31/25 at 10:58 A.M., indicating a missed quarter. Second-shift fire drills were recorded on 02/26/26 at 5:20 P.M., 06/03/25 at 4:35 P.M., 08/29/25 at 3:46 P.M., and 11/25/25 at 5:09 P.M., and third-shift drills on 02/28/26 at 11:47 P.M., 05/30/25 at 12:18 A.M., 07/22/25 at 11:34 P.M., 09/26/25 at 11:40 P.M., and 12/15/25 at 5:17 A.M. The surveyor determined that drills were not conducted under varied conditions and that the required quarterly drill on each shift was not consistently performed. The Maintenance Director confirmed these findings at the time they were identified, and the deficiency had the potential to affect all 59 residents and staff response in an emergency. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency related to facility-wide emergency preparedness practices and documentation of fire drills.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 05/29/2026 K-0712 Fire Drills Corrective action for resident/s: There were no records of a fire drill for the first shift of the third quarter of 2025. First shift fire drill completed on 5/24/2026 by maintenance director/designee with no findings or corrective action necessary. Identification of other residents who may be affected: On 5/26/2026 Maintenance director/designee completed 100% audit of the scheduled fire drills to ensure a drill is scheduled quarterly each shift with no findings or corrective action necessary. Measures for systemic change: LNHA educated Maintenance Director on 05/26/2026 regarding NFPA 101-2012 section 19.7.1.4 through 19.7.1.7. specifically including fire drill frequency requirements. How Corrective Action will be monitored Ongoing "Fire Drill Audit" to be completed weekly x 2 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 05/29/2026
Obstructed Egress Corridors Due to Equipment and Chairs
Penalty
Summary
The facility failed to maintain required clear egress widths in corridors in accordance with NFPA 101, 2012 Edition, sections 19.2.3.4 through 19.2.3.5 and 7.3.2 through 7.3.2.3, creating projections into the egress corridor that exceeded allowable limits. Surveyors observed that on one day in Station #3, a cart with a television and video equipment was plugged into an outlet in the corridor by room 38, and five activity room chairs were placed in the corridor near the secured unit dining room directly in front of a fire extinguisher. On the following day, surveyors again observed chairs in the Station #3 corridor, with four by room 35 and four by the activities room, and the same television cart still in the corridor; the chairs were not secured. The corridor was approximately eight feet wide, and the projections extended approximately 29 inches into the corridor in front of the handrail. These conditions had the potential to affect 28 residents in the facility and the staff’s ability to assist in an emergency, and the Maintenance Director confirmed the observations at the time of discovery. No specific resident medical histories or conditions were described in the report, only that 28 residents were potentially affected and the facility census was 59.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be subsequent remedial measures and should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 05/29/2026 K-0232 Clear path of egress Corrective action for resident/s: 1. On 05/18/2026 station 3 had a cart with a television parked in the corridor by room 38 that exceeded allowable limits. Maintenance director/designee moved the TV cart into the activity room, out to the corridor on 05/18/2026 in accordance with applicable code. 2. On 5/18/2026 station 3 had 5 chairs in the corridor near the dining room directly in front of the fire extinguisher. Maintenance director/designee moved the chairs into the dining room, out of the corridor on 5/18/2026 in accordance with applicable code. 3. On 5/19/2026 station 3 had 4 chairs by the activity room and 4 by room 35. In addition, the TV cart was in the corridor. The maintenance director/designee moved the chairs and TV cart into the dining room, out of the corridor on 5/19/2026 in accordance with applicable code. Identification of other residents who may be affected: Maintenance director/designee completed a 100% facility audit for clear paths of egress on 5/26/26 with no findings or corrective action necessary. Measures for systemic change: Maintenance Director/designee educated staff on 5/26/2026 regarding NFPA 101-2012 section 19.2.3.4 and 19.2.3.5 specifically including maintaining a clear path of egress. How Corrective Action will be monitored Ongoing "Path of Egress Audit" to be completed weekly x 2 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 05/29/2026
Failure to Issue Required SNF ABN When Discontinuing Medicare Part A Services
Penalty
Summary
The deficiency involves the facility’s failure to issue a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) when Medicare Part A services were discontinued for a resident who still had available benefit days. The resident was admitted with a diagnosis of metabolic encephalopathy and had intact cognition per the Minimum Data Set assessment. The facility’s own SNF Beneficiary Notification Review documented that Medicare Part A skilled services began on 02/11/26 and the last covered day was 03/11/26, and that the facility initiated discharge from Medicare Part A services before the resident’s benefit days were exhausted. Despite this, no SNF ABN was provided to the resident or the resident’s representative. During interviews, the Social Services Director stated that the SNF ABN was issued hours prior to the last covered day but, upon reviewing her files, confirmed that no SNF ABN had actually been issued for this resident. She further explained that she believed an SNF ABN was only required if one skilled service remained and that if all skilled services were being discontinued, only the Notice of Medicare Non-Coverage (NOMNC) needed to be issued. The Administrator, however, stated that a resident should always receive both a SNF ABN and a NOMNC when Medicare Part A services are discontinued and benefit days remain. Review of the facility’s written policy dated 03/28/23 showed that the facility was required to issue SNF ABNs for initiation, reduction, or termination of extended care items or services when Medicare payment was not expected, which did not occur in this case.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as its allegation of substantial compliance as of 05/29/2026 F-0582 Corrective action for resident/s: On 5/14/26 Resident #34 was informed of rights and responsibilities related to Advanced Beneficiary Notice and voiced understanding of information for future reference by administrator. Identification of other residents who may be affected: Any resident receiving skilled services from nursing or therapy services. The Administrator audited all residents who were discharged from skilled services in the past 30 days to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary Notice on 5/29/26. No non-compliance was noted. Measures for systemic change: On 5/14/2026 Business Office Manager, Director of Rehab, Minimum Data Set nurse, Director of Nursing and Social Services Director were educated on proper procedure of issuing of Notice Of Medicare Non Coverage and Advanced Beneficiary Notice by administrator. All upcoming discharges from skilled services will be reviewed weekly at Utilization Review meeting to ensure notices will be delivered timely. How Corrective Action will be monitored: Administrator or designee to complete audits of all residents being discharged from skilled services to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 5/29/26
Insulin Administration Errors and Failure to Prime Insulin Pens
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5%, with surveyors identifying 3 errors out of 28 medication administration opportunities, resulting in a 10.71% error rate. For one resident with type 2 diabetes mellitus and moderate cognitive impairment, the physician’s order directed Novolog insulin 10 units via subcutaneous pen-injector to be given before meals. During an observed medication pass, the LPN administered 10 units of Novolog insulin without priming the pen and did so after the resident had already consumed approximately 50% of the breakfast meal. The LPN later confirmed she did not prime the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer instructions for the Novolog FlexPen specified that an air shot (priming) must be performed before each injection to ensure proper dosing. Another resident, also diagnosed with type 2 diabetes mellitus and with intact cognition, had orders for insulin glargine 35 units subcutaneously twice daily and insulin lispro 20 units subcutaneously before meals, plus 12 units subcutaneously if blood glucose was between 251 mg/dL and 300 mg/dL. During an observed medication administration, an LPN administered 35 units of insulin glargine and 32 units of insulin lispro without priming the insulin pens and after the resident had consumed approximately 90% of the breakfast meal, despite orders for insulin lispro to be given before meals. The LPN later stated she could not remember if she had primed the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer information for insulin lispro stated that the pen must be primed before each injection to confirm insulin delivery and remove air, and that failure to prime could result in too much or too little insulin. The DON confirmed the expectation that insulin be administered as ordered, including priming each pen with two units before dialing the prescribed dose, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and required time frames.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 5/29/2026. F-0759 Corrective action for resident/s: Residents #21 and #22 were assessed and evaluated by nurse and Director of Nursing 5/14/26. Resident #21 and #22 both denied any adverse effects and none were noted upon assessment by the Director of Nursing on 5/14/2026. Notification made to physician on 5/14/2026. LPN # 2 competency Eval on insulin administration with the Director of Nursing completed 5/14/2026. Identification of other residents who may be affected: Diabetic residents on assignment of LPN #2/station 2 have the potential to be affected and were assessed by the DON/Designee on 5/14/26 and found to be within normal limits. Measures for systemic change: All Nurses were educated by the Director of Nursing on the steps for Insulin administration per competency, diabetes clinical protocol policy, Medication and treatment orders policy, administering medications policy, and Obtaining fingerstick Glucose Level policy On 5/14/2026. How Corrective Action will be monitored: Director of Nursing and Assistant Director of Nursing will complete insulin administration audits on 5 nurses. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance: 5/29/2026
Inaccurate Crash Cart Audits and Missing Emergency Equipment
Penalty
Summary
The facility failed to ensure accurate and complete crash cart audits for residents requiring basic life support, affecting eighteen of thirty-five residents who were designated as full code. During an observation of the crash cart with the DON, surveyors found that the daily audit documentation for the month did not include verification of expiration dates for crash cart supplies. Review of the crash cart audit logs showed that an extension cord was documented as being in the cart on multiple dates, but the extension cord was not present in the cart at the time of inspection. Additionally, the audit documentation indicated that required items, including eye protection, saline, and clear plastic, were not present in the crash cart, yet they were documented as being in the cart. The facility’s undated “Emergency Crash Cart” policy stated that the crash cart is to be checked every 24 hours and after every use, and that equipment and supplies are to be noted and replaced promptly, but the observed documentation and contents of the cart did not match these requirements. This deficiency was verified with the DON at the time of the survey and was cited under the requirement that personnel provide basic life support, including CPR, to residents requiring emergency care, subject to physician orders and advance directives, and was investigated under Complaint Number 2687380.
Plan Of Correction
Cridersville Care Center Provider Number:366171 Survey Type: Complaint Survey Survey Date: 04/29/26 This Plan of Correction (PoC) outlines the actions completed by the facility with regards to the deficiency citation. This Plan of correction does not constitute any admission of guilt or liability by the facility and is submitted only in response to the regulatory requirements. Please accept the following as the facility's credible allegation of compliance as of 4/30/26. F678 CPR All Full Code residents #18 have the potential to be affected by the alleged deficiency. On 4/27/26 the DON/ADON re-stocked the crash cart per the inventory sheet for all missing items. Crash cart inventory sheet updated and new one will go into effect on 5/1/26. All licensed nursing staff provided with training related to crash cart inventory being a daily audit review using inventory sheet on 4/27/26 per DON/designee. The DON/designee will conduct clinical rounds and conduct a random audit of crash cart three times per week for 4 (four) weeks to ensure compliance. The results of the audit will be documented. The facility conducted an Ad-Hoc QAPI meeting on 4/27/26 and discussed the alleged deficiency and corrective actions. Date when corrective action will be completed: 4/30/26
Unsafe Smoking Practices with Oxygen and Missed Fall-Prevention Interventions
Penalty
Summary
The deficiency involves the facility’s failure to provide a safe smoking environment, adequate supervision, and appropriate implementation of its smoking policy for a resident who used oxygen and smoked, as well as failure to implement fall-prevention interventions as care planned for another resident. One resident had multiple relevant diagnoses, including chronic respiratory failure with hypoxia, COPD, end-stage renal disease, dependence on supplemental oxygen, diabetes, and necrotizing fasciitis. Her care plans identified impaired visual function, risk for respiratory complications related to a history of smoking, and risk for cognitive decline, with interventions including use of oxygen per order and observation for understanding. A smoking-related care plan created earlier documented that she wished to use smoking products, had been assessed as safe to smoke "with supervision," and was non-compliant with the smoking policy, with family continuing to provide smoking supplies despite education and a verbal warning for non-compliance. Smoking assessments and progress notes showed a pattern of non-compliance and inconsistent classification of this resident’s smoking safety. Multiple smoking observation/assessments completed earlier in March documented that she had no cognitive loss, visual deficits, or dexterity problems but was unsafe to smoke without supervision because she did not return smoking materials and did not follow designated smoke times. Progress notes described her going out to smoke multiple times by herself or with family, including sneaking out next door with a cigarette and going out multiple times in one evening, with staff documenting that she was "reeducated" and that family brought in cigarettes and lighters which she did not return to staff. Despite this history, a smoking assessment completed after a three-day hospital stay assessed her as safe to smoke without supervision, with no documentation explaining how this conclusion was reached or evidence that her care plan was updated accordingly. On the day of the incident, the resident reported she had cigarettes and a lighter on her person after returning from dialysis and stated she "could not find a nurse" and went outside to smoke, saying she "guessed" she forgot she had her oxygen on. A CNA observed her outside and saw a flame coming through the resident’s oxygen nasal cannula tubing, turned off the oxygen tank, removed the tubing, and patted out sparks on the resident’s shirt sleeve. The resident’s face and hands appeared black in color, and EMS documented first-degree burns to the head and face, with the resident stating she lit a cigarette with her nasal cannula on, causing the burn. The hospital record described her face as black from smoke and her lips and mouth as "burnt and charred," with a recommendation for intubation that she refused. The facility’s incident report recorded that she went outside with oxygen on to smoke without notifying staff, that staff witnessed the occurrence as she walked through the dining room door to the courtyard, and that she stated she thought she had turned her oxygen off. The facility’s smoking policy required interdisciplinary evaluation to determine safe versus unsafe smokers, staff maintenance of all smoking paraphernalia for both safe and unsafe smokers, and progressive consequences for policy violations. A separate deficiency involved another resident at risk for falls whose care plan included use of non-skid strips on the floor in front of her recliner as a fall-prevention intervention. This resident had severe cognitive impairment, used a walker and wheelchair, required supervision or touching assistance for transfers and ambulation, and had experienced two or more falls without injury since the prior assessment. The fall-risk care plan, initiated at admission, specified non-skid strips in front of the recliner beginning in November. However, nursing staff interviewed were not familiar with all of the resident’s fall-prevention interventions without checking the record, and observation of the room showed two recliners with no non-skid strips on the floor in front of them. An LPN confirmed that the non-skid strips were not present despite the intervention remaining active in the care plan, and moving the recliners did not reveal any strips. The facility’s fall management policy required identification of hazards and risk factors, implementation of interventions to minimize falls and injuries, and development and implementation of a care plan based on interdisciplinary evaluation, with interventions related to identified risk factors.
Plan Of Correction
Smoking: On 03/21/26 at 3:16 P.M. 911 response was activated for Resident #11 and Medical Director #601 was notified by Registered Nurse (RN) #322. On 03/21/26 at 3:18 P.M. on-call Nurse/Social Services #423 immediately notified the Administrator and Director of Nursing (DON) #304 of the incident involving Resident #11. On 03/21/26 at 3:22 P.M. Emergency Medical Services (EMS) arrived onsite. At 3:30 P.M. Resident #11 was transported to the emergency room. On 03/21/26 at 3:30 P.M. RN #322 completed a smoking re-assessment of Resident #11 assessing the resident to be an unsafe smoker requiring supervision due to failure to remove oxygen prior to entering designated smoking area. On 03/21/26 from 3:38 P.M. through 7:57 P.M. Licensed Practical Nurse (LPN) #337, #336, #335, #338; RN #334, and DON #304 re-assessed residents (who smoke). This included Resident #22, Resident #3, Resident #47, Resident #50, Resident #60, Resident #150, Resident #86, and Resident #10 to determine smoking safety (via smoking assessment). Each resident was re-educated regarding the facility smoking policy and staff verified there were no smoking materials on their person. The residents' smoking materials would be maintained by facility staff and distributed per policy. On 03/21/26 at 4:30 P.M. DON #304 responded to facility and an Ad Hoc (not scheduled) Quality Assurance (QA) meeting was held via telephone with the Administrator, DON #304 and Medical Director #601 to review investigative findings and plan of action. A root cause analysis was completed and determined Resident #11 had smoking materials on her person (believed to be obtained from family without staff knowledge) and failed to remove her oxygen. The QA team discussed a corrective action plan. On 03/21/26 from 5:00 P.M through 03/22/26 at 3:00 P.M. 26 RNs, 13 LPNs, one medical technician (MT), 54 Certified Nursing Assistants (CNA) four activities staff, one central supply staff, 11 dietary staff, 12 housekeeping staff, three laundry staff, one medical records staff, two social designees, two maintenance staff, nine administrative staff, and 19 therapy staff (158 staff at the time of the incident) were provided education regarding the facility smoking policy by DON #304 and the Administrator. This was completed via 1:1, small group in-services or via phone. Newly hired staff would receive education during general orientation regarding the facility's smoking policy. On 03/21/26 at 5:00 P.M. DON #304 completed an audit of all residents who smoke (Resident #22, Resident #3, Resident #47, Resident #50, Resident #60, Resident #150, Resident #86, and Resident #10) to verify smoking evaluations and plans of care accurately reflected the residents' smoking safety needs. The residents were educated on the facility smoking policy, and smoking materials were to be maintained at the nurses' station. An audit was completed which included verification of required safety measures present in designated smoking areas, including an ash can, fire extinguisher, fire blanket, ash trays and no oxygen signs. There were no identified concerns or changes made because of the audits. On 03/21/26 at 8:55 P.M. Resident #11 returned from the ED. LPN #332 verbally educated the resident regarding the facility smoking policy which included the need for supervision, a smoking apron (to be worn) and the facility smoke times. LPN #332 verified no smoking materials were on the resident's person or in her room at this time. On 03/23/26 at 11:00 A.M. the Interdisciplinary Team (IDT) (Administrator, DON #304, Medical Director #601, RN #302, Social Services #427, Social Services #423, DON #300, and Maintenance #436) met in-person to review the plan of action with DON #304/designee to complete weekly monitoring of residents who smoke and designated smoking areas weekly for four weeks with Housekeeping responsible to complete the cleaning. Housekeeping staff were responsible for cleaning ashtrays and the designated smoking area daily. Audits to be reviewed and any further actions required to be directed by the Quality Assurance and Performance Improvement (QAPI) Committee during scheduled meetings. The IDT also reviewed all current smoking assessments and care plans for residents who smoke. Resident #50 required a change in supervision levels with smoking due to cognition levels and her plan of care as well as Resident #11's plan of care was updated to reflect supervision/safety. On 03/23/26 from 3:45 P.M. to 8:55 P.M. Social Services #423 re-educated residents who smoke (Resident #22, Resident #3, Resident #47, Resident #50, Resident #60, Resident #150, Resident #86, Resident #10) and responsible parties, if applicable regarding the facility smoking policy and supervision levels. On 03/23/26 at12:13 P.M. Social Services #427 contacted Resident #11's family member (#602) to schedule a care conference. Family member #602 and Family Member #603 were not available to meet until 03/27/26. On 03/23/26 at 1:00 P.M. staff education related to smoking areas, removal of oxygen prior to entering smoking area and maintaining smoking materials at the nurses' station for residents who smoke was initiated by DON #304 and the Administrator via 1:1, small group in-services or via phone call. Education was completed for all 158 staff by 03/24/26 at 1:00 P.M. Newly hired staff would be educated during general orientation regarding the facility's smoking policy. The facility does not utilize agency staff. On 03/27/26 at 11:00 A.M. a care conference was held with Resident #11 and Family Members #602 and #603, the Administrator, Social Services #423 and Social Services #427. The facility smoking policy was reviewed. The resident and family were informed an involuntary discharge would be initiated should the resident exhibit non-compliance moving forward and supervision would be increased beyond the two-hour standard of care to monitor more closely for non-compliance with the facility smoking policy. Family Member #602 stated he educated his siblings as well. On 04/10/26 at 2:00 P.M. DON #304 initiated education with 26 RNs and 13 LPNs (100% of nurses educated) regarding completion of the smoking evaluation via 1:1, small group in-services, or phone. The education was completed by 6:00 P.M. on 04/10/26. A new resident who smokes must remain supervised until the interdisciplinary team (IDT) reviews and determines smoking safety, at which time the care plan is developed and resident and family education is provided. The communication through the staff would be the care plan. Newly hired staff receive education during general orientation regarding the facility's smoking policy and completion of smoking evaluation via Point Click Care (PCC). On 04/10/26 at 4:29 P.M. DON #304 initiated an order in PCC for the nurse to verify, each shift, that Resident #11's smoking materials were maintained at the nurses' station. On 04/13/26 at 5:30 P.M. DON #304 initiated orders in PCC for nurses to verify, each shift, that all residents who smoke would have smoking materials maintained at the nurses' station. An updated list of smokers included: Resident #60, Resident #50, Resident #11, Resident #86, Resident #113, and Resident #151. On 04/13/26 at 5:45 P.M. DON #304 initiated questionnaires for staff regarding the smoking policy with re-education provided as needed via 1:1 and small group in-services for staff currently in the facility with all staff to be questioned/educated prior to working their next scheduled shift. Falls: On 4/9/26, Maintenance Director placed non-skid strips on the floor in front of Resident #12's recliner. Like Residents are identified as residents who have had a fall within the facility. Utilizing the Fall Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, an audit of falls and appropriate interventions for the past 30 days will be completed by the Director of Nursing or designee to ensure fall interventions are in place per plan of care. This audit along with identified corrections will be completed on or F 0689 before 5/13/26. The Director of Nursing or designee will re-educate licensed nurses and STNA/CNAs on the Fall Management Policy to include fall interventions to be in place per the care plan. This education will be completed on or before 5/13/26. Utilizing the Fall Management Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, the Director of Nursing or designee will complete an audit of new admissions, new readmissions and residents who experience a fall within the last 7 days, weekly for four weeks, beginning 5/14/26 to ensure fall safety interventions are in place per plan of care. Current fall interventions found to not be in place will be corrected with all intervention in place per plan of care. Negative findings to be addressed immediately and negative trends or system wide issues will be reported to the QAPI committee, and the action plan will be adjusted as needed.
Removal Plan
- Activated 911 response for Resident #11 and notified the Medical Director.
- On-call Nurse/Social Services immediately notified the Administrator and DON of the incident.
- EMS arrived onsite and Resident #11 was transported to the emergency room.
- Completed a smoking re-assessment of Resident #11, determining the resident was an unsafe smoker requiring supervision due to failure to remove oxygen prior to entering the designated smoking area.
- Re-assessed all residents who smoke (Residents #22, #3, #47, #50, #60, #150, #86, and #10) to determine smoking safety via smoking assessment.
- Re-educated residents who smoke regarding the facility smoking policy and verified there were no smoking materials on their person.
- Implemented that smoking materials would be maintained by facility staff and distributed per policy.
- Held an ad hoc QA meeting to review investigative findings and plan of action.
- Completed a root cause analysis determining Resident #11 had smoking materials on her person and failed to remove oxygen.
- Developed a corrective action plan.
- Provided facility-wide education to staff on the facility smoking policy.
- Implemented that newly hired staff would receive smoking policy education during orientation.
- Completed an audit of all residents who smoke to verify smoking evaluations and plans of care accurately reflected smoking safety needs.
- Ensured smoking materials were maintained at the nurses’ station.
- Audited designated smoking areas for required safety measures (ash can, fire extinguisher, fire blanket, ash trays, and no-oxygen signs).
- Provided verbal education to Resident #11 on smoking policy (supervision, smoking apron, smoke times).
- Verified no smoking materials were on Resident #11’s person or in her room.
- Conducted an in-person IDT meeting to implement weekly monitoring of residents who smoke and designated smoking areas weekly for four weeks.
- Assigned housekeeping to clean ashtrays and the designated smoking area daily.
- Directed audits to be reviewed by QAPI.
- Reviewed all current smoking assessments and care plans for residents who smoke.
- Updated Resident #50’s supervision level.
- Updated Resident #11’s plan of care to reflect supervision/safety.
- Re-educated residents who smoke and responsible parties (as applicable) regarding the facility smoking policy and supervision levels.
- Contacted Resident #11’s family to schedule a care conference.
- Initiated additional staff education regarding smoking areas, removal of oxygen prior to entering smoking area, and maintaining smoking materials at the nurses’ station.
- Held a care conference with Resident #11 and family to review smoking policy.
- Informed resident/family that involuntary discharge would be initiated for future non-compliance.
- Increased supervision beyond the two-hour standard of care to monitor more closely for non-compliance.
- Provided education to all nurses regarding completion of the smoking evaluation.
- Implemented that new residents who smoke must remain supervised until IDT review determines smoking safety and care plan/education are completed.
- Entered an order in PCC for nursing to verify each shift that Resident #11’s smoking materials were maintained at the nurses’ station.
- Entered orders in PCC for nursing to verify each shift that all residents who smoke have smoking materials maintained at the nurses’ station.
- Initiated staff questionnaires regarding the smoking policy with re-education as needed.
- Required all staff to be questioned/educated prior to working their next scheduled shift.
Failure to Provide Scheduled Bathing and Shaving Assistance for Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide scheduled and needed bathing and shaving assistance to multiple dependent residents in accordance with their care plans, preferences, and the facility’s routine care policy. One resident with spinal stenosis and recent L2–L5 decompression fixation fusion was care planned for substantial/maximal assistance with shower/bath and toileting hygiene and was scheduled for showers on Tuesdays and Fridays. Electronic documentation from early January through early April showed this resident did not receive a shower or bed bath on 11 identified scheduled days, and the DON confirmed these missed bathing events. Another resident with dysphagia and developmental issues, who required assistance with self-care and mobility, reported that she asked staff to shave her but they did not, which bothered her. During an observation following a recent shower, she stated she had not been shaved and that the hair "itched"; small gray hairs were visible on her chin. A CNA confirmed the presence of gray chin hairs and acknowledged the resident needed shaving, stating it would be addressed with the next scheduled shower. A further resident with chronic respiratory failure, tracheostomy status, heart failure, moderate intellectual disabilities, anxiety, depression, and PTSD required substantial/maximal assistance with personal hygiene and had a care plan for assistance with self-care, including personal hygiene. Her shower schedule called for showers on Monday and Thursday nights, with complete shaves for men and women. Review of documentation showed her last recorded shower/bath was nearly a year earlier, with no indication of additional personal hygiene or facial hair removal on that date. Observations on two separate days showed long white hairs on her chin and jaw line, which a CNA later confirmed, stating facial hair removal should occur with baths/showers or as needed. A resident with end stage renal disease, respiratory failure, hyperlipidemia, and congestive heart failure, who had impaired cognition and required partial/moderate assistance with bathing and personal hygiene, was scheduled for showers on Wednesdays and Saturdays. Review of shower documentation from admission through early April revealed no showers provided or refusals documented on at least ten scheduled shower days. In interviews, this resident reported not receiving scheduled showers, was unsure of his shower days, and stated he could use a good scrub down, adding that he had asked aides who told him they did not have time. A CNA explained that shower days appear on shower sheets and in the computer and that CNAs are supposed to document daily, with nurses checking the documentation; the DON verified the resident had not received showers per schedule or preference. Another resident with a fracture of the lower end of the left humerus, hemiplegia and hemiparesis after cerebral infarction, rheumatoid arthritis, hypertensive heart disease, urinary retention, and osteoarthritis was care planned as non–weight bearing to the left upper extremity and requiring substantial/maximal assistance with showering/bathing. Her electronic record showed she was scheduled for showers on Wednesdays and Saturdays. The shower task question "did the resident receive a shower/bath/bed bath?" was documented as "no" on three dates, indicating no shower/bath/bed bath was completed, and left unanswered on three additional dates. The DON confirmed that one missed shower was due to an outside appointment, that on two dates the "no" response meant no bathing of any type occurred, and that on three dates there was no documentation at all. The resident, who was cognitively intact, reported that missing showers made her feel unimportant compared to others and that she did not feel clean when her shower was missed. Facility policy on routine resident care stated that showers, tub baths, and shampoos are to be scheduled according to person-centered care or state guidelines, with additional showers given upon request, but the documented and observed care did not reflect consistent provision of scheduled bathing and shaving for these residents.
Plan Of Correction
1. Resident #5 received a shower by the STNA on 4/13/26. Resident #8 received a shower by the STNA on 4/8/26. Resident #9 received a shower and had their chin shaved by the STNA on 4/14/26. Resident #70 received a shower by the STNA on 4/13/26. Resident #76 received a shower and had their chin shaved by the STNA on 4/15/26. 2. Like residents are identified as residents who need assistance with showering and shaving. Utilizing the Shower Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, an audit of like residents will be completed by the Director of Nursing or designee to ensure that showers and resident shaving are completed. This audit along with identified corrections will be completed on or before 5/13/26. 3. The Director of Nursing or designee will re-educate licensed nurses and STNA's on the Routine Resident Care Policy to include bathing and shaving residents. This education will be completed on or before 5/13/26. 4. Utilizing the Shower Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, the Director of Nursing or designee will complete an audit of 4-6 residents weekly for four weeks, beginning 5/14/26 to ensure that showers and resident shaving are completed. Noncompliance found during audits will be addressed and assistance with showers and/or shaving provided. Negative findings to be addressed immediately and negative trends or system wide issues will be reported to the QAPI committee, and the action plan will be adjusted as needed.
Uncovered Urinary Catheter Drainage Bag Compromises Resident Dignity
Penalty
Summary
The facility failed to maintain a resident’s right to privacy and dignity related to management of an indwelling urinary catheter. A resident admitted with malignant neoplasm of the esophagus and type II diabetes mellitus had a care plan identifying risk for urinary tract infection and catheter-related trauma due to an indwelling catheter for urinary retention. The care plan interventions included ensuring the catheter tubing was secured and the drainage bag was properly secured with a dignity cover in place. Physician orders directed that the resident’s 16 French indwelling urinary catheter be changed every 30 days and as needed, and the comprehensive MDS documented that the resident had an indwelling catheter and was cognitively intact. During observation, the resident was seen seated in a chair with the urinary catheter drainage bag hanging from the chair without a dignity cover, and dark yellow urine was visible in the bag from the hallway. In a later observation and interview, an LPN confirmed that the catheter bag was lying directly on the floor and did not have a dignity cover. Attempts to interview the resident to confirm cognitive status were unsuccessful, as the resident was unable to answer screening questions. Review of the facility’s “Resident Dignity & Personal Privacy” policy stated that the facility should provide care in a manner that respects and enhances each resident’s dignity, individuality, and right to personal property, which was not followed in this instance when the catheter drainage bag was left uncovered and visible.
Plan Of Correction
The Laurels of Athens wishes to have this plan of correction submitted as our written allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission to nor agreement with, either the existence of, or the scope and severity of, any of the cited deficiencies or conclusions set forth in the statement of deficiencies. This plan is prepared and/or executed to ensure continuing compliance with regulatory requirements. Our alleged date of compliance is 5/13/2026. 1. On 4/6/26, Resident #92's catheter bag was removed from the floor, the bag changed and covered for dignity by the licensed nurse. Resident #92 discharged from the facility on 4/11/26. 2. Like Residents are identified as residents who utilize urinary catheters. An audit will be completed by the Director of Nursing or designee for like residents utilizing the Urinary Catheter Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC to ensure catheter bags are covered for dignity and not laying directly on the floor. This audit along with identified corrections will be completed on or before 5/13/26. 3. The Director of Nursing or designee will re-educate licensed nurses on the Indwelling Urinary Catheter Policy as well as Resident Dignity & Personal Privacy Policy to include privacy covers are in place for urinary catheters and that the catheter is not laying on the floor. This education will be completed on or before 5/13/26. 4. Utilizing the Urinary Catheter Audit Tool which was created on 4/20/26 by the Director of Nursing for purpose of this POC, the Director of Nursing or designee will complete an audit of all residents with catheters weekly for four weeks, beginning 5/14/26 to ensure catheter bags are covered for dignity and not laying directly on the floor. Any catheters found to be touching the floor or uncovered will be removed from the floor, the bag changed and covered for dignity. Negative findings to be addressed immediately and negative trends or system wide issues will be reported to the QAPI committee, and the action plan will be adjusted as needed.
Failure to Prevent Possible Misappropriation and Poor Documentation of PRN Narcotics
Penalty
Summary
The deficiency involves failure to prevent potential misappropriation of a resident’s narcotic medication and failure to ensure accurate documentation of controlled substance administration. A cognitively intact resident with chronic pain related to an internal orthopedic device and left knee pain had an order for oxycodone 5 mg PO every four hours PRN for pain and a care plan directing staff to administer medications as ordered and observe for effectiveness and side effects. The resident’s MDS showed she rated her pain as 7/10 and received opioid medication. However, review of the February MAR and the narcotic log revealed multiple discrepancies between narcotic sign-outs and documented administration. On several occasions, oxycodone doses were signed out on the narcotic log by an RN without corresponding documentation on the MAR. Specifically, oxycodone was signed out on one evening at 9:30 p.m. with no MAR entry, and again on a subsequent night at 1:30 a.m. and 5:30 a.m. with no MAR entries for those times. Another dose was signed out at 9:00 p.m. while the MAR reflected administration at 10:16 p.m., and a later dose at 5:30 a.m. was documented on both the narcotic log and MAR. There was also no documentation of pain assessments before or after PRN opioid administration. These documentation gaps meant there was no evidence that all narcotic doses signed out were actually administered to the resident. Staff interviews further highlighted concerns about the handling of narcotics. A CNA/med tech reported frequently taking the narcotic keys from the RN and described the RN’s behavior as erratic, with repeated problems involving incorrect narcotic counts and missing documentation on both the MAR and narcotic log. The resident stated she did not receive oxycodone more than once or twice a day, preferring to take Tylenol the rest of the time, which conflicted with the number of oxycodone doses signed out. When questioned, the RN gave inconsistent explanations about how often she pulled and administered PRN narcotics and acknowledged struggling with the new system, while also suggesting the resident may have received PRN tizanidine instead of remembering oxycodone. The facility’s investigation concluded that evidence was inconclusive as to whether misappropriation occurred or whether the issue was solely lack of documentation, but confirmed there was no evidence the resident received all doses signed out on the narcotic log.
Plan Of Correction
1. Resident #99 had a Self-Reported Incident submitted and investigated via the EIDC on 3/2/26. The investigation was inconclusive as we could not prove that misappropriation occurred. On 2/24/26, Resident #99 was interviewed and pain assessed by Director of Nursing and resident had no ill effects related to the inconsistent documentation in the medical record as it relates to her controlled substance pain medication. 2. Like Residents are identified as residents who utilize controlled substance PRN pain medications. An audit will be completed by the Director of Nursing or designee for like residents utilizing the Controlled Substance Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC to ensure PRN controlled substance pain medications that are signed off the control sheet are documented in the resident medical record as well. This audit along with identified corrections will be completed on or before 5/13/26. 3. The Director of Nursing or designee will re-educate licensed nurses on the Controlled Substances Policy to include appropriate documentation of controlled substances. In addition, the licensed nurses will be re-educated by the Director of Nursing or designee on the Abuse Prohibition Policy to include misappropriation of resident property. This education will be completed on or before 5/13/26. 4. Utilizing the Controlled Substance Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, the Director of Nursing or designee will complete an audit three controlled substance sheets from each of the nine medication carts for a total of twenty-seven sheets weekly for four weeks, beginning 5/14/26 to ensure PRN controlled substance pain medications that are signed off the control sheet are documented in the resident medical record as well. Inconsistencies noted from the audit will be investigated for misappropriation. Negative findings to be addressed immediately and negative trends or system wide issues will be reported to the QAPI committee, and the action plan will be adjusted as needed.
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