Westmoreland Place
Inspection history, citations, penalties and survey trends for this long-term care facility in Chillicothe, Ohio.
- Location
- 230 Cherry St, Chillicothe, Ohio 45601
- CMS Provider Number
- 365597
- Inspections on file
- 36
- Latest survey
- January 30, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Westmoreland Place during CMS and state inspections, most recent first.
The facility did not maintain the substitution log when chilled pears were replaced with pineapple and applesauce for lunch, as confirmed by kitchen staff interviews. The kitchen manager and dietician were unaware of the change, indicating a lapse in communication and documentation, potentially affecting all 94 residents.
The facility failed to maintain safe food storage and handling practices, with expired and undated items found in storage, and food served at unsafe temperatures. The Kitchen Manager lacked knowledge of proper procedures, including the use of the dishwasher and food temperature maintenance.
The facility failed to provide residents with access to their personal funds during evenings and weekends. A resident reported being unable to access funds on weekends, and nursing staff confirmed the unavailability of funds during these times. The facility's policy did not address fund access during these periods, and there was a discrepancy in the reported location of available funds.
The facility failed to maintain comfortable water temperatures, affecting 31 residents. Observations and interviews revealed that residents experienced cold water in their bathrooms, with temperatures significantly below the comfortable range. Staff confirmed that maintenance requests had been made, but the issue persisted for weeks to months. Despite weekly monitoring logs showing adequate temperatures, the problem continued, indicating a discrepancy between recorded data and actual conditions.
A resident with an indwelling urinary catheter was observed multiple times with the collection bag visible from the hallway, lacking a privacy cover, which compromised her dignity. Despite facility policy requiring catheter bags to be covered, this was not adhered to, as confirmed by an RN. The resident's care plan included catheter care and dignity maintenance, but these were not followed, leading to the deficiency.
A facility failed to notify a resident or their responsible party when the resident's account balance reached $200 less than the Medicaid resource limit. The resident's balance exceeded $1800.00 from early October through late January, but no notification was provided, potentially affecting Medicaid eligibility. The Business Office Manager confirmed the oversight.
A facility failed to notify a resident's physician of blood sugar levels outside the ordered parameters, affecting a resident with diabetes. Despite several instances of blood sugar readings below 70 and above 400, there was no documented evidence of physician notification, as confirmed by staff interviews. This oversight violated the facility's policy requiring prompt notification of changes in a resident's condition.
A resident with a complex medical history, including diabetes and chronic respiratory failure, experienced a breach of privacy during a dressing change. The RN did not close the door or draw curtains, and failed to follow proper hand hygiene protocols, violating the facility's dignity policy.
A facility failed to accurately assess a resident's dental health, missing the presence of missing and carious teeth. Despite the resident's complex medical history and need for assistance with personal hygiene, assessments inaccurately reflected her dental condition. Observations and interviews confirmed the inaccuracies, highlighting a deficiency in the assessment process.
The facility failed to ensure accurate assessments for three residents, affecting areas such as smoking compliance, dental status, and mental health diagnoses. A resident was inaccurately assessed as compliant with the smoking policy, another had unrecorded dental issues, and a third had an unrecorded active mental health diagnosis. These inaccuracies were confirmed by staff interviews and observations.
The facility failed to update PASARR assessments for three residents, omitting critical mental health diagnoses such as schizoaffective disorder and anxiety disorder. These inaccuracies were confirmed through staff interviews and record reviews, indicating a lapse in following Medicaid guidelines.
A facility failed to complete a PASARR within 30 days for a resident admitted with multiple diagnoses, including bipolar disorder and major depressive disorder. Despite a preadmission screen at the hospital, the required resident review PASARR was not conducted within the first 30 days, as confirmed by a Licensed Social Worker. The facility's policy, aligned with Ohio Department of Medicaid guidelines, was not followed.
The facility failed to develop comprehensive care plans for three residents, affecting their smoking habits, ADL, and dental care. One resident lacked a plan for dental issues and ADL needs, while two others were non-compliant with smoking policies, smoking in non-designated areas without supervision. Their care plans were not updated to address these issues until recently, leading to deficiencies in meeting their needs.
The facility failed to update care plans for three residents after incidents. Two residents with cognitive impairments were involved in an altercation, and a stop sign intervention was not consistently used. Another resident at risk of falls had a delayed care plan update for non-skid socks after a fall. Facility policies require timely updates, which were not followed.
The facility failed to provide meal assistance to a resident with severe cognitive impairment and physical limitations, leaving her without necessary support during a meal. Additionally, another resident requiring extensive assistance with personal hygiene was observed with long, jagged nails, contrary to the facility's nail care policy.
A facility failed to maintain proper hospice records for a resident receiving hospice services. The resident, with multiple diagnoses and cognitive impairment, had no hospice notes uploaded to their medical record. The hospice binder showed only three visit notes since admission to hospice. Interviews revealed concerns about the provision of hospice services, and the facility's policy required maintaining documentation of hospice communication, which was not followed.
The facility failed to ensure safe smoking practices for two residents and safe hot water temperatures for three residents. Observations revealed water temperatures significantly above the safe limit, confirmed by the Maintenance Director. One resident, a supervised smoker, repeatedly violated the smoking policy by smoking in non-designated areas and keeping cigarettes and a lighter unsupervised. Another resident, an independent smoker, also violated the smoking policy by smoking in non-designated areas and keeping smoking materials against facility rules. The facility did not complete a smoking safety assessment for this resident.
The facility failed to provide adequate hydration to residents, as evidenced by the lack of access to fresh ice water at bedside and failure to provide beverages with meals. A resident with multiple medical conditions reported only receiving fresh ice water upon request, and observations confirmed warm water in her pitcher. Another resident with severe cognitive impairment did not receive a requested beverage with her meal, and a third resident with no cognitive deficit but multiple health issues also lacked access to fresh ice water, with staff confirming water was only provided upon request.
A facility failed to monitor a resident's blood pressure before administering Hydralazine, a medication used to lower blood pressure. The resident, with a complex medical history including hypertension and dementia, had physician orders for Hydralazine to be taken three times daily and as needed for specific blood pressure levels. However, the facility did not monitor the resident's blood pressure prior to administering the medication, as confirmed by a corporate nurse.
The facility failed to obtain physician-ordered lab tests for two residents. One resident with multiple diagnoses did not have a CBC and BMP completed as ordered in August 2024. Another resident with a complex medical history did not have a Hemoglobin A1c test conducted as ordered, which was due in October 2024. These deficiencies were confirmed through interviews with facility staff.
A resident with a complex medical history, including dementia and cerebral infarction, did not receive necessary dental services despite having missing and carious teeth. The facility's policy to assist residents in obtaining dental care was not followed, and the resident had not been seen by a dentist since admission, leading to a deficiency.
A facility failed to maintain proper infection control during a dressing change for a resident with a diabetic foot ulcer. The RN did not wear a gown or sanitize hands between glove changes, violating enhanced barrier precautions. The resident had multiple health issues, including diabetes and chronic respiratory failure, and was on enhanced barrier precautions due to a wound.
The facility failed to maintain an adequate resident call system, affecting two residents who were unable to alert staff for assistance due to a malfunctioning call light system. Despite multiple notifications and a maintenance request dated months prior, no action was taken to repair the system. The facility Administrator was unaware of the issue, and resident council meeting minutes documented a request for repair.
The facility did not maintain a comfortable environment for a resident, as the walls in their room had multiple marks needing repair. The resident, with a history of atrial fibrillation, diabetes, and other conditions, confirmed the walls had been in disrepair since their admission. The Maintenance Director verified the issue.
Failure to Maintain Substitution Log for Menu Changes
Penalty
Summary
The facility failed to maintain the substitution log for the menu, which is a requirement to ensure that the nutritional needs of residents are met. On the specified date, chilled pears were scheduled to be served for lunch, but due to a shortage, kitchen staff substituted them with pineapple for regular texture and applesauce for puree texture. This substitution was not recorded in the substitution log, as confirmed by interviews with kitchen staff and the kitchen manager. The kitchen manager and the dietician were unaware of the substitution, indicating a lapse in communication and documentation. The failure to document the substitution had the potential to affect all 94 residents in the facility.
Deficiencies in Food Storage and Handling
Penalty
Summary
The facility failed to maintain safe and sanitary food storage conditions, as observed during a survey. In the freezers, several food items, including pie crumbles and black olives, were found with expired or smudged dates, and some appeared frostbitten. The refrigerator contained undated or expired items such as ham, fruit cups, milk, blueberries, salad dressing, and various leftovers. The dry storage area had open and undated brownie mix and noodles, and uncovered sweet potato pies. The Kitchen Manager acknowledged the issues but was unsure of the requirements for dating and covering food items. The facility's policy mandates that all refrigerated and frozen foods be covered, labeled, and dated, which was not adhered to. Additionally, the facility failed to ensure food was held at safe temperatures. A hamburger ordered by a resident was found to be at 110 degrees, below the required 135 degrees, indicating a failure to maintain proper food holding temperatures. The Kitchen Manager was unable to explain why the warming box was not keeping food hot enough. Furthermore, the Kitchen Manager demonstrated a lack of knowledge regarding the dishwasher's operation, incorrectly using chlorine strips instead of sanitation strips and misunderstanding the required chemical concentration. The facility's policy requires kitchen equipment to be cleaned and sanitized after each use, which was not properly executed.
Deficiency in Access to Resident Personal Funds
Penalty
Summary
The facility failed to ensure that residents had ready and reasonable access to their personal funds during evenings and weekends. This deficiency was identified through interviews with residents and staff, as well as a review of the facility's policy on managing residents' personal funds. A resident reported that he could not access his money on weekends, which was corroborated by interviews with nursing staff who confirmed that funds were not available during these times. The Business Office Manager stated that funds were available at a specific location on weekends, but this was contradicted by the nursing staff's statements. The facility's policy on the management of residents' personal funds, last revised in March 2021, did not address the availability of funds to residents during evenings or weekends. The Administrator confirmed that the policy lacked guidance on this issue and that there was a discrepancy in the reported location of available funds. The Business Office Manager mentioned that funds were placed in a locked box at the receptionist desk, but this could not be confirmed at the time of the survey. This lack of access to personal funds could potentially affect all 50 residents whose funds were managed by the facility.
Facility Fails to Maintain Comfortable Water Temperatures
Penalty
Summary
The facility failed to ensure comfortable water temperatures for its residents, affecting 31 individuals. Observations and interviews revealed that residents, including one with dementia and other medical conditions, experienced cold water in their private bathrooms. A resident reported that the water had been cold since moving into the room several months ago, and a CNA confirmed that the water temperature reached only 52 degrees Fahrenheit after running for over three minutes. Staff interviews indicated that maintenance requests had been made multiple times, but the issue persisted, with the most recent work order response suggesting waiting for the tank to warm up. During a tour of a secured dementia unit, hot water temperatures in several rooms were found to be significantly below the comfortable range of 100-110 degrees Fahrenheit, with readings between 50 and 60 degrees Fahrenheit. Staff interviews confirmed that the problem had been ongoing for weeks to months, with maintenance requests made but not effectively resolved. The maintenance director acknowledged the recurring issue and the lack of documentation for repairs. Despite weekly monitoring logs showing adequate temperatures, the problem persisted, indicating a discrepancy between recorded data and actual conditions.
Failure to Maintain Resident Dignity with Catheter Care
Penalty
Summary
The facility failed to ensure that a resident was treated in a dignified manner concerning the management of an indwelling urinary catheter collection bag. The resident, who had a complex medical history including cerebral infarction, dementia, and obstructive uropathy, was observed on multiple occasions with her urinary catheter collection bag visible without a privacy cover. This lack of privacy was noted during observations on different days, where the urine in the collection bag was visible from the hallway, compromising the resident's dignity. The facility's policy on dignity, which mandates that residents be treated with respect and that urinary catheter bags be covered, was not adhered to. A registered nurse confirmed the absence of a privacy cover on the resident's catheter bag, acknowledging the visibility of the urine from the hallway. The resident's care plan included interventions for catheter care and maintaining dignity, but these were not followed, leading to the deficiency noted in the report.
Failure to Notify Resident of Account Balance Nearing Medicaid Limit
Penalty
Summary
The facility failed to notify a resident or their responsible party when the resident's account balance reached $200 less than the resource limit for Medicaid eligibility. This oversight affected one resident whose personal funds were managed by the facility. The resident's account balance was $1778.78 on September 30, 2024, and had not exceeded $1800.00 between July 1, 2024, and September 30, 2024. The Business Office Manager confirmed that a notification letter was sent to the resident's responsible party on September 30, 2024, indicating the balance was $1778.78. However, the resident's account balance increased to $1828.78 on October 1, 2024, and remained above $1800.00 through January 30, 2025, with a current balance of $1889.13. There was no evidence that the resident or their responsible party was notified between October 1, 2024, and January 30, 2025, that the account balance had reached $200 less than the resource limit, which could potentially affect the resident's Medicaid or Social Security eligibility. The Business Office Manager confirmed the lack of notification during this period.
Failure to Notify Physician of Critical Blood Sugar Levels
Penalty
Summary
The facility failed to notify a resident's physician of blood sugar levels that were outside the parameters set by the physician's orders. This deficiency affected a resident who was admitted with multiple diagnoses, including diabetes mellitus, and was receiving hypoglycemic medications. The resident's medical record indicated several instances where blood sugar levels were either not obtained or were outside the specified range, including levels below 70 and above 400. Despite these occurrences, there was no documented evidence that the physician was informed as required by the facility's policy. The facility's policy mandates prompt notification of the resident's physician and representative in the event of changes in the resident's medical condition. However, interviews with facility staff confirmed that the physician was not notified of the critical blood sugar readings or the failure to obtain the readings. This oversight was identified during a review of the resident's medical records and interviews with facility staff, highlighting a lapse in adherence to the established protocol for managing changes in a resident's condition.
Failure to Maintain Resident Privacy During Dressing Change
Penalty
Summary
The facility failed to maintain personal privacy for a resident during a dressing change, which was observed by surveyors. Resident #74, who has a complex medical history including sepsis, type two diabetes mellitus, and chronic respiratory failure, was affected by this deficiency. The resident, who is moderately cognitively impaired and uses mobility aids, was undergoing a dressing change for a diabetic ulcer on the right heel. During the procedure, the Registered Nurse (RN) #257 did not close the door or draw the curtains to ensure the resident's privacy. Additionally, the RN did not follow proper hand hygiene protocols during the dressing change. After removing the soiled dressing, the RN changed gloves without sanitizing or washing hands. This was repeated when the RN removed gloves again and put on a new pair without washing hands. The facility's dignity policy, which emphasizes the importance of maintaining resident privacy and dignity during personal care and treatment procedures, was not adhered to in this instance.
Inaccurate Dental Assessment for Resident
Penalty
Summary
The facility failed to ensure an accurate comprehensive assessment for a resident, specifically regarding dental health. The resident, who had a complex medical history including cerebral infarction, dementia, and other conditions, was admitted with her own teeth. However, the admission review did not address whether she had broken or carious teeth. Subsequent assessments also failed to accurately reflect the resident's dental condition, as they did not note her missing and carious teeth. Observations later confirmed that the resident had missing natural teeth and obvious carious teeth. Interviews with the MDS Coordinator confirmed that the assessments were inaccurate in reflecting the resident's dental status. The resident's comprehensive Minimum Data Set (MDS) assessment inaccurately indicated no cognitive deficit and no obvious dental issues, despite the resident requiring reminders for oral hygiene and having impaired hand dexterity and decreased mobility. This inaccuracy in the resident's assessment highlights a deficiency in the facility's assessment process.
Inaccurate Resident Assessments in Smoking, Dental, and Mental Health
Penalty
Summary
The facility failed to ensure accurate assessments in several areas, affecting three residents. For Resident #6, the facility did not accurately assess his compliance with the smoking policy. Despite being listed as a supervised smoker, he was observed smoking independently in a non-designated area with a lighter and cigarettes in his possession. The MDS Nurse confirmed that the smoking assessment was inaccurately completed, as it stated the resident followed the smoking policy when he did not. Resident #89's assessments were also inaccurate, particularly regarding her dental status. The admission review failed to address the condition of her teeth, and subsequent assessments did not reflect her missing and carious teeth. An observation confirmed the presence of missing and carious teeth, which was not accurately coded in the MDS. The MDS Coordinator verified the inaccuracies in the coding of the resident's dental status. For Resident #70, the facility did not accurately document his mental health diagnoses. The MDS assessment failed to reflect his active diagnosis of schizoaffective disorder, despite a psychiatry progress note indicating an exacerbation of this condition. The Corporate Nurse confirmed that the MDS was not coded to reflect the resident's schizoaffective disorder, highlighting a discrepancy between the resident's documented condition and the assessment records.
Inaccurate PASARR Assessments for Residents
Penalty
Summary
The facility failed to ensure the accuracy of Pre-Admission Screening and Resident Review (PASARR) assessments for three residents, affecting their mental health diagnosis records. Resident #7, who was admitted with multiple diagnoses including schizoaffective disorder bipolar type, did not have an updated PASARR reflecting this diagnosis until nearly a year after it was given. Similarly, Resident #81, who was diagnosed with anxiety disorder and psychotic disorder with delusions, had no mental disorders listed in their PASARR until several months after the diagnoses were made. These oversights were confirmed during an interview with Social Services. Additionally, Resident #32's PASARR, dated from several years prior, failed to include a diagnosis of schizophrenia, despite the resident having multiple mental health diagnoses including schizoaffective disorder bipolar type and schizophrenia. The facility's policy on PASARR, dated April 2023, mandates adherence to Medicaid guidelines, which was not followed in these cases. This deficiency was identified through staff interviews and record reviews, highlighting a lapse in updating critical mental health information in the PASARR assessments.
Failure to Complete PASARR Within 30 Days of Admission
Penalty
Summary
The facility failed to complete a Preadmission Screening and Resident Review (PASARR) within 30 days following admission for one resident. This deficiency was identified during a review of the medical record, interviews, and facility policy review. The resident in question was admitted with multiple diagnoses, including bipolar disorder, major depressive disorder, and anxiety disorder, among others. Despite the completion of a preadmission screen at the acute care hospital, the facility did not conduct the required resident review PASARR within the first 30 days of the resident's admission. The facility's policy, which follows the Ohio Department of Medicaid guidelines for PASARR, was not adhered to in this instance. An interview with a Licensed Social Worker confirmed the oversight. The resident's plan of care indicated undetermined discharge plans and possible long-term care placement, with interventions to support the resident's adjustment and transition. However, the lack of a timely PASARR review represents a failure to comply with regulatory requirements for new admissions and continued stays.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for three residents, affecting their smoking habits, activities of daily living (ADL), and dental care. Resident #89, who had multiple diagnoses including cerebral infarction and dementia, was admitted without a complete assessment of her dental status or ADL needs. Her care plan lacked specific interventions for her dental issues, such as missing and carious teeth, and did not address her need for assistance with daily activities, despite her impairments in hand dexterity and mobility. Resident #6, diagnosed with chronic obstructive pulmonary disease and bilateral above-knee amputations, was identified as a supervised smoker. Despite this, he was observed smoking in non-designated areas without supervision, contrary to the facility's smoking policy. His care plan, dated only recently, did not reflect previous non-compliance with smoking regulations, and there was no evidence of a comprehensive plan addressing his smoking behavior prior to the recent updates. Resident #75, with a history of diabetes and a below-knee amputation, was also found to be non-compliant with the smoking policy. He smoked in non-designated areas and even in his room, despite being educated on the policy. His care plan, like Resident #6's, was only recently updated to address smoking, with no prior comprehensive plan in place. The facility's failure to develop and implement comprehensive, person-centered care plans with measurable objectives and timetables for these residents led to deficiencies in meeting their physical, psychosocial, and functional needs.
Failure to Update Care Plans After Incidents
Penalty
Summary
The facility failed to ensure care plan interventions were updated for three residents involved in separate incidents. Resident #13, who has schizophrenia and cognitive impairment, was involved in a resident-to-resident altercation with Resident #67, who also has schizophrenia and cognitive impairment. The altercation occurred when Resident #67 wandered into Resident #13's room, resulting in Resident #13 striking Resident #67, causing bruising and a laceration. Although a stop sign was ordered to be placed on Resident #13's door as an intervention, it was not consistently used, and the facility staff were unaware of its absence during the survey. Additionally, Resident #17, who has dementia and is at risk of falls, experienced a fall on 11/07/24. The intervention of non-skid socks was planned but not added to the care plan until 12 days after the fall. The Director of Nursing confirmed the delay in updating the care plan. The facility's policies on falls and comprehensive person-centered care plans require timely updates and interventions, which were not adhered to in these cases.
Failure to Provide Meal and Nail Care Assistance
Penalty
Summary
The facility failed to provide adequate meal assistance to a resident with severe cognitive impairment and physical limitations. The resident, who had a history of cerebrovascular accident with right-sided hemiplegia and other significant health issues, was observed during a meal without receiving necessary assistance or cues from staff. Despite the resident's care plan indicating a need for setup to limited assistance with eating, the staff did not provide the required support, leaving the resident's bedside table pushed away and the head of the bed laid down, which hindered the resident's ability to eat independently. Additionally, the facility did not provide necessary nail care for another resident who required extensive assistance with personal hygiene. This resident, who had multiple health conditions including dementia and visual loss, was observed with long and jagged nails, which she expressed a preference against. The facility's policy on nail care, which includes regular trimming to prevent infection, was not followed, as confirmed by a CNA who acknowledged the resident's need for nail care.
Failure to Maintain Hospice Records
Penalty
Summary
The facility failed to maintain proper hospice records for a resident receiving hospice services. The resident, who was admitted with multiple diagnoses including encephalopathy, COPD, respiratory failure, dementia, epilepsy, schizophrenia, muscle weakness, and cognitive communication deficit, was cognitively impaired and receiving hospice care. However, upon review of the medical record, there was no evidence of hospice notes being uploaded directly to the resident's medical record. The hospice binder maintained by the facility showed that the resident was admitted to hospice in June 2024, but only three visit notes were documented. Interviews with the resident's family and facility staff revealed concerns about whether hospice services were being provided as promised. The facility's policy required maintaining documentation of hospice communication, which was not adhered to in this case.
Failure to Ensure Safe Smoking Practices and Water Temperatures
Penalty
Summary
The facility failed to ensure safe smoking practices for two residents and safe hot water temperatures for three residents. Observations revealed that the water temperatures in the rooms of three residents were significantly above the maximum limit of 120 degrees, with temperatures recorded at 131.2, 125.7, and 138.8 degrees. The Maintenance Director confirmed these temperatures were above the safe limit, posing a potential risk to the residents. Regarding smoking safety, Resident #6, who has chronic obstructive pulmonary disease and bilateral above-knee amputations, was observed smoking in a non-designated area despite being a supervised smoker. The resident's care plan indicated non-compliance with the smoking policy, and multiple staff members confirmed the resident's repeated violations. The facility's policy required supervision during smoking, but the resident was found with cigarettes and a lighter unsupervised, indicating a failure to enforce the policy effectively. Similarly, Resident #75, who is cognitively intact and uses a wheelchair, was identified as an independent smoker but was found smoking in non-designated areas and even in his room. Despite being educated on the smoking policy, the resident continued to violate it, keeping cigarettes and a lighter against the facility's rules. The facility failed to complete a smoking safety assessment for this resident, and there was no evidence of a care plan addressing smoking safety prior to the surveyor's observations.
Failure to Provide Adequate Hydration to Residents
Penalty
Summary
The facility failed to ensure adequate hydration for residents, as evidenced by the lack of access to fresh ice water at bedside and failure to provide beverages with meals. Resident #8, who has multiple complex medical conditions including fibromyalgia, COPD, and chronic kidney disease, reported only receiving fresh ice water upon request. Observations confirmed that the resident's water pitcher contained warm water on multiple occasions, and staff interviews revealed that fresh ice water was not routinely passed. Resident #9, with severe cognitive impairment and a history of anorexia and cerebrovascular accident, was observed to have only unsweetened tea with her meal, which she refused to drink. Despite requesting another beverage, she did not receive one, and there was no fresh ice water at her bedside. Staff interviews confirmed the lack of beverage provision as requested. Resident #89, who has no cognitive deficit but suffers from conditions such as cerebral infarction and acute kidney failure, also did not have access to fresh ice water at her bedside. Observations noted her lips and mouth were dry, indicating potential dehydration. Staff confirmed that ice water was only provided upon request, contrary to the facility's hydration policy, which mandates routine provision of water with meals and at each shift.
Failure to Monitor Blood Pressure Before Administering Hydralazine
Penalty
Summary
The facility failed to monitor a resident's blood pressure prior to administering the medication Hydralazine, which is used to lower blood pressure. This deficiency affected one resident out of five reviewed for unnecessary medications. The resident, who had a complex medical history including conditions such as hypertension, diabetes mellitus, COPD, and dementia, was admitted with the latest readmission on 08/28/24. The resident's physician orders included Hydralazine 10 mg to be taken three times daily and as needed for specific blood pressure thresholds. However, the medical record review revealed that the resident's blood pressure was not being monitored before administering the scheduled doses of Hydralazine. This was confirmed during an interview with a corporate nurse, who verified the lack of blood pressure monitoring prior to medication administration.
Failure to Obtain Physician-Ordered Lab Tests
Penalty
Summary
The facility failed to obtain physician-ordered laboratory tests for two residents, which was identified during a survey. Resident #81, who has multiple diagnoses including dementia with psychotic disturbance and malignant neoplasm of the prostate, had physician orders for a complete blood count (CBC) and basic metabolic panel (BMP) on two separate occasions in August 2024. However, a review of the medical records on January 30, 2025, revealed that these laboratory tests were not documented as completed. This was confirmed by the Regional Director of Clinical Operations during an interview. Similarly, Resident #70, who has a complex medical history including rhabdomyolysis, diabetes mellitus, and chronic obstructive pulmonary disease, had a physician order for a Hemoglobin A1c test to be conducted three months after July 23, 2024. The medical record review showed no results for this test, which was due on October 23, 2024. This oversight was verified by a Corporate Nurse during an interview. The facility's policy on lab and diagnostic test results, last revised in November 2018, outlines the process for ordering and obtaining lab tests, which was not followed in these instances.
Failure to Provide Dental Services to Resident
Penalty
Summary
The facility failed to ensure that a resident received necessary dental services, affecting one of the two residents reviewed for dental care. The resident, who had a complex medical history including cerebral infarction, dementia, and other conditions, was admitted with her own teeth, but the admission review did not address the condition of her teeth. The resident's plan of care did not include any information on her dental status, despite observations of missing and carious teeth. Additionally, the resident's oral assessment indicated a need for daily reminders to clean her teeth due to intermittent confusion and impaired hand dexterity. Despite having orders for dental consultation, the resident had not been seen by a dentist since her admission. The Licensed Social Worker confirmed that there was no documented evidence of the resident refusing the new facility-contracted dental service. The facility's policy on dental services, which was last revised in September 2024, states that the facility is responsible for assisting residents in obtaining routine and emergency dental care. However, this policy was not followed in the case of the resident, leading to the deficiency noted in the report.
Infection Control Lapses During Wound Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by improper hand hygiene and failure to follow enhanced barrier precautions during a dressing change for a resident with a diabetic foot ulcer. The resident, who was admitted with multiple diagnoses including sepsis, type two diabetes mellitus, and chronic respiratory failure, was on enhanced barrier precautions due to a wound. During the dressing change, the registered nurse did not wear a gown as required by the facility's enhanced barrier precautions policy and failed to sanitize or wash hands after removing soiled gloves and before putting on new gloves. The resident's medical records indicated a physician's order for daily wound care, which included cleansing the wound and applying specific dressings. Despite the presence of a sign indicating enhanced barrier precautions and available personal protective equipment, the nurse did not adhere to the facility's policies. The nurse acknowledged these lapses during an interview, confirming the failure to follow proper infection control procedures, which are critical in preventing the transmission of infections in the facility.
Inadequate Resident Call System Maintenance
Penalty
Summary
The facility failed to maintain an adequate resident call system, affecting two residents out of the 30 reviewed for call light function. Resident #48, who has diagnoses including inflammatory neuropathy, heart failure, paraplegia, and chronic obstructive pulmonary disease, and Resident #20, with diagnoses of radiculopathy, polyneuropathy, type II diabetes mellitus, and chronic obstructive pulmonary disease, were unable to alert staff for assistance due to a malfunctioning call light system. Observations confirmed that when Resident #48 activated the call light, the hallway notification light did not illuminate, leaving staff unaware of the resident's need for assistance. Interviews with the residents and a Certified Nursing Assistant (CNA) revealed that the call light system had been non-functional for at least four months, despite multiple notifications to staff. A maintenance request dated 10/27/24 for the repair of the call light system was found in the Maintenance Request Log, but no action had been taken as the work completion section was left blank. The facility Administrator was unaware of the issue, and resident council meeting minutes from 01/23/25 also documented a request for the repair of the call light system.
Facility Failed to Maintain Wall Condition in Resident's Room
Penalty
Summary
The facility failed to maintain a functional and comfortable environment for its residents, as evidenced by the condition of the walls in a resident's room. Specifically, the walls in the room of Resident #65 were observed to have multiple marks that required sanding and painting. This issue was confirmed during an observation and interview with the resident, who indicated that the walls had been in this state since their admission. The Maintenance Director also verified the condition of the walls during a subsequent observation. Resident #65 has a medical history that includes atrial fibrillation, type two diabetes mellitus, peripheral vascular disease, congestive heart failure, and insomnia.
Latest citations in Ohio
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
