Willow Woods Rehabilitation And Nursing
Inspection history, citations, penalties and survey trends for this long-term care facility in North Lima, Ohio.
- Location
- 9625 Market Street, North Lima, Ohio 44452
- CMS Provider Number
- 365708
- Inspections on file
- 33
- Latest survey
- February 13, 2026
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Willow Woods Rehabilitation And Nursing during CMS and state inspections, most recent first.
The facility failed to maintain clean, private, and homelike resident rooms, as multiple cognitively intact residents reported that blinds did not fully cover their windows, leaving gaps that allowed light in and visibility from the parking lot. Observations confirmed short and broken blinds in several rooms facing the parking lot, stained privacy curtains, and dust and debris on windowsills, dressers, and other surfaces. Some residents reported difficulty sleeping due to light entering their rooms and concerns about being seen while using bedside commodes. Staff, including housekeeping, CNAs, an RN, an LPN, laundry, and maintenance, acknowledged that resident rooms were not being dusted regularly, many privacy curtains were dirty, there was no schedule for curtain cleaning, and blinds were too short or broken, contrary to the facility’s homelike environment policy.
A resident with impaired cognition and significant physical limitations was left unattended in a Sara Steady lift by a CNA, contrary to manufacturer guidelines and facility policy. The resident was found unresponsive and required emergency intervention after being left alone in the lift for several minutes, resulting in cardiac arrest and subsequent transfer to the hospital, where the resident later died. The incident was attributed to failure to follow lift protocols and lack of supervision.
A resident with a history of wandering and multiple psychiatric diagnoses exited a locked unit through a fire door after staff failed to respond appropriately to a door alarm. The alarm was silenced without a head count or notification to nursing staff, and the resident was later found at another facility. Required procedures for investigating and reporting missing residents were not followed.
A resident with mental health diagnoses and mild intellectual disabilities was involved in a verbal and physical altercation with a CNA after attempting to move another resident in a wheelchair. The CNA confronted the resident, leading to a fight in which the CNA initiated physical contact, resulting in the resident being pushed to the ground and hitting her head. Witnesses and a police report confirmed the CNA was the aggressor, and the incident was determined to be staff-to-resident physical abuse.
The facility did not ensure that residents and their legal representatives were properly notified or involved in care conferences, as required by policy. Multiple residents with cognitive impairments and their guardians or POAs were not invited to participate in care planning, and there was no documentation of notification or attendance. Staff interviews confirmed that notifications were not consistently documented, and representatives reported not being informed about care meetings or changes in care.
The facility did not ensure that food and nutrition services staff attended care conferences as required, with the DON instead completing dietary sections of care plans. Multiple residents with complex medical conditions were affected, and interviews confirmed that dietary staff had not participated in these meetings due to staffing challenges.
The facility did not provide the correct dessert to all residents on a Reduced Concentrated Sweets (RCS) diet during lunch, serving brownies or pureed brownies instead of the required fresh fruit, despite physician orders and care plans specifying the need for therapeutic diets due to conditions such as diabetes and dysphagia. Dietary staff confirmed the error, and facility policy required adherence to prescribed diets.
A resident with cognitive impairment and a history of falls was found with a wedge cushion placed between the mattress and bed frame to prevent falling, while the bed was positioned against the wall on the other side. Staff confirmed the wedge was used to restrict movement and prevent the resident from climbing out of bed, but there was no care plan documentation or physician order for this intervention, and facility policy prohibits physical restraints not required for medical treatment.
A resident with multiple medical conditions and frequent incontinence did not have incontinence care addressed in their care plan, despite requiring extensive assistance with activities of daily living. The omission was confirmed by the MDS RN, and the facility's policy requires comprehensive, person-centered care plans with measurable objectives.
A resident with hyponatremia and a physician-ordered 1500 ml fluid restriction did not have their fluid intake properly tracked or coordinated between nursing and dietary staff. Nursing acknowledged the restriction but did not document actual fluid amounts given, while dietary limited only beverages and not other fluid-containing foods. Lack of communication and tracking made it impossible to ensure compliance with the fluid restriction.
A resident with known aggressive behaviors physically assaulted another resident, causing harm. The aggressive resident had a history of psychosis and dementia, and the facility failed to adequately monitor and manage these behaviors, leading to the incident.
A resident with severe cognitive impairment sustained a second-degree burn after accessing a lighter brought into the facility by another resident. The incident occurred due to inadequate supervision and failure to enforce the facility's smoking policy, which prohibited residents from keeping smoking materials. The resident required emergency treatment and follow-up care for the burn.
The facility failed to provide written notice of room changes to residents and their representatives, affecting eight residents with various conditions such as schizophrenia and dementia. The facility's policy required advance notice and documentation, but this was not followed, leading to a deficiency. The administrator was unaware of the requirement, and the absence of a social worker designee contributed to the oversight.
A facility failed to develop a comprehensive care plan for a resident with a history of cognitive impairment and aggressive behaviors. Despite multiple incidents of aggression, the care plan was not updated in a timely manner to address these issues. Interviews confirmed that staff were aware of the resident's behavioral history, but a behavior care plan was only initiated after physical aggression occurred.
The facility failed to maintain a sanitary kitchen, affecting nearly all residents. A drain under the dishwasher flooded the kitchen with foul-smelling liquid, and staff had to walk through the contaminated material while preparing and serving food. Despite directives to use disposable dishware, the issue persisted for over a month, causing health concerns among staff and permeating the Buckeye unit with a strong odor.
The facility failed to maintain a homelike environment on the Buckeye unit due to a malfunctioning drain under the kitchen dishwasher, emitting a strong odor resembling fecal matter and sour milk. This issue persisted for over a month, affecting all 31 residents and was confirmed by multiple staff members and residents.
A resident was not treated in a dignified manner while being assisted with her meal, as an STNA was observed talking on a personal cellphone and standing over the resident. The resident confirmed that this was a recurring issue, and facility policies on cellphone use and meal assistance were violated.
Failure to Maintain Clean, Private, and Homelike Resident Rooms
Penalty
Summary
The deficiency involves the facility’s failure to provide a safe, clean, comfortable, and homelike environment, specifically related to inadequate window coverings, unclean privacy curtains, and insufficient room cleaning. Multiple cognitively intact residents with various medical and psychiatric diagnoses reported that their room blinds did not extend to the windowsills, leaving gaps that allowed light into the room and permitted visibility from the facility parking lot into their rooms. Observations confirmed that in several rooms facing the parking lot, the blinds were too short, had broken slats, and left gaps of four to twelve inches between the bottom of the blinds and the windowsills. Residents reported difficulty achieving a dark room for sleep and concerns that people in the parking lot could see into their rooms, including when using bedside commodes. In addition to the window blind issues, surveyors observed stained and unclean privacy curtains and dust and debris in resident rooms. In one resident’s room, there were various colored stains on the privacy curtain, a visible layer of white dust on the dresser and TV base, and a windowsill with a buildup of dirt and debris, including dried flower petals. Another resident’s privacy curtain had dark brown stains, and another had multiple orange stains. Several residents stated they had not seen anyone dusting their rooms and believed their privacy curtains had not been cleaned since admission, with one resident reporting that he had to dust his own room and another stating the curtain had never been cleaned during nearly two years at the facility. Staff interviews corroborated these observations and resident reports. A housekeeper stated that on the day of the survey she was the only housekeeper on day shift and would only be able to clean common areas, not resident rooms, and she was unsure who was responsible for cleaning privacy curtains. Nursing staff, including an RN, an LPN, and multiple CNAs, reported seeing accumulations of dust on dressers and windowsills, dead bugs and debris on windowsills, and generally filthy privacy curtains, and several were unsure how often or by whom the curtains were cleaned. Laundry staff and the Maintenance Director confirmed there was no current schedule for cleaning privacy curtains and that they were only cleaned as needed. The Maintenance Director and Administrator acknowledged that many privacy curtains needed cleaning, rooms were not being dusted as often as they should, and many blinds were too short or broken, despite the facility’s policy stating it would provide a safe, clean, comfortable, and homelike environment with comfortable lighting and minimal glare. The combination of these conditions—short and broken blinds that did not fully cover windows facing a public parking lot, stained and unclean privacy curtains, and inadequate dusting and cleaning of resident rooms—resulted in residents experiencing disturbed sleep, using privacy curtains to block sunlight due to inadequate blinds, and expressing concerns about lack of privacy and feeling watched from outside. These findings affected multiple residents whose rooms faced the parking lot and were within view of anyone entering the facility.
Failure to Provide Adequate Supervision During Mechanical Lift Transfer
Penalty
Summary
A deficiency occurred when staff failed to ensure the safe use of a Sara Steady lift for a resident with multiple complex medical conditions, including impaired cognition, hemiplegia, and a history of traumatic brain injury. The resident required dependent assistance for activities of daily living and had no documented intervention or physician's order for the use of a Sara Steady lift for transfers. Despite this, a CNA placed the resident in the Sara Steady lift and left the resident unattended while seeking help, contrary to manufacturer guidelines and facility policy. The manufacturer's guidelines for the Sara Steady lift explicitly state that a resident must never be left unattended in the device, as it is intended only for active, supervised transfers and not for unassisted seating or prolonged periods. Witness statements and facility investigation confirmed that the CNA left the resident alone in the lift for approximately four to five minutes. During this time, the resident was found slumped over the lift's bar, unresponsive, and with a bloody bowel movement. Staff responded, initiated CPR, and emergency services were called. The root cause analysis conducted by facility leadership determined that the incident resulted from the staff member not following protocol for the resident lift and a lack of supervision. The event led to the resident experiencing cardiac arrest and being transferred to the hospital, where the resident later expired. The deficiency was identified as a failure to provide adequate supervision and to ensure the area was free from accident hazards, specifically regarding the use of mechanical lifts.
Failure to Respond to Door Alarm Results in Resident Elopement
Penalty
Summary
A deficiency occurred when staff failed to provide adequate supervision and did not respond appropriately to a door alarm on a locked unit, resulting in a resident leaving the facility unsupervised. The resident involved had a complex medical history, including paranoid schizophrenia, bipolar disorder with psychotic features, dementia, and other mental health diagnoses. The resident was known to wander, had a history of pushing code pads at doors, and was identified as an elopement risk due to impaired cognition and competence. The care plan included interventions such as distraction, structured activities, and supervision, but the resident did not exhibit exit-seeking behavior prior to the incident. On the day of the incident, the resident exited the facility through a fire door at the end of a hallway that was not visible from the nurse station or dining room. The door could be opened by pressing on the handle for 15 seconds, which triggered a loud alarm. A certified nurse assistant heard the alarm, checked the door, did not see anyone outside, and turned off the alarm, assuming it was set off by the wind. The staff member did not notify the nurse or conduct a head count, and the resident was not signed out for a leave of absence. The resident was later found at another facility after walking approximately 75 feet outside, and staff only became aware of the elopement when contacted by the other facility. Interviews with staff and the resident confirmed that the alarm sounded when the resident exited, but no staff were present in the area at the time. The resident stated she left to inquire about moving to another facility and was not supervised during her time outside. The facility's policies required staff to investigate and report missing residents and to notify supervisors if a resident left without being properly signed out, but these procedures were not followed during the incident.
Failure to Protect Resident from Staff-to-Resident Physical Abuse
Penalty
Summary
A deficiency occurred when a resident with schizoaffective disorder, borderline personality disorder, and mild intellectual disabilities was not protected from staff-to-resident physical abuse. The resident, who was cognitively intact and required supervision for personal care, became involved in an altercation with a certified nurse aide (CNA) after attempting to move another resident in a wheelchair. The CNA shouted at the resident, leading to a verbal argument that escalated into a physical confrontation in the hallway. Multiple witness statements and a police report indicated that the CNA approached the resident, engaged in a face-to-face confrontation, and initiated physical contact by belly bumping the resident, which led to a fight and the resident being pushed to the ground and hitting her head. The incident was witnessed by another CNA and an LPN, who confirmed that the CNA and the resident exchanged insults and that the CNA was the aggressor in the situation. The police were called, and the CNA was arrested for assault. The resident was assessed for injuries and transported to the hospital, where a CT scan revealed no abnormal findings, and she was discharged back to the facility. The facility's investigation included reviewing statements from involved staff and the resident, as well as the police report, which corroborated that the CNA initiated the physical altercation. The facility's policy defined abuse as willful injury or intimidation resulting in physical harm, pain, or mental anguish, and the actions of the CNA were found to be in violation of this policy. The root cause was identified as a failure to appropriately deescalate and manage resident behaviors, leading to the escalation and subsequent physical abuse of the resident by staff.
Failure to Notify and Involve Residents and Representatives in Care Conferences
Penalty
Summary
The facility failed to ensure that residents and/or their representatives were invited to participate in care conferences as required by policy. In multiple cases, there was no documented evidence that residents or their legal representatives were notified of or attended care plan meetings. This deficiency was identified through record reviews, interviews, and examination of care conference attendance records and facility policies. For example, one resident with multiple diagnoses including COPD, dementia, and chronic respiratory failure, had a legal guardian who reported never being invited to or attending a care conference. The resident herself also stated she did not attend care plan meetings, and documentation confirmed the absence of invitations or attendance records for both the resident and her guardian. Another resident, who was cognitively intact but had a legal guardian, similarly had no documentation of being invited to care conferences, and the guardian stated he was not notified of meetings unless he initiated contact with the facility. Additional cases included residents with moderate to mild cognitive impairment and their representatives, who reported never being invited to care conferences or informed of changes in care. Facility staff interviews revealed that notifications were often made verbally and not documented, with staff relying on memory rather than maintaining records as required by facility policy. The policy specified that a seven-day notice should be provided and documented, including the method of contact and any input or refusal, but this was not followed in the reviewed cases.
Failure to Include Food and Nutrition Services Staff in Care Conferences
Penalty
Summary
The facility failed to ensure that a member of the food and nutrition services staff, as required by policy, attended care conferences for residents. Record reviews for four residents revealed that there was no documented evidence of food and nutrition services staff participation in care conferences, despite the facility's policy stating that the interdisciplinary team (IDT) must include such a member. Instead, the Director of Nursing (DON) was completing the dietary section of the care conference forms. Interviews with the Dietary Manager and Dietitian confirmed that dietary staff had not been attending care conferences due to staffing challenges. The Dietary Manager acknowledged past attendance but stated she had not been able to participate recently. The Dietitian also confirmed non-attendance and indicated that dietary staff should be present at these meetings. The Social Service Designee corroborated that no dietary staff had attended, and the DON was filling out the relevant sections instead. The affected residents had complex medical histories, including conditions such as COPD, dementia, schizophrenia, diabetes, and various cognitive impairments. Documentation for each resident showed that care conferences were held with other disciplines present, but not with food and nutrition services staff, as required. In some cases, there was also no evidence that the resident or their representative was invited to or participated in the care planning process.
Failure to Provide Appropriate RCS Diet Desserts
Penalty
Summary
On 04/08/25, the facility failed to provide the appropriate dessert to all residents identified as being on a Reduced Concentrated Sweets (RCS) diet during lunch. According to the facility's menu for that day, residents on an RCS diet were to receive four ounces of fresh fruit in place of a brownie. However, observations of the tray line revealed that all residents, regardless of their dietary orders, received either a brownie or a pureed brownie as dessert. There was no evidence of fresh fruit being provided to any resident on the RCS diet. Record reviews for eleven residents with orders for an RCS diet showed that each had physician orders, care plans, and Minimum Data Set (MDS) assessments specifying the need for a therapeutic diet due to diagnoses such as type two diabetes mellitus, schizoaffective disorder, schizophrenia, dysphagia, and other chronic conditions. The care plans for these residents included interventions to provide diets as ordered, specifically to address their nutritional and medical needs. Despite these documented requirements, the dietary staff did not follow the prescribed menu substitutions for the RCS diet on the date in question. Interviews with dietary staff confirmed the failure to provide the correct dessert. The dietary aide responsible for placing desserts on trays acknowledged that only brownies or pureed brownies were served, and the assistant regional dietary staff member confirmed that residents on an RCS diet should have received fresh fruit instead. Review of the facility's policy on therapeutic diets further indicated that the facility was responsible for ensuring residents received diets as ordered, which did not occur in this instance.
Unapproved Use of Physical Restraint for Fall Prevention
Penalty
Summary
A deficiency occurred when a resident with multiple diagnoses, including schizoaffective disorder, intellectual disabilities, a wedge compression fracture, and a history of falls, was found to have a blue wedge cushion placed between the mattress and bed frame on one side of the bed, while the other side of the bed was against the wall. The wedge cushion was used to prevent the resident from falling out of bed, as confirmed by interviews with nursing staff. The resident's care plan addressed fall risk and included interventions such as ensuring a safe environment and keeping the call light within reach, but did not mention the use of a wedge cushion. There was also no physician order or care plan documentation for the wedge cushion. Observations over two days confirmed the continued use of the wedge cushion in this manner. Staff interviews revealed the wedge was intended to keep the resident from falling or climbing out of bed, and the DON acknowledged that this setup could restrict the resident's movement. Facility policy states that residents have the right to be free from physical restraints not required for medical treatment, and the facility had identified no residents as having a physical restraint. The use of the wedge cushion in this way constituted a physical restraint that was not care planned or ordered.
Failure to Include Incontinence Care in Resident Care Plan
Penalty
Summary
The facility failed to develop and implement an accurate and comprehensive care plan for a resident with multiple diagnoses, including schizophrenia, type two diabetes mellitus, and cerebral infarction. The resident required extensive assistance with all activities of daily living and was frequently incontinent of urine and bowel, as documented in the medical record and quarterly MDS assessment. Despite these needs, the care plan did not include a focus area or interventions for incontinence care. This omission was confirmed during an interview with the MDS RN, who acknowledged the lack of incontinence-related interventions in the resident's care plan. The facility's policy requires that care plans be comprehensive and person-centered, with measurable objectives and timetables to meet each resident's needs, but this was not followed in this case.
Failure to Monitor and Enforce Physician-Ordered Fluid Restriction
Penalty
Summary
The facility failed to ensure that a physician-ordered fluid restriction was properly monitored and followed for a resident diagnosed with hyponatremia and hypo-osmolality, among other conditions. The resident had a physician's order for a 1500 ml fluid restriction, which was documented in the care plan and dietary assessments. However, there was no clear system in place to track or allocate the total allowed fluids between nursing and dietary services, nor was there documentation of how much fluid was actually provided by each department. Review of the resident's medical record and medication administration record showed that while nursing staff acknowledged the fluid restriction order, they did not record the amount of fluids given during each shift. Dietary staff reported that only the beverages on the meal tray were limited, but other fluid-containing foods such as soups, gelatin, pudding, and ice cream were still provided without being counted toward the restriction. There was no coordination or communication between nursing and dietary regarding the total fluid intake, and the dietitian was unsure of the process or whether nursing was aware of the fluids provided by dietary. Interviews with nursing, dietary, and the dietitian confirmed the lack of tracking and communication regarding the resident's fluid intake. The facility's policy required that fluids be shared between nursing and dietary using a fluid restriction breakdown and that input/output records be maintained for residents on fluid restriction. Despite this, the required monitoring and documentation were not implemented, making it impossible to determine if the resident's fluid restriction was being adhered to as ordered.
Failure to Protect Resident from Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident, resulting in actual harm. Resident #2, who was alert and oriented, was punched in the face by Resident #44, who had known aggressive behaviors. This incident occurred while Resident #2 was lying in bed, leading to a hematoma to the right eye area and bruising to the right upper arm. Resident #2 was taken to the hospital for evaluation and diagnosed with a facial hematoma. The incident was a stressor for Resident #2, who expressed feeling shaken up by the unprovoked attack. Resident #44 had a documented history of aggressive behaviors and cognitive impairment, including psychosis and dementia. Prior to the incident, Resident #44 had exhibited aggressive behaviors towards staff and other residents, including throwing objects and making threats. Despite these behaviors, there was no behavior care plan developed for Resident #44 until after a previous incident of aggression. Behavior tracking for Resident #44 was discontinued shortly after admission, and there was no documentation of behavior monitoring leading up to the incident with Resident #2. The facility's failure to adequately monitor and manage Resident #44's behaviors contributed to the incident. Interviews with staff revealed that Resident #44 was known to be aggressive and had issues with sharing a bathroom with Resident #2. The facility's policy on abuse prevention emphasized the need for assessment, care planning, and monitoring of residents with behaviors that might lead to conflict. However, the lack of behavior tracking and an updated care plan for Resident #44 indicated a lapse in following these procedures, ultimately resulting in harm to Resident #2.
Resident Burn Incident Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision and intervention to prevent a resident with severe cognitive impairment from sustaining a burn injury. The incident occurred when the resident was found in his room with a cigarette lighter, which belonged to another resident, and his clothing was smoldering. This resulted in a second-degree burn to his abdomen, requiring emergency room treatment and follow-up care at a wound clinic. The resident had a history of severe cognitive impairment and required substantial assistance with daily activities, including dressing and toileting. Despite these needs, the facility did not prevent the resident from accessing a lighter, which was brought into the facility by another resident after a leave of absence. The facility's incident documentation and investigation revealed that the resident was unable to explain how he obtained the lighter, and there was no initial assessment or measurement of the burn in the incident report. The facility's policies on safety and supervision, as well as smoking, were not effectively implemented, as evidenced by the resident's access to smoking materials. The incident highlighted a lapse in the facility's procedures for monitoring and controlling potentially hazardous items brought into the facility by residents or their families.
Removal Plan
- An Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting was held with the Administrator, DON, Assistant DON, the Medical Director, Social Services, the Dietary Manager, Business Office Manager, Activity Director, Maintenance, Central Supply/Scheduler and Admissions. The root cause of the incident was identified as a family member allowed Resident #85 to retain smoking materials when they returned from leave of absence.
- Resident #64 was sent to the emergency room.
- Room sweeps on all rooms were completed to check for smoking materials.
- Room sweeps of five rooms per week for four weeks was started.
- The smoking policy was reviewed and updated to include that any smoking materials obtained on LOA must be returned to staff upon return to the facility.
- Smoking assessments for all residents who smoke (#6, #7, #8, #11, #13, #18, #25, #30, #32, #38, #40, #46, #47, #50, #53, #57, #61, #66, #71, and #85) were updated.
- Education was completed by Admissions #220 to all residents who smoke.
- All care plans of residents who smoke were reviewed and updated for all residents who smoke.
- A handout was created for Leave of Absence binders and the front desk reminding family and friends that smoking materials must be returned to staff.
- Education was provided to Resident #85's family to turn in smoking materials to staff after leave of absence.
- All staff were in-serviced on resident supervision, smoking policy, leave of absence process and ensuring residents who return from leave of absence do not retain smoking materials.
- Five resident and or family interview upon return from leave of absence was started and continued for four weeks.
Failure to Provide Written Notice of Room Changes
Penalty
Summary
The facility failed to ensure that residents and their representatives received written notice of room changes, affecting eight residents. These residents included individuals with schizophrenia, alcohol dependence, and dementia, among other conditions. The facility's policy required advance notice and documentation of room changes in the residents' medical records, but this was not adhered to. For instance, Resident #2, who had a court-appointed guardian, experienced a room change without the guardian being notified. Similarly, Resident #3's mother, who was the resident representative, was not informed of a room change. The deficiency was further highlighted by the lack of documentation for other residents, such as Resident #6, who had multiple room changes without notification to their legal guardian, and Resident #57, who filed a grievance after not being informed of a room change. The facility's administrator admitted to handling room changes without being aware of the requirement for written notification. The absence of a social worker designee since early November contributed to this oversight. The facility's policy, dated May 2017, clearly outlined the need for advance notice and documentation, which was not followed, leading to the deficiency.
Failure to Develop Comprehensive Behavior Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan to address the behavioral needs of a resident, identified as Resident #44, who had a history of cognitive impairment and aggressive behaviors. The resident was admitted with multiple diagnoses, including encephalopathy, unspecified psychosis, dementia, and a history of homelessness. Despite these conditions and a documented history of aggression during a hospital stay, the facility did not create a behavior care plan upon admission. The resident exhibited aggressive behaviors on multiple occasions, including becoming belligerent with staff, throwing a lunch tray, and physically assaulting staff members. These incidents led to the resident being sent to the emergency room for psychiatric evaluation and readmission to the facility. Despite these repeated episodes, the care plan was not updated to reflect the resident's behavioral issues until several weeks after admission, and even then, it was not revised following further incidents of aggression. Interviews with facility staff, including the Director of Nursing, confirmed that the facility was aware of the resident's behavioral issues prior to admission. However, a behavior care plan was not initiated until after the resident had already exhibited physical aggression. The facility's policy required care plans to be comprehensive and person-centered, with measurable objectives and timetables, but this was not adhered to in the case of Resident #44.
Unsanitary Kitchen Conditions Due to Drain Issue
Penalty
Summary
The facility did not maintain the kitchen in a sanitary manner, which had the potential to affect all residents except two who did not receive food from the kitchen. Observations revealed a strong offensive odor in the kitchen and dining room, resembling fecal matter and sour milk. The source of the odor was traced to a drain under the dishwasher, which was flooding the kitchen with greenish-brown liquid material. Staff were observed walking through the contaminated material while preparing and serving food. Interviews with dietary aides and cooks confirmed that the drain had been an issue for over a month, with the flooding occurring daily and the smell causing headaches and stomachaches among staff. The Administrator was aware of the issue and had scheduled a plumbing contractor to address it, but the problem persisted in the meantime. Further interviews revealed that the dietary staff had been instructed to use disposable dishes and utensils and to avoid using the dishwasher, but this directive was not consistently followed. The kitchen continued to flood, and the smell permeated the Buckeye unit, where residents resided. The Maintenance Director confirmed that the drain was connected to a sewer sanitation pipe, and the issue was exacerbated when showers were being provided on the unit. The Dietary Manager expressed concerns about the unsanitary conditions and the safety risks posed by standing in contaminated water while preparing and serving food. Despite sending pictures to corporate and discussing the issue with the Regional Dietary Manager, the problem remained unresolved. The Regional Dietary Manager confirmed that he had given the directive to use disposable dishware and to stop using the dishwasher, but he was unaware that this directive had not been consistently followed. Upon learning of the ongoing issue, he ordered the kitchen to be shut down and arranged for a mobile kitchen to be brought in until the drain was fixed. The facility's policy on preventing foodborne illness emphasized the importance of serving, preparing, handling, and servicing food in a manner that minimizes the risk of foodborne illness, which was not adhered to in this case.
Pervasive Offensive Odor on Buckeye Unit
Penalty
Summary
The facility did not ensure a homelike environment was maintained on the Buckeye unit, as there was a pervasive offensive odor affecting all 31 residents on the unit. The issue was primarily due to a malfunctioning drain under the dishwasher in the kitchen, which emitted a strong odor resembling fecal matter and sour milk. This problem had persisted for over a month, as confirmed by multiple staff members and residents. Observations revealed greenish-brown liquid material pouring out of the drain, covering the kitchen floor and emitting a foul smell that spread to the dining room and surrounding areas. Staff were observed walking through the contaminated area while attempting to complete their tasks, further exacerbating the issue. Interviews with residents revealed that the smell was particularly bothersome during meal times, with one resident describing it as smelling like vomit. Staff members, including dietary aides and cooks, confirmed the severity of the odor and the ongoing nature of the problem. The facility's administrator acknowledged the issue but had not personally inspected the drain. The maintenance director suggested that the drain might be connected to the main sewer line, which could explain the persistent odor. Despite the acknowledgment of the problem, the facility did not have a policy in place to ensure a homelike environment or to prevent pervasive offensive odors.
Staff Use of Personal Cellphones During Meal Assistance
Penalty
Summary
The facility did not ensure Resident #29 was treated in a dignified manner while being assisted with her meal. An STNA was observed standing over Resident #29, who was in her wheelchair, and talking on a personal cellphone while assisting her with breakfast. The STNA continued the phone conversation without interacting with the resident, and the conversation was loud enough to be heard from the hallway. Resident #29 confirmed that this was not the first time staff talked on their personal phones during her care, and it bothered her, especially when she had to wait for her next bite of food because the staff were distracted by their phone conversations. The facility's policies on employee cellphone use and assistance with meals were reviewed and found to be in violation. The policy stated that cellular phones may only be used during authorized breaks and must remain off or silent during work hours. Additionally, the policy on meal assistance emphasized that residents should be fed with attention to safety, comfort, and dignity, including not standing over residents while assisting them with meals. The Regional Director of Clinical Services confirmed that staff were not to be on their personal phones or standing while feeding residents.
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Surveyors found that multiple hazardous storage areas, including a closet near medical records, a beauty salon used to store chemical cases, a supply room in one nursing station, a room leading to a smoking area, a housekeeping room near therapy, and a lobby storage room, lacked required self-closing or automatic-closing doors. These conditions did not comply with NFPA 101 requirements for hazardous area enclosure and had the potential to affect all residents and staff in an emergency.
Surveyors found that the facility did not conduct fire drills on every shift each quarter and did not vary drill conditions as required by NFPA 101. Record review showed that one shift lacked a documented drill for an entire quarter, and the pattern of drill times and dates did not demonstrate varied conditions. The Maintenance Director confirmed the incomplete and noncompliant fire drill schedule, which affected all residents and staff emergency preparedness.
Surveyors found that the facility did not maintain clear egress corridors as required by NFPA 101, with a TV/video cart plugged into a corridor outlet and multiple unsecured chairs placed in the hallway near resident rooms and the secured unit dining room, including directly in front of a fire extinguisher. These items projected about 29 inches into an approximately eight-foot-wide corridor and were located in front of the handrail, potentially affecting 28 residents and staff’s ability to assist in an emergency. The Maintenance Director confirmed these corridor obstructions during the survey.
A resident with intact cognition receiving Medicare Part A skilled services for metabolic encephalopathy had services discontinued while benefit days remained, but the facility did not issue the required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN). The Social Services Director later confirmed that no SNF ABN was provided and reported she believed only a Notice of Medicare Non-Coverage (NOMNC) was needed when all skilled services were stopped. This practice conflicted with the facility’s written policy, which required SNF ABNs to be issued when extended care items or services were initiated, reduced, or terminated due to expected non-coverage by Medicare.
Surveyors identified that the facility exceeded the acceptable medication error rate when two residents with type 2 DM received insulin doses that were not administered according to orders or manufacturer instructions. In two separate observations, an LPN administered Novolog and another LPN administered insulin glargine and insulin lispro without priming the insulin pens, and the insulin lispro and Novolog were given after the residents had already consumed a significant portion of their breakfast meals, despite orders for administration before meals. Manufacturer information for both insulin products required priming before each injection to ensure accurate dosing, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and specified time frames.
The facility failed to maintain accurate and complete crash cart audits for multiple full-code residents. Surveyors, accompanied by the DON, found that daily crash cart checks did not include verification of supply expiration dates, and that an extension cord documented as present on several audit dates was not actually in the cart. Audit logs also conflicted with the cart’s contents by indicating that required items such as eye protection, saline, and clear plastic were present when they were not. These findings were inconsistent with the facility’s policy requiring the crash cart to be checked every 24 hours and after each use, with prompt replacement of equipment and supplies.
A resident with chronic respiratory failure on supplemental O2, COPD, and cognitive risk factors was repeatedly documented as non-compliant with the smoking policy, including going out to smoke outside designated times and retaining cigarettes and lighters provided by family. Despite prior assessments identifying this resident as unsafe to smoke without supervision, a later assessment classified the resident as safe to smoke independently without documented rationale or care plan update. The resident subsequently went outside alone with an O2 nasal cannula in place, lit a cigarette, and sustained facial burns when the cannula ignited, as observed by staff and confirmed by EMS and ED records. In a separate case, another cognitively impaired resident with a history of falls had a care-planned intervention for non-skid strips in front of a recliner, but observation and staff confirmation showed the strips were not present, despite remaining on the active fall-risk care plan.
Multiple dependent residents did not receive scheduled showers, bed baths, or shaving as outlined in their care plans and the facility’s routine care policy. One resident recovering from spinal surgery missed numerous scheduled showers over several months. Another resident who relied on staff for self-care repeatedly requested shaving but was not shaved, and visible facial hair was observed after a recent shower. A resident with chronic respiratory failure and a tracheostomy, requiring substantial/maximal assist with personal hygiene, had no documented showers for an extended period and was observed with long facial hair, which staff acknowledged should be removed during bathing or as needed. A cognitively impaired resident with ESRD and CHF, scheduled for twice-weekly showers, had multiple undocumented or missed showers and reported not getting showers despite asking aides who said they lacked time. Another cognitively intact resident with hemiplegia and multiple comorbidities, also scheduled for twice-weekly showers, had several dates where documentation showed no shower/bath/bed bath provided or no entry at all, and she reported feeling unclean and unimportant when her showers were missed.
A resident with an indwelling urinary catheter for urinary retention, and care plan interventions requiring the drainage bag to be properly secured with a dignity cover, was observed seated in a chair with the catheter drainage bag uncovered and containing visible dark yellow urine that could be seen from the hallway. Later, an LPN confirmed the catheter bag was lying directly on the floor without a dignity cover. This situation occurred despite facility policy requiring care to be provided in a manner that respects and enhances each resident’s dignity and personal privacy.
A cognitively intact resident with chronic orthopedic pain had a PRN oxycodone order, but multiple doses were signed out on the narcotic log by an RN without corresponding entries on the MAR or documented pain assessments. A CNA/med tech reported frequent problems with this RN’s narcotic counts and documentation, describing erratic behavior when handling narcotic keys. The resident reported taking oxycodone only once or twice daily and otherwise using Tylenol, which conflicted with the number of oxycodone doses signed out. The facility’s investigation found it was inconclusive whether narcotics were misappropriated or whether there was a failure of documentation, but confirmed there was no evidence that all signed-out doses were administered.
Failure to Maintain Self-Closing Doors for Multiple Hazardous Storage Areas
Penalty
Summary
Surveyors identified a deficiency related to hazardous area protection and door requirements under NFPA 101, 2012 Edition. During facility tours, they observed that multiple hazardous storage areas did not have self-closing or automatic-closing doors as required for hazardous areas such as combustible storage and chemical storage. These areas included a closet next to medical records, a beauty salon being used to store cases of chemicals, a supply room in Station #2, and the room leading to the smoking area in Station #3. On a subsequent tour, surveyors observed additional hazardous areas without self-closing doors. The housekeeping room across from therapy and the lobby storage room were both noted to lack self-closing door mechanisms. The facility census at the time was 59 residents, and the surveyors stated that this deficient practice had the potential to affect all residents and staff's ability to assist in an emergency. The Maintenance Director verified these findings at the time they were observed.
Plan Of Correction
K 0321 This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be admissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as its allegation of substantial compliance as of 06/12/2026 K-0321 Doors with Self-Closing Devices Corrective action for resident/s: 1. The closet door next to medical records was lacking a self-closing door on 5/19/2026. Maintenance director to add self-closing device to closet door next to medical records on or before 06/12/2026 in accordance with applicable code. 2. The beauty salon had chemicals stored in it on 5/19/2026. Maintenance director moved chemicals from beauty salon on 05/20/2026 in accordance with applicable code. 3. The supply room on station 2 was lacking a self-closing door on 5/19/2026. Maintenance director to add self-closing door to supply room on station 2 on or before 06/12/2026 in accordance with applicable code. 4. The room to the smoking area on station 3 was lacking a self-closing door on 5/19/2026. Maintenance director to add a self-closing door to the smoking are on station 3 on or before 06/12/2026 in accordance with applicable code. 4. The housekeeping room across from therapy was lacking a self-closing door on 5/19/2026. Maintenance director to add a self-closing door to the housekeeping room across from therapy gym on or before 06/12/2026 in accordance with applicable code. 5. The lobby storage room was lacking a self-closing door on 5/19/2026. Maintenance director to add a self-closing door to the lobby storage room on or before 06/12/2026 in accordance with applicable code. Identification of other residents who may be affected: LNHA and Maintenance director/designee completed a full facility audit for doors with self-closing devices on 05/26/2026. Any corrective action, including, doors identified as needing self-closures will be added on or before 06/09/2026 in accordance with applicable code. Measures for systemic change: LNHA educated Maintenance Director on 05/26/2026 regarding NFPA 101-2012 sections 19.3.2.1 and 19.3.5.9 specifically regarding doors with self-closing devices. How Corrective Action will be monitored Ongoing "Doors with Self-Closing device audit" to be completed weekly x 2 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 06/12/2026
Failure to Conduct Required Quarterly Fire Drills on All Shifts
Penalty
Summary
The facility failed to conduct fire drills in accordance with NFPA 101, 2012 Edition, sections 19.7.1 through 19.7.1.8, specifically by not holding drills every shift each quarter and not varying drill conditions as required. Record review on 06/09/25 at approximately 10:32 A.M. showed there was no fire drill conducted for the first shift during the third quarter. The documented first-shift fire drills occurred on 01/30/26 at 2:42 P.M., 04/30/26 at 1:51 P.M., and 10/31/25 at 10:58 A.M., indicating a missed quarter. Second-shift fire drills were recorded on 02/26/26 at 5:20 P.M., 06/03/25 at 4:35 P.M., 08/29/25 at 3:46 P.M., and 11/25/25 at 5:09 P.M., and third-shift drills on 02/28/26 at 11:47 P.M., 05/30/25 at 12:18 A.M., 07/22/25 at 11:34 P.M., 09/26/25 at 11:40 P.M., and 12/15/25 at 5:17 A.M. The surveyor determined that drills were not conducted under varied conditions and that the required quarterly drill on each shift was not consistently performed. The Maintenance Director confirmed these findings at the time they were identified, and the deficiency had the potential to affect all 59 residents and staff response in an emergency. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency related to facility-wide emergency preparedness practices and documentation of fire drills.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 05/29/2026 K-0712 Fire Drills Corrective action for resident/s: There were no records of a fire drill for the first shift of the third quarter of 2025. First shift fire drill completed on 5/24/2026 by maintenance director/designee with no findings or corrective action necessary. Identification of other residents who may be affected: On 5/26/2026 Maintenance director/designee completed 100% audit of the scheduled fire drills to ensure a drill is scheduled quarterly each shift with no findings or corrective action necessary. Measures for systemic change: LNHA educated Maintenance Director on 05/26/2026 regarding NFPA 101-2012 section 19.7.1.4 through 19.7.1.7. specifically including fire drill frequency requirements. How Corrective Action will be monitored Ongoing "Fire Drill Audit" to be completed weekly x 2 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 05/29/2026
Obstructed Egress Corridors Due to Equipment and Chairs
Penalty
Summary
The facility failed to maintain required clear egress widths in corridors in accordance with NFPA 101, 2012 Edition, sections 19.2.3.4 through 19.2.3.5 and 7.3.2 through 7.3.2.3, creating projections into the egress corridor that exceeded allowable limits. Surveyors observed that on one day in Station #3, a cart with a television and video equipment was plugged into an outlet in the corridor by room 38, and five activity room chairs were placed in the corridor near the secured unit dining room directly in front of a fire extinguisher. On the following day, surveyors again observed chairs in the Station #3 corridor, with four by room 35 and four by the activities room, and the same television cart still in the corridor; the chairs were not secured. The corridor was approximately eight feet wide, and the projections extended approximately 29 inches into the corridor in front of the handrail. These conditions had the potential to affect 28 residents in the facility and the staff’s ability to assist in an emergency, and the Maintenance Director confirmed the observations at the time of discovery. No specific resident medical histories or conditions were described in the report, only that 28 residents were potentially affected and the facility census was 59.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be subsequent remedial measures and should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 05/29/2026 K-0232 Clear path of egress Corrective action for resident/s: 1. On 05/18/2026 station 3 had a cart with a television parked in the corridor by room 38 that exceeded allowable limits. Maintenance director/designee moved the TV cart into the activity room, out to the corridor on 05/18/2026 in accordance with applicable code. 2. On 5/18/2026 station 3 had 5 chairs in the corridor near the dining room directly in front of the fire extinguisher. Maintenance director/designee moved the chairs into the dining room, out of the corridor on 5/18/2026 in accordance with applicable code. 3. On 5/19/2026 station 3 had 4 chairs by the activity room and 4 by room 35. In addition, the TV cart was in the corridor. The maintenance director/designee moved the chairs and TV cart into the dining room, out of the corridor on 5/19/2026 in accordance with applicable code. Identification of other residents who may be affected: Maintenance director/designee completed a 100% facility audit for clear paths of egress on 5/26/26 with no findings or corrective action necessary. Measures for systemic change: Maintenance Director/designee educated staff on 5/26/2026 regarding NFPA 101-2012 section 19.2.3.4 and 19.2.3.5 specifically including maintaining a clear path of egress. How Corrective Action will be monitored Ongoing "Path of Egress Audit" to be completed weekly x 2 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 05/29/2026
Failure to Issue Required SNF ABN When Discontinuing Medicare Part A Services
Penalty
Summary
The deficiency involves the facility’s failure to issue a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) when Medicare Part A services were discontinued for a resident who still had available benefit days. The resident was admitted with a diagnosis of metabolic encephalopathy and had intact cognition per the Minimum Data Set assessment. The facility’s own SNF Beneficiary Notification Review documented that Medicare Part A skilled services began on 02/11/26 and the last covered day was 03/11/26, and that the facility initiated discharge from Medicare Part A services before the resident’s benefit days were exhausted. Despite this, no SNF ABN was provided to the resident or the resident’s representative. During interviews, the Social Services Director stated that the SNF ABN was issued hours prior to the last covered day but, upon reviewing her files, confirmed that no SNF ABN had actually been issued for this resident. She further explained that she believed an SNF ABN was only required if one skilled service remained and that if all skilled services were being discontinued, only the Notice of Medicare Non-Coverage (NOMNC) needed to be issued. The Administrator, however, stated that a resident should always receive both a SNF ABN and a NOMNC when Medicare Part A services are discontinued and benefit days remain. Review of the facility’s written policy dated 03/28/23 showed that the facility was required to issue SNF ABNs for initiation, reduction, or termination of extended care items or services when Medicare payment was not expected, which did not occur in this case.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as its allegation of substantial compliance as of 05/29/2026 F-0582 Corrective action for resident/s: On 5/14/26 Resident #34 was informed of rights and responsibilities related to Advanced Beneficiary Notice and voiced understanding of information for future reference by administrator. Identification of other residents who may be affected: Any resident receiving skilled services from nursing or therapy services. The Administrator audited all residents who were discharged from skilled services in the past 30 days to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary Notice on 5/29/26. No non-compliance was noted. Measures for systemic change: On 5/14/2026 Business Office Manager, Director of Rehab, Minimum Data Set nurse, Director of Nursing and Social Services Director were educated on proper procedure of issuing of Notice Of Medicare Non Coverage and Advanced Beneficiary Notice by administrator. All upcoming discharges from skilled services will be reviewed weekly at Utilization Review meeting to ensure notices will be delivered timely. How Corrective Action will be monitored: Administrator or designee to complete audits of all residents being discharged from skilled services to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 5/29/26
Insulin Administration Errors and Failure to Prime Insulin Pens
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5%, with surveyors identifying 3 errors out of 28 medication administration opportunities, resulting in a 10.71% error rate. For one resident with type 2 diabetes mellitus and moderate cognitive impairment, the physician’s order directed Novolog insulin 10 units via subcutaneous pen-injector to be given before meals. During an observed medication pass, the LPN administered 10 units of Novolog insulin without priming the pen and did so after the resident had already consumed approximately 50% of the breakfast meal. The LPN later confirmed she did not prime the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer instructions for the Novolog FlexPen specified that an air shot (priming) must be performed before each injection to ensure proper dosing. Another resident, also diagnosed with type 2 diabetes mellitus and with intact cognition, had orders for insulin glargine 35 units subcutaneously twice daily and insulin lispro 20 units subcutaneously before meals, plus 12 units subcutaneously if blood glucose was between 251 mg/dL and 300 mg/dL. During an observed medication administration, an LPN administered 35 units of insulin glargine and 32 units of insulin lispro without priming the insulin pens and after the resident had consumed approximately 90% of the breakfast meal, despite orders for insulin lispro to be given before meals. The LPN later stated she could not remember if she had primed the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer information for insulin lispro stated that the pen must be primed before each injection to confirm insulin delivery and remove air, and that failure to prime could result in too much or too little insulin. The DON confirmed the expectation that insulin be administered as ordered, including priming each pen with two units before dialing the prescribed dose, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and required time frames.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 5/29/2026. F-0759 Corrective action for resident/s: Residents #21 and #22 were assessed and evaluated by nurse and Director of Nursing 5/14/26. Resident #21 and #22 both denied any adverse effects and none were noted upon assessment by the Director of Nursing on 5/14/2026. Notification made to physician on 5/14/2026. LPN # 2 competency Eval on insulin administration with the Director of Nursing completed 5/14/2026. Identification of other residents who may be affected: Diabetic residents on assignment of LPN #2/station 2 have the potential to be affected and were assessed by the DON/Designee on 5/14/26 and found to be within normal limits. Measures for systemic change: All Nurses were educated by the Director of Nursing on the steps for Insulin administration per competency, diabetes clinical protocol policy, Medication and treatment orders policy, administering medications policy, and Obtaining fingerstick Glucose Level policy On 5/14/2026. How Corrective Action will be monitored: Director of Nursing and Assistant Director of Nursing will complete insulin administration audits on 5 nurses. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance: 5/29/2026
Inaccurate Crash Cart Audits and Missing Emergency Equipment
Penalty
Summary
The facility failed to ensure accurate and complete crash cart audits for residents requiring basic life support, affecting eighteen of thirty-five residents who were designated as full code. During an observation of the crash cart with the DON, surveyors found that the daily audit documentation for the month did not include verification of expiration dates for crash cart supplies. Review of the crash cart audit logs showed that an extension cord was documented as being in the cart on multiple dates, but the extension cord was not present in the cart at the time of inspection. Additionally, the audit documentation indicated that required items, including eye protection, saline, and clear plastic, were not present in the crash cart, yet they were documented as being in the cart. The facility’s undated “Emergency Crash Cart” policy stated that the crash cart is to be checked every 24 hours and after every use, and that equipment and supplies are to be noted and replaced promptly, but the observed documentation and contents of the cart did not match these requirements. This deficiency was verified with the DON at the time of the survey and was cited under the requirement that personnel provide basic life support, including CPR, to residents requiring emergency care, subject to physician orders and advance directives, and was investigated under Complaint Number 2687380.
Plan Of Correction
Cridersville Care Center Provider Number:366171 Survey Type: Complaint Survey Survey Date: 04/29/26 This Plan of Correction (PoC) outlines the actions completed by the facility with regards to the deficiency citation. This Plan of correction does not constitute any admission of guilt or liability by the facility and is submitted only in response to the regulatory requirements. Please accept the following as the facility's credible allegation of compliance as of 4/30/26. F678 CPR All Full Code residents #18 have the potential to be affected by the alleged deficiency. On 4/27/26 the DON/ADON re-stocked the crash cart per the inventory sheet for all missing items. Crash cart inventory sheet updated and new one will go into effect on 5/1/26. All licensed nursing staff provided with training related to crash cart inventory being a daily audit review using inventory sheet on 4/27/26 per DON/designee. The DON/designee will conduct clinical rounds and conduct a random audit of crash cart three times per week for 4 (four) weeks to ensure compliance. The results of the audit will be documented. The facility conducted an Ad-Hoc QAPI meeting on 4/27/26 and discussed the alleged deficiency and corrective actions. Date when corrective action will be completed: 4/30/26
Unsafe Smoking Practices with Oxygen and Missed Fall-Prevention Interventions
Penalty
Summary
The deficiency involves the facility’s failure to provide a safe smoking environment, adequate supervision, and appropriate implementation of its smoking policy for a resident who used oxygen and smoked, as well as failure to implement fall-prevention interventions as care planned for another resident. One resident had multiple relevant diagnoses, including chronic respiratory failure with hypoxia, COPD, end-stage renal disease, dependence on supplemental oxygen, diabetes, and necrotizing fasciitis. Her care plans identified impaired visual function, risk for respiratory complications related to a history of smoking, and risk for cognitive decline, with interventions including use of oxygen per order and observation for understanding. A smoking-related care plan created earlier documented that she wished to use smoking products, had been assessed as safe to smoke "with supervision," and was non-compliant with the smoking policy, with family continuing to provide smoking supplies despite education and a verbal warning for non-compliance. Smoking assessments and progress notes showed a pattern of non-compliance and inconsistent classification of this resident’s smoking safety. Multiple smoking observation/assessments completed earlier in March documented that she had no cognitive loss, visual deficits, or dexterity problems but was unsafe to smoke without supervision because she did not return smoking materials and did not follow designated smoke times. Progress notes described her going out to smoke multiple times by herself or with family, including sneaking out next door with a cigarette and going out multiple times in one evening, with staff documenting that she was "reeducated" and that family brought in cigarettes and lighters which she did not return to staff. Despite this history, a smoking assessment completed after a three-day hospital stay assessed her as safe to smoke without supervision, with no documentation explaining how this conclusion was reached or evidence that her care plan was updated accordingly. On the day of the incident, the resident reported she had cigarettes and a lighter on her person after returning from dialysis and stated she "could not find a nurse" and went outside to smoke, saying she "guessed" she forgot she had her oxygen on. A CNA observed her outside and saw a flame coming through the resident’s oxygen nasal cannula tubing, turned off the oxygen tank, removed the tubing, and patted out sparks on the resident’s shirt sleeve. The resident’s face and hands appeared black in color, and EMS documented first-degree burns to the head and face, with the resident stating she lit a cigarette with her nasal cannula on, causing the burn. The hospital record described her face as black from smoke and her lips and mouth as "burnt and charred," with a recommendation for intubation that she refused. The facility’s incident report recorded that she went outside with oxygen on to smoke without notifying staff, that staff witnessed the occurrence as she walked through the dining room door to the courtyard, and that she stated she thought she had turned her oxygen off. The facility’s smoking policy required interdisciplinary evaluation to determine safe versus unsafe smokers, staff maintenance of all smoking paraphernalia for both safe and unsafe smokers, and progressive consequences for policy violations. A separate deficiency involved another resident at risk for falls whose care plan included use of non-skid strips on the floor in front of her recliner as a fall-prevention intervention. This resident had severe cognitive impairment, used a walker and wheelchair, required supervision or touching assistance for transfers and ambulation, and had experienced two or more falls without injury since the prior assessment. The fall-risk care plan, initiated at admission, specified non-skid strips in front of the recliner beginning in November. However, nursing staff interviewed were not familiar with all of the resident’s fall-prevention interventions without checking the record, and observation of the room showed two recliners with no non-skid strips on the floor in front of them. An LPN confirmed that the non-skid strips were not present despite the intervention remaining active in the care plan, and moving the recliners did not reveal any strips. The facility’s fall management policy required identification of hazards and risk factors, implementation of interventions to minimize falls and injuries, and development and implementation of a care plan based on interdisciplinary evaluation, with interventions related to identified risk factors.
Plan Of Correction
Smoking: On 03/21/26 at 3:16 P.M. 911 response was activated for Resident #11 and Medical Director #601 was notified by Registered Nurse (RN) #322. On 03/21/26 at 3:18 P.M. on-call Nurse/Social Services #423 immediately notified the Administrator and Director of Nursing (DON) #304 of the incident involving Resident #11. On 03/21/26 at 3:22 P.M. Emergency Medical Services (EMS) arrived onsite. At 3:30 P.M. Resident #11 was transported to the emergency room. On 03/21/26 at 3:30 P.M. RN #322 completed a smoking re-assessment of Resident #11 assessing the resident to be an unsafe smoker requiring supervision due to failure to remove oxygen prior to entering designated smoking area. On 03/21/26 from 3:38 P.M. through 7:57 P.M. Licensed Practical Nurse (LPN) #337, #336, #335, #338; RN #334, and DON #304 re-assessed residents (who smoke). This included Resident #22, Resident #3, Resident #47, Resident #50, Resident #60, Resident #150, Resident #86, and Resident #10 to determine smoking safety (via smoking assessment). Each resident was re-educated regarding the facility smoking policy and staff verified there were no smoking materials on their person. The residents' smoking materials would be maintained by facility staff and distributed per policy. On 03/21/26 at 4:30 P.M. DON #304 responded to facility and an Ad Hoc (not scheduled) Quality Assurance (QA) meeting was held via telephone with the Administrator, DON #304 and Medical Director #601 to review investigative findings and plan of action. A root cause analysis was completed and determined Resident #11 had smoking materials on her person (believed to be obtained from family without staff knowledge) and failed to remove her oxygen. The QA team discussed a corrective action plan. On 03/21/26 from 5:00 P.M through 03/22/26 at 3:00 P.M. 26 RNs, 13 LPNs, one medical technician (MT), 54 Certified Nursing Assistants (CNA) four activities staff, one central supply staff, 11 dietary staff, 12 housekeeping staff, three laundry staff, one medical records staff, two social designees, two maintenance staff, nine administrative staff, and 19 therapy staff (158 staff at the time of the incident) were provided education regarding the facility smoking policy by DON #304 and the Administrator. This was completed via 1:1, small group in-services or via phone. Newly hired staff would receive education during general orientation regarding the facility's smoking policy. On 03/21/26 at 5:00 P.M. DON #304 completed an audit of all residents who smoke (Resident #22, Resident #3, Resident #47, Resident #50, Resident #60, Resident #150, Resident #86, and Resident #10) to verify smoking evaluations and plans of care accurately reflected the residents' smoking safety needs. The residents were educated on the facility smoking policy, and smoking materials were to be maintained at the nurses' station. An audit was completed which included verification of required safety measures present in designated smoking areas, including an ash can, fire extinguisher, fire blanket, ash trays and no oxygen signs. There were no identified concerns or changes made because of the audits. On 03/21/26 at 8:55 P.M. Resident #11 returned from the ED. LPN #332 verbally educated the resident regarding the facility smoking policy which included the need for supervision, a smoking apron (to be worn) and the facility smoke times. LPN #332 verified no smoking materials were on the resident's person or in her room at this time. On 03/23/26 at 11:00 A.M. the Interdisciplinary Team (IDT) (Administrator, DON #304, Medical Director #601, RN #302, Social Services #427, Social Services #423, DON #300, and Maintenance #436) met in-person to review the plan of action with DON #304/designee to complete weekly monitoring of residents who smoke and designated smoking areas weekly for four weeks with Housekeeping responsible to complete the cleaning. Housekeeping staff were responsible for cleaning ashtrays and the designated smoking area daily. Audits to be reviewed and any further actions required to be directed by the Quality Assurance and Performance Improvement (QAPI) Committee during scheduled meetings. The IDT also reviewed all current smoking assessments and care plans for residents who smoke. Resident #50 required a change in supervision levels with smoking due to cognition levels and her plan of care as well as Resident #11's plan of care was updated to reflect supervision/safety. On 03/23/26 from 3:45 P.M. to 8:55 P.M. Social Services #423 re-educated residents who smoke (Resident #22, Resident #3, Resident #47, Resident #50, Resident #60, Resident #150, Resident #86, Resident #10) and responsible parties, if applicable regarding the facility smoking policy and supervision levels. On 03/23/26 at12:13 P.M. Social Services #427 contacted Resident #11's family member (#602) to schedule a care conference. Family member #602 and Family Member #603 were not available to meet until 03/27/26. On 03/23/26 at 1:00 P.M. staff education related to smoking areas, removal of oxygen prior to entering smoking area and maintaining smoking materials at the nurses' station for residents who smoke was initiated by DON #304 and the Administrator via 1:1, small group in-services or via phone call. Education was completed for all 158 staff by 03/24/26 at 1:00 P.M. Newly hired staff would be educated during general orientation regarding the facility's smoking policy. The facility does not utilize agency staff. On 03/27/26 at 11:00 A.M. a care conference was held with Resident #11 and Family Members #602 and #603, the Administrator, Social Services #423 and Social Services #427. The facility smoking policy was reviewed. The resident and family were informed an involuntary discharge would be initiated should the resident exhibit non-compliance moving forward and supervision would be increased beyond the two-hour standard of care to monitor more closely for non-compliance with the facility smoking policy. Family Member #602 stated he educated his siblings as well. On 04/10/26 at 2:00 P.M. DON #304 initiated education with 26 RNs and 13 LPNs (100% of nurses educated) regarding completion of the smoking evaluation via 1:1, small group in-services, or phone. The education was completed by 6:00 P.M. on 04/10/26. A new resident who smokes must remain supervised until the interdisciplinary team (IDT) reviews and determines smoking safety, at which time the care plan is developed and resident and family education is provided. The communication through the staff would be the care plan. Newly hired staff receive education during general orientation regarding the facility's smoking policy and completion of smoking evaluation via Point Click Care (PCC). On 04/10/26 at 4:29 P.M. DON #304 initiated an order in PCC for the nurse to verify, each shift, that Resident #11's smoking materials were maintained at the nurses' station. On 04/13/26 at 5:30 P.M. DON #304 initiated orders in PCC for nurses to verify, each shift, that all residents who smoke would have smoking materials maintained at the nurses' station. An updated list of smokers included: Resident #60, Resident #50, Resident #11, Resident #86, Resident #113, and Resident #151. On 04/13/26 at 5:45 P.M. DON #304 initiated questionnaires for staff regarding the smoking policy with re-education provided as needed via 1:1 and small group in-services for staff currently in the facility with all staff to be questioned/educated prior to working their next scheduled shift. Falls: On 4/9/26, Maintenance Director placed non-skid strips on the floor in front of Resident #12's recliner. Like Residents are identified as residents who have had a fall within the facility. Utilizing the Fall Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, an audit of falls and appropriate interventions for the past 30 days will be completed by the Director of Nursing or designee to ensure fall interventions are in place per plan of care. This audit along with identified corrections will be completed on or F 0689 before 5/13/26. The Director of Nursing or designee will re-educate licensed nurses and STNA/CNAs on the Fall Management Policy to include fall interventions to be in place per the care plan. This education will be completed on or before 5/13/26. Utilizing the Fall Management Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, the Director of Nursing or designee will complete an audit of new admissions, new readmissions and residents who experience a fall within the last 7 days, weekly for four weeks, beginning 5/14/26 to ensure fall safety interventions are in place per plan of care. Current fall interventions found to not be in place will be corrected with all intervention in place per plan of care. Negative findings to be addressed immediately and negative trends or system wide issues will be reported to the QAPI committee, and the action plan will be adjusted as needed.
Removal Plan
- Activated 911 response for Resident #11 and notified the Medical Director.
- On-call Nurse/Social Services immediately notified the Administrator and DON of the incident.
- EMS arrived onsite and Resident #11 was transported to the emergency room.
- Completed a smoking re-assessment of Resident #11, determining the resident was an unsafe smoker requiring supervision due to failure to remove oxygen prior to entering the designated smoking area.
- Re-assessed all residents who smoke (Residents #22, #3, #47, #50, #60, #150, #86, and #10) to determine smoking safety via smoking assessment.
- Re-educated residents who smoke regarding the facility smoking policy and verified there were no smoking materials on their person.
- Implemented that smoking materials would be maintained by facility staff and distributed per policy.
- Held an ad hoc QA meeting to review investigative findings and plan of action.
- Completed a root cause analysis determining Resident #11 had smoking materials on her person and failed to remove oxygen.
- Developed a corrective action plan.
- Provided facility-wide education to staff on the facility smoking policy.
- Implemented that newly hired staff would receive smoking policy education during orientation.
- Completed an audit of all residents who smoke to verify smoking evaluations and plans of care accurately reflected smoking safety needs.
- Ensured smoking materials were maintained at the nurses’ station.
- Audited designated smoking areas for required safety measures (ash can, fire extinguisher, fire blanket, ash trays, and no-oxygen signs).
- Provided verbal education to Resident #11 on smoking policy (supervision, smoking apron, smoke times).
- Verified no smoking materials were on Resident #11’s person or in her room.
- Conducted an in-person IDT meeting to implement weekly monitoring of residents who smoke and designated smoking areas weekly for four weeks.
- Assigned housekeeping to clean ashtrays and the designated smoking area daily.
- Directed audits to be reviewed by QAPI.
- Reviewed all current smoking assessments and care plans for residents who smoke.
- Updated Resident #50’s supervision level.
- Updated Resident #11’s plan of care to reflect supervision/safety.
- Re-educated residents who smoke and responsible parties (as applicable) regarding the facility smoking policy and supervision levels.
- Contacted Resident #11’s family to schedule a care conference.
- Initiated additional staff education regarding smoking areas, removal of oxygen prior to entering smoking area, and maintaining smoking materials at the nurses’ station.
- Held a care conference with Resident #11 and family to review smoking policy.
- Informed resident/family that involuntary discharge would be initiated for future non-compliance.
- Increased supervision beyond the two-hour standard of care to monitor more closely for non-compliance.
- Provided education to all nurses regarding completion of the smoking evaluation.
- Implemented that new residents who smoke must remain supervised until IDT review determines smoking safety and care plan/education are completed.
- Entered an order in PCC for nursing to verify each shift that Resident #11’s smoking materials were maintained at the nurses’ station.
- Entered orders in PCC for nursing to verify each shift that all residents who smoke have smoking materials maintained at the nurses’ station.
- Initiated staff questionnaires regarding the smoking policy with re-education as needed.
- Required all staff to be questioned/educated prior to working their next scheduled shift.
Failure to Provide Scheduled Bathing and Shaving Assistance for Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide scheduled and needed bathing and shaving assistance to multiple dependent residents in accordance with their care plans, preferences, and the facility’s routine care policy. One resident with spinal stenosis and recent L2–L5 decompression fixation fusion was care planned for substantial/maximal assistance with shower/bath and toileting hygiene and was scheduled for showers on Tuesdays and Fridays. Electronic documentation from early January through early April showed this resident did not receive a shower or bed bath on 11 identified scheduled days, and the DON confirmed these missed bathing events. Another resident with dysphagia and developmental issues, who required assistance with self-care and mobility, reported that she asked staff to shave her but they did not, which bothered her. During an observation following a recent shower, she stated she had not been shaved and that the hair "itched"; small gray hairs were visible on her chin. A CNA confirmed the presence of gray chin hairs and acknowledged the resident needed shaving, stating it would be addressed with the next scheduled shower. A further resident with chronic respiratory failure, tracheostomy status, heart failure, moderate intellectual disabilities, anxiety, depression, and PTSD required substantial/maximal assistance with personal hygiene and had a care plan for assistance with self-care, including personal hygiene. Her shower schedule called for showers on Monday and Thursday nights, with complete shaves for men and women. Review of documentation showed her last recorded shower/bath was nearly a year earlier, with no indication of additional personal hygiene or facial hair removal on that date. Observations on two separate days showed long white hairs on her chin and jaw line, which a CNA later confirmed, stating facial hair removal should occur with baths/showers or as needed. A resident with end stage renal disease, respiratory failure, hyperlipidemia, and congestive heart failure, who had impaired cognition and required partial/moderate assistance with bathing and personal hygiene, was scheduled for showers on Wednesdays and Saturdays. Review of shower documentation from admission through early April revealed no showers provided or refusals documented on at least ten scheduled shower days. In interviews, this resident reported not receiving scheduled showers, was unsure of his shower days, and stated he could use a good scrub down, adding that he had asked aides who told him they did not have time. A CNA explained that shower days appear on shower sheets and in the computer and that CNAs are supposed to document daily, with nurses checking the documentation; the DON verified the resident had not received showers per schedule or preference. Another resident with a fracture of the lower end of the left humerus, hemiplegia and hemiparesis after cerebral infarction, rheumatoid arthritis, hypertensive heart disease, urinary retention, and osteoarthritis was care planned as non–weight bearing to the left upper extremity and requiring substantial/maximal assistance with showering/bathing. Her electronic record showed she was scheduled for showers on Wednesdays and Saturdays. The shower task question "did the resident receive a shower/bath/bed bath?" was documented as "no" on three dates, indicating no shower/bath/bed bath was completed, and left unanswered on three additional dates. The DON confirmed that one missed shower was due to an outside appointment, that on two dates the "no" response meant no bathing of any type occurred, and that on three dates there was no documentation at all. The resident, who was cognitively intact, reported that missing showers made her feel unimportant compared to others and that she did not feel clean when her shower was missed. Facility policy on routine resident care stated that showers, tub baths, and shampoos are to be scheduled according to person-centered care or state guidelines, with additional showers given upon request, but the documented and observed care did not reflect consistent provision of scheduled bathing and shaving for these residents.
Plan Of Correction
1. Resident #5 received a shower by the STNA on 4/13/26. Resident #8 received a shower by the STNA on 4/8/26. Resident #9 received a shower and had their chin shaved by the STNA on 4/14/26. Resident #70 received a shower by the STNA on 4/13/26. Resident #76 received a shower and had their chin shaved by the STNA on 4/15/26. 2. Like residents are identified as residents who need assistance with showering and shaving. Utilizing the Shower Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, an audit of like residents will be completed by the Director of Nursing or designee to ensure that showers and resident shaving are completed. This audit along with identified corrections will be completed on or before 5/13/26. 3. The Director of Nursing or designee will re-educate licensed nurses and STNA's on the Routine Resident Care Policy to include bathing and shaving residents. This education will be completed on or before 5/13/26. 4. Utilizing the Shower Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, the Director of Nursing or designee will complete an audit of 4-6 residents weekly for four weeks, beginning 5/14/26 to ensure that showers and resident shaving are completed. Noncompliance found during audits will be addressed and assistance with showers and/or shaving provided. Negative findings to be addressed immediately and negative trends or system wide issues will be reported to the QAPI committee, and the action plan will be adjusted as needed.
Uncovered Urinary Catheter Drainage Bag Compromises Resident Dignity
Penalty
Summary
The facility failed to maintain a resident’s right to privacy and dignity related to management of an indwelling urinary catheter. A resident admitted with malignant neoplasm of the esophagus and type II diabetes mellitus had a care plan identifying risk for urinary tract infection and catheter-related trauma due to an indwelling catheter for urinary retention. The care plan interventions included ensuring the catheter tubing was secured and the drainage bag was properly secured with a dignity cover in place. Physician orders directed that the resident’s 16 French indwelling urinary catheter be changed every 30 days and as needed, and the comprehensive MDS documented that the resident had an indwelling catheter and was cognitively intact. During observation, the resident was seen seated in a chair with the urinary catheter drainage bag hanging from the chair without a dignity cover, and dark yellow urine was visible in the bag from the hallway. In a later observation and interview, an LPN confirmed that the catheter bag was lying directly on the floor and did not have a dignity cover. Attempts to interview the resident to confirm cognitive status were unsuccessful, as the resident was unable to answer screening questions. Review of the facility’s “Resident Dignity & Personal Privacy” policy stated that the facility should provide care in a manner that respects and enhances each resident’s dignity, individuality, and right to personal property, which was not followed in this instance when the catheter drainage bag was left uncovered and visible.
Plan Of Correction
The Laurels of Athens wishes to have this plan of correction submitted as our written allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission to nor agreement with, either the existence of, or the scope and severity of, any of the cited deficiencies or conclusions set forth in the statement of deficiencies. This plan is prepared and/or executed to ensure continuing compliance with regulatory requirements. Our alleged date of compliance is 5/13/2026. 1. On 4/6/26, Resident #92's catheter bag was removed from the floor, the bag changed and covered for dignity by the licensed nurse. Resident #92 discharged from the facility on 4/11/26. 2. Like Residents are identified as residents who utilize urinary catheters. An audit will be completed by the Director of Nursing or designee for like residents utilizing the Urinary Catheter Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC to ensure catheter bags are covered for dignity and not laying directly on the floor. This audit along with identified corrections will be completed on or before 5/13/26. 3. The Director of Nursing or designee will re-educate licensed nurses on the Indwelling Urinary Catheter Policy as well as Resident Dignity & Personal Privacy Policy to include privacy covers are in place for urinary catheters and that the catheter is not laying on the floor. This education will be completed on or before 5/13/26. 4. Utilizing the Urinary Catheter Audit Tool which was created on 4/20/26 by the Director of Nursing for purpose of this POC, the Director of Nursing or designee will complete an audit of all residents with catheters weekly for four weeks, beginning 5/14/26 to ensure catheter bags are covered for dignity and not laying directly on the floor. Any catheters found to be touching the floor or uncovered will be removed from the floor, the bag changed and covered for dignity. Negative findings to be addressed immediately and negative trends or system wide issues will be reported to the QAPI committee, and the action plan will be adjusted as needed.
Failure to Prevent Possible Misappropriation and Poor Documentation of PRN Narcotics
Penalty
Summary
The deficiency involves failure to prevent potential misappropriation of a resident’s narcotic medication and failure to ensure accurate documentation of controlled substance administration. A cognitively intact resident with chronic pain related to an internal orthopedic device and left knee pain had an order for oxycodone 5 mg PO every four hours PRN for pain and a care plan directing staff to administer medications as ordered and observe for effectiveness and side effects. The resident’s MDS showed she rated her pain as 7/10 and received opioid medication. However, review of the February MAR and the narcotic log revealed multiple discrepancies between narcotic sign-outs and documented administration. On several occasions, oxycodone doses were signed out on the narcotic log by an RN without corresponding documentation on the MAR. Specifically, oxycodone was signed out on one evening at 9:30 p.m. with no MAR entry, and again on a subsequent night at 1:30 a.m. and 5:30 a.m. with no MAR entries for those times. Another dose was signed out at 9:00 p.m. while the MAR reflected administration at 10:16 p.m., and a later dose at 5:30 a.m. was documented on both the narcotic log and MAR. There was also no documentation of pain assessments before or after PRN opioid administration. These documentation gaps meant there was no evidence that all narcotic doses signed out were actually administered to the resident. Staff interviews further highlighted concerns about the handling of narcotics. A CNA/med tech reported frequently taking the narcotic keys from the RN and described the RN’s behavior as erratic, with repeated problems involving incorrect narcotic counts and missing documentation on both the MAR and narcotic log. The resident stated she did not receive oxycodone more than once or twice a day, preferring to take Tylenol the rest of the time, which conflicted with the number of oxycodone doses signed out. When questioned, the RN gave inconsistent explanations about how often she pulled and administered PRN narcotics and acknowledged struggling with the new system, while also suggesting the resident may have received PRN tizanidine instead of remembering oxycodone. The facility’s investigation concluded that evidence was inconclusive as to whether misappropriation occurred or whether the issue was solely lack of documentation, but confirmed there was no evidence the resident received all doses signed out on the narcotic log.
Plan Of Correction
1. Resident #99 had a Self-Reported Incident submitted and investigated via the EIDC on 3/2/26. The investigation was inconclusive as we could not prove that misappropriation occurred. On 2/24/26, Resident #99 was interviewed and pain assessed by Director of Nursing and resident had no ill effects related to the inconsistent documentation in the medical record as it relates to her controlled substance pain medication. 2. Like Residents are identified as residents who utilize controlled substance PRN pain medications. An audit will be completed by the Director of Nursing or designee for like residents utilizing the Controlled Substance Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC to ensure PRN controlled substance pain medications that are signed off the control sheet are documented in the resident medical record as well. This audit along with identified corrections will be completed on or before 5/13/26. 3. The Director of Nursing or designee will re-educate licensed nurses on the Controlled Substances Policy to include appropriate documentation of controlled substances. In addition, the licensed nurses will be re-educated by the Director of Nursing or designee on the Abuse Prohibition Policy to include misappropriation of resident property. This education will be completed on or before 5/13/26. 4. Utilizing the Controlled Substance Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, the Director of Nursing or designee will complete an audit three controlled substance sheets from each of the nine medication carts for a total of twenty-seven sheets weekly for four weeks, beginning 5/14/26 to ensure PRN controlled substance pain medications that are signed off the control sheet are documented in the resident medical record as well. Inconsistencies noted from the audit will be investigated for misappropriation. Negative findings to be addressed immediately and negative trends or system wide issues will be reported to the QAPI committee, and the action plan will be adjusted as needed.
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