Windsor Lane Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Gibsonburg, Ohio.
- Location
- 355 Windsor Lane, Gibsonburg, Ohio 43431
- CMS Provider Number
- 365681
- Inspections on file
- 38
- Latest survey
- February 27, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Windsor Lane Healthcare Center during CMS and state inspections, most recent first.
The facility failed to follow its abuse and neglect policy by not reporting to the state agency or documenting an investigation after an Activity Assistant submitted written allegations that two CNAs verbally mistreated and neglected toileting needs of two cognitively impaired residents on a dementia unit. One resident with severe cognitive impairment, incontinence, and dependence for ADLs reportedly requested to use the restroom repeatedly over about an hour while a CNA, occupied with her phone, told her to wait despite her repeated statements that she would soil herself. Another resident with Alzheimer’s disease and severe cognitive impairment was reportedly yelled at on multiple occasions, publicly told it was acceptable to void in a brief instead of being taken to the bathroom, and subjected to a distressing incident in which a CNA threw her stuffed dog and joked that it had grown wings. These events were not documented in the medical records and were not reported or investigated as required.
The facility failed to promptly report, investigate, and document serious allegations that two residents with severe cognitive impairment and total dependence for ADLs were denied timely toileting and subjected to demeaning and bullying behavior by CNAs. An activity assistant reported that one resident was repeatedly refused access to the bathroom and told it was acceptable to use her brief in front of others, and that another resident was made to wait for an hour to toilet while a CNA remained on her phone, despite the resident’s repeated statements that she would soil herself. The assistant also described CNAs yelling at a resident, speaking to her in a demeaning tone, and intentionally distressing her by mishandling a stuffed dog she believed was real. Despite these written allegations, leadership acknowledged that no formal investigation was completed, the state agency was not notified, the accused staff were not removed from duty as required by policy, and there was no related documentation in the residents’ medical records.
A resident who was cognitively intact and dependent on staff for daily care reported experiencing verbal abuse from a CNA during toileting assistance, when the CNA made a comment urging the resident to hurry up because other people needed care. The incident was substantiated by facility investigation and confirmed through interviews and record review, constituting a failure to protect residents from verbal abuse as defined by facility policy.
A resident with multiple skin conditions and at risk for skin breakdown did not receive prescribed skin treatments as ordered. The resident self-administered treatments, kept them at bedside without authorization, and was out of medication for several days despite notifying staff. Staff continued to document treatments as given on the TAR, even though the medications were unavailable and not administered according to physician orders.
A medication was left unsecured on a resident's bedside table without a physician's order for self-administration or bedside storage. The medication was observed accessible while the resident was not present, and an LPN confirmed this practice, which was not authorized by facility policy. The resident also reported that nurses often left medication at the bedside.
A resident with multiple skin conditions was self-administering prescribed topical treatments, which were kept in her room without a physician's order for self-administration or bedside storage. Nursing staff documented these treatments as administered on the TARs without verifying application, contrary to facility policy requiring direct documentation by the person administering the medication.
A resident with severe cognitive impairment and high fall risk was left unattended in a Broda chair with unlocked wheels, leading to a fall and serious injuries. The facility failed to assess the chair for proper use and did not include specific interventions in the care plan, resulting in non-compliance with safety protocols.
A physical altercation occurred between two residents, one of whom was planning a party, leading to a confrontation over party supplies placed on a dining table. The altercation escalated when one resident used derogatory language, prompting the other to grab his arm and run her wheelchair into his leg, causing a skin tear. Staff intervened to separate them, and the incident was later substantiated as abuse.
The facility failed to complete and update comprehensive care plans for three residents, including two registered sex offenders and a resident with dementia. The care plans lacked necessary documentation for addressing the residents' specific needs, as confirmed by the DON, who cited issues with the electronic medical record system.
The facility failed to update care plans for three residents, including one who underwent bariatric surgery and required a high protein diet, another who resumed smoking despite a chronic respiratory condition, and a third receiving hemodialysis. These omissions were confirmed by facility staff.
The facility failed to assess and monitor the skin conditions of two residents, leading to deficiencies in care. One resident had a large red and scabbed area on the shin, which was not documented despite weekly skin assessments being required. Another resident had moisture-associated skin damage on the buttock, inaccurately reported as intact in assessments. Interviews confirmed the lack of proper documentation and monitoring, contrary to facility policy.
A resident with chronic respiratory failure was observed smoking without a required smoking apron, despite a physician's order. The resident had resumed smoking, but the facility did not offer a smoking apron, and the care plan lacked a smoking care area. The DON confirmed the order was still active but should have been discontinued.
A resident with type II diabetes, morbid obesity, and irritable bowel syndrome did not receive the recommended high protein nutritional supplementation. Despite a dietary manager's recommendation for a high protein shake, the resident only received a yogurt and occasionally an orange, lacking sufficient protein intake. The ADON confirmed the absence of an order for the supplement in the resident's medical record.
A facility failed to assess and monitor the nutritional and hydration needs of a resident who began hemodialysis. The resident, with moderately impaired cognition, was readmitted after hospitalization for dialysis. The RD recommended a specific diet but did not reassess nutritional needs or document the continuation of double protein portions. The RD also failed to coordinate care with the HD clinic, as no lab tests were received since the resident started HD. The facility's policy for nutritional service coordination was not adequately followed.
A resident with a history of prostate cancer experienced a delay in receiving his prescribed anti-cancer medication upon readmission to the facility. Although the resident brought the medication with him, the facility took it and delayed obtaining a physician's order for 10 days, resulting in the resident not receiving his medication until 12 days after readmission. The delay was confirmed by the ADON, and the resident expressed dissatisfaction with the situation.
A resident with intact cognition and multiple health issues required dental extractions by an oral surgeon. Despite a care plan to coordinate dental care, the facility failed to arrange an appointment. Interviews revealed attempts to contact dentists who could not accommodate the resident's size, and no general surgeon was contacted. The facility's policy stated it would assist in obtaining dental care.
The facility failed to provide residents with diets as ordered and recommended by the dietitian, affecting three residents. A resident with kidney failure did not receive the double protein portion ordered, while another with diabetes and dementia received a standard portion instead of the required double protein. Additionally, a resident with morbid obesity and diabetes did not receive the recommended weekly protein intake. The facility's policy required the Nutritional Service Coordinator to prepare and discuss clinical recommendations, but these were not adequately implemented.
A resident with kidney failure and moderately impaired cognition was not provided with nectar thickened liquids as ordered by the physician. Observations revealed the resident received unthickened milk and water, confirmed by a speech therapist familiar with the resident's risk for choking. The resident admitted to consuming the unthickened water.
The facility failed to complete employee reference checks and verify staff in the Ohio Abuse Registry, affecting multiple staff members including an Activity Aide, STNAs, Housekeepers, Dietary Staff, Maintenance Staff, Admissions Staff, and an RN. The facility's policy lacked guidelines for reference checks, and Human Resource Staff confirmed these deficiencies.
The facility did not follow its procedure to maintain an adequate emergency water supply on site, potentially affecting all 61 residents. The emergency water supply was kept off site, contrary to the facility's policy, which required storing three days' worth of water in the old assembly hall supply closet.
The facility did not ensure that STNAs received the required twelve hours of annual training, potentially affecting all 61 residents. Personnel files for four STNAs showed no documented education hours in the past year. Interviews with HR staff and the DON confirmed the lack of documentation for training hours, despite the job description requiring 12 hours of continuing education.
Failure to Report and Investigate Allegations of Neglect and Verbal Mistreatment
Penalty
Summary
The deficiency involves the facility’s failure to report allegations of resident neglect to the state agency and to document an investigation, as required by its abuse and neglect policy. The facility’s policy dated 2016 states that all incidents and allegations of abuse, neglect, exploitation, mistreatment, misappropriation of resident property, and injuries of unknown source must be immediately reported to the administrator or designee, and that the administrator or designee will notify the state survey agency of all such alleged violations within 24 hours of the allegation being made known to staff. Despite this policy, the Human Resources Director acknowledged that written allegations submitted by an Activity Assistant regarding staff treatment of residents on the dementia unit were not reported to the state agency and that no written investigation was completed. Resident #2, admitted on 10/28/25, had diagnoses including type II diabetes mellitus, epilepsy, dementia, major depression, cerebral infarction, parosmia, and hypertension. The most recent MDS showed severe cognitive impairment, no behaviors, dependence for all ADLs including toileting, frequent incontinence, and risk for pressure ulcer without current skin breakdown. Progress notes from October 2025 through February 2026 contained no documentation of alleged incidents. In the Activity Assistant’s written statement, she reported that Resident #2, while seated at a table with other residents, repeatedly stated she needed to use the restroom over the course of about an hour. CNA #401 was assisting another resident, and CNA #400, who was on her phone, repeatedly told Resident #2 she had to wait, while Resident #2 repeatedly said she was going to soil herself and needed the bathroom immediately. Resident #3, admitted on 09/01/25, had diagnoses including Alzheimer’s disease, dementia, epilepsy, major depressive disorder, anemia, and anxiety disorder. The MDS indicated severe cognitive impairment, behaviors directed at others, dependence on staff for ADLs, bladder incontinence, bowel continence, and risk for pressure ulcer development with no current skin breakdown. The Activity Assistant’s statement described multiple occasions where CNA #400 raised her voice at Resident #3, including telling her she was not allowed to speak to people a certain way and that she needed to apologize, and later yelling at her to be quiet from down the hall. On another occasion, when Resident #3 requested to use the restroom about 45 minutes after a prior toileting, CNA #400 questioned her in a demeaning tone, delayed responding for 5–10 minutes, then refused to take her when the lunch cart arrived, telling her in front of others that it was acceptable because she was wearing a brief. The statement also described CNA #400 and CNA #401 recounting as a joke an incident where CNA #401 threw Resident #3’s stuffed dog in front of her, telling her the dog grew wings, which caused the resident distress. These allegations were not documented in the residents’ progress notes, not reported to the state agency, and not formally investigated by the facility.
Failure to Investigate and Report Allegations of Neglect and Disrespectful Care
Penalty
Summary
The deficiency involves the facility’s failure to promptly act on and thoroughly investigate allegations of neglect and disrespectful treatment toward two cognitively impaired residents on the dementia unit. Resident #2, admitted with multiple diagnoses including type II diabetes mellitus, epilepsy, dementia, major depression, cerebral infarction, and hypertension, had a recent MDS showing severe cognitive impairment, dependence for all ADLs including toileting, frequent incontinence, and risk for pressure ulcers without current skin breakdown. Resident #3, admitted with Alzheimer’s disease, dementia, epilepsy, major depressive disorder, anemia, and anxiety disorder, had an MDS indicating severe cognitive impairment, behaviors directed at others, dependence for ADLs, bladder incontinence, bowel continence, and risk for pressure ulcer development without current skin breakdown. Progress notes for both residents from October 2025 through February 2026 contained no documentation of any alleged incidents related to neglect or mistreatment. According to a written statement dated 12/03/25 from Activity Assistant #300, CNA #400 repeatedly raised her voice at Resident #3, including telling the resident she was not allowed to speak to people a certain way and that she needed to apologize, and later yelling at her to be quiet while the resident was in her room. On another occasion, Resident #3 requested to use the restroom about 45 minutes after a prior toileting; CNA #400 responded in a demeaning tone, questioned whether the resident would actually go, and repeatedly told her to “hold on.” After five to ten minutes of continued requests, when the lunch cart arrived, CNA #400 told Resident #3 she could not be taken to the bathroom because it was lunch time and stated in front of others that it was okay because the resident was wearing a brief, leaving the resident clearly upset. AA #300 also reported that CNA #400 and CNA #401 recounted, as if humorous, an incident where CNA #401 took Resident #3’s stuffed dog (which the resident considers real), threw it in front of her, and told her the dog grew wings, causing the resident distress. AA #300 stated Resident #3 was regularly targeted and subjected to bullying and neglectful treatment. AA #300 further reported that a few weeks prior, Resident #2, who was seated at a table with other residents, announced she needed to use the restroom. CNA #401 was assisting another resident, and CNA #400 told Resident #2 they would help her soon. Over the next hour, Resident #2 repeatedly asked to use the restroom while CNA #400, who was on her phone, continued to tell her she had to wait; Resident #2 repeatedly stated she was going to defecate in her pants and needed to go to the bathroom immediately. Despite these allegations, the Human Resources Director confirmed that when AA #300 submitted the written allegations on 12/03/25, no investigation was documented, the state survey agency was not notified, and the accused CNAs were not removed from the facility but instead reassigned to a different unit. This response was inconsistent with the facility’s Abuse, Neglect, Exploitation and Misappropriation of Resident Property policy, which requires immediate reporting to the administrator, notification of the state agency within 24 hours, removal of accused staff from the facility pending investigation, completion of an investigation within five working days, and documentation of resident assessment and notifications in the medical record.
Verbal Abuse by CNA During Toileting Assistance
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) was verbally abusive to a resident during toileting assistance. The resident, who was cognitively intact and dependent on staff for several activities of daily living, reported that the CNA told her to hurry up and finish on the bedpan because the CNA had other people to take care of. This comment was perceived by the resident as verbally abusive and caused her mental anguish. The incident was substantiated by the facility after investigation, and the CNA was identified as the perpetrator of the verbal abuse. The facility's policy defines abuse as the willful infliction of injury, intimidation, or punishment resulting in physical harm, pain, or mental anguish, including verbal abuse. The incident was reported through the facility's self-reported incident process, and interviews with the resident and facility leadership confirmed the occurrence of verbal abuse. The deficiency was identified during a review of records, interviews, and facility policy, affecting one resident among those reviewed for abuse.
Failure to Administer Skin Treatments per Physician Orders
Penalty
Summary
The facility failed to ensure that skin treatments for a resident were completed according to physician orders. The resident, who had diagnoses including morbid obesity, psoriasis vulgaris, seborrheic dermatitis, and Type I diabetes mellitus, was at risk for chronic cellulitis and skin breakdown. Physician orders required the application of ketoconazole cream, miconazole powder, and triamcinolone cream at specific intervals. Review of the Treatment Administration Record (TAR) indicated these treatments were documented as administered as ordered. However, interviews revealed that the resident was self-administering her skin treatments and had been out of the prescribed treatments for three days, despite informing nursing staff. The treatments were kept at the resident's bedside without an order permitting self-administration or bedside storage. The LPN/Unit Manager confirmed that the treatments were not available in the medication cart and had not been available for some time, yet staff continued to sign off on the TAR as if the treatments had been given. Facility policy required medications to be administered in accordance with physician orders, which was not followed in this case.
Medication Storage Deficiency: Unsecured Medication Left at Bedside
Penalty
Summary
A deficiency occurred when a medication, specifically fluticasone propionate nasal suspension, was left unsecured on a resident's bedside table without a physician's order for self-administration or for medications to be left at bedside. The resident, who had diagnoses including morbid obesity, chronic respiratory failure with hypoxia, Type I diabetes mellitus, COPD, and CHF, was not present in the room at the time the medication was observed. The medication was found with the prescription box, clearly labeled with the resident's name, and accessible in the resident's absence. Interviews confirmed that nursing staff, including an LPN, left the medication at the bedside after morning administration, despite facility policy requiring a physician's order for self-administration or bedside storage. The resident reported that nurses often left her medication on the bedside table. Review of the medical record and facility policy further substantiated that there was no authorization for this practice, resulting in non-compliance with requirements for proper medication storage.
Inaccurate Documentation of Treatment Administration Records
Penalty
Summary
The facility failed to ensure the accuracy of Treatment Administration Records (TARs) for one resident. A review of the medical record for a resident with multiple diagnoses, including morbid obesity, psoriasis vulgaris, seborrheic dermatitis, and Type I diabetes mellitus, showed that the resident was at risk for chronic cellulitis and skin breakdown. Physician orders were in place for several topical treatments, including ketoconazole cream, miconazole powder, and triamcinolone cream, to be administered at specific intervals. The TARs indicated that these treatments were documented as administered according to the orders. However, interviews with the resident and the LPN/Unit Manager revealed that the resident was self-administering her skin treatments, and the medications were kept in her room. Nursing staff did not have an order for the resident to self-administer these treatments or to keep them at bedside. Despite this, nursing staff continued to sign off on the TARs as if they had administered the treatments themselves, without verifying whether the treatments were actually applied. The facility's policy required that the individual who administered the medication record the administration immediately after giving the medication, which was not followed in this case.
Failure to Ensure Safe Use of Specialized Chair Results in Resident Injury
Penalty
Summary
The facility failed to ensure the safe and proper use of specialized chairs, resulting in actual harm to a resident. Resident #01, who had severe cognitive impairment and was at high risk for falls, was placed in a Broda chair with caster wheels that were not locked. The resident was left unattended in the chair, which had not been assessed for proper use. As a result, the resident leaned forward, causing the chair to tip over, leading to serious injuries including a skin tear and fractures that required surgical repair. The resident's medical history included dementia, muscular dystrophy, and rheumatoid arthritis, among other conditions. The resident was dependent on staff for daily activities and used a wheelchair for mobility. Despite being at high risk for falls, the care plan did not include specific interventions for the use of a Broda chair. On the day of the incident, the resident was left alone in the memory care unit dining room, and the chair tipped forward when the resident leaned over, resulting in a fall. Interviews and observations revealed that the staff did not lock the wheels of the Broda chair due to concerns about it being a restraint. The facility's Director of Nursing confirmed that there was no documentation of the chair being assessed for proper use. The Broda chair's operating manual emphasized the importance of locking the wheels and supervising the resident to prevent tipping. The facility's fall management policy required staff to assess residents for fall risk and implement appropriate interventions, which were not adequately followed in this case.
Physical Altercation Between Residents
Penalty
Summary
The deficiency involved an incident of physical abuse between two residents at the facility. Resident #2, who had diagnoses including morbid obesity, lymphedema, and chronic pain, was involved in an altercation with Resident #3, who had diagnoses including morbid obesity, congestive heart failure, and pulmonary edema. Both residents had intact cognition and no negative behaviors noted in their assessments. The incident occurred when Resident #2 was planning a birthday party, and Resident #3 became annoyed because the party supplies were placed on a dining room table he normally used for lunch. This led to a verbal confrontation outside the building. During the altercation, Resident #2 confronted Resident #3 about taking photos of the party decorations. Resident #3 responded with derogatory remarks, which escalated the situation. Resident #2 admitted to grabbing Resident #3's arm and running her wheelchair into his leg, causing a skin tear. Resident #3 threatened to hit Resident #2 if she did not let go. The altercation was witnessed by other residents and staff, who intervened to separate the two residents. Resident #3 later reported an open area on his leg, which was treated by the nursing staff. The facility's policy on abuse, neglect, exploitation, and misappropriation of resident property defines abuse as the willful infliction of injury or intimidation resulting in physical harm or mental anguish. The incident was unwitnessed by the nurse initially, but staff and other residents provided accounts of the event. The facility substantiated the abuse, and Resident #3 expressed a desire to press charges against Resident #2. The deficiency was identified as past non-compliance that was subsequently corrected prior to the survey.
Incomplete Care Plans for Residents with Special Needs
Penalty
Summary
The facility failed to ensure that comprehensive care plans were completed and updated for three residents, affecting their ability to receive appropriate care. Resident #12, who was cognitively intact and required a wheelchair for mobility, was identified as a registered sex offender. However, his care plan lacked documentation regarding care and interventions related to his status as a sex offender. Similarly, Resident #25, also cognitively intact and using a wheelchair, was a registered sex offender with no corresponding care plan documentation addressing this aspect of his care needs. The Director of Nursing (DON) confirmed the absence of these critical care plan components during an interview. Additionally, Resident #2, diagnosed with dementia and dependent on staff for personal hygiene, had an incomplete care plan that did not address activities of daily living. The DON acknowledged the care plan's deficiencies and attributed the issue to difficulties with the electronic medical record system, which resulted in care plans not being consistently updated in resident records. These oversights in care planning highlight significant gaps in the facility's ability to meet the comprehensive needs of its residents.
Failure to Update Resident Care Plans
Penalty
Summary
The facility failed to ensure timely updates to resident care plans, affecting three residents. Resident #46, who had undergone bariatric surgery and was prescribed high protein nutrition shakes, did not have these changes reflected in their care plan. Despite receiving high protein shakes post-surgery, the care plan lacked documentation of the surgery and the dietary requirements. This oversight was confirmed by the Assistant Director of Nursing and the Dietary Manager. Resident #5, diagnosed with chronic respiratory failure, had a care plan that did not address their smoking habits. Although the resident had quit smoking, they resumed the habit, which was not updated in the care plan. The Director of Nursing confirmed that the smoking assessment was outdated and did not reflect the resident's current status. Additionally, Resident #10, who was undergoing hemodialysis, did not have this treatment documented in their care plan. The Director of Nursing confirmed that Resident #10 was the only resident receiving hemodialysis, yet this critical information was missing from the care plan.
Failure to Monitor and Document Skin Conditions
Penalty
Summary
The facility failed to adequately assess and monitor the skin conditions of two residents, leading to deficiencies in care. Resident #15, who has diagnoses including muscular dystrophies, congestive heart failure, morbid obesity, and cerebral vascular accident, was found to have a large red and scabbed area on the left lower shin during an observation. Despite the resident's care plan indicating a need for weekly skin assessments due to risks associated with anticoagulant therapy and morbid obesity, the medical record lacked documentation of this skin condition. Interviews with the Assistant Director of Nursing and the resident confirmed the absence of documentation and the long-standing nature of the skin issue. Similarly, Resident #50, with diagnoses including chronic respiratory failure and anxiety, had a new wound identified as moisture-associated skin damage (MASD) on the right buttock. Despite this, weekly skin observation assessments inaccurately reported the resident's skin as clean, dry, and intact. Interviews with the resident, the Director of Nursing, and a Wound Care Nurse Practitioner confirmed the ongoing presence of MASD and the lack of proper skin assessments since the wound was first noted. The facility's policy required weekly skin assessments, which were not adhered to, resulting in a failure to monitor and document the resident's skin condition accurately.
Failure to Ensure Resident Wore Smoking Apron
Penalty
Summary
The facility failed to ensure that a resident wore a smoking apron as ordered by the physician, which was necessary to prevent accidents related to smoking. The resident, who had a diagnosis of chronic respiratory failure and intact cognition, was required to wear a smoking apron while smoking, as per a physician's order initiated in March 2023. However, the most recent smoking assessment indicated that the resident no longer smoked, and there was no clarification on whether the resident could smoke independently. Despite this, the resident was observed smoking without a smoking apron on multiple occasions, and the facility's list of residents who smoked confirmed that the resident was still smoking. Interviews with the resident and staff, including the Director of Nursing (DON), revealed that the resident had resumed smoking after previously quitting and was not offered a smoking apron by the facility. The DON confirmed that the order for the smoking apron was still active but should have been discontinued. The facility's smoking policy required smoking evaluations upon admission, change of condition, and annually, but the resident's care plan did not include a care area for smoking, indicating a lapse in adherence to the policy and physician's orders.
Failure to Provide Recommended High Protein Supplementation
Penalty
Summary
The facility failed to ensure that a resident received high protein nutritional supplementation as recommended by the dietary manager. The resident, who had diagnoses of type II diabetes mellitus, morbid obesity, and irritable bowel syndrome, was on a 1,200 kilocalorie partial liquid diet. Despite the dietary manager's recommendation to include a high protein shake with breakfast and lunch, the resident did not receive the Ensure High Protein shake she requested, as she did not like the facility's in-house shake. The dietary manager stated that the resident did not request an alternative, and the kitchen continued to send the in-house shake. Observations and interviews revealed that the resident's meal trays only contained a yogurt and occasionally an orange, with the yogurt providing only 60 kilocalories and four grams of protein. The Assistant Director of Nursing confirmed that there was no order for a nutrition supplement in the resident's medical record, despite the dietary manager's progress note indicating the need for a high-protein shake. This oversight affected the resident's nutritional intake, as she did not receive the recommended high protein supplementation.
Failure to Monitor Nutritional Needs for Dialysis Resident
Penalty
Summary
The facility failed to ensure proper nutritional and hydration assessment and monitoring for a resident who began hemodialysis (HD). The resident, who had moderately impaired cognition, was readmitted to the facility after hospitalization to establish dialysis. The Registered Dietitian (RD) recommended a no concentrated sweets, no added salt diet with thickened liquids but did not reassess the resident's nutritional needs or document whether double protein portions should continue. The RD did not conduct further assessments or document any progress notes regarding the resident's condition after starting HD. The Director of Nursing (DON) confirmed that the resident was the only one receiving HD in the facility and that the resident began HD treatments on a specific date. The RD admitted to not reassessing the resident's nutritional needs after the initiation of HD, relying instead on the initial dietary recommendations. The RD also failed to coordinate care with the HD clinic, as no laboratory tests had been received from the clinic since the resident began HD. The facility's policy required the Nutritional Service Coordinator or Consult Dietician to prepare a list of clinical recommendations and discuss them with the Nutrition Service Director and/or Nursing, which was not adequately followed in this case.
Delay in Cancer Medication Administration
Penalty
Summary
The facility failed to timely provide a cancer medication to a resident with a history of prostate cancer. The resident was readmitted to the facility with a past medical history of prostate cancer, type II diabetes mellitus, and obesity. Upon readmission, the resident brought his prescribed long-term anti-cancer medication to the facility. However, the medication was taken from him with the assurance that the facility would obtain an order from the physician for its administration. Despite this, the request for the medication order was not addressed until 10 days later, resulting in the resident not receiving his medication from the time of his readmission. The delay in obtaining the medication order was confirmed by the Assistant Director of Nursing, who acknowledged that the request made on 07/12/24 was not addressed until 07/22/24, and the order was only initiated on 07/23/24. The resident expressed dissatisfaction with the delay, as he had not received his medication since his readmission on 07/11/24 until 07/23/24. This deficiency affected the resident's continuity of care and timely access to necessary medication.
Failure to Arrange Timely Dental Services for Resident
Penalty
Summary
The facility failed to timely arrange dental services for a resident, affecting one of three residents reviewed for dental services. The resident, who had intact cognition, was admitted with diagnoses including morbid obesity with alveolar hypoventilation, atrial fibrillation, and chronic respiratory failure with hypoxia. The care plan initiated in April indicated dental problems related to poor oral hygiene, with interventions to coordinate dental care and provide mouth care. A dental note from June indicated the need for extraction of two teeth by an oral surgeon, but no appointment was documented as set up with an oral surgeon by late July. Interviews revealed that the resident was informed by the dentist about the need for an oral surgeon, but the facility had not made the appointment. The Director of Nursing confirmed the lack of an appointment, citing attempts to contact three dentists who could not accommodate the resident's size. The facility considered contacting a general surgeon instead. Transportation staff confirmed contacting three oral surgeons who could not perform the extraction and had not attempted to call a general surgeon. The facility's undated policy stated it would assist residents in obtaining routine and emergency dental care.
Failure to Provide Diets as Ordered and Recommended
Penalty
Summary
The facility failed to provide residents with diets as ordered and as recommended by the registered dietitian, affecting three residents. Resident #10, who had moderately impaired cognition and a diagnosis of kidney failure, was ordered a no-added salt, no concentrated sweets diet with double protein. However, during meal service, the dietary staff failed to provide the double protein portion, instead offering a standard portion of spaghetti and compensating with cheese after the error was identified. Resident #26, diagnosed with type II diabetes mellitus and dementia, was also ordered a no-added salt, no concentrated sweets diet with high protein. During meal service, the resident received a standard portion of ham and potato casserole, contrary to the double protein portion indicated on the tray ticket. Additionally, Resident #17, with multiple diagnoses including morbid obesity and diabetes, required a therapeutic diet with 100 to 110 grams of protein per day. However, the facility's menu provided only 588.7 grams of protein per week, falling short of the 700 to 770 grams recommended by the dietitian. The facility's policy required the Nutritional Service Coordinator to prepare and discuss clinical recommendations, but these were not adequately implemented for Resident #17.
Failure to Provide Thickened Liquids as Ordered
Penalty
Summary
The facility failed to ensure that a resident received thickened fluids as ordered by the physician. The resident, who was admitted with a diagnosis of kidney failure and had moderately impaired cognition, was prescribed a diet that included nectar thickened liquids. However, during observations, it was noted that the resident was provided with unthickened milk and water during meals. This was contrary to the physician's order for nectar thickened liquids. During an observation and interview with a speech therapist, it was confirmed that the resident was at risk for choking with unthickened liquids. The speech therapist verified that the water provided to the resident was not thickened to the required consistency. The resident also confirmed having consumed some of the unthickened water, indicating a lapse in adherence to the prescribed dietary requirements.
Failure to Complete Employee Reference Checks and Abuse Registry Verification
Penalty
Summary
The facility failed to ensure proper employee reference checks and verification in the Ohio Abuse Registry for several staff members, which had the potential to affect all 61 residents residing in the facility. Personnel records revealed that an Activity Aide, two State Tested Nursing Assistants, a Housekeeper, Dietary Staff, Maintenance Staff, Admissions Staff, and a Registered Nurse were either not checked in the Ohio Abuse Registry or did not have completed reference checks. Specifically, the Activity Aide, Housekeeper, Dietary Staff, Maintenance Staff, Admissions Staff, and Registered Nurse were not verified in the Ohio Abuse Registry, while the State Tested Nursing Assistants and Maintenance Staff lacked completed reference checks. The facility's policy titled "Abuse, Neglect, Exploitation & Misappropriation of Resident Property," dated 2016, did not include guidelines for completing employee reference checks. The policy stated that the facility would check with all applicable licensing and certification authorities to ensure employees hold the requisite license and/or certification status and do not have disciplinary actions against their professional license due to findings of abuse, neglect, exploitation, or misappropriation of resident property. However, the lack of adherence to these procedures was confirmed by Human Resource Staff, who verified the deficiencies in the employee verification process.
Failure to Maintain On-Site Emergency Water Supply
Penalty
Summary
The facility failed to adhere to its procedure for maintaining an adequate emergency water supply, which had the potential to affect all 61 residents. During an interview with the Director of Nursing and the Director of Maintenance, it was confirmed that the facility did not have an emergency water supply on site, as it was kept off site. A review of the facility's undated policy titled 'Emergency Water Supply' indicated that the facility was supposed to provide three days of food and water for staff or other persons who would stay at the facility during an emergency. Additionally, the policy stated that the water should be stored in the old assembly hall supply closet.
Failure to Provide Required Annual Training for STNAs
Penalty
Summary
The facility failed to ensure that State tested Nursing Assistants (STNAs) received the required twelve hours of annual training, which had the potential to affect all 61 residents in the facility. Personnel files for four STNAs revealed no documented hours of education completed in the past year. Interviews with Human Resources Staff and the Director of Nursing confirmed the absence of documentation for the annual inservice training hours. The job description for STNAs, dated 06/01/05, required a minimum of 12 hours of continuing education programs to maintain certification.
Latest citations in Ohio
Surveyors found that multiple hazardous storage areas, including a closet near medical records, a beauty salon used to store chemical cases, a supply room in one nursing station, a room leading to a smoking area, a housekeeping room near therapy, and a lobby storage room, lacked required self-closing or automatic-closing doors. These conditions did not comply with NFPA 101 requirements for hazardous area enclosure and had the potential to affect all residents and staff in an emergency.
Surveyors found that the facility did not conduct fire drills on every shift each quarter and did not vary drill conditions as required by NFPA 101. Record review showed that one shift lacked a documented drill for an entire quarter, and the pattern of drill times and dates did not demonstrate varied conditions. The Maintenance Director confirmed the incomplete and noncompliant fire drill schedule, which affected all residents and staff emergency preparedness.
Surveyors found that the facility did not maintain clear egress corridors as required by NFPA 101, with a TV/video cart plugged into a corridor outlet and multiple unsecured chairs placed in the hallway near resident rooms and the secured unit dining room, including directly in front of a fire extinguisher. These items projected about 29 inches into an approximately eight-foot-wide corridor and were located in front of the handrail, potentially affecting 28 residents and staff’s ability to assist in an emergency. The Maintenance Director confirmed these corridor obstructions during the survey.
A resident with intact cognition receiving Medicare Part A skilled services for metabolic encephalopathy had services discontinued while benefit days remained, but the facility did not issue the required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN). The Social Services Director later confirmed that no SNF ABN was provided and reported she believed only a Notice of Medicare Non-Coverage (NOMNC) was needed when all skilled services were stopped. This practice conflicted with the facility’s written policy, which required SNF ABNs to be issued when extended care items or services were initiated, reduced, or terminated due to expected non-coverage by Medicare.
Surveyors identified that the facility exceeded the acceptable medication error rate when two residents with type 2 DM received insulin doses that were not administered according to orders or manufacturer instructions. In two separate observations, an LPN administered Novolog and another LPN administered insulin glargine and insulin lispro without priming the insulin pens, and the insulin lispro and Novolog were given after the residents had already consumed a significant portion of their breakfast meals, despite orders for administration before meals. Manufacturer information for both insulin products required priming before each injection to ensure accurate dosing, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and specified time frames.
The facility failed to maintain accurate and complete crash cart audits for multiple full-code residents. Surveyors, accompanied by the DON, found that daily crash cart checks did not include verification of supply expiration dates, and that an extension cord documented as present on several audit dates was not actually in the cart. Audit logs also conflicted with the cart’s contents by indicating that required items such as eye protection, saline, and clear plastic were present when they were not. These findings were inconsistent with the facility’s policy requiring the crash cart to be checked every 24 hours and after each use, with prompt replacement of equipment and supplies.
A resident with chronic respiratory failure on supplemental O2, COPD, and cognitive risk factors was repeatedly documented as non-compliant with the smoking policy, including going out to smoke outside designated times and retaining cigarettes and lighters provided by family. Despite prior assessments identifying this resident as unsafe to smoke without supervision, a later assessment classified the resident as safe to smoke independently without documented rationale or care plan update. The resident subsequently went outside alone with an O2 nasal cannula in place, lit a cigarette, and sustained facial burns when the cannula ignited, as observed by staff and confirmed by EMS and ED records. In a separate case, another cognitively impaired resident with a history of falls had a care-planned intervention for non-skid strips in front of a recliner, but observation and staff confirmation showed the strips were not present, despite remaining on the active fall-risk care plan.
Multiple dependent residents did not receive scheduled showers, bed baths, or shaving as outlined in their care plans and the facility’s routine care policy. One resident recovering from spinal surgery missed numerous scheduled showers over several months. Another resident who relied on staff for self-care repeatedly requested shaving but was not shaved, and visible facial hair was observed after a recent shower. A resident with chronic respiratory failure and a tracheostomy, requiring substantial/maximal assist with personal hygiene, had no documented showers for an extended period and was observed with long facial hair, which staff acknowledged should be removed during bathing or as needed. A cognitively impaired resident with ESRD and CHF, scheduled for twice-weekly showers, had multiple undocumented or missed showers and reported not getting showers despite asking aides who said they lacked time. Another cognitively intact resident with hemiplegia and multiple comorbidities, also scheduled for twice-weekly showers, had several dates where documentation showed no shower/bath/bed bath provided or no entry at all, and she reported feeling unclean and unimportant when her showers were missed.
A resident with an indwelling urinary catheter for urinary retention, and care plan interventions requiring the drainage bag to be properly secured with a dignity cover, was observed seated in a chair with the catheter drainage bag uncovered and containing visible dark yellow urine that could be seen from the hallway. Later, an LPN confirmed the catheter bag was lying directly on the floor without a dignity cover. This situation occurred despite facility policy requiring care to be provided in a manner that respects and enhances each resident’s dignity and personal privacy.
A cognitively intact resident with chronic orthopedic pain had a PRN oxycodone order, but multiple doses were signed out on the narcotic log by an RN without corresponding entries on the MAR or documented pain assessments. A CNA/med tech reported frequent problems with this RN’s narcotic counts and documentation, describing erratic behavior when handling narcotic keys. The resident reported taking oxycodone only once or twice daily and otherwise using Tylenol, which conflicted with the number of oxycodone doses signed out. The facility’s investigation found it was inconclusive whether narcotics were misappropriated or whether there was a failure of documentation, but confirmed there was no evidence that all signed-out doses were administered.
Failure to Maintain Self-Closing Doors for Multiple Hazardous Storage Areas
Penalty
Summary
Surveyors identified a deficiency related to hazardous area protection and door requirements under NFPA 101, 2012 Edition. During facility tours, they observed that multiple hazardous storage areas did not have self-closing or automatic-closing doors as required for hazardous areas such as combustible storage and chemical storage. These areas included a closet next to medical records, a beauty salon being used to store cases of chemicals, a supply room in Station #2, and the room leading to the smoking area in Station #3. On a subsequent tour, surveyors observed additional hazardous areas without self-closing doors. The housekeeping room across from therapy and the lobby storage room were both noted to lack self-closing door mechanisms. The facility census at the time was 59 residents, and the surveyors stated that this deficient practice had the potential to affect all residents and staff's ability to assist in an emergency. The Maintenance Director verified these findings at the time they were observed.
Plan Of Correction
K 0321 This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be admissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as its allegation of substantial compliance as of 06/12/2026 K-0321 Doors with Self-Closing Devices Corrective action for resident/s: 1. The closet door next to medical records was lacking a self-closing door on 5/19/2026. Maintenance director to add self-closing device to closet door next to medical records on or before 06/12/2026 in accordance with applicable code. 2. The beauty salon had chemicals stored in it on 5/19/2026. Maintenance director moved chemicals from beauty salon on 05/20/2026 in accordance with applicable code. 3. The supply room on station 2 was lacking a self-closing door on 5/19/2026. Maintenance director to add self-closing door to supply room on station 2 on or before 06/12/2026 in accordance with applicable code. 4. The room to the smoking area on station 3 was lacking a self-closing door on 5/19/2026. Maintenance director to add a self-closing door to the smoking are on station 3 on or before 06/12/2026 in accordance with applicable code. 4. The housekeeping room across from therapy was lacking a self-closing door on 5/19/2026. Maintenance director to add a self-closing door to the housekeeping room across from therapy gym on or before 06/12/2026 in accordance with applicable code. 5. The lobby storage room was lacking a self-closing door on 5/19/2026. Maintenance director to add a self-closing door to the lobby storage room on or before 06/12/2026 in accordance with applicable code. Identification of other residents who may be affected: LNHA and Maintenance director/designee completed a full facility audit for doors with self-closing devices on 05/26/2026. Any corrective action, including, doors identified as needing self-closures will be added on or before 06/09/2026 in accordance with applicable code. Measures for systemic change: LNHA educated Maintenance Director on 05/26/2026 regarding NFPA 101-2012 sections 19.3.2.1 and 19.3.5.9 specifically regarding doors with self-closing devices. How Corrective Action will be monitored Ongoing "Doors with Self-Closing device audit" to be completed weekly x 2 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 06/12/2026
Failure to Conduct Required Quarterly Fire Drills on All Shifts
Penalty
Summary
The facility failed to conduct fire drills in accordance with NFPA 101, 2012 Edition, sections 19.7.1 through 19.7.1.8, specifically by not holding drills every shift each quarter and not varying drill conditions as required. Record review on 06/09/25 at approximately 10:32 A.M. showed there was no fire drill conducted for the first shift during the third quarter. The documented first-shift fire drills occurred on 01/30/26 at 2:42 P.M., 04/30/26 at 1:51 P.M., and 10/31/25 at 10:58 A.M., indicating a missed quarter. Second-shift fire drills were recorded on 02/26/26 at 5:20 P.M., 06/03/25 at 4:35 P.M., 08/29/25 at 3:46 P.M., and 11/25/25 at 5:09 P.M., and third-shift drills on 02/28/26 at 11:47 P.M., 05/30/25 at 12:18 A.M., 07/22/25 at 11:34 P.M., 09/26/25 at 11:40 P.M., and 12/15/25 at 5:17 A.M. The surveyor determined that drills were not conducted under varied conditions and that the required quarterly drill on each shift was not consistently performed. The Maintenance Director confirmed these findings at the time they were identified, and the deficiency had the potential to affect all 59 residents and staff response in an emergency. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency related to facility-wide emergency preparedness practices and documentation of fire drills.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 05/29/2026 K-0712 Fire Drills Corrective action for resident/s: There were no records of a fire drill for the first shift of the third quarter of 2025. First shift fire drill completed on 5/24/2026 by maintenance director/designee with no findings or corrective action necessary. Identification of other residents who may be affected: On 5/26/2026 Maintenance director/designee completed 100% audit of the scheduled fire drills to ensure a drill is scheduled quarterly each shift with no findings or corrective action necessary. Measures for systemic change: LNHA educated Maintenance Director on 05/26/2026 regarding NFPA 101-2012 section 19.7.1.4 through 19.7.1.7. specifically including fire drill frequency requirements. How Corrective Action will be monitored Ongoing "Fire Drill Audit" to be completed weekly x 2 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 05/29/2026
Obstructed Egress Corridors Due to Equipment and Chairs
Penalty
Summary
The facility failed to maintain required clear egress widths in corridors in accordance with NFPA 101, 2012 Edition, sections 19.2.3.4 through 19.2.3.5 and 7.3.2 through 7.3.2.3, creating projections into the egress corridor that exceeded allowable limits. Surveyors observed that on one day in Station #3, a cart with a television and video equipment was plugged into an outlet in the corridor by room 38, and five activity room chairs were placed in the corridor near the secured unit dining room directly in front of a fire extinguisher. On the following day, surveyors again observed chairs in the Station #3 corridor, with four by room 35 and four by the activities room, and the same television cart still in the corridor; the chairs were not secured. The corridor was approximately eight feet wide, and the projections extended approximately 29 inches into the corridor in front of the handrail. These conditions had the potential to affect 28 residents in the facility and the staff’s ability to assist in an emergency, and the Maintenance Director confirmed the observations at the time of discovery. No specific resident medical histories or conditions were described in the report, only that 28 residents were potentially affected and the facility census was 59.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be subsequent remedial measures and should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 05/29/2026 K-0232 Clear path of egress Corrective action for resident/s: 1. On 05/18/2026 station 3 had a cart with a television parked in the corridor by room 38 that exceeded allowable limits. Maintenance director/designee moved the TV cart into the activity room, out to the corridor on 05/18/2026 in accordance with applicable code. 2. On 5/18/2026 station 3 had 5 chairs in the corridor near the dining room directly in front of the fire extinguisher. Maintenance director/designee moved the chairs into the dining room, out of the corridor on 5/18/2026 in accordance with applicable code. 3. On 5/19/2026 station 3 had 4 chairs by the activity room and 4 by room 35. In addition, the TV cart was in the corridor. The maintenance director/designee moved the chairs and TV cart into the dining room, out of the corridor on 5/19/2026 in accordance with applicable code. Identification of other residents who may be affected: Maintenance director/designee completed a 100% facility audit for clear paths of egress on 5/26/26 with no findings or corrective action necessary. Measures for systemic change: Maintenance Director/designee educated staff on 5/26/2026 regarding NFPA 101-2012 section 19.2.3.4 and 19.2.3.5 specifically including maintaining a clear path of egress. How Corrective Action will be monitored Ongoing "Path of Egress Audit" to be completed weekly x 2 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 05/29/2026
Failure to Issue Required SNF ABN When Discontinuing Medicare Part A Services
Penalty
Summary
The deficiency involves the facility’s failure to issue a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) when Medicare Part A services were discontinued for a resident who still had available benefit days. The resident was admitted with a diagnosis of metabolic encephalopathy and had intact cognition per the Minimum Data Set assessment. The facility’s own SNF Beneficiary Notification Review documented that Medicare Part A skilled services began on 02/11/26 and the last covered day was 03/11/26, and that the facility initiated discharge from Medicare Part A services before the resident’s benefit days were exhausted. Despite this, no SNF ABN was provided to the resident or the resident’s representative. During interviews, the Social Services Director stated that the SNF ABN was issued hours prior to the last covered day but, upon reviewing her files, confirmed that no SNF ABN had actually been issued for this resident. She further explained that she believed an SNF ABN was only required if one skilled service remained and that if all skilled services were being discontinued, only the Notice of Medicare Non-Coverage (NOMNC) needed to be issued. The Administrator, however, stated that a resident should always receive both a SNF ABN and a NOMNC when Medicare Part A services are discontinued and benefit days remain. Review of the facility’s written policy dated 03/28/23 showed that the facility was required to issue SNF ABNs for initiation, reduction, or termination of extended care items or services when Medicare payment was not expected, which did not occur in this case.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as its allegation of substantial compliance as of 05/29/2026 F-0582 Corrective action for resident/s: On 5/14/26 Resident #34 was informed of rights and responsibilities related to Advanced Beneficiary Notice and voiced understanding of information for future reference by administrator. Identification of other residents who may be affected: Any resident receiving skilled services from nursing or therapy services. The Administrator audited all residents who were discharged from skilled services in the past 30 days to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary Notice on 5/29/26. No non-compliance was noted. Measures for systemic change: On 5/14/2026 Business Office Manager, Director of Rehab, Minimum Data Set nurse, Director of Nursing and Social Services Director were educated on proper procedure of issuing of Notice Of Medicare Non Coverage and Advanced Beneficiary Notice by administrator. All upcoming discharges from skilled services will be reviewed weekly at Utilization Review meeting to ensure notices will be delivered timely. How Corrective Action will be monitored: Administrator or designee to complete audits of all residents being discharged from skilled services to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 5/29/26
Insulin Administration Errors and Failure to Prime Insulin Pens
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5%, with surveyors identifying 3 errors out of 28 medication administration opportunities, resulting in a 10.71% error rate. For one resident with type 2 diabetes mellitus and moderate cognitive impairment, the physician’s order directed Novolog insulin 10 units via subcutaneous pen-injector to be given before meals. During an observed medication pass, the LPN administered 10 units of Novolog insulin without priming the pen and did so after the resident had already consumed approximately 50% of the breakfast meal. The LPN later confirmed she did not prime the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer instructions for the Novolog FlexPen specified that an air shot (priming) must be performed before each injection to ensure proper dosing. Another resident, also diagnosed with type 2 diabetes mellitus and with intact cognition, had orders for insulin glargine 35 units subcutaneously twice daily and insulin lispro 20 units subcutaneously before meals, plus 12 units subcutaneously if blood glucose was between 251 mg/dL and 300 mg/dL. During an observed medication administration, an LPN administered 35 units of insulin glargine and 32 units of insulin lispro without priming the insulin pens and after the resident had consumed approximately 90% of the breakfast meal, despite orders for insulin lispro to be given before meals. The LPN later stated she could not remember if she had primed the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer information for insulin lispro stated that the pen must be primed before each injection to confirm insulin delivery and remove air, and that failure to prime could result in too much or too little insulin. The DON confirmed the expectation that insulin be administered as ordered, including priming each pen with two units before dialing the prescribed dose, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and required time frames.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 5/29/2026. F-0759 Corrective action for resident/s: Residents #21 and #22 were assessed and evaluated by nurse and Director of Nursing 5/14/26. Resident #21 and #22 both denied any adverse effects and none were noted upon assessment by the Director of Nursing on 5/14/2026. Notification made to physician on 5/14/2026. LPN # 2 competency Eval on insulin administration with the Director of Nursing completed 5/14/2026. Identification of other residents who may be affected: Diabetic residents on assignment of LPN #2/station 2 have the potential to be affected and were assessed by the DON/Designee on 5/14/26 and found to be within normal limits. Measures for systemic change: All Nurses were educated by the Director of Nursing on the steps for Insulin administration per competency, diabetes clinical protocol policy, Medication and treatment orders policy, administering medications policy, and Obtaining fingerstick Glucose Level policy On 5/14/2026. How Corrective Action will be monitored: Director of Nursing and Assistant Director of Nursing will complete insulin administration audits on 5 nurses. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance: 5/29/2026
Inaccurate Crash Cart Audits and Missing Emergency Equipment
Penalty
Summary
The facility failed to ensure accurate and complete crash cart audits for residents requiring basic life support, affecting eighteen of thirty-five residents who were designated as full code. During an observation of the crash cart with the DON, surveyors found that the daily audit documentation for the month did not include verification of expiration dates for crash cart supplies. Review of the crash cart audit logs showed that an extension cord was documented as being in the cart on multiple dates, but the extension cord was not present in the cart at the time of inspection. Additionally, the audit documentation indicated that required items, including eye protection, saline, and clear plastic, were not present in the crash cart, yet they were documented as being in the cart. The facility’s undated “Emergency Crash Cart” policy stated that the crash cart is to be checked every 24 hours and after every use, and that equipment and supplies are to be noted and replaced promptly, but the observed documentation and contents of the cart did not match these requirements. This deficiency was verified with the DON at the time of the survey and was cited under the requirement that personnel provide basic life support, including CPR, to residents requiring emergency care, subject to physician orders and advance directives, and was investigated under Complaint Number 2687380.
Plan Of Correction
Cridersville Care Center Provider Number:366171 Survey Type: Complaint Survey Survey Date: 04/29/26 This Plan of Correction (PoC) outlines the actions completed by the facility with regards to the deficiency citation. This Plan of correction does not constitute any admission of guilt or liability by the facility and is submitted only in response to the regulatory requirements. Please accept the following as the facility's credible allegation of compliance as of 4/30/26. F678 CPR All Full Code residents #18 have the potential to be affected by the alleged deficiency. On 4/27/26 the DON/ADON re-stocked the crash cart per the inventory sheet for all missing items. Crash cart inventory sheet updated and new one will go into effect on 5/1/26. All licensed nursing staff provided with training related to crash cart inventory being a daily audit review using inventory sheet on 4/27/26 per DON/designee. The DON/designee will conduct clinical rounds and conduct a random audit of crash cart three times per week for 4 (four) weeks to ensure compliance. The results of the audit will be documented. The facility conducted an Ad-Hoc QAPI meeting on 4/27/26 and discussed the alleged deficiency and corrective actions. Date when corrective action will be completed: 4/30/26
Unsafe Smoking Practices with Oxygen and Missed Fall-Prevention Interventions
Penalty
Summary
The deficiency involves the facility’s failure to provide a safe smoking environment, adequate supervision, and appropriate implementation of its smoking policy for a resident who used oxygen and smoked, as well as failure to implement fall-prevention interventions as care planned for another resident. One resident had multiple relevant diagnoses, including chronic respiratory failure with hypoxia, COPD, end-stage renal disease, dependence on supplemental oxygen, diabetes, and necrotizing fasciitis. Her care plans identified impaired visual function, risk for respiratory complications related to a history of smoking, and risk for cognitive decline, with interventions including use of oxygen per order and observation for understanding. A smoking-related care plan created earlier documented that she wished to use smoking products, had been assessed as safe to smoke "with supervision," and was non-compliant with the smoking policy, with family continuing to provide smoking supplies despite education and a verbal warning for non-compliance. Smoking assessments and progress notes showed a pattern of non-compliance and inconsistent classification of this resident’s smoking safety. Multiple smoking observation/assessments completed earlier in March documented that she had no cognitive loss, visual deficits, or dexterity problems but was unsafe to smoke without supervision because she did not return smoking materials and did not follow designated smoke times. Progress notes described her going out to smoke multiple times by herself or with family, including sneaking out next door with a cigarette and going out multiple times in one evening, with staff documenting that she was "reeducated" and that family brought in cigarettes and lighters which she did not return to staff. Despite this history, a smoking assessment completed after a three-day hospital stay assessed her as safe to smoke without supervision, with no documentation explaining how this conclusion was reached or evidence that her care plan was updated accordingly. On the day of the incident, the resident reported she had cigarettes and a lighter on her person after returning from dialysis and stated she "could not find a nurse" and went outside to smoke, saying she "guessed" she forgot she had her oxygen on. A CNA observed her outside and saw a flame coming through the resident’s oxygen nasal cannula tubing, turned off the oxygen tank, removed the tubing, and patted out sparks on the resident’s shirt sleeve. The resident’s face and hands appeared black in color, and EMS documented first-degree burns to the head and face, with the resident stating she lit a cigarette with her nasal cannula on, causing the burn. The hospital record described her face as black from smoke and her lips and mouth as "burnt and charred," with a recommendation for intubation that she refused. The facility’s incident report recorded that she went outside with oxygen on to smoke without notifying staff, that staff witnessed the occurrence as she walked through the dining room door to the courtyard, and that she stated she thought she had turned her oxygen off. The facility’s smoking policy required interdisciplinary evaluation to determine safe versus unsafe smokers, staff maintenance of all smoking paraphernalia for both safe and unsafe smokers, and progressive consequences for policy violations. A separate deficiency involved another resident at risk for falls whose care plan included use of non-skid strips on the floor in front of her recliner as a fall-prevention intervention. This resident had severe cognitive impairment, used a walker and wheelchair, required supervision or touching assistance for transfers and ambulation, and had experienced two or more falls without injury since the prior assessment. The fall-risk care plan, initiated at admission, specified non-skid strips in front of the recliner beginning in November. However, nursing staff interviewed were not familiar with all of the resident’s fall-prevention interventions without checking the record, and observation of the room showed two recliners with no non-skid strips on the floor in front of them. An LPN confirmed that the non-skid strips were not present despite the intervention remaining active in the care plan, and moving the recliners did not reveal any strips. The facility’s fall management policy required identification of hazards and risk factors, implementation of interventions to minimize falls and injuries, and development and implementation of a care plan based on interdisciplinary evaluation, with interventions related to identified risk factors.
Plan Of Correction
Smoking: On 03/21/26 at 3:16 P.M. 911 response was activated for Resident #11 and Medical Director #601 was notified by Registered Nurse (RN) #322. On 03/21/26 at 3:18 P.M. on-call Nurse/Social Services #423 immediately notified the Administrator and Director of Nursing (DON) #304 of the incident involving Resident #11. On 03/21/26 at 3:22 P.M. Emergency Medical Services (EMS) arrived onsite. At 3:30 P.M. Resident #11 was transported to the emergency room. On 03/21/26 at 3:30 P.M. RN #322 completed a smoking re-assessment of Resident #11 assessing the resident to be an unsafe smoker requiring supervision due to failure to remove oxygen prior to entering designated smoking area. On 03/21/26 from 3:38 P.M. through 7:57 P.M. Licensed Practical Nurse (LPN) #337, #336, #335, #338; RN #334, and DON #304 re-assessed residents (who smoke). This included Resident #22, Resident #3, Resident #47, Resident #50, Resident #60, Resident #150, Resident #86, and Resident #10 to determine smoking safety (via smoking assessment). Each resident was re-educated regarding the facility smoking policy and staff verified there were no smoking materials on their person. The residents' smoking materials would be maintained by facility staff and distributed per policy. On 03/21/26 at 4:30 P.M. DON #304 responded to facility and an Ad Hoc (not scheduled) Quality Assurance (QA) meeting was held via telephone with the Administrator, DON #304 and Medical Director #601 to review investigative findings and plan of action. A root cause analysis was completed and determined Resident #11 had smoking materials on her person (believed to be obtained from family without staff knowledge) and failed to remove her oxygen. The QA team discussed a corrective action plan. On 03/21/26 from 5:00 P.M through 03/22/26 at 3:00 P.M. 26 RNs, 13 LPNs, one medical technician (MT), 54 Certified Nursing Assistants (CNA) four activities staff, one central supply staff, 11 dietary staff, 12 housekeeping staff, three laundry staff, one medical records staff, two social designees, two maintenance staff, nine administrative staff, and 19 therapy staff (158 staff at the time of the incident) were provided education regarding the facility smoking policy by DON #304 and the Administrator. This was completed via 1:1, small group in-services or via phone. Newly hired staff would receive education during general orientation regarding the facility's smoking policy. On 03/21/26 at 5:00 P.M. DON #304 completed an audit of all residents who smoke (Resident #22, Resident #3, Resident #47, Resident #50, Resident #60, Resident #150, Resident #86, and Resident #10) to verify smoking evaluations and plans of care accurately reflected the residents' smoking safety needs. The residents were educated on the facility smoking policy, and smoking materials were to be maintained at the nurses' station. An audit was completed which included verification of required safety measures present in designated smoking areas, including an ash can, fire extinguisher, fire blanket, ash trays and no oxygen signs. There were no identified concerns or changes made because of the audits. On 03/21/26 at 8:55 P.M. Resident #11 returned from the ED. LPN #332 verbally educated the resident regarding the facility smoking policy which included the need for supervision, a smoking apron (to be worn) and the facility smoke times. LPN #332 verified no smoking materials were on the resident's person or in her room at this time. On 03/23/26 at 11:00 A.M. the Interdisciplinary Team (IDT) (Administrator, DON #304, Medical Director #601, RN #302, Social Services #427, Social Services #423, DON #300, and Maintenance #436) met in-person to review the plan of action with DON #304/designee to complete weekly monitoring of residents who smoke and designated smoking areas weekly for four weeks with Housekeeping responsible to complete the cleaning. Housekeeping staff were responsible for cleaning ashtrays and the designated smoking area daily. Audits to be reviewed and any further actions required to be directed by the Quality Assurance and Performance Improvement (QAPI) Committee during scheduled meetings. The IDT also reviewed all current smoking assessments and care plans for residents who smoke. Resident #50 required a change in supervision levels with smoking due to cognition levels and her plan of care as well as Resident #11's plan of care was updated to reflect supervision/safety. On 03/23/26 from 3:45 P.M. to 8:55 P.M. Social Services #423 re-educated residents who smoke (Resident #22, Resident #3, Resident #47, Resident #50, Resident #60, Resident #150, Resident #86, Resident #10) and responsible parties, if applicable regarding the facility smoking policy and supervision levels. On 03/23/26 at12:13 P.M. Social Services #427 contacted Resident #11's family member (#602) to schedule a care conference. Family member #602 and Family Member #603 were not available to meet until 03/27/26. On 03/23/26 at 1:00 P.M. staff education related to smoking areas, removal of oxygen prior to entering smoking area and maintaining smoking materials at the nurses' station for residents who smoke was initiated by DON #304 and the Administrator via 1:1, small group in-services or via phone call. Education was completed for all 158 staff by 03/24/26 at 1:00 P.M. Newly hired staff would be educated during general orientation regarding the facility's smoking policy. The facility does not utilize agency staff. On 03/27/26 at 11:00 A.M. a care conference was held with Resident #11 and Family Members #602 and #603, the Administrator, Social Services #423 and Social Services #427. The facility smoking policy was reviewed. The resident and family were informed an involuntary discharge would be initiated should the resident exhibit non-compliance moving forward and supervision would be increased beyond the two-hour standard of care to monitor more closely for non-compliance with the facility smoking policy. Family Member #602 stated he educated his siblings as well. On 04/10/26 at 2:00 P.M. DON #304 initiated education with 26 RNs and 13 LPNs (100% of nurses educated) regarding completion of the smoking evaluation via 1:1, small group in-services, or phone. The education was completed by 6:00 P.M. on 04/10/26. A new resident who smokes must remain supervised until the interdisciplinary team (IDT) reviews and determines smoking safety, at which time the care plan is developed and resident and family education is provided. The communication through the staff would be the care plan. Newly hired staff receive education during general orientation regarding the facility's smoking policy and completion of smoking evaluation via Point Click Care (PCC). On 04/10/26 at 4:29 P.M. DON #304 initiated an order in PCC for the nurse to verify, each shift, that Resident #11's smoking materials were maintained at the nurses' station. On 04/13/26 at 5:30 P.M. DON #304 initiated orders in PCC for nurses to verify, each shift, that all residents who smoke would have smoking materials maintained at the nurses' station. An updated list of smokers included: Resident #60, Resident #50, Resident #11, Resident #86, Resident #113, and Resident #151. On 04/13/26 at 5:45 P.M. DON #304 initiated questionnaires for staff regarding the smoking policy with re-education provided as needed via 1:1 and small group in-services for staff currently in the facility with all staff to be questioned/educated prior to working their next scheduled shift. Falls: On 4/9/26, Maintenance Director placed non-skid strips on the floor in front of Resident #12's recliner. Like Residents are identified as residents who have had a fall within the facility. Utilizing the Fall Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, an audit of falls and appropriate interventions for the past 30 days will be completed by the Director of Nursing or designee to ensure fall interventions are in place per plan of care. This audit along with identified corrections will be completed on or F 0689 before 5/13/26. The Director of Nursing or designee will re-educate licensed nurses and STNA/CNAs on the Fall Management Policy to include fall interventions to be in place per the care plan. This education will be completed on or before 5/13/26. Utilizing the Fall Management Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, the Director of Nursing or designee will complete an audit of new admissions, new readmissions and residents who experience a fall within the last 7 days, weekly for four weeks, beginning 5/14/26 to ensure fall safety interventions are in place per plan of care. Current fall interventions found to not be in place will be corrected with all intervention in place per plan of care. Negative findings to be addressed immediately and negative trends or system wide issues will be reported to the QAPI committee, and the action plan will be adjusted as needed.
Removal Plan
- Activated 911 response for Resident #11 and notified the Medical Director.
- On-call Nurse/Social Services immediately notified the Administrator and DON of the incident.
- EMS arrived onsite and Resident #11 was transported to the emergency room.
- Completed a smoking re-assessment of Resident #11, determining the resident was an unsafe smoker requiring supervision due to failure to remove oxygen prior to entering the designated smoking area.
- Re-assessed all residents who smoke (Residents #22, #3, #47, #50, #60, #150, #86, and #10) to determine smoking safety via smoking assessment.
- Re-educated residents who smoke regarding the facility smoking policy and verified there were no smoking materials on their person.
- Implemented that smoking materials would be maintained by facility staff and distributed per policy.
- Held an ad hoc QA meeting to review investigative findings and plan of action.
- Completed a root cause analysis determining Resident #11 had smoking materials on her person and failed to remove oxygen.
- Developed a corrective action plan.
- Provided facility-wide education to staff on the facility smoking policy.
- Implemented that newly hired staff would receive smoking policy education during orientation.
- Completed an audit of all residents who smoke to verify smoking evaluations and plans of care accurately reflected smoking safety needs.
- Ensured smoking materials were maintained at the nurses’ station.
- Audited designated smoking areas for required safety measures (ash can, fire extinguisher, fire blanket, ash trays, and no-oxygen signs).
- Provided verbal education to Resident #11 on smoking policy (supervision, smoking apron, smoke times).
- Verified no smoking materials were on Resident #11’s person or in her room.
- Conducted an in-person IDT meeting to implement weekly monitoring of residents who smoke and designated smoking areas weekly for four weeks.
- Assigned housekeeping to clean ashtrays and the designated smoking area daily.
- Directed audits to be reviewed by QAPI.
- Reviewed all current smoking assessments and care plans for residents who smoke.
- Updated Resident #50’s supervision level.
- Updated Resident #11’s plan of care to reflect supervision/safety.
- Re-educated residents who smoke and responsible parties (as applicable) regarding the facility smoking policy and supervision levels.
- Contacted Resident #11’s family to schedule a care conference.
- Initiated additional staff education regarding smoking areas, removal of oxygen prior to entering smoking area, and maintaining smoking materials at the nurses’ station.
- Held a care conference with Resident #11 and family to review smoking policy.
- Informed resident/family that involuntary discharge would be initiated for future non-compliance.
- Increased supervision beyond the two-hour standard of care to monitor more closely for non-compliance.
- Provided education to all nurses regarding completion of the smoking evaluation.
- Implemented that new residents who smoke must remain supervised until IDT review determines smoking safety and care plan/education are completed.
- Entered an order in PCC for nursing to verify each shift that Resident #11’s smoking materials were maintained at the nurses’ station.
- Entered orders in PCC for nursing to verify each shift that all residents who smoke have smoking materials maintained at the nurses’ station.
- Initiated staff questionnaires regarding the smoking policy with re-education as needed.
- Required all staff to be questioned/educated prior to working their next scheduled shift.
Failure to Provide Scheduled Bathing and Shaving Assistance for Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide scheduled and needed bathing and shaving assistance to multiple dependent residents in accordance with their care plans, preferences, and the facility’s routine care policy. One resident with spinal stenosis and recent L2–L5 decompression fixation fusion was care planned for substantial/maximal assistance with shower/bath and toileting hygiene and was scheduled for showers on Tuesdays and Fridays. Electronic documentation from early January through early April showed this resident did not receive a shower or bed bath on 11 identified scheduled days, and the DON confirmed these missed bathing events. Another resident with dysphagia and developmental issues, who required assistance with self-care and mobility, reported that she asked staff to shave her but they did not, which bothered her. During an observation following a recent shower, she stated she had not been shaved and that the hair "itched"; small gray hairs were visible on her chin. A CNA confirmed the presence of gray chin hairs and acknowledged the resident needed shaving, stating it would be addressed with the next scheduled shower. A further resident with chronic respiratory failure, tracheostomy status, heart failure, moderate intellectual disabilities, anxiety, depression, and PTSD required substantial/maximal assistance with personal hygiene and had a care plan for assistance with self-care, including personal hygiene. Her shower schedule called for showers on Monday and Thursday nights, with complete shaves for men and women. Review of documentation showed her last recorded shower/bath was nearly a year earlier, with no indication of additional personal hygiene or facial hair removal on that date. Observations on two separate days showed long white hairs on her chin and jaw line, which a CNA later confirmed, stating facial hair removal should occur with baths/showers or as needed. A resident with end stage renal disease, respiratory failure, hyperlipidemia, and congestive heart failure, who had impaired cognition and required partial/moderate assistance with bathing and personal hygiene, was scheduled for showers on Wednesdays and Saturdays. Review of shower documentation from admission through early April revealed no showers provided or refusals documented on at least ten scheduled shower days. In interviews, this resident reported not receiving scheduled showers, was unsure of his shower days, and stated he could use a good scrub down, adding that he had asked aides who told him they did not have time. A CNA explained that shower days appear on shower sheets and in the computer and that CNAs are supposed to document daily, with nurses checking the documentation; the DON verified the resident had not received showers per schedule or preference. Another resident with a fracture of the lower end of the left humerus, hemiplegia and hemiparesis after cerebral infarction, rheumatoid arthritis, hypertensive heart disease, urinary retention, and osteoarthritis was care planned as non–weight bearing to the left upper extremity and requiring substantial/maximal assistance with showering/bathing. Her electronic record showed she was scheduled for showers on Wednesdays and Saturdays. The shower task question "did the resident receive a shower/bath/bed bath?" was documented as "no" on three dates, indicating no shower/bath/bed bath was completed, and left unanswered on three additional dates. The DON confirmed that one missed shower was due to an outside appointment, that on two dates the "no" response meant no bathing of any type occurred, and that on three dates there was no documentation at all. The resident, who was cognitively intact, reported that missing showers made her feel unimportant compared to others and that she did not feel clean when her shower was missed. Facility policy on routine resident care stated that showers, tub baths, and shampoos are to be scheduled according to person-centered care or state guidelines, with additional showers given upon request, but the documented and observed care did not reflect consistent provision of scheduled bathing and shaving for these residents.
Plan Of Correction
1. Resident #5 received a shower by the STNA on 4/13/26. Resident #8 received a shower by the STNA on 4/8/26. Resident #9 received a shower and had their chin shaved by the STNA on 4/14/26. Resident #70 received a shower by the STNA on 4/13/26. Resident #76 received a shower and had their chin shaved by the STNA on 4/15/26. 2. Like residents are identified as residents who need assistance with showering and shaving. Utilizing the Shower Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, an audit of like residents will be completed by the Director of Nursing or designee to ensure that showers and resident shaving are completed. This audit along with identified corrections will be completed on or before 5/13/26. 3. The Director of Nursing or designee will re-educate licensed nurses and STNA's on the Routine Resident Care Policy to include bathing and shaving residents. This education will be completed on or before 5/13/26. 4. Utilizing the Shower Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, the Director of Nursing or designee will complete an audit of 4-6 residents weekly for four weeks, beginning 5/14/26 to ensure that showers and resident shaving are completed. Noncompliance found during audits will be addressed and assistance with showers and/or shaving provided. Negative findings to be addressed immediately and negative trends or system wide issues will be reported to the QAPI committee, and the action plan will be adjusted as needed.
Uncovered Urinary Catheter Drainage Bag Compromises Resident Dignity
Penalty
Summary
The facility failed to maintain a resident’s right to privacy and dignity related to management of an indwelling urinary catheter. A resident admitted with malignant neoplasm of the esophagus and type II diabetes mellitus had a care plan identifying risk for urinary tract infection and catheter-related trauma due to an indwelling catheter for urinary retention. The care plan interventions included ensuring the catheter tubing was secured and the drainage bag was properly secured with a dignity cover in place. Physician orders directed that the resident’s 16 French indwelling urinary catheter be changed every 30 days and as needed, and the comprehensive MDS documented that the resident had an indwelling catheter and was cognitively intact. During observation, the resident was seen seated in a chair with the urinary catheter drainage bag hanging from the chair without a dignity cover, and dark yellow urine was visible in the bag from the hallway. In a later observation and interview, an LPN confirmed that the catheter bag was lying directly on the floor and did not have a dignity cover. Attempts to interview the resident to confirm cognitive status were unsuccessful, as the resident was unable to answer screening questions. Review of the facility’s “Resident Dignity & Personal Privacy” policy stated that the facility should provide care in a manner that respects and enhances each resident’s dignity, individuality, and right to personal property, which was not followed in this instance when the catheter drainage bag was left uncovered and visible.
Plan Of Correction
The Laurels of Athens wishes to have this plan of correction submitted as our written allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission to nor agreement with, either the existence of, or the scope and severity of, any of the cited deficiencies or conclusions set forth in the statement of deficiencies. This plan is prepared and/or executed to ensure continuing compliance with regulatory requirements. Our alleged date of compliance is 5/13/2026. 1. On 4/6/26, Resident #92's catheter bag was removed from the floor, the bag changed and covered for dignity by the licensed nurse. Resident #92 discharged from the facility on 4/11/26. 2. Like Residents are identified as residents who utilize urinary catheters. An audit will be completed by the Director of Nursing or designee for like residents utilizing the Urinary Catheter Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC to ensure catheter bags are covered for dignity and not laying directly on the floor. This audit along with identified corrections will be completed on or before 5/13/26. 3. The Director of Nursing or designee will re-educate licensed nurses on the Indwelling Urinary Catheter Policy as well as Resident Dignity & Personal Privacy Policy to include privacy covers are in place for urinary catheters and that the catheter is not laying on the floor. This education will be completed on or before 5/13/26. 4. Utilizing the Urinary Catheter Audit Tool which was created on 4/20/26 by the Director of Nursing for purpose of this POC, the Director of Nursing or designee will complete an audit of all residents with catheters weekly for four weeks, beginning 5/14/26 to ensure catheter bags are covered for dignity and not laying directly on the floor. Any catheters found to be touching the floor or uncovered will be removed from the floor, the bag changed and covered for dignity. Negative findings to be addressed immediately and negative trends or system wide issues will be reported to the QAPI committee, and the action plan will be adjusted as needed.
Failure to Prevent Possible Misappropriation and Poor Documentation of PRN Narcotics
Penalty
Summary
The deficiency involves failure to prevent potential misappropriation of a resident’s narcotic medication and failure to ensure accurate documentation of controlled substance administration. A cognitively intact resident with chronic pain related to an internal orthopedic device and left knee pain had an order for oxycodone 5 mg PO every four hours PRN for pain and a care plan directing staff to administer medications as ordered and observe for effectiveness and side effects. The resident’s MDS showed she rated her pain as 7/10 and received opioid medication. However, review of the February MAR and the narcotic log revealed multiple discrepancies between narcotic sign-outs and documented administration. On several occasions, oxycodone doses were signed out on the narcotic log by an RN without corresponding documentation on the MAR. Specifically, oxycodone was signed out on one evening at 9:30 p.m. with no MAR entry, and again on a subsequent night at 1:30 a.m. and 5:30 a.m. with no MAR entries for those times. Another dose was signed out at 9:00 p.m. while the MAR reflected administration at 10:16 p.m., and a later dose at 5:30 a.m. was documented on both the narcotic log and MAR. There was also no documentation of pain assessments before or after PRN opioid administration. These documentation gaps meant there was no evidence that all narcotic doses signed out were actually administered to the resident. Staff interviews further highlighted concerns about the handling of narcotics. A CNA/med tech reported frequently taking the narcotic keys from the RN and described the RN’s behavior as erratic, with repeated problems involving incorrect narcotic counts and missing documentation on both the MAR and narcotic log. The resident stated she did not receive oxycodone more than once or twice a day, preferring to take Tylenol the rest of the time, which conflicted with the number of oxycodone doses signed out. When questioned, the RN gave inconsistent explanations about how often she pulled and administered PRN narcotics and acknowledged struggling with the new system, while also suggesting the resident may have received PRN tizanidine instead of remembering oxycodone. The facility’s investigation concluded that evidence was inconclusive as to whether misappropriation occurred or whether the issue was solely lack of documentation, but confirmed there was no evidence the resident received all doses signed out on the narcotic log.
Plan Of Correction
1. Resident #99 had a Self-Reported Incident submitted and investigated via the EIDC on 3/2/26. The investigation was inconclusive as we could not prove that misappropriation occurred. On 2/24/26, Resident #99 was interviewed and pain assessed by Director of Nursing and resident had no ill effects related to the inconsistent documentation in the medical record as it relates to her controlled substance pain medication. 2. Like Residents are identified as residents who utilize controlled substance PRN pain medications. An audit will be completed by the Director of Nursing or designee for like residents utilizing the Controlled Substance Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC to ensure PRN controlled substance pain medications that are signed off the control sheet are documented in the resident medical record as well. This audit along with identified corrections will be completed on or before 5/13/26. 3. The Director of Nursing or designee will re-educate licensed nurses on the Controlled Substances Policy to include appropriate documentation of controlled substances. In addition, the licensed nurses will be re-educated by the Director of Nursing or designee on the Abuse Prohibition Policy to include misappropriation of resident property. This education will be completed on or before 5/13/26. 4. Utilizing the Controlled Substance Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, the Director of Nursing or designee will complete an audit three controlled substance sheets from each of the nine medication carts for a total of twenty-seven sheets weekly for four weeks, beginning 5/14/26 to ensure PRN controlled substance pain medications that are signed off the control sheet are documented in the resident medical record as well. Inconsistencies noted from the audit will be investigated for misappropriation. Negative findings to be addressed immediately and negative trends or system wide issues will be reported to the QAPI committee, and the action plan will be adjusted as needed.
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