Wyant Woods Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Akron, Ohio.
- Location
- 200 Wyant Rd, Akron, Ohio 44313
- CMS Provider Number
- 365779
- Inspections on file
- 30
- Latest survey
- February 26, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Wyant Woods Healthcare Center during CMS and state inspections, most recent first.
Multiple residents with complex medical and psychiatric conditions had discontinued medications, including analgesics, antipsychotics, antibiotics, antiemetics, muscle relaxants, and other drugs, that were later discovered in the home of a former LPN. A Board of Pharmacy investigation linked these medications to the facility and found that they had been removed after discontinuation and resident discharge or transfer. The investigation also identified inconsistent and incomplete medication documentation, pre‑signed shift‑to‑shift narcotic counts, and a lack of any reliable method to verify that discontinued non‑narcotic medications were actually placed into pharmacy return bags, resulting in misappropriation of residents’ medications.
Staff failed to follow infection control practices when administering medications and performing blood glucose monitoring. An LPN placed multiple medications directly into her bare hand before giving them to a resident with cognitive impairment, and another LPN handled medications in her bare hand for two cognitively intact residents, without hand hygiene or gloves. For a resident with diabetes and peripheral vascular disease, an LPN carried a blood glucose meter by hand after use and stored it in the medication cart without disinfecting it, and reported never cleaning meters since starting work. Facility policies required that staff not touch medications when opening dose packs and that glucose meters be disinfected with a high-level antimicrobial product, and leadership confirmed that medications should not be placed in staff hands and that meters should be sanitized between residents.
A resident with COPD, hypertension, and muscle weakness, but intact cognition, repeatedly operated a power scooter at excessive speeds inside the facility despite multiple OT assessments documenting poor safety awareness, impulsivity, and aggressive behavior, and recommending that scooter use be limited to outdoor areas only. The resident declined an alternative wheelchair, continued to ignore speed settings and safety education, and was observed speeding down hallways with the scooter set to the highest mode on several occasions. A CNA reported that the resident had previously struck her at full speed with the scooter, fracturing her leg, and that he had run into others as well. Staff, including CNAs and an LPN, acknowledged that the resident routinely “flew” down the hall and refused to cooperate with safety instructions, while the scooter itself showed heavy front-end damage, indicating repeated collisions. The facility did not implement effective supervision or restrictions to prevent ongoing unsafe scooter operation indoors.
A resident with COPD and intact cognition was observed receiving a BREO steroid inhaler from an LPN, taking one inhalation, and returning the device without being prompted to rinse his mouth, despite manufacturer guidelines and facility policy requiring mouth rinsing after steroid inhaler use. The LPN reported she did not prompt the resident because he had previously refused to rinse, and the Regional Director of Clinical Operations later confirmed that staff are expected to encourage mouth rinsing after steroid inhaler administration.
A resident with hemiplegia, depression, and anxiety, who was cognitively intact, had scheduled doses of acetaminophen, hydroxyzine, and rabeprazole that were repeatedly administered far outside the facility’s required one-hour before/after window and beyond the liberalized pass times. Medication administration records and an internal audit showed multiple morning doses given in early afternoon and evening doses given after midnight. The Regional Director of Clinical Operations confirmed that these medications were administered outside the ordered timeframes.
Two residents with complex medical and psychiatric conditions did not receive timely care plan meetings as required, with both staff and guardians confirming that meetings were overdue and not offered within the expected quarterly timeframe. Facility staff acknowledged the deficiency and could not provide reasons for the missed meetings, in violation of facility policy.
A resident with multiple seizure medications did not receive timely laboratory monitoring as required, despite pharmacy recommendations and facility policy. The lack of monitoring led to a critical increase in Phenobarbital levels, resulting in hospitalization for altered mental status and failure to thrive. Staff interviews and record reviews confirmed that pharmacy recommendations for lab monitoring were not addressed and that the facility failed to ensure ongoing medication safety.
A resident with multiple medical conditions did not receive two scheduled doses of a prescribed antibiotic for pneumonia because the medication was unavailable from the pharmacy. Nursing staff did not notify the physician about the missed doses, contrary to facility policy, resulting in a significant medication error.
A resident with a history of dementia, psychiatric disorders, and elopement risk was able to leave the facility during a smoking break when staff failed to provide direct supervision as required by policy. The resident exited the secured courtyard and was found in the parking lot before being safely returned. Staff responsible for supervision were not present outside, enabling the elopement to occur.
Residents repeatedly voiced concerns about the lack of activities and outings, with staff and leadership confirming that insufficient staffing and the absence of a transportation bus prevented the facility from providing scheduled activities, especially after hours and on weekends. Despite ongoing complaints documented in Resident Council meetings, there was no evidence that the facility responded to or resolved these concerns.
The facility did not provide adequate activities to meet resident interests and needs, with no scheduled activities after 4:00 P.M. or on weekends and only handouts distributed during these times. Residents with various cognitive and medical conditions repeatedly voiced concerns about the lack of engaging activities, especially those outside the facility, and the absence of transportation. Staff confirmed insufficient staffing and resources, leading to minimal engagement and unmet needs for many residents.
An LPN failed to follow infection control protocols by picking up dropped medications with bare hands and returning them to a medication cup, and by not promptly or properly disinfecting a glucometer after blood sugar monitoring for a resident with diabetes. Facility policies prohibit direct contact with medications and require EPA-approved disinfectants for glucometer cleaning, but these were not followed.
Three residents requiring assistance with ADLs did not receive proper personal hygiene and grooming care, including shaving and nail maintenance. One resident had a full beard and long fingernails, another had facial hair she wanted removed, and a third had long, jagged, discolored toenails that had not been maintained by staff or podiatry, despite care plans and facility policy requiring such assistance. Staff interviews confirmed the lack of care and confusion regarding responsibilities.
A resident in a LTC facility was physically abused by an STNA who sprayed them with pepper spray, causing immediate physical and psychosocial harm. The incident was not promptly addressed, with a delay in investigation and continued presence of the STNA in the facility. The resident, with a history of complex medical and psychiatric conditions, experienced trauma from the event.
The facility failed to manage food storage and labeling, affecting nearly all residents receiving food services. Surveyors found several items in the refrigerator that were expired or lacked proper labeling, including beans, mayonnaise, sour cream, cheese, lettuce, hot dogs, and yogurt. The Culinary Supervisor confirmed these issues, acknowledging staff responsibility for labeling and checking expiration dates.
A facility failed to promptly remove a staff member who sprayed a resident with pepper spray, affecting the resident's well-being and potentially impacting others. The incident was not reported to management until hours later, despite immediate notification by a staff member. The resident, with a complex medical history, experienced trauma and symptoms of PTSD following the event.
A resident with multiple diagnoses was sprayed with pepper spray by a staff member during a heated conversation about a smoke break. The incident occurred in the morning, but facility management was not notified until the afternoon, despite immediate reporting by another staff member. The initial report inaccurately suggested cleaning chemicals were involved, delaying the investigation. The resident experienced distress and symptoms consistent with pepper spray exposure, highlighting a deficiency in the facility's abuse reporting procedures.
A facility failed to assess and monitor a resident's fractures, including the left ankle and right first proximal phalanx, from admission until the survey date. The resident's orthopedic follow-up was delayed due to insurance issues, and observations showed inadequate care, with the resident using paper products to wrap her feet. Staff interviews confirmed the lack of monitoring, and the facility's wound care policy was not followed.
A facility failed to maintain proper infection control during wound care for a resident requiring Enhanced Barrier Precautions and during insulin administration for another resident. Nurses did not use PPE or perform hand hygiene as required by facility policy, leading to deficiencies in infection prevention and control.
A resident with diabetes did not receive insulin according to physician orders in a LTC facility. The resident was prescribed 15 units of Fiasp before meals, but an RN initially dialed 18 units and then administered 12 units. The DON confirmed the correct order was 15 units, indicating a failure to follow the facility's medication administration policy.
A resident with cognitive impairments was physically abused by an Activity Aide after the resident hit the aide with a cane. Despite staff instructions to back away, the aide continued the assault until restrained. The resident, who had a history of Alzheimer's and vascular dementia, expressed feeling unsafe. The incident was substantiated, and the aide was terminated with assault charges filed.
A resident with mental health issues eloped from a facility after an STNA propped open a secured door, leaving it accessible. Staff failed to conduct proper rounds, and the resident was found missing the next morning. The resident, identified as an elopement risk, was later located at a family member's home 16 miles away.
The facility failed to follow its hiring policy by employing staff with disqualifying offenses, including charges related to child neglect and drug possession. This oversight affected three out of five personnel files reviewed and had the potential to impact all residents. The Administrator confirmed that internal processes for handling questionable background checks were not followed.
The facility failed to implement its abuse policy by not checking three staff members against the Ohio Nurse Aide Registry before hiring. This oversight affected personnel files of an STNA, a Maintenance Technician, and an Activity Aide, contrary to the facility's policy requiring registry checks before employment offers.
The facility failed to timely implement and monitor effective and individualized interventions for a resident with behavioral health concerns, leading to multiple episodes of yelling, agitation, and attempts to self-transfer without consistent documentation or evaluation of the interventions' effectiveness.
Misappropriation of Discontinued Resident Medications and Inadequate Medication Control
Penalty
Summary
The deficiency involves the facility’s failure to protect multiple residents from misappropriation of their medications, which are considered the residents’ belongings. Ten residents had medications that were later found in the home of a former LPN who had worked part‑time at the facility. These residents had various diagnoses including paranoid schizophrenia, Alzheimer’s disease, bipolar and schizoaffective disorders, COPD, diabetes, osteoarthritis, paraplegia, end‑stage renal disease, and anxiety disorders. Their treatment regimens included antipsychotics, antidepressants, antianxiety agents, anticonvulsants, opioids, antibiotics, antiplatelet agents, hypoglycemics, and other medications such as ibuprofen, quetiapine, ondansetron, hydroxyzine, olanzapine, cyproheptadine, ampicillin, gabapentin, metronidazole, and baclofen. The Ohio Board of Pharmacy and law enforcement identified probable drug diversion by an LPN who had worked at the facility. After the LPN’s death from an overdose of prescription drugs, medications labeled for ten different residents from the facility were found at the LPN’s residence. These included ibuprofen 600 mg and 800 mg, quetiapine 100 mg, ondansetron 4 mg, hydroxyzine 25 mg, olanzapine 10 mg, cyproheptadine 4 mg, ampicillin 500 mg, metronidazole 500 mg, baclofen 10 mg, and an empty blister pack of gabapentin 300 mg. The medications had been discontinued at the facility, and the Board of Pharmacy determined they had been removed from the facility after discontinuation and after residents were discharged or transferred. During the Board of Pharmacy’s inspection of the facility, multiple documentation and control issues were identified that related to the handling and security of medications. Signatures on controlled drug documentation were inconsistent, with variations in initials and full names, and some shift‑to‑shift narcotic counts were pre‑signed by the off‑going nurse. Documentation on medication cards or sheets did not always match the actual count, and some shift‑to‑shift counts were missing dates, signatures, and counts. Facility staff, including the Regional Director of Clinical Operations and an LPN, explained that when non‑narcotic medications were discontinued, nurses were expected to remove them from the medication cart and place them in a pharmacy return bag, but there was no method to verify that this actually occurred. The facility’s own abuse, neglect, and misappropriation policy defined misappropriation as the deliberate misplacement, exploitation, or wrongful use of a resident’s belongings without consent, and the findings showed that discontinued resident medications were not adequately secured or tracked, allowing them to be wrongfully removed and found in the former employee’s home.
Failure to Sanitize Glucose Meters and Maintain Hand Hygiene During Medication Administration
Penalty
Summary
The deficiency involves failures in the facility’s infection prevention and control practices related to blood glucose monitoring and medication administration. One resident with diabetes and peripheral vascular disease required blood glucose monitoring; after this resident’s blood glucose level was checked, the LPN carried the blood glucose meter in her hand and then placed it in the top drawer of the medication cart without sanitizing it. The LPN stated she did not clean the meters between residents, was unsure how to clean them, and reported that she had worked at the facility for three weeks without ever cleaning the meters. Manufacturer guidelines for the meter indicated it should be cleaned and disinfected with an EPA-registered disinfectant detergent or germicide wipe, and the facility’s policy required glucose meters to be disinfected with a high-level antimicrobial wipe. The facility also failed to follow infection control standards during medication administration for three residents with various diagnoses including Alzheimer’s disease, heart failure, diabetes mellitus, schizoaffective disorder, depressive type, and chronic obstructive pulmonary disease. During observations, one LPN placed multiple medications directly into her bare hand without sanitizing or wearing gloves before administering them to a resident with impaired cognition, and another LPN placed medications into her bare hand without sanitizing or wearing gloves when administering to two residents with intact cognition. Both LPNs confirmed these practices during interviews, with one acknowledging she should have worn gloves before touching medications. The Regional Director of Clinical Operations confirmed that staff should not be popping medications into their hands and that blood glucose meters should be sanitized between each resident. Facility policy on medication administration stated that staff are not to touch medications when opening liquid or dose packs. The census at the time was 170 residents, and the deficiency was identified incidentally during a complaint investigation.
Failure to Adequately Supervise Unsafe Power Wheelchair Use
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and implement appropriate safety interventions for a resident who operated a power wheelchair at excessive speeds inside the facility despite multiple OT assessments identifying him as unsafe and recommending restriction of power wheelchair use to outdoor areas only. The resident, admitted and re-admitted with diagnoses including COPD, hypertension, and muscle weakness, had intact cognition per a quarterly MDS. OT progress notes documented that the resident hit a door and ran over someone’s foot while driving his scooter, was very impulsive, and showed aggressive behavior quickly. Social Services, the Therapy Director, and the Nurse Unit Manager met with the resident to discuss safety concerns and offered a more appropriate wheelchair, which he declined, and informed him that further incidents would result in removal of the scooter. Subsequent OT notes showed repeated safety education and training, with the resident continuing to demonstrate poor maneuverability skills, refusing to adhere to appropriate facility speed settings, and being recommended to use the power scooter only outside the facility while using a manual wheelchair safely indoors. Further documentation and interviews showed ongoing unsafe operation of the scooter within the facility. OT notes indicated poor safety awareness, including attempts to fit through doorways that were too narrow. A CNA reported that the resident had previously run full speed into her leg with the scooter, fracturing her leg, and that she had seen him run into other people, and also reported a lack of staffing on a specified shift. Multiple observations on survey dates showed the resident speeding down hallways with the scooter set on the highest (rabbit) mode. Staff interviews confirmed that the resident “always” sped down the hall, that staff educated him but he refused to cooperate, and that he was stubborn and would not give up the scooter. The scooter was observed to be heavily damaged in the front, with the resident stating he had run into something he could not remember and that his hand had gotten stuck in the trigger area, while the scooter was again noted to be set at the fastest speed. These findings demonstrate that the resident continued to operate the power scooter unsafely inside the facility without effective supervisory or safety interventions being implemented.
Failure to Prompt Mouth Rinsing After Steroid Inhaler Use
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident rinsed his mouth after using a steroid inhaler, as required by manufacturer guidelines and facility policy. Resident #218, admitted on 07/28/25 with diagnoses including schizoaffective disorder, depressive type, and chronic obstructive pulmonary disease, had an MDS assessment indicating intact cognition. During a medication pass observed on 02/26/26 at 8:44 A.M., LPN #584 handed Resident #218 a BREO steroid inhaler. The resident took one breath from the inhaler and returned it to the nurse, and the nurse did not encourage or prompt the resident to rinse his mouth afterward. Immediately after the observation, LPN #584 stated that the resident had refused to rinse his mouth in the past, so she did not say anything on this occasion, and she agreed she should have prompted him to rinse. Later, the Regional Director of Clinical Operations confirmed that staff should be encouraging residents to rinse their mouths after using a steroid inhaler. Review of the BREO inhaler guidelines from accessdata.fda.gov indicated that after inhalation, the resident should rinse the mouth with water without swallowing to help reduce the risk of overgrowth of yeast in the mouth (oropharyngeal candidiasis). Review of the facility’s undated Medication Administration policy also noted that residents were to rinse their mouths after using a steroid inhaler. This incident was identified as an incidental finding during a complaint investigation.
Failure to Administer Medications Within Required Timeframes
Penalty
Summary
The deficiency involves the facility’s failure to administer a resident’s scheduled medications within the facility’s required timeframes. A resident with diagnoses including hemiplegia and hemiparesis, major depressive disorder, and anxiety disorder, and with intact cognition per a quarterly MDS assessment, was ordered acetaminophen 1000 mg twice daily for pain, hydroxyzine 50 mg twice daily for anxiety, and rabeprazole 20 mg twice daily for heartburn. The facility’s medication administration policy required medications to be given within one hour before or after the ordered time, and the facility’s liberalized medication pass times defined specific time ranges for early morning, A.M., afternoon, P.M., and HS doses. Review of the MAR and the facility’s medication administration audit report showed multiple instances where the resident’s medications were administered significantly outside the ordered times. On several dates, morning doses scheduled for 7:00 A.M. were not given until early afternoon, and evening doses scheduled for around 7:30 P.M. were not administered until after midnight. These late administrations affected acetaminophen, hydroxyzine, and rabeprazole on multiple occasions. During an interview, the Regional Director of Clinical Operations confirmed that the medications listed on the audit were administered outside the scheduled timeframes. The resident was not available for interview.
Failure to Hold Timely Care Plan Meetings for Residents and Guardians
Penalty
Summary
The facility failed to ensure that care plan meetings were offered in a timely manner to residents and their guardians, as required by facility policy. For one resident with a history of hemiplegia, epilepsy, and other neurological and psychiatric conditions, documentation showed that the last care conference occurred in May, with no subsequent meetings documented for the following quarters. The resident's guardian confirmed that no care conferences had been offered for approximately four months. Facility staff, including the social worker and LPN, acknowledged that the care plan meeting was overdue and could not provide a reason for the delay. Similarly, another resident with multiple chronic conditions, including fibromyalgia, diabetes, and psychiatric disorders, had not received a timely care plan meeting. The last documented care conference for this resident was also in May, with no further meetings scheduled until October, missing the required quarterly interval. The resident could not recall when the last care conference occurred, and staff confirmed the delay without explanation. Facility policy required attendees to sign and date care plan meeting documents, but this process was not followed as required for these residents.
Failure to Monitor Seizure Medication Levels Leads to Toxicity
Penalty
Summary
The facility failed to ensure that monthly pharmacy reviews and laboratory monitoring for seizure medications were conducted in a timely manner for a resident with multiple diagnoses, including epilepsy and hemiplegia. The resident was prescribed several anticonvulsant medications, such as Phenobarbital, Levetiracetam (Keppra), Carbamazepine (Tegretol), Gabapentin, Dilantin, and Divalproex Sodium (Depakote). Despite being on these medications, there was a significant lapse in laboratory monitoring, with the last documented lab for seizure medication levels occurring in January. Pharmacy recommendations for ongoing lab monitoring were not addressed by the attending physician, and the pharmacist did not identify the need for additional lab tests during monthly reviews over several months. The resident experienced a decline in condition, including decreased food and fluid intake, functional decline, and increased dependence on staff for care. This change in condition led to the resident being sent to the hospital, where laboratory results revealed a critically high Phenobarbital level, well above the normal therapeutic range. Hospital records indicated that the elevated Phenobarbital level required immediate medical intervention, and neurology held the medication for a period due to toxicity concerns. The facility's documentation confirmed that no labs had been ordered to monitor the resident's seizure medications in the months leading up to the hospitalization. Interviews with facility staff, including the DON, corporate nurse, pharmacist, and physician, confirmed that appropriate laboratory monitoring for seizure medications had not been performed as required. The facility's policy stated that pharmacists should report medication irregularities and that these should be addressed in a timely manner, but this process was not followed. The pharmacy recommendation form requesting regular lab monitoring was not completed or signed by the physician, and the DON acknowledged the oversight. This deficiency was substantiated through record review, interviews, and policy review.
Missed Antibiotic Doses Due to Medication Unavailability and Lack of Physician Notification
Penalty
Summary
A deficiency occurred when a resident with multiple diagnoses, including hemiplegia, epilepsy, and pneumonia, did not receive their prescribed antibiotic medication as ordered by the physician. The resident was dependent on staff for several activities of daily living and had intact cognition. The physician ordered Levofloxacin 250 mg, three tablets (totaling 750 mg), to be administered once daily for several days. The medication was administered as ordered on the first two days, but on the following two days, the medication was not available and was not given to the resident. There was no documented evidence that the physician was notified about the missed doses on either day. Staff interviews confirmed that the medication was not available in the facility's medication dispensing system and that the pharmacy was contacted, but the medication was not delivered. Facility policy required medications to be administered only as prescribed, but this was not followed in this instance, resulting in the resident missing two doses of their antibiotic without physician notification.
Failure to Supervise Smoking Break Leads to Resident Elopement
Penalty
Summary
A deficiency occurred when staff failed to provide appropriate supervision to a resident during a designated smoking break, resulting in the resident eloping from the facility. The resident involved had a complex medical history, including alcohol dependence with alcohol-induced persisting dementia, major depressive disorder, paranoid schizophrenia, bipolar disorder, delusional disorder, mild cognitive impairment, impulsive disorder, intermittent explosive disorder, cocaine abuse, and severe dementia with behavioral disturbances. The resident was identified as an elopement risk and had a care plan in place that required supervision during smoking times and placement in a secured unit. On the day of the incident, staff responsible for supervising the smoking break allowed residents to go outside to smoke but did not remain with them, instead observing from a window due to rain. During this time, the resident at risk for elopement managed to leave the secured courtyard by kicking the gate and exited the premises. The absence of direct supervision enabled the resident to leave the facility undetected for several minutes until discovered in the parking lot by another staff member who was leaving for the day. The resident was safely returned to the facility without injury. Interviews and witness statements confirmed that the staff assigned to supervise the smoking break were not physically present outside with the residents, contrary to facility policy requiring supervised smoking. The Director of Nursing verified that the root cause of the elopement was the lack of appropriate supervision during the smoke break, which allowed the resident to elope from the secured area. Facility records and policies reviewed indicated that the resident's risk for elopement was well-documented, and interventions for supervision were clearly outlined but not followed at the time of the incident.
Failure to Address Resident Council Concerns Regarding Activities and Outings
Penalty
Summary
The facility failed to respond to or resolve concerns voiced by residents regarding the lack of activities, both within and outside the facility, as documented in Resident Council meeting minutes from January 2024 through April 2025. Residents repeatedly requested more activities, including outings, but there was no documentation or evidence that the facility took action or provided responses to these concerns. Multiple interviews with residents and activity staff confirmed that activities were not provided after 4:00 P.M. or on weekends due to insufficient staffing, and the facility had not had a transportation bus for years, preventing residents from attending outside activities such as shopping, movies, or community events. Activity staff and the Activity Director acknowledged being aware of the residents' ongoing complaints about the lack of activities and transportation, citing inadequate staffing as the primary barrier. During a Resident Council meeting, all participating residents confirmed they had voiced these concerns to staff, including the Activity Director, without resolution. Facility leadership, including the Administrator and DON, confirmed awareness of the lack of transportation and insufficient daily activities, with little response to the residents' requests for outside activities.
Failure to Provide Activities Meeting Resident Needs and Interests
Penalty
Summary
The facility failed to provide activities that met the interests and needs of its residents, as evidenced by a lack of scheduled activities after 4:00 P.M. and on weekends, with only handouts being distributed during these times. Multiple residents, including those with intact cognition and diagnoses such as anxiety disorders, schizophrenia, dementia, and chronic medical conditions, expressed that attending activities was very important to them. Resident Council meeting minutes and interviews with residents and staff consistently documented ongoing complaints about the lack of activities, especially those occurring outside the facility, such as shopping or going to the movies, and the absence of a transportation bus for several years. Observations on various units revealed that residents were often left sitting in common areas with minimal engagement, such as a television playing unwatched, and scheduled activities like crafts were not provided as planned. Staff interviews confirmed that insufficient staffing prevented the delivery of activities as scheduled, and that activity staff typically left by 4:00 P.M., leaving direct-care staff to distribute handouts instead of facilitating interactive activities. The activity department was also reported to rarely visit certain units, and when activities like the in-house store were offered, residents without funds could not participate, leading to further dissatisfaction and confusion. The facility's own policy required a comprehensive activities program, including social, indoor, outdoor, and community activities tailored to individual needs and interests. However, both staff and residents reported that these requirements were not being met, with the last outside trip occurring before the COVID-19 pandemic. The lack of transportation and insufficient staffing were repeatedly cited as reasons for the failure to provide adequate activities, resulting in unmet needs for a significant portion of the resident population.
Failure to Maintain Infection Control During Medication Administration and Glucometer Cleaning
Penalty
Summary
A deficiency was identified when an LPN failed to maintain infection control standards during medication administration and blood glucose monitoring for a resident with type 2 diabetes mellitus. The LPN prepared four medications for the resident, but after accidentally dropping them onto the medication cart, picked them up with a bare, ungloved hand and placed them back into the medication cup. The LPN confirmed during an interview that gloves were not used and appeared confused about hand hygiene requirements during medication administration. Facility policy specifically prohibits touching medications directly. Additionally, the LPN was observed checking the resident's blood sugar and then placing the used, un-sanitized glucometer on the medication cart. The glucometer remained uncleaned for approximately five minutes until prompted by surveyors, at which point the LPN used an alcohol wipe to clean it. The LPN stated that alcohol wipes and bleach wipes were used for cleaning, but bleach wipes were not always available. Facility policy requires the use of an EPA-approved disinfectant effective against Hepatitis B, Hepatitis C, and HIV, and specifically states that alcohol wipes are not appropriate for disinfecting glucometers.
Failure to Provide Assistance with Personal Hygiene and Grooming
Penalty
Summary
The facility failed to provide proper assistance with personal hygiene and grooming tasks for three residents who required help with activities of daily living (ADLs). One resident with hypertensive heart and chronic kidney disease, asthma, moderate intellectual disabilities, and dementia was observed with a full beard and long fingernails, and expressed a desire to be shaved and have his nails cut. A second resident with COPD, arthritis, dementia, and cataracts was observed with a mustache and chin hairs, and stated she wanted her mustache shaved but staff had not done it. Both residents' care plans indicated a need for moderate assistance with personal hygiene, which was not provided as observed and confirmed by staff interviews. A third resident with bipolar disorder, Alzheimer's disease, and osteoarthritis was found with long, jagged, and discolored toenails. Although there was a physician order for a podiatry consultation and a care plan indicating the need for staff assistance with ADLs, the resident's toenails had not been maintained by staff or the podiatrist. Staff interviews revealed confusion about podiatry scheduling and responsibility, and the resident had not been added to the list for podiatry services. Facility policy required routine nail hygiene services, but this policy was not implemented for the affected residents.
Failure to Prevent Staff-to-Resident Abuse with Pepper Spray
Penalty
Summary
The facility failed to prevent an incident of staff-to-resident abuse involving a resident who was physically abused by a State Tested Nursing Assistant (STNA) using oleoresin capsicum (OC) spray, commonly known as pepper spray. This incident resulted in immediate jeopardy and caused actual physical and psychosocial harm to the resident. The resident experienced burning eyes and redness, and a subsequent PTSD assessment indicated that the resident found the event traumatic, experiencing nightmares, heightened alertness, and feelings of guilt or blame. The incident occurred when the STNA sprayed the resident in the face with pepper spray following a heated conversation. Despite the severity of the incident, the facility's response was delayed. The Unit Manager was informed of the incident via text message approximately four hours before an investigation began. During this time, the STNA continued to work in the facility, and the resident's condition was not immediately addressed by management. The resident involved had a complex medical history, including hemiplegia, aphasia, vascular dementia, and several psychiatric disorders. The behavior care plan for the resident included interventions for managing impulsive and aggressive behaviors, but these were not effectively implemented to prevent the incident. The facility's failure to promptly address the situation and protect the resident from harm highlights a significant lapse in ensuring resident safety and adherence to abuse prevention protocols.
Removal Plan
- Educated STNA #919 that she was to report any incidents related to abuse to the Administrator and DON immediately.
- Obtained STNA #919's witness statement.
- The DON interviewed STNA #942 of the alleged incident. STNA #942 relayed she was cleaning the hallway and Resident #78 must have touched the railing and touched his eyes. She also stated the floor nurse already educated her and made her dispose of the cleaning supplies. The DON obtained STNA #942's witness statement and placed STNA #942 in the receptionist area to immediately separate Resident #78 and STNA #942.
- The DON interviewed Licensed Practical Nurse (LPN) #941 who communicated cleaning supplies were used on Hickory unit and that she made STNA #942 empty the chemical mixture and educated her on not using cleaning supplies in the facility again.
- The DON notified the Administrator, Regional Director of Operations #943 and Regional Director of Clinical Operations #944 of the incident.
- The DON notified the facility's nurse practitioner (NP) of the incident and requested for NP to assess resident. The resident was assessed.
- The DON suspended STNA #942 for possibly spraying [NAME] towards Resident #78.
- The DON obtained a new order to monitor Resident #78's eyes and face for abnormalities. New order confirmed. The resident was assessed by the DON.
- The DON attempted to call Resident #78's guardian to notify the guardian of the incident. A voicemail message was left. The guardian was notified.
- The DON notified the local police department of the incident.
- Unit Manager #809 completed a respiratory assessment on Resident #78.
- Unit Manager #835 suspended LPN #941.
- All residents on the Hickory unit were assessed for respiratory, skin and eye concerns related to the chemicals that were sprayed on the unit.
- All interviewable residents were interviewed regarding abuse by Unit Manager #861. Skin sweeps were completed for residents with a low cognition.
- Facility managers completed skin checks and interviews on all facility residents.
- The DON notified the Medical Director of the incident.
- Social services staff met with Resident #78 to provide support to the resident.
- Resident #78's psych physician was notified of incident and new orders were given to increase Seroquel (antipsychotic medication).
- The DON/Designee interviewed staff on any potential abuse to ensure all incidents had been investigated and reported.
- The DON/Designee interviewed all staff on the current shift and next shift to identify if any weapons were on the facility grounds.
- The DON/Designee educated all staff on the facility policy identified as, abuse, neglect, and misappropriation with emphasis on timely reporting, who to report incidents of abuse to, ensuring safety of the residents, and effective investigation.
- The DON/Designee educated all staff on no tolerance/allowance of weapons in the facility with emphasis on what was considered a weapon. Staff were educated that all harmful substances on person, key chains, purses, backpacks must be left outside of facility. All harmful substances on keychains must be removed prior to entrance in the building. Staff educated that increase observation would be ongoing for such items and that all violations identified would result in suspension until a thorough investigation was completed and had the potential to lead to termination.
- The DON/Designee educated all facility department managers on increase supervision and Ambassador rounds with emphasis on monitoring and observation of any form of weapon, this includes observation of uniforms, keys, and open bags or purses.
- Divisional [NAME] President of Risk educated the DON and Unit Managers on reporting guidelines related to abuse, investigation, reporting, maintaining safety of residents, and what constitutes an allegation, company weapons policy and expectations.
- STNA #942's employment was terminated related to the incident with Resident #78.
- Local police were updated with findings of the facility investigation. The police were pursuing assault charges against STNA #942.
- The Administrator/Designee reviewed LPN #941 and STNA #942's employee files for background checks, references, abuse and resident rights training due to the fact they were the perpetrators in this incident.
- All facility staff were educated by an outside company on Empathy, Psychiatric Behaviors, and De-Escalation. Staff on Leave or Paid Time Off will be educated upon return and prior to working. Two employees remain on leave and will be educated by the ED/Designee upon return.
- The facility implemented a plan for the DON/Designee to educate all new staff in behavioral health management, abuse, and weapons policy. This would be ongoing as part of new hire orientation which was ongoing.
- The DON/Designee would interview five residents weekly for four weeks for any abuse concerns. Then three residents weekly for four weeks. Then randomly thereafter until compliance was confirmed.
- The Administrator/Designee would interview five staff members weekly for four weeks for any abuse concerns. Then three staff members weekly for four weeks. Then randomly thereafter until compliance was confirmed.
- The DON/Designee would review five weekly skin assessments on residents who were unable to be interviewed to ensure no new skin findings for four weeks. Then three weekly skin assessments weekly four weeks. Then randomly thereafter.
- The Administrator/Designee would audit completion of daily ambassador rounds for increased surveillance of weapons in the facility daily for four weeks then three times weekly for four weeks, then randomly thereafter.
- The Administrator/Designee would audit completion of new hire education on Weapon Free Workplace policy weekly for four weeks then randomly thereafter.
- The Administrator or DON would monitor compliance in monthly Quality Assessment and Performance Improvement (QAPI) meeting for three months, then as needed for one year.
- To ensure staff comprehend understanding of education on responding to challenging behaviors the facility implemented monthly monitoring with education and pre/post test times for months.
- The facility implemented a plan for all allegations of abuse to be reported to the Regional Director of Clinical Operations #944 by the Director of Nursing or Administrator as soon as the allegation was made as additional oversight.
- The facility implemented a plan for Regional Director of Clinical Operations #944 to monitor compliance during monthly visits for three months then on an as needed basis.
Improper Food Storage and Labeling in Kitchen
Penalty
Summary
The facility failed to properly manage food storage and labeling in the kitchen, which had the potential to affect nearly all residents receiving food services. During an inspection, surveyors observed several food items in the reach-in refrigerator that were either expired or lacked proper labeling and dating. These items included a container of beans, mayonnaise, sour cream, sliced cheese, lettuce, hot dogs, and a brown substance, all of which were not labeled or dated. Additionally, a container of yogurt was found with an expiration date that had passed, and it was noted that the yogurt had been opened without checking the expiration date. The Culinary Supervisor confirmed these observations and acknowledged that kitchen staff were responsible for ensuring food items were labeled, dated, and checked for expiration before use. This deficiency was investigated under specific complaint numbers.
Failure to Immediately Remove Perpetrator of Abuse
Penalty
Summary
The facility failed to immediately remove a perpetrator of abuse, which affected one resident and potentially impacted 22 others. The incident involved a staff member spraying oleoresin capsicum (OC) spray, commonly known as pepper spray, at a resident. The resident, who had a complex medical history including hemiplegia, vascular dementia, and several mood disorders, was involved in a heated conversation with staff about a smoke break, which escalated to the use of pepper spray. The resident experienced burning and redness in the eyes, and the event was considered traumatic, leading to symptoms consistent with post-traumatic stress disorder (PTSD). The facility's self-reported incident (SRI) and investigation revealed that the alleged abuse occurred around 10:00 A.M., but facility management was not notified until nearly four hours later. During this time, the staff member who used the spray continued to work until being suspended at 2:15 P.M. The delay in reporting and removing the staff member from the facility exposed other residents to potential harm. Witness statements corroborated the incident, with one staff member reporting the event to a nurse and unit manager immediately after it occurred. The facility's policy on abuse prevention and response mandates the immediate removal of any employee accused of abuse from resident care areas. However, in this case, the policy was not followed promptly, as evidenced by the timeline of events and staff interviews. The failure to act swiftly in removing the perpetrator and notifying management highlights a significant lapse in the facility's adherence to its own policies, resulting in a deficiency related to resident safety and protection.
Failure to Timely Report Abuse Incident
Penalty
Summary
The facility failed to ensure timely reporting of an abuse allegation involving a resident who was sprayed with pepper spray by a staff member. The incident affected a resident with multiple diagnoses, including hemiplegia, aphasia, vascular dementia, and bipolar disorder. The resident's behavior care plan included interventions for managing impulse disorder and aggressive behavior. On the day of the incident, the resident was involved in a heated conversation with staff about a smoke break, which escalated to the staff member using pepper spray on the resident. The facility's investigation revealed that the incident occurred around 10:00 A.M., but management was not notified until 1:55 P.M. Witness statements indicated that another staff member reported the incident to a nurse and unit manager immediately after it happened. However, the initial report suggested that the resident had cleaning chemicals in their eyes, which delayed the proper investigation. The facility's policy required immediate reporting of such incidents to the Director of Nursing and Executive Director, which did not occur in this case. Interviews with staff confirmed the timeline of events and the delay in reporting. A staff member texted a unit manager about the incident shortly after it occurred, but the information was not acted upon until later in the day. The resident experienced symptoms consistent with exposure to pepper spray, such as burning eyes and distress, and described the event as traumatic in subsequent PTSD assessments. The facility's failure to report the incident promptly and accurately represents a deficiency in compliance with their abuse prevention policy.
Failure to Monitor and Assess Fractures
Penalty
Summary
The facility failed to appropriately assess and monitor a resident's closed reduction of multiple fractures, including the left ankle, right first proximal phalanx, and L1 inferior endplate. The resident was admitted with these conditions, and the medical record lacked evidence of assessments and monitoring from the time of admission until the survey date. The resident's orthopedic follow-up appointment was initially scheduled but canceled due to insurance issues, and it was rescheduled for a later date. Observations revealed inadequate care, as the resident had wrapped her feet in paper products and debris, and the left foot was wrapped with a soiled ace wrap. Interviews with facility staff, including a nurse practitioner and a licensed practical nurse unit manager, indicated that the resident's fractures were not being followed by the wound care team. The facility's administrator confirmed the lack of assessments and monitoring in the resident's medical record. The facility's wound care policy stated that residents with skin integrity issues should receive treatment based on location, stage, and drainage, but this was not adhered to in the resident's case. This deficiency was investigated under a specific complaint number.
Infection Control Deficiencies in Wound Care and Insulin Administration
Penalty
Summary
The facility failed to maintain proper infection control techniques during wound care for Resident #40 and insulin administration for Resident #165. Resident #40, who had a diagnosis of diabetes and required Enhanced Barrier Precautions (EBP) due to a wound, was observed receiving wound care without the use of appropriate Personal Protective Equipment (PPE) by Registered Nurses #304 and #427. The nurses did not don PPE, failed to clean the bedside table or use a barrier, and used a soiled towel and unclean scissors during the procedure. Additionally, they did not perform hand hygiene after completing the wound care, despite the facility's policy requiring PPE for high-contact care activities. In another incident, Resident #165, who had diagnoses including diabetes and required insulin administration, was observed receiving insulin from RN #427 without the nurse wearing gloves or performing hand hygiene. The nurse administered the insulin and checked the resident's blood sugar without following proper infection control protocols. The facility's policy on medication administration mandates appropriate hand hygiene before and after each resident's medication is administered, which was not adhered to in this case.
Insulin Administration Error for a Resident
Penalty
Summary
The facility failed to manage a resident's diabetes appropriately by not administering insulin according to physician orders. Resident #165, who has diagnoses including diabetes, developmental delays, and schizophrenia, was observed during a medication administration session. The resident's physician orders for September 2024 specified administering 15 units of Fiasp, a fast-acting insulin, before meals. However, during the observation on 09/10/24, RN #427 initially dialed 18 units on the insulin pen instead of the prescribed 15 units. After realizing the mistake, the RN adjusted the dosage to 12 units and administered it. The Director of Nursing later confirmed that the correct order was for 15 units. The facility's policy mandates administering medications only as prescribed, which was not followed in this instance.
Resident Abuse by Staff Member
Penalty
Summary
The facility failed to protect a resident from physical abuse by a staff member, resulting in Immediate Jeopardy. The incident occurred when an Activity Aide (AA) physically assaulted a resident after the resident hit the aide with a cane. Despite being instructed by other staff to back away, the aide continued to attack the resident until restrained by a Maintenance Technician. This incident was witnessed by multiple staff members, and the resident expressed feeling unsafe at the facility following the event. The resident involved had a medical history that included atrial fibrillation, type two diabetes mellitus, major depressive disorder, Alzheimer's disease, and vascular dementia. The resident was noted to have moderate cognitive impairment and used a walker and wheelchair. The resident's care plan included interventions for impaired cognitive function, such as using the resident's preferred name and providing necessary cues to prevent agitation. The incident was substantiated by the facility's investigation, which included witness statements and a police report. The Activity Aide was terminated, and assault charges were filed. The facility's policy defined abuse as the willful infliction of injury or punishment resulting in harm, and the incident was found to be a violation of this policy.
Resident Elopement Due to Inadequate Supervision and Security
Penalty
Summary
The facility failed to maintain a safe environment and provide necessary supervision to prevent a resident with multiple mental health diagnoses, including schizoaffective disorder and dementia, from eloping. The resident, who was identified as an elopement risk and had a legal guardian, managed to leave the facility without staff knowledge. This occurred after a State Tested Nursing Assistant (STNA) propped open a secured door with a wet floor sign, rendering it unsecured and accessible to residents. On the night of the incident, staff, including an STNA and a Licensed Practical Nurse (LPN), did not conduct complete rounding and were unaware that the resident had exited the facility. The resident was discovered missing the following morning when a staff member went to deliver breakfast and found the resident's room empty. The facility was unaware of the resident's whereabouts until a family member called to inform them that the resident was at their home, 16 miles away, and had been there since early morning. The resident's medical record indicated a history of elopement risk and the need for a secured unit due to her mental health conditions. Despite this, the facility's failure to ensure the door was secured and to conduct proper rounds allowed the resident to leave the facility unnoticed. The resident's care plan included interventions for elopement risk, but these were not effectively implemented, leading to the resident's unauthorized departure.
Failure to Adhere to Hiring Policies for Staff with Disqualifying Offenses
Penalty
Summary
The facility failed to adhere to its policy of hiring staff free of disqualifying offenses, including abuse, which affected three out of five personnel files reviewed. This oversight had the potential to impact all 161 residents in the facility. During a review of personnel files, it was discovered that a State Tested Nursing Assistant (STNA) was hired despite having a background check revealing past charges related to child neglect and cruelty, although these charges were dropped. Another STNA was hired with a background check showing charges for endangering children and drug possession. Additionally, a Maintenance Technician was hired with a charge for drug possession. Interviews with the Administrator confirmed that the facility's internal processes for handling questionable background checks were not followed. The Administrator acknowledged that any applicant with findings on their background checks should have been referred to the Divisional President of Human Resources for further review. The facility's policy clearly states that individuals with disqualifying offenses should not be employed, and the Administrator admitted that STNA #356 should not have been hired due to the findings of child neglect.
Failure to Implement Abuse Policy and Procedure
Penalty
Summary
The facility failed to implement its abuse policy and procedure regarding checking potential applicants against the Ohio Nurse Aide Registry (NAR). This deficiency was identified during a review of personnel files, which revealed that three out of five personnel files lacked evidence of being checked against the NAR prior to employment. Specifically, the personnel files of a State Tested Nursing Assistant (STNA), a Maintenance Technician (MT), and an Activity Aide (AA) did not contain documentation of NAR checks before their hire dates. The Administrator confirmed these findings and acknowledged that all staff, regardless of position, should be checked against the NAR to ensure they do not have a history of abuse, neglect, mistreatment, exploitation of residents, or misappropriation of property. The facility's policy, dated October 1, 2019, mandates that a check of the Ohio STNA registry be completed on all candidates for employment before a job offer is made. Another policy, without a specified date, requires licensure/registry checks to be performed after the interview to verify the Nurse Aide Registry. These checks are to be managed by the facility's Human Resources manager or designee, with results reviewed by the appropriate department head and administration. The failure to adhere to these policies represents noncompliance and was investigated under specific complaint numbers.
Failure to Implement and Monitor Effective Behavioral Health Interventions
Penalty
Summary
The facility failed to timely implement effective and individualized interventions to address the behavioral health concerns of Resident #70, who had a history of mental disorders and behavioral issues. Despite being transferred from another facility with documented behaviors such as yelling, agitation, and attempts to self-transfer, the initial care plan did not include specific interventions for these behaviors. It was only six days after admission that a care plan focus area was initiated to address these behavioral challenges, but there was no documentation to evaluate the effectiveness of the interventions implemented. Resident #70 exhibited multiple episodes of yelling, delusions, agitation, and attempts to crawl out of bed, which were documented in the Medication Administration Record (MAR) and nursing notes. However, there was a lack of documented evidence of staff interventions to address these behaviors effectively. For instance, despite being administered medications like quetiapine and venlafaxine for psychosis and depression, and hydroxyzine for anxiety, the records did not show consistent monitoring or evaluation of the effectiveness of these medications and other non-pharmacological interventions. Interviews with staff members revealed that Resident #70's behaviors were challenging and required frequent attention, but staff were often unable to provide continuous one-on-one care due to other responsibilities. The facility's policy on behavior management indicated that residents would be provided with a resident-centered behavioral management plan, but in the case of Resident #70, there was no consistent documentation or evaluation of the interventions' effectiveness. This lack of timely and effective intervention and monitoring contributed to the deficiency in providing appropriate behavioral health services to Resident #70.
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Surveyors found that multiple hazardous storage areas, including a closet near medical records, a beauty salon used to store chemical cases, a supply room in one nursing station, a room leading to a smoking area, a housekeeping room near therapy, and a lobby storage room, lacked required self-closing or automatic-closing doors. These conditions did not comply with NFPA 101 requirements for hazardous area enclosure and had the potential to affect all residents and staff in an emergency.
Surveyors found that the facility did not conduct fire drills on every shift each quarter and did not vary drill conditions as required by NFPA 101. Record review showed that one shift lacked a documented drill for an entire quarter, and the pattern of drill times and dates did not demonstrate varied conditions. The Maintenance Director confirmed the incomplete and noncompliant fire drill schedule, which affected all residents and staff emergency preparedness.
Surveyors found that the facility did not maintain clear egress corridors as required by NFPA 101, with a TV/video cart plugged into a corridor outlet and multiple unsecured chairs placed in the hallway near resident rooms and the secured unit dining room, including directly in front of a fire extinguisher. These items projected about 29 inches into an approximately eight-foot-wide corridor and were located in front of the handrail, potentially affecting 28 residents and staff’s ability to assist in an emergency. The Maintenance Director confirmed these corridor obstructions during the survey.
A resident with intact cognition receiving Medicare Part A skilled services for metabolic encephalopathy had services discontinued while benefit days remained, but the facility did not issue the required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN). The Social Services Director later confirmed that no SNF ABN was provided and reported she believed only a Notice of Medicare Non-Coverage (NOMNC) was needed when all skilled services were stopped. This practice conflicted with the facility’s written policy, which required SNF ABNs to be issued when extended care items or services were initiated, reduced, or terminated due to expected non-coverage by Medicare.
Surveyors identified that the facility exceeded the acceptable medication error rate when two residents with type 2 DM received insulin doses that were not administered according to orders or manufacturer instructions. In two separate observations, an LPN administered Novolog and another LPN administered insulin glargine and insulin lispro without priming the insulin pens, and the insulin lispro and Novolog were given after the residents had already consumed a significant portion of their breakfast meals, despite orders for administration before meals. Manufacturer information for both insulin products required priming before each injection to ensure accurate dosing, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and specified time frames.
The facility failed to maintain accurate and complete crash cart audits for multiple full-code residents. Surveyors, accompanied by the DON, found that daily crash cart checks did not include verification of supply expiration dates, and that an extension cord documented as present on several audit dates was not actually in the cart. Audit logs also conflicted with the cart’s contents by indicating that required items such as eye protection, saline, and clear plastic were present when they were not. These findings were inconsistent with the facility’s policy requiring the crash cart to be checked every 24 hours and after each use, with prompt replacement of equipment and supplies.
A resident with chronic respiratory failure on supplemental O2, COPD, and cognitive risk factors was repeatedly documented as non-compliant with the smoking policy, including going out to smoke outside designated times and retaining cigarettes and lighters provided by family. Despite prior assessments identifying this resident as unsafe to smoke without supervision, a later assessment classified the resident as safe to smoke independently without documented rationale or care plan update. The resident subsequently went outside alone with an O2 nasal cannula in place, lit a cigarette, and sustained facial burns when the cannula ignited, as observed by staff and confirmed by EMS and ED records. In a separate case, another cognitively impaired resident with a history of falls had a care-planned intervention for non-skid strips in front of a recliner, but observation and staff confirmation showed the strips were not present, despite remaining on the active fall-risk care plan.
Multiple dependent residents did not receive scheduled showers, bed baths, or shaving as outlined in their care plans and the facility’s routine care policy. One resident recovering from spinal surgery missed numerous scheduled showers over several months. Another resident who relied on staff for self-care repeatedly requested shaving but was not shaved, and visible facial hair was observed after a recent shower. A resident with chronic respiratory failure and a tracheostomy, requiring substantial/maximal assist with personal hygiene, had no documented showers for an extended period and was observed with long facial hair, which staff acknowledged should be removed during bathing or as needed. A cognitively impaired resident with ESRD and CHF, scheduled for twice-weekly showers, had multiple undocumented or missed showers and reported not getting showers despite asking aides who said they lacked time. Another cognitively intact resident with hemiplegia and multiple comorbidities, also scheduled for twice-weekly showers, had several dates where documentation showed no shower/bath/bed bath provided or no entry at all, and she reported feeling unclean and unimportant when her showers were missed.
A resident with an indwelling urinary catheter for urinary retention, and care plan interventions requiring the drainage bag to be properly secured with a dignity cover, was observed seated in a chair with the catheter drainage bag uncovered and containing visible dark yellow urine that could be seen from the hallway. Later, an LPN confirmed the catheter bag was lying directly on the floor without a dignity cover. This situation occurred despite facility policy requiring care to be provided in a manner that respects and enhances each resident’s dignity and personal privacy.
A cognitively intact resident with chronic orthopedic pain had a PRN oxycodone order, but multiple doses were signed out on the narcotic log by an RN without corresponding entries on the MAR or documented pain assessments. A CNA/med tech reported frequent problems with this RN’s narcotic counts and documentation, describing erratic behavior when handling narcotic keys. The resident reported taking oxycodone only once or twice daily and otherwise using Tylenol, which conflicted with the number of oxycodone doses signed out. The facility’s investigation found it was inconclusive whether narcotics were misappropriated or whether there was a failure of documentation, but confirmed there was no evidence that all signed-out doses were administered.
Failure to Maintain Self-Closing Doors for Multiple Hazardous Storage Areas
Penalty
Summary
Surveyors identified a deficiency related to hazardous area protection and door requirements under NFPA 101, 2012 Edition. During facility tours, they observed that multiple hazardous storage areas did not have self-closing or automatic-closing doors as required for hazardous areas such as combustible storage and chemical storage. These areas included a closet next to medical records, a beauty salon being used to store cases of chemicals, a supply room in Station #2, and the room leading to the smoking area in Station #3. On a subsequent tour, surveyors observed additional hazardous areas without self-closing doors. The housekeeping room across from therapy and the lobby storage room were both noted to lack self-closing door mechanisms. The facility census at the time was 59 residents, and the surveyors stated that this deficient practice had the potential to affect all residents and staff's ability to assist in an emergency. The Maintenance Director verified these findings at the time they were observed.
Plan Of Correction
K 0321 This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be admissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as its allegation of substantial compliance as of 06/12/2026 K-0321 Doors with Self-Closing Devices Corrective action for resident/s: 1. The closet door next to medical records was lacking a self-closing door on 5/19/2026. Maintenance director to add self-closing device to closet door next to medical records on or before 06/12/2026 in accordance with applicable code. 2. The beauty salon had chemicals stored in it on 5/19/2026. Maintenance director moved chemicals from beauty salon on 05/20/2026 in accordance with applicable code. 3. The supply room on station 2 was lacking a self-closing door on 5/19/2026. Maintenance director to add self-closing door to supply room on station 2 on or before 06/12/2026 in accordance with applicable code. 4. The room to the smoking area on station 3 was lacking a self-closing door on 5/19/2026. Maintenance director to add a self-closing door to the smoking are on station 3 on or before 06/12/2026 in accordance with applicable code. 4. The housekeeping room across from therapy was lacking a self-closing door on 5/19/2026. Maintenance director to add a self-closing door to the housekeeping room across from therapy gym on or before 06/12/2026 in accordance with applicable code. 5. The lobby storage room was lacking a self-closing door on 5/19/2026. Maintenance director to add a self-closing door to the lobby storage room on or before 06/12/2026 in accordance with applicable code. Identification of other residents who may be affected: LNHA and Maintenance director/designee completed a full facility audit for doors with self-closing devices on 05/26/2026. Any corrective action, including, doors identified as needing self-closures will be added on or before 06/09/2026 in accordance with applicable code. Measures for systemic change: LNHA educated Maintenance Director on 05/26/2026 regarding NFPA 101-2012 sections 19.3.2.1 and 19.3.5.9 specifically regarding doors with self-closing devices. How Corrective Action will be monitored Ongoing "Doors with Self-Closing device audit" to be completed weekly x 2 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 06/12/2026
Failure to Conduct Required Quarterly Fire Drills on All Shifts
Penalty
Summary
The facility failed to conduct fire drills in accordance with NFPA 101, 2012 Edition, sections 19.7.1 through 19.7.1.8, specifically by not holding drills every shift each quarter and not varying drill conditions as required. Record review on 06/09/25 at approximately 10:32 A.M. showed there was no fire drill conducted for the first shift during the third quarter. The documented first-shift fire drills occurred on 01/30/26 at 2:42 P.M., 04/30/26 at 1:51 P.M., and 10/31/25 at 10:58 A.M., indicating a missed quarter. Second-shift fire drills were recorded on 02/26/26 at 5:20 P.M., 06/03/25 at 4:35 P.M., 08/29/25 at 3:46 P.M., and 11/25/25 at 5:09 P.M., and third-shift drills on 02/28/26 at 11:47 P.M., 05/30/25 at 12:18 A.M., 07/22/25 at 11:34 P.M., 09/26/25 at 11:40 P.M., and 12/15/25 at 5:17 A.M. The surveyor determined that drills were not conducted under varied conditions and that the required quarterly drill on each shift was not consistently performed. The Maintenance Director confirmed these findings at the time they were identified, and the deficiency had the potential to affect all 59 residents and staff response in an emergency. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency related to facility-wide emergency preparedness practices and documentation of fire drills.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 05/29/2026 K-0712 Fire Drills Corrective action for resident/s: There were no records of a fire drill for the first shift of the third quarter of 2025. First shift fire drill completed on 5/24/2026 by maintenance director/designee with no findings or corrective action necessary. Identification of other residents who may be affected: On 5/26/2026 Maintenance director/designee completed 100% audit of the scheduled fire drills to ensure a drill is scheduled quarterly each shift with no findings or corrective action necessary. Measures for systemic change: LNHA educated Maintenance Director on 05/26/2026 regarding NFPA 101-2012 section 19.7.1.4 through 19.7.1.7. specifically including fire drill frequency requirements. How Corrective Action will be monitored Ongoing "Fire Drill Audit" to be completed weekly x 2 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 05/29/2026
Obstructed Egress Corridors Due to Equipment and Chairs
Penalty
Summary
The facility failed to maintain required clear egress widths in corridors in accordance with NFPA 101, 2012 Edition, sections 19.2.3.4 through 19.2.3.5 and 7.3.2 through 7.3.2.3, creating projections into the egress corridor that exceeded allowable limits. Surveyors observed that on one day in Station #3, a cart with a television and video equipment was plugged into an outlet in the corridor by room 38, and five activity room chairs were placed in the corridor near the secured unit dining room directly in front of a fire extinguisher. On the following day, surveyors again observed chairs in the Station #3 corridor, with four by room 35 and four by the activities room, and the same television cart still in the corridor; the chairs were not secured. The corridor was approximately eight feet wide, and the projections extended approximately 29 inches into the corridor in front of the handrail. These conditions had the potential to affect 28 residents in the facility and the staff’s ability to assist in an emergency, and the Maintenance Director confirmed the observations at the time of discovery. No specific resident medical histories or conditions were described in the report, only that 28 residents were potentially affected and the facility census was 59.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be subsequent remedial measures and should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 05/29/2026 K-0232 Clear path of egress Corrective action for resident/s: 1. On 05/18/2026 station 3 had a cart with a television parked in the corridor by room 38 that exceeded allowable limits. Maintenance director/designee moved the TV cart into the activity room, out to the corridor on 05/18/2026 in accordance with applicable code. 2. On 5/18/2026 station 3 had 5 chairs in the corridor near the dining room directly in front of the fire extinguisher. Maintenance director/designee moved the chairs into the dining room, out of the corridor on 5/18/2026 in accordance with applicable code. 3. On 5/19/2026 station 3 had 4 chairs by the activity room and 4 by room 35. In addition, the TV cart was in the corridor. The maintenance director/designee moved the chairs and TV cart into the dining room, out of the corridor on 5/19/2026 in accordance with applicable code. Identification of other residents who may be affected: Maintenance director/designee completed a 100% facility audit for clear paths of egress on 5/26/26 with no findings or corrective action necessary. Measures for systemic change: Maintenance Director/designee educated staff on 5/26/2026 regarding NFPA 101-2012 section 19.2.3.4 and 19.2.3.5 specifically including maintaining a clear path of egress. How Corrective Action will be monitored Ongoing "Path of Egress Audit" to be completed weekly x 2 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 05/29/2026
Failure to Issue Required SNF ABN When Discontinuing Medicare Part A Services
Penalty
Summary
The deficiency involves the facility’s failure to issue a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) when Medicare Part A services were discontinued for a resident who still had available benefit days. The resident was admitted with a diagnosis of metabolic encephalopathy and had intact cognition per the Minimum Data Set assessment. The facility’s own SNF Beneficiary Notification Review documented that Medicare Part A skilled services began on 02/11/26 and the last covered day was 03/11/26, and that the facility initiated discharge from Medicare Part A services before the resident’s benefit days were exhausted. Despite this, no SNF ABN was provided to the resident or the resident’s representative. During interviews, the Social Services Director stated that the SNF ABN was issued hours prior to the last covered day but, upon reviewing her files, confirmed that no SNF ABN had actually been issued for this resident. She further explained that she believed an SNF ABN was only required if one skilled service remained and that if all skilled services were being discontinued, only the Notice of Medicare Non-Coverage (NOMNC) needed to be issued. The Administrator, however, stated that a resident should always receive both a SNF ABN and a NOMNC when Medicare Part A services are discontinued and benefit days remain. Review of the facility’s written policy dated 03/28/23 showed that the facility was required to issue SNF ABNs for initiation, reduction, or termination of extended care items or services when Medicare payment was not expected, which did not occur in this case.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as its allegation of substantial compliance as of 05/29/2026 F-0582 Corrective action for resident/s: On 5/14/26 Resident #34 was informed of rights and responsibilities related to Advanced Beneficiary Notice and voiced understanding of information for future reference by administrator. Identification of other residents who may be affected: Any resident receiving skilled services from nursing or therapy services. The Administrator audited all residents who were discharged from skilled services in the past 30 days to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary Notice on 5/29/26. No non-compliance was noted. Measures for systemic change: On 5/14/2026 Business Office Manager, Director of Rehab, Minimum Data Set nurse, Director of Nursing and Social Services Director were educated on proper procedure of issuing of Notice Of Medicare Non Coverage and Advanced Beneficiary Notice by administrator. All upcoming discharges from skilled services will be reviewed weekly at Utilization Review meeting to ensure notices will be delivered timely. How Corrective Action will be monitored: Administrator or designee to complete audits of all residents being discharged from skilled services to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 5/29/26
Insulin Administration Errors and Failure to Prime Insulin Pens
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5%, with surveyors identifying 3 errors out of 28 medication administration opportunities, resulting in a 10.71% error rate. For one resident with type 2 diabetes mellitus and moderate cognitive impairment, the physician’s order directed Novolog insulin 10 units via subcutaneous pen-injector to be given before meals. During an observed medication pass, the LPN administered 10 units of Novolog insulin without priming the pen and did so after the resident had already consumed approximately 50% of the breakfast meal. The LPN later confirmed she did not prime the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer instructions for the Novolog FlexPen specified that an air shot (priming) must be performed before each injection to ensure proper dosing. Another resident, also diagnosed with type 2 diabetes mellitus and with intact cognition, had orders for insulin glargine 35 units subcutaneously twice daily and insulin lispro 20 units subcutaneously before meals, plus 12 units subcutaneously if blood glucose was between 251 mg/dL and 300 mg/dL. During an observed medication administration, an LPN administered 35 units of insulin glargine and 32 units of insulin lispro without priming the insulin pens and after the resident had consumed approximately 90% of the breakfast meal, despite orders for insulin lispro to be given before meals. The LPN later stated she could not remember if she had primed the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer information for insulin lispro stated that the pen must be primed before each injection to confirm insulin delivery and remove air, and that failure to prime could result in too much or too little insulin. The DON confirmed the expectation that insulin be administered as ordered, including priming each pen with two units before dialing the prescribed dose, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and required time frames.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 5/29/2026. F-0759 Corrective action for resident/s: Residents #21 and #22 were assessed and evaluated by nurse and Director of Nursing 5/14/26. Resident #21 and #22 both denied any adverse effects and none were noted upon assessment by the Director of Nursing on 5/14/2026. Notification made to physician on 5/14/2026. LPN # 2 competency Eval on insulin administration with the Director of Nursing completed 5/14/2026. Identification of other residents who may be affected: Diabetic residents on assignment of LPN #2/station 2 have the potential to be affected and were assessed by the DON/Designee on 5/14/26 and found to be within normal limits. Measures for systemic change: All Nurses were educated by the Director of Nursing on the steps for Insulin administration per competency, diabetes clinical protocol policy, Medication and treatment orders policy, administering medications policy, and Obtaining fingerstick Glucose Level policy On 5/14/2026. How Corrective Action will be monitored: Director of Nursing and Assistant Director of Nursing will complete insulin administration audits on 5 nurses. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance: 5/29/2026
Inaccurate Crash Cart Audits and Missing Emergency Equipment
Penalty
Summary
The facility failed to ensure accurate and complete crash cart audits for residents requiring basic life support, affecting eighteen of thirty-five residents who were designated as full code. During an observation of the crash cart with the DON, surveyors found that the daily audit documentation for the month did not include verification of expiration dates for crash cart supplies. Review of the crash cart audit logs showed that an extension cord was documented as being in the cart on multiple dates, but the extension cord was not present in the cart at the time of inspection. Additionally, the audit documentation indicated that required items, including eye protection, saline, and clear plastic, were not present in the crash cart, yet they were documented as being in the cart. The facility’s undated “Emergency Crash Cart” policy stated that the crash cart is to be checked every 24 hours and after every use, and that equipment and supplies are to be noted and replaced promptly, but the observed documentation and contents of the cart did not match these requirements. This deficiency was verified with the DON at the time of the survey and was cited under the requirement that personnel provide basic life support, including CPR, to residents requiring emergency care, subject to physician orders and advance directives, and was investigated under Complaint Number 2687380.
Plan Of Correction
Cridersville Care Center Provider Number:366171 Survey Type: Complaint Survey Survey Date: 04/29/26 This Plan of Correction (PoC) outlines the actions completed by the facility with regards to the deficiency citation. This Plan of correction does not constitute any admission of guilt or liability by the facility and is submitted only in response to the regulatory requirements. Please accept the following as the facility's credible allegation of compliance as of 4/30/26. F678 CPR All Full Code residents #18 have the potential to be affected by the alleged deficiency. On 4/27/26 the DON/ADON re-stocked the crash cart per the inventory sheet for all missing items. Crash cart inventory sheet updated and new one will go into effect on 5/1/26. All licensed nursing staff provided with training related to crash cart inventory being a daily audit review using inventory sheet on 4/27/26 per DON/designee. The DON/designee will conduct clinical rounds and conduct a random audit of crash cart three times per week for 4 (four) weeks to ensure compliance. The results of the audit will be documented. The facility conducted an Ad-Hoc QAPI meeting on 4/27/26 and discussed the alleged deficiency and corrective actions. Date when corrective action will be completed: 4/30/26
Unsafe Smoking Practices with Oxygen and Missed Fall-Prevention Interventions
Penalty
Summary
The deficiency involves the facility’s failure to provide a safe smoking environment, adequate supervision, and appropriate implementation of its smoking policy for a resident who used oxygen and smoked, as well as failure to implement fall-prevention interventions as care planned for another resident. One resident had multiple relevant diagnoses, including chronic respiratory failure with hypoxia, COPD, end-stage renal disease, dependence on supplemental oxygen, diabetes, and necrotizing fasciitis. Her care plans identified impaired visual function, risk for respiratory complications related to a history of smoking, and risk for cognitive decline, with interventions including use of oxygen per order and observation for understanding. A smoking-related care plan created earlier documented that she wished to use smoking products, had been assessed as safe to smoke "with supervision," and was non-compliant with the smoking policy, with family continuing to provide smoking supplies despite education and a verbal warning for non-compliance. Smoking assessments and progress notes showed a pattern of non-compliance and inconsistent classification of this resident’s smoking safety. Multiple smoking observation/assessments completed earlier in March documented that she had no cognitive loss, visual deficits, or dexterity problems but was unsafe to smoke without supervision because she did not return smoking materials and did not follow designated smoke times. Progress notes described her going out to smoke multiple times by herself or with family, including sneaking out next door with a cigarette and going out multiple times in one evening, with staff documenting that she was "reeducated" and that family brought in cigarettes and lighters which she did not return to staff. Despite this history, a smoking assessment completed after a three-day hospital stay assessed her as safe to smoke without supervision, with no documentation explaining how this conclusion was reached or evidence that her care plan was updated accordingly. On the day of the incident, the resident reported she had cigarettes and a lighter on her person after returning from dialysis and stated she "could not find a nurse" and went outside to smoke, saying she "guessed" she forgot she had her oxygen on. A CNA observed her outside and saw a flame coming through the resident’s oxygen nasal cannula tubing, turned off the oxygen tank, removed the tubing, and patted out sparks on the resident’s shirt sleeve. The resident’s face and hands appeared black in color, and EMS documented first-degree burns to the head and face, with the resident stating she lit a cigarette with her nasal cannula on, causing the burn. The hospital record described her face as black from smoke and her lips and mouth as "burnt and charred," with a recommendation for intubation that she refused. The facility’s incident report recorded that she went outside with oxygen on to smoke without notifying staff, that staff witnessed the occurrence as she walked through the dining room door to the courtyard, and that she stated she thought she had turned her oxygen off. The facility’s smoking policy required interdisciplinary evaluation to determine safe versus unsafe smokers, staff maintenance of all smoking paraphernalia for both safe and unsafe smokers, and progressive consequences for policy violations. A separate deficiency involved another resident at risk for falls whose care plan included use of non-skid strips on the floor in front of her recliner as a fall-prevention intervention. This resident had severe cognitive impairment, used a walker and wheelchair, required supervision or touching assistance for transfers and ambulation, and had experienced two or more falls without injury since the prior assessment. The fall-risk care plan, initiated at admission, specified non-skid strips in front of the recliner beginning in November. However, nursing staff interviewed were not familiar with all of the resident’s fall-prevention interventions without checking the record, and observation of the room showed two recliners with no non-skid strips on the floor in front of them. An LPN confirmed that the non-skid strips were not present despite the intervention remaining active in the care plan, and moving the recliners did not reveal any strips. The facility’s fall management policy required identification of hazards and risk factors, implementation of interventions to minimize falls and injuries, and development and implementation of a care plan based on interdisciplinary evaluation, with interventions related to identified risk factors.
Plan Of Correction
Smoking: On 03/21/26 at 3:16 P.M. 911 response was activated for Resident #11 and Medical Director #601 was notified by Registered Nurse (RN) #322. On 03/21/26 at 3:18 P.M. on-call Nurse/Social Services #423 immediately notified the Administrator and Director of Nursing (DON) #304 of the incident involving Resident #11. On 03/21/26 at 3:22 P.M. Emergency Medical Services (EMS) arrived onsite. At 3:30 P.M. Resident #11 was transported to the emergency room. On 03/21/26 at 3:30 P.M. RN #322 completed a smoking re-assessment of Resident #11 assessing the resident to be an unsafe smoker requiring supervision due to failure to remove oxygen prior to entering designated smoking area. On 03/21/26 from 3:38 P.M. through 7:57 P.M. Licensed Practical Nurse (LPN) #337, #336, #335, #338; RN #334, and DON #304 re-assessed residents (who smoke). This included Resident #22, Resident #3, Resident #47, Resident #50, Resident #60, Resident #150, Resident #86, and Resident #10 to determine smoking safety (via smoking assessment). Each resident was re-educated regarding the facility smoking policy and staff verified there were no smoking materials on their person. The residents' smoking materials would be maintained by facility staff and distributed per policy. On 03/21/26 at 4:30 P.M. DON #304 responded to facility and an Ad Hoc (not scheduled) Quality Assurance (QA) meeting was held via telephone with the Administrator, DON #304 and Medical Director #601 to review investigative findings and plan of action. A root cause analysis was completed and determined Resident #11 had smoking materials on her person (believed to be obtained from family without staff knowledge) and failed to remove her oxygen. The QA team discussed a corrective action plan. On 03/21/26 from 5:00 P.M through 03/22/26 at 3:00 P.M. 26 RNs, 13 LPNs, one medical technician (MT), 54 Certified Nursing Assistants (CNA) four activities staff, one central supply staff, 11 dietary staff, 12 housekeeping staff, three laundry staff, one medical records staff, two social designees, two maintenance staff, nine administrative staff, and 19 therapy staff (158 staff at the time of the incident) were provided education regarding the facility smoking policy by DON #304 and the Administrator. This was completed via 1:1, small group in-services or via phone. Newly hired staff would receive education during general orientation regarding the facility's smoking policy. On 03/21/26 at 5:00 P.M. DON #304 completed an audit of all residents who smoke (Resident #22, Resident #3, Resident #47, Resident #50, Resident #60, Resident #150, Resident #86, and Resident #10) to verify smoking evaluations and plans of care accurately reflected the residents' smoking safety needs. The residents were educated on the facility smoking policy, and smoking materials were to be maintained at the nurses' station. An audit was completed which included verification of required safety measures present in designated smoking areas, including an ash can, fire extinguisher, fire blanket, ash trays and no oxygen signs. There were no identified concerns or changes made because of the audits. On 03/21/26 at 8:55 P.M. Resident #11 returned from the ED. LPN #332 verbally educated the resident regarding the facility smoking policy which included the need for supervision, a smoking apron (to be worn) and the facility smoke times. LPN #332 verified no smoking materials were on the resident's person or in her room at this time. On 03/23/26 at 11:00 A.M. the Interdisciplinary Team (IDT) (Administrator, DON #304, Medical Director #601, RN #302, Social Services #427, Social Services #423, DON #300, and Maintenance #436) met in-person to review the plan of action with DON #304/designee to complete weekly monitoring of residents who smoke and designated smoking areas weekly for four weeks with Housekeeping responsible to complete the cleaning. Housekeeping staff were responsible for cleaning ashtrays and the designated smoking area daily. Audits to be reviewed and any further actions required to be directed by the Quality Assurance and Performance Improvement (QAPI) Committee during scheduled meetings. The IDT also reviewed all current smoking assessments and care plans for residents who smoke. Resident #50 required a change in supervision levels with smoking due to cognition levels and her plan of care as well as Resident #11's plan of care was updated to reflect supervision/safety. On 03/23/26 from 3:45 P.M. to 8:55 P.M. Social Services #423 re-educated residents who smoke (Resident #22, Resident #3, Resident #47, Resident #50, Resident #60, Resident #150, Resident #86, Resident #10) and responsible parties, if applicable regarding the facility smoking policy and supervision levels. On 03/23/26 at12:13 P.M. Social Services #427 contacted Resident #11's family member (#602) to schedule a care conference. Family member #602 and Family Member #603 were not available to meet until 03/27/26. On 03/23/26 at 1:00 P.M. staff education related to smoking areas, removal of oxygen prior to entering smoking area and maintaining smoking materials at the nurses' station for residents who smoke was initiated by DON #304 and the Administrator via 1:1, small group in-services or via phone call. Education was completed for all 158 staff by 03/24/26 at 1:00 P.M. Newly hired staff would be educated during general orientation regarding the facility's smoking policy. The facility does not utilize agency staff. On 03/27/26 at 11:00 A.M. a care conference was held with Resident #11 and Family Members #602 and #603, the Administrator, Social Services #423 and Social Services #427. The facility smoking policy was reviewed. The resident and family were informed an involuntary discharge would be initiated should the resident exhibit non-compliance moving forward and supervision would be increased beyond the two-hour standard of care to monitor more closely for non-compliance with the facility smoking policy. Family Member #602 stated he educated his siblings as well. On 04/10/26 at 2:00 P.M. DON #304 initiated education with 26 RNs and 13 LPNs (100% of nurses educated) regarding completion of the smoking evaluation via 1:1, small group in-services, or phone. The education was completed by 6:00 P.M. on 04/10/26. A new resident who smokes must remain supervised until the interdisciplinary team (IDT) reviews and determines smoking safety, at which time the care plan is developed and resident and family education is provided. The communication through the staff would be the care plan. Newly hired staff receive education during general orientation regarding the facility's smoking policy and completion of smoking evaluation via Point Click Care (PCC). On 04/10/26 at 4:29 P.M. DON #304 initiated an order in PCC for the nurse to verify, each shift, that Resident #11's smoking materials were maintained at the nurses' station. On 04/13/26 at 5:30 P.M. DON #304 initiated orders in PCC for nurses to verify, each shift, that all residents who smoke would have smoking materials maintained at the nurses' station. An updated list of smokers included: Resident #60, Resident #50, Resident #11, Resident #86, Resident #113, and Resident #151. On 04/13/26 at 5:45 P.M. DON #304 initiated questionnaires for staff regarding the smoking policy with re-education provided as needed via 1:1 and small group in-services for staff currently in the facility with all staff to be questioned/educated prior to working their next scheduled shift. Falls: On 4/9/26, Maintenance Director placed non-skid strips on the floor in front of Resident #12's recliner. Like Residents are identified as residents who have had a fall within the facility. Utilizing the Fall Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, an audit of falls and appropriate interventions for the past 30 days will be completed by the Director of Nursing or designee to ensure fall interventions are in place per plan of care. This audit along with identified corrections will be completed on or F 0689 before 5/13/26. The Director of Nursing or designee will re-educate licensed nurses and STNA/CNAs on the Fall Management Policy to include fall interventions to be in place per the care plan. This education will be completed on or before 5/13/26. Utilizing the Fall Management Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, the Director of Nursing or designee will complete an audit of new admissions, new readmissions and residents who experience a fall within the last 7 days, weekly for four weeks, beginning 5/14/26 to ensure fall safety interventions are in place per plan of care. Current fall interventions found to not be in place will be corrected with all intervention in place per plan of care. Negative findings to be addressed immediately and negative trends or system wide issues will be reported to the QAPI committee, and the action plan will be adjusted as needed.
Removal Plan
- Activated 911 response for Resident #11 and notified the Medical Director.
- On-call Nurse/Social Services immediately notified the Administrator and DON of the incident.
- EMS arrived onsite and Resident #11 was transported to the emergency room.
- Completed a smoking re-assessment of Resident #11, determining the resident was an unsafe smoker requiring supervision due to failure to remove oxygen prior to entering the designated smoking area.
- Re-assessed all residents who smoke (Residents #22, #3, #47, #50, #60, #150, #86, and #10) to determine smoking safety via smoking assessment.
- Re-educated residents who smoke regarding the facility smoking policy and verified there were no smoking materials on their person.
- Implemented that smoking materials would be maintained by facility staff and distributed per policy.
- Held an ad hoc QA meeting to review investigative findings and plan of action.
- Completed a root cause analysis determining Resident #11 had smoking materials on her person and failed to remove oxygen.
- Developed a corrective action plan.
- Provided facility-wide education to staff on the facility smoking policy.
- Implemented that newly hired staff would receive smoking policy education during orientation.
- Completed an audit of all residents who smoke to verify smoking evaluations and plans of care accurately reflected smoking safety needs.
- Ensured smoking materials were maintained at the nurses’ station.
- Audited designated smoking areas for required safety measures (ash can, fire extinguisher, fire blanket, ash trays, and no-oxygen signs).
- Provided verbal education to Resident #11 on smoking policy (supervision, smoking apron, smoke times).
- Verified no smoking materials were on Resident #11’s person or in her room.
- Conducted an in-person IDT meeting to implement weekly monitoring of residents who smoke and designated smoking areas weekly for four weeks.
- Assigned housekeeping to clean ashtrays and the designated smoking area daily.
- Directed audits to be reviewed by QAPI.
- Reviewed all current smoking assessments and care plans for residents who smoke.
- Updated Resident #50’s supervision level.
- Updated Resident #11’s plan of care to reflect supervision/safety.
- Re-educated residents who smoke and responsible parties (as applicable) regarding the facility smoking policy and supervision levels.
- Contacted Resident #11’s family to schedule a care conference.
- Initiated additional staff education regarding smoking areas, removal of oxygen prior to entering smoking area, and maintaining smoking materials at the nurses’ station.
- Held a care conference with Resident #11 and family to review smoking policy.
- Informed resident/family that involuntary discharge would be initiated for future non-compliance.
- Increased supervision beyond the two-hour standard of care to monitor more closely for non-compliance.
- Provided education to all nurses regarding completion of the smoking evaluation.
- Implemented that new residents who smoke must remain supervised until IDT review determines smoking safety and care plan/education are completed.
- Entered an order in PCC for nursing to verify each shift that Resident #11’s smoking materials were maintained at the nurses’ station.
- Entered orders in PCC for nursing to verify each shift that all residents who smoke have smoking materials maintained at the nurses’ station.
- Initiated staff questionnaires regarding the smoking policy with re-education as needed.
- Required all staff to be questioned/educated prior to working their next scheduled shift.
Failure to Provide Scheduled Bathing and Shaving Assistance for Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide scheduled and needed bathing and shaving assistance to multiple dependent residents in accordance with their care plans, preferences, and the facility’s routine care policy. One resident with spinal stenosis and recent L2–L5 decompression fixation fusion was care planned for substantial/maximal assistance with shower/bath and toileting hygiene and was scheduled for showers on Tuesdays and Fridays. Electronic documentation from early January through early April showed this resident did not receive a shower or bed bath on 11 identified scheduled days, and the DON confirmed these missed bathing events. Another resident with dysphagia and developmental issues, who required assistance with self-care and mobility, reported that she asked staff to shave her but they did not, which bothered her. During an observation following a recent shower, she stated she had not been shaved and that the hair "itched"; small gray hairs were visible on her chin. A CNA confirmed the presence of gray chin hairs and acknowledged the resident needed shaving, stating it would be addressed with the next scheduled shower. A further resident with chronic respiratory failure, tracheostomy status, heart failure, moderate intellectual disabilities, anxiety, depression, and PTSD required substantial/maximal assistance with personal hygiene and had a care plan for assistance with self-care, including personal hygiene. Her shower schedule called for showers on Monday and Thursday nights, with complete shaves for men and women. Review of documentation showed her last recorded shower/bath was nearly a year earlier, with no indication of additional personal hygiene or facial hair removal on that date. Observations on two separate days showed long white hairs on her chin and jaw line, which a CNA later confirmed, stating facial hair removal should occur with baths/showers or as needed. A resident with end stage renal disease, respiratory failure, hyperlipidemia, and congestive heart failure, who had impaired cognition and required partial/moderate assistance with bathing and personal hygiene, was scheduled for showers on Wednesdays and Saturdays. Review of shower documentation from admission through early April revealed no showers provided or refusals documented on at least ten scheduled shower days. In interviews, this resident reported not receiving scheduled showers, was unsure of his shower days, and stated he could use a good scrub down, adding that he had asked aides who told him they did not have time. A CNA explained that shower days appear on shower sheets and in the computer and that CNAs are supposed to document daily, with nurses checking the documentation; the DON verified the resident had not received showers per schedule or preference. Another resident with a fracture of the lower end of the left humerus, hemiplegia and hemiparesis after cerebral infarction, rheumatoid arthritis, hypertensive heart disease, urinary retention, and osteoarthritis was care planned as non–weight bearing to the left upper extremity and requiring substantial/maximal assistance with showering/bathing. Her electronic record showed she was scheduled for showers on Wednesdays and Saturdays. The shower task question "did the resident receive a shower/bath/bed bath?" was documented as "no" on three dates, indicating no shower/bath/bed bath was completed, and left unanswered on three additional dates. The DON confirmed that one missed shower was due to an outside appointment, that on two dates the "no" response meant no bathing of any type occurred, and that on three dates there was no documentation at all. The resident, who was cognitively intact, reported that missing showers made her feel unimportant compared to others and that she did not feel clean when her shower was missed. Facility policy on routine resident care stated that showers, tub baths, and shampoos are to be scheduled according to person-centered care or state guidelines, with additional showers given upon request, but the documented and observed care did not reflect consistent provision of scheduled bathing and shaving for these residents.
Plan Of Correction
1. Resident #5 received a shower by the STNA on 4/13/26. Resident #8 received a shower by the STNA on 4/8/26. Resident #9 received a shower and had their chin shaved by the STNA on 4/14/26. Resident #70 received a shower by the STNA on 4/13/26. Resident #76 received a shower and had their chin shaved by the STNA on 4/15/26. 2. Like residents are identified as residents who need assistance with showering and shaving. Utilizing the Shower Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, an audit of like residents will be completed by the Director of Nursing or designee to ensure that showers and resident shaving are completed. This audit along with identified corrections will be completed on or before 5/13/26. 3. The Director of Nursing or designee will re-educate licensed nurses and STNA's on the Routine Resident Care Policy to include bathing and shaving residents. This education will be completed on or before 5/13/26. 4. Utilizing the Shower Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, the Director of Nursing or designee will complete an audit of 4-6 residents weekly for four weeks, beginning 5/14/26 to ensure that showers and resident shaving are completed. Noncompliance found during audits will be addressed and assistance with showers and/or shaving provided. Negative findings to be addressed immediately and negative trends or system wide issues will be reported to the QAPI committee, and the action plan will be adjusted as needed.
Uncovered Urinary Catheter Drainage Bag Compromises Resident Dignity
Penalty
Summary
The facility failed to maintain a resident’s right to privacy and dignity related to management of an indwelling urinary catheter. A resident admitted with malignant neoplasm of the esophagus and type II diabetes mellitus had a care plan identifying risk for urinary tract infection and catheter-related trauma due to an indwelling catheter for urinary retention. The care plan interventions included ensuring the catheter tubing was secured and the drainage bag was properly secured with a dignity cover in place. Physician orders directed that the resident’s 16 French indwelling urinary catheter be changed every 30 days and as needed, and the comprehensive MDS documented that the resident had an indwelling catheter and was cognitively intact. During observation, the resident was seen seated in a chair with the urinary catheter drainage bag hanging from the chair without a dignity cover, and dark yellow urine was visible in the bag from the hallway. In a later observation and interview, an LPN confirmed that the catheter bag was lying directly on the floor and did not have a dignity cover. Attempts to interview the resident to confirm cognitive status were unsuccessful, as the resident was unable to answer screening questions. Review of the facility’s “Resident Dignity & Personal Privacy” policy stated that the facility should provide care in a manner that respects and enhances each resident’s dignity, individuality, and right to personal property, which was not followed in this instance when the catheter drainage bag was left uncovered and visible.
Plan Of Correction
The Laurels of Athens wishes to have this plan of correction submitted as our written allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission to nor agreement with, either the existence of, or the scope and severity of, any of the cited deficiencies or conclusions set forth in the statement of deficiencies. This plan is prepared and/or executed to ensure continuing compliance with regulatory requirements. Our alleged date of compliance is 5/13/2026. 1. On 4/6/26, Resident #92's catheter bag was removed from the floor, the bag changed and covered for dignity by the licensed nurse. Resident #92 discharged from the facility on 4/11/26. 2. Like Residents are identified as residents who utilize urinary catheters. An audit will be completed by the Director of Nursing or designee for like residents utilizing the Urinary Catheter Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC to ensure catheter bags are covered for dignity and not laying directly on the floor. This audit along with identified corrections will be completed on or before 5/13/26. 3. The Director of Nursing or designee will re-educate licensed nurses on the Indwelling Urinary Catheter Policy as well as Resident Dignity & Personal Privacy Policy to include privacy covers are in place for urinary catheters and that the catheter is not laying on the floor. This education will be completed on or before 5/13/26. 4. Utilizing the Urinary Catheter Audit Tool which was created on 4/20/26 by the Director of Nursing for purpose of this POC, the Director of Nursing or designee will complete an audit of all residents with catheters weekly for four weeks, beginning 5/14/26 to ensure catheter bags are covered for dignity and not laying directly on the floor. Any catheters found to be touching the floor or uncovered will be removed from the floor, the bag changed and covered for dignity. Negative findings to be addressed immediately and negative trends or system wide issues will be reported to the QAPI committee, and the action plan will be adjusted as needed.
Failure to Prevent Possible Misappropriation and Poor Documentation of PRN Narcotics
Penalty
Summary
The deficiency involves failure to prevent potential misappropriation of a resident’s narcotic medication and failure to ensure accurate documentation of controlled substance administration. A cognitively intact resident with chronic pain related to an internal orthopedic device and left knee pain had an order for oxycodone 5 mg PO every four hours PRN for pain and a care plan directing staff to administer medications as ordered and observe for effectiveness and side effects. The resident’s MDS showed she rated her pain as 7/10 and received opioid medication. However, review of the February MAR and the narcotic log revealed multiple discrepancies between narcotic sign-outs and documented administration. On several occasions, oxycodone doses were signed out on the narcotic log by an RN without corresponding documentation on the MAR. Specifically, oxycodone was signed out on one evening at 9:30 p.m. with no MAR entry, and again on a subsequent night at 1:30 a.m. and 5:30 a.m. with no MAR entries for those times. Another dose was signed out at 9:00 p.m. while the MAR reflected administration at 10:16 p.m., and a later dose at 5:30 a.m. was documented on both the narcotic log and MAR. There was also no documentation of pain assessments before or after PRN opioid administration. These documentation gaps meant there was no evidence that all narcotic doses signed out were actually administered to the resident. Staff interviews further highlighted concerns about the handling of narcotics. A CNA/med tech reported frequently taking the narcotic keys from the RN and described the RN’s behavior as erratic, with repeated problems involving incorrect narcotic counts and missing documentation on both the MAR and narcotic log. The resident stated she did not receive oxycodone more than once or twice a day, preferring to take Tylenol the rest of the time, which conflicted with the number of oxycodone doses signed out. When questioned, the RN gave inconsistent explanations about how often she pulled and administered PRN narcotics and acknowledged struggling with the new system, while also suggesting the resident may have received PRN tizanidine instead of remembering oxycodone. The facility’s investigation concluded that evidence was inconclusive as to whether misappropriation occurred or whether the issue was solely lack of documentation, but confirmed there was no evidence the resident received all doses signed out on the narcotic log.
Plan Of Correction
1. Resident #99 had a Self-Reported Incident submitted and investigated via the EIDC on 3/2/26. The investigation was inconclusive as we could not prove that misappropriation occurred. On 2/24/26, Resident #99 was interviewed and pain assessed by Director of Nursing and resident had no ill effects related to the inconsistent documentation in the medical record as it relates to her controlled substance pain medication. 2. Like Residents are identified as residents who utilize controlled substance PRN pain medications. An audit will be completed by the Director of Nursing or designee for like residents utilizing the Controlled Substance Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC to ensure PRN controlled substance pain medications that are signed off the control sheet are documented in the resident medical record as well. This audit along with identified corrections will be completed on or before 5/13/26. 3. The Director of Nursing or designee will re-educate licensed nurses on the Controlled Substances Policy to include appropriate documentation of controlled substances. In addition, the licensed nurses will be re-educated by the Director of Nursing or designee on the Abuse Prohibition Policy to include misappropriation of resident property. This education will be completed on or before 5/13/26. 4. Utilizing the Controlled Substance Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, the Director of Nursing or designee will complete an audit three controlled substance sheets from each of the nine medication carts for a total of twenty-seven sheets weekly for four weeks, beginning 5/14/26 to ensure PRN controlled substance pain medications that are signed off the control sheet are documented in the resident medical record as well. Inconsistencies noted from the audit will be investigated for misappropriation. Negative findings to be addressed immediately and negative trends or system wide issues will be reported to the QAPI committee, and the action plan will be adjusted as needed.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
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