Citations in Ohio
Comprehensive analysis of citations, statistics, and compliance trends for long-term care facilities in Ohio.
Statistics for Ohio (Last 12 Months)
Financial Impact (Last 12 Months)
Some of the Latest Corrective Actions taken by Facilities in Ohio
- Updated the Narcotic Pain Patch Policy to mandate dual-nurse verification of patch placement at every shift change and dual-nurse removal/disposal with documentation in the controlled-substance log (J - F0760 - OH)
- Provided staff with a standardized list of approved patch-placement sites and abbreviations to ensure consistent and accurate documentation (J - F0760 - OH)
- Placed a reminder sheet in the narcotic log book directing nurses to physically verify fentanyl patch placement during each shift-change count (J - F0760 - OH)
- Delivered focused education on the revised narcotic pain-patch procedures covering physical checks, dual-nurse disposal, standardized abbreviations, and immediate reporting of missing patches (J - F0760 - OH)
- Educated facility leadership on risk-event reporting and investigation protocols to strengthen proactive identification and mitigation of medication errors (J - F0760 - OH)
Failure to Initiate CPR for Full Code Resident Due to Delayed Access to Advance Directives
Penalty
Summary
A deficiency occurred when staff failed to provide basic life support (BLS), including cardiopulmonary resuscitation (CPR), to a resident who was found unresponsive on the toilet, despite the resident's advance directive indicating full code status. Certified Nursing Assistants (CNAs) discovered the resident in distress and alerted an LPN, who assessed the resident and found no pulse. Instead of initiating immediate CPR, the LPN sought guidance from another LPN on a different floor, who then contacted the Unit Manager at home for advice on locating the resident's advance directives. During this time, the LPN was unable to quickly access the resident's code status due to difficulties finding the medical chart and lack of immediate computer access. The delay in action resulted in no CPR being performed while staff attempted to confirm the resident's code status. EMS was contacted and arrived to find the resident deceased, with rigor mortis and other signs of irreversible death present. EMS staff indicated it was too late for resuscitation efforts. The resident was left slumped over on the toilet until EMS arrived, and staff did not attempt to move the resident or initiate life-saving measures as required by the facility's policy and the resident's documented wishes. The resident involved had a history of cognitive, social, and emotional deficits following cerebrovascular disease, mild vascular dementia, chronic obstructive pulmonary disease, atrial fibrillation, congestive heart failure, polyosteoarthritis, and a previous myocardial infarction. The resident's physician orders and care plan clearly indicated a full code status, meaning all life-saving measures were to be used in a medical emergency. Despite this, the staff's failure to promptly initiate CPR and their inability to access the resident's advance directives in a timely manner directly contributed to the deficiency.
Removal Plan
- The Director of Nursing (DON) provided education on Advance Directives, location of advanced directives, change of condition, and immediate response of CPR to all staff.
- Training was verified by review of sign in sheets.
- The DON and Administrator interviewed and/or collected statements from all staff working at the time of the incident involving Resident #61.
- A whole house audit of all residents was completed by the Regional Director of Clinical Services (RDCS) verifying code status, care plans and signed Do Not Resuscitate (DNR) forms.
- The Human Resource Director reviewed all nursing staff files to verify cardiopulmonary resuscitation (CPR) certifications were valid.
- The RDCS verified all laptops on the units were accounted for and available for nursing access.
- The DON audited crash carts to ensure all equipment was in place.
- An ADHOC Quality Assurance and Performance Improvement (QAPI) meeting was completed to discuss Advance Directives for all residents and develop education pertaining to Advance Directives, location of advanced directives, change in condition, and immediate response of CPR.
- A second ADHOC QAPI meeting was held to discuss code status levels, staff response expectations, and implementation/adjustment of the corrective action plan.
- Staff received education on advanced directives, location of the advanced directives, immediate response of CPR and change in condition by the RDCS and DON, with completion verified via sign-in sheets and random staff interviews.
- The facility implemented a plan for the DON/Designee to conduct Code Blue drills and location of advance directives on alternating shifts.
- The facility implemented a plan for the Administrator/Designee to audit all deaths to ensure resident's advanced directives were honored per preference.
- The facility implemented a plan for the DON/Designee to conduct audits to ensure that residents' change in conditions were addressed.
- The facility implemented a plan for the DON/Designee to conduct audits to ensure each unit had a laptop for nursing access.
Failure to Prevent Significant Medication Error with Fentanyl Patch Administration
Penalty
Summary
A significant medication error occurred when a resident with severe cognitive impairment and chronic pain, who had a physician's order for a Fentanyl transdermal patch, was administered a new Fentanyl patch without the removal of the previous one. The LPN responsible was unable to locate or remove the previously administered patch but proceeded to apply a new patch and did not report the missing patch at the time. This resulted in the resident wearing two Fentanyl patches simultaneously, which was not discovered until after the resident exhibited symptoms of overdose, including lethargy, inability to walk or sit upright, and drooling. The facility failed to accurately assess the resident when the change in condition was noted. The nurse who responded to the resident's altered state did not complete a head-to-toe assessment and was unaware that the resident was receiving Fentanyl. Emergency Medical Services were called, and upon their assessment, two Fentanyl patches were found on the resident, one of which was initially hidden under a blood pressure cuff. Narcan was administered, and the resident was transported to the hospital, where an accidental overdose was confirmed. Documentation and monitoring of Fentanyl patch placement were inconsistent and inaccurate in the days leading up to the incident. There were multiple instances where the location of the patch was incorrectly documented or not documented at all, and missing patches were not reported to the physician or nursing management. Staff interviews revealed a lack of standardized procedures for patch administration, removal, and documentation, as well as insufficient training and communication regarding controlled substance protocols. The facility did not initiate an incident investigation or implement immediate interventions following the discovery of the overdose.
Removal Plan
- The DON completed a skin sweep on Resident #86 to ensure there were no additional patches applied.
- The DON completed a review of Resident #86's care plan and verified to show chronic pain and potential side effects.
- The DON completed a skin sweep on a like resident (Resident #50) who had discontinued orders for Fentanyl patches. The DON verified there were no patches present.
- RNCC #302 educated the Administrator and DON on reporting risk events and initiating investigation and implementing interventions.
- The Narcotic Pain Patch Policy was updated to include: Both nurses, oncoming and off going to check placement and document in medication administration record at shift change, and removal of Fentanyl pain patch to be completed by two nurses and documented in the controlled substance/narcotic log with two nurses for disposal.
- The DON updated Resident #86's orders to include documentation of Fentanyl patch location.
- The DON updated Resident #86's order to check Fentanyl patch placement every shift to also include location observed.
- The DON provided a standard list of locations and abbreviations placed on the unit for staff reference to ensure correct abbreviation documentation.
- The DON placed a reminder sheet in the narcotic book for the nurses to physically go to check narcotic placement at shift change.
- The DON provided education on the narcotic pain patch policy to include: Checking patch physically during count and documenting in the record; disposal of patch with two nurses and to fold patch and dispose by flushing and both nurses to document on the controlled substances/narcotic log with both nurses signing the log; using the standard list of locations and abbreviations to ensure correct abbreviation of location of Fentanyl patch; and on call manager to be notified immediately if Fentanyl patch missing.
- A root cause analysis was completed by the Interdisciplinary Team (IDT) including Medical Director (MD) #102, the Administrator, the DON, Assistant Director of Nursing (ADON) #208, and RNCC #302 with an ad hoc QAPI meeting.
- Auditing includes DON or designee to review shift to shift count with physical checking of patch placement is completed, validating placement of patch to match the medical record once daily for two weeks, then four times a week for four weeks.
- Auditing to include DON or designee to audit removal of Fentanyl patch to be with two nurses and documented accurately in the narcotic log daily for two weeks, then four times a week for four weeks.
- The DON provided education to LPN #242 on completing head-to-toe assessments.
Latest Citations in Ohio
Staff failed to use appropriate equipment during a mechanical lift transfer, resulting in a resident sustaining a head laceration that required ER treatment. In a separate event, a resident with bilateral amputations fell from bed during care when a CNA worked alone, and the incident was not accurately documented or investigated. Both cases involved lapses in supervision, use of assistive devices, and adherence to safety protocols.
A resident with cognitive impairment was given another resident's medications, including cardiac and anti-anxiety drugs, after an LPN failed to verify the correct identity before administration. The error led to hypotension, bradycardia, and required hospital admission for observation and IV fluids. The facility's policy requiring verification of the '5 rights' of medication administration was not followed.
A nurse crushed and administered extended release potassium chloride and verapamil tablets to a resident with swallowing difficulties, despite guidelines stating these medications should not be crushed. The nurse also failed to provide a prescribed multivitamin due to its unavailability. These actions resulted in a medication error rate of 10.7% during the observed medication pass.
A resident with a history of behavioral issues and multiple medical diagnoses was placed on 1:1 supervision following an incident of inappropriate sexual behavior. Despite ongoing supervision and awareness of the resident's behavioral concerns, the facility did not develop or implement a behavioral care plan or document interventions addressing these behaviors, as confirmed by staff and record review.
A resident with multiple medical conditions was prescribed Diltiazem, but due to a transcription error by staff, received Dilantin instead. The error was discovered after the medication was administered, and it was confirmed that the facility's policy for administering medications as prescribed was not followed.
Residents repeatedly raised concerns during council meetings about delayed call light responses, staff rudeness, cold showers, and requests for additional smoking breaks, but these issues remained unresolved for several months. Residents also reported that their requests to meet without staff and have a resident take meeting minutes were not accommodated. Staff interviews confirmed that these concerns were not addressed in a timely manner, and the facility's required documentation and follow-up process was not effectively implemented.
During a medication pass, two residents received medications incorrectly: one was given the wrong formulation of a laxative by an LPN, and another received crushed extended-release Potassium Chloride from an RN, resulting in a medication error rate above 5%.
Several residents were served popcorn shrimp that was not properly prepared, resulting in a hard, white coating that was difficult to chew and unappetizing. The shrimp was cooked in an oven instead of a deep fryer, contrary to the product's requirements and facility policy, leading to multiple residents being unable to eat their meal.
Staff responsible for food preparation and service failed to maintain sanitary practices, including not covering a noncommunicable skin condition on the forearms, not keeping hair fully restrained, and not sanitizing hands after touching the face and hair. These actions resulted in unsanitary food handling and equipment use, affecting nearly all residents receiving food from the kitchen.
Staff failed to perform hand hygiene during both medication administration and meal tray delivery. A nurse used bare hands to pick up dropped medications from an unclean cart before administering them to a resident with severe cognitive impairment and multiple chronic conditions. Additionally, a dietary manager delivered meal trays to three residents without using hand sanitizer between rooms, despite facility policy requiring hand hygiene after contact with the patient environment.
Failure to Ensure Safe Transfers and Fall Prevention
Penalty
Summary
Staff failed to safely transfer a resident with severe cognitive impairment and bilateral lower extremity functional limitations using a mechanical Hoyer lift. During a transfer to a recliner, staff used a Hoyer lift that was not wide enough to accommodate the recliner, but proceeded with the transfer regardless. As the resident was being lowered, the lift's bar swung back and struck the resident in the forehead, causing a laceration and bruising that required emergency room treatment and sutures. The incident involved both a hospice aide and a facility aide, and it was confirmed that the staff continued the transfer despite recognizing the equipment was not appropriate for the task. In a separate incident, another resident with bilateral below-knee amputations and chronic respiratory failure experienced a fall from bed during routine care. The resident, who was cognitively intact and required substantial assistance with bed mobility, was rolled onto his right side by a CNA working alone, after being unable to find another staff member to assist. The resident rolled out of bed and onto the floor. The fall report was found to be inaccurate, and the resident was not interviewed about the incident. The nurse on duty did not assess or interview the resident following the fall, and the fall investigation report was incomplete. Both incidents demonstrate failures in providing adequate supervision and assistance devices to prevent accidents, as well as failures in thoroughly investigating and accurately documenting resident falls. The facility's policies required staff to ensure resident safety during activities of daily living and to identify interventions related to specific fall risks, but these were not followed in the cases described.
Plan Of Correction
What corrective actions will be accomplished for those residents found to have been affected by the deficient practice: Resident #19 has been assessed and evaluated for appropriate transferring techniques, per facility policy, on multiple dates (note attached audit of completion). Through ongoing assessment, resident has been transferred, with no difficulty, and without injury obtained. Patient denies any concerns/discomfort with transferring techniques concluded. The oversized recliner was removed prior to survey initiation, per family request. Hospice provider has been advised to provide ample amount of time/notification for DME changes/removal to allow for appropriate transition of resident. Resident #25 has been interviewed for bed mobility preferences. Resident states he prefers to be a two person assist despite his ability to complete tasks with one individual. Resident's plan of care has been updated to identify specifics of patient preference (note attached). Facility staff educated on change of care, same date (included for reference). How will you identify other residents having the potential to be affected by the deficient practice and what corrective action will be taken: Managerial personnel will conduct random audits of bed mobility tasks and transfer completion guided per each individual's plan of care. Audits will be assessed daily, on each unit, at random time intervals x 1 week, twice weekly x 2 weeks, and once per week x 4 weeks. If concerns are identified, those individuals will be re-educated of the facility's transfer policy and procedures with hands-on guidance to be done. Initiation of a Performance Improvement Plan will be conducted, as needed. What measures will be put into place or what systemic changes will you make to ensure the deficient practice does not recur: Upon admission, each resident shall be assessed for safe transfers/bed mobility tasks guided per the functional status and personal preference expressed. Activities of daily living will be re-assessed quarterly, as needed, and with any significant medical changes following the initial admit, per facility designee, and will be reflected on the individualized plan of care. How the corrective actions will be monitored to ensure the deficient practice will not recur, ie., what quality assurance program will be put into place; and dates when corrective action will be completed: This plan of correction will be implemented, and the corrective action will be evaluated for its efficiency. The plan of correction is integrated into the facility's Quality Assurance Program. All auditing tools will be completed, as dictated, with thorough review. Any adverse findings/trends noted will be corrected immediately and brought to the Quality Assurance and Performance Improvement Committee for review. Please consider this plan of correction to be an allegation of compliance as if 07-18-2025. Resident #19's most recent assessment was done on 07/18/2025, which was completed by nurse on the unit. Hospice nurse was notified the date of the incident, which was 06/06/2025. The Director of Nursing, unit managers, and maintenance director reviewed wheelchairs and personal chair sizes to ensure mechanical lifts meet manufacturer guidelines when in use. No concerns were identified, and audit was completed the week of survey. Mechanical lift inspections are done monthly by the maintenance director. Maintenance Director reports any adverse findings to the Director of Nursing. A thorough investigation was completed per interdisciplinary team on 04/14/2025, which included Director of Nursing, Unit Manager, and MDS nurse. Initial interview incident was conducted per agency nurse at time of fall. Subsequent communication completed on 04/14/2025 per Unit Manager. In clinical care meeting on 04/14/25, resident #25 incident reviewed including preference stated by resident and during that time resident did not express any concerns with changes in the plan of care. During plan of correction review, resident was reinterviewed and expressed the desire to have two staff assist during bed mobility this time forward, which was 07/22/25. Plan of care updated with the following information. Yes, each fall investigation is led by the Director of Nursing and reviewed with the clinical team. The new processes were put into place and the implementation of the IPRO fall tracking tool alongside current facility policy and procedures for incident investigations. The licensed nurses and STNA are educated on transferring techniques including Hoyer lift policy and procedure at time of hire, annually, and with any manufacturer changes or new equipment. Upon hire would be our HR representative, annually or any changes would be completed by managerial nursing staff. Maintenance Director supplies any information regarding new lifts introduced into the facility. All nurses are oriented upon hire regarding risk management completion, interviewing staff/obtaining witness statements, and interviewing residents when applicable regarding cognition. In specific to this incident, agency staff was reeducated on thorough investigation; however, per risk management completion, it appears incident review was conducted accordingly. Director of Nursing reviews and signs each risk management. If concerns are identified, the Director of Nursing does a one-on-one reeducation with the staff member. Yes, all audits observed will include Hoyer transfers guided per resident’s individual plan of care. Yes, all falls are investigated to ensure thoroughness, including resident/staff interviews as applicable. Director of Nursing reviews with clinical staff. Every fall is reviewed and will continue to be reviewed indefinitely. Yes, it is the facility's utmost opinion that a thorough investigation was concluded on 04/14/2025 following the fall of resident #25. The initial interview of the incident was concluded immediately per agency nurse at the time of fall. Subsequent communication was completed, post ED return, per unit manager 04/14/2025. The new IPRO fall tracking tool was initiated 07/08/2025. The IPRO tracking tool has been utilized for all falls in July 2025. This new process will continue indefinitely. Yes, all staff (nurses and CNA's) have been educated on the proper transferring techniques, via Hoyer lift, post survey initiation and the AOC date, conducted per managerial nursing staff beginning 07/02/2025 through survey completion. Yes, all nurses have been re-educated on thorough fall investigation completion to include interviewing residents and staff (as applicable) after the survey start and prior to the AOC date. This guidance was transcribed per Director of Nursing and expressed to staff per nurse managers. The agency nurse was provided appropriate policy and procedure guidelines for incident/progress note completion on 04/14/2025 directly via the agency portal.
Significant Medication Error Due to Failure to Identify Resident
Penalty
Summary
A deficiency occurred when a resident with moderately impaired cognition, dependent on staff for medication administration, was given medications prescribed for another resident. The medications administered in error included cardiac medications that lower heart rate and blood pressure, an anti-platelet agent, a medication for gout, and an anti-anxiety medication. The error was due to the nurse's failure to properly identify the resident before administering the medications, as confirmed by both the nurse and the facility administrator. The facility's policy required verification of the '5 rights' of medication administration, including ensuring the medication is given to the correct person, but this was not followed. Following the administration of the incorrect medications, the resident experienced a change in condition, including hypotension (low blood pressure), bradycardia (low pulse), and lethargy. The resident was transported to the emergency room, where she was admitted for overnight observation and treated with intravenous fluids. Hospital records confirmed the resident had received multiple medications not prescribed to her, resulting in hypotension and bradycardia throughout her ER stay, which improved with treatment. Medical record review showed that none of the medications given in error were ordered for the resident. The incident was identified before the nurse administered the resident's own medications to another individual. The error was documented in the facility's medication error report, and the nurse involved acknowledged the failure to verify the resident's identity prior to administration. The event affected one of two residents reviewed for medication errors during the survey.
Plan Of Correction
Resident #10 was sent to the ER by the physician on 6/6/25. She returned to the facility on 6/7/25 with no lasting effects of medication error. She was assessed on 6/23/25, 6/30/25, and 7/8/25 by NP since readmit with no ill effects identified. A care conference was held with the family on 6/17/25 with no concerns identified. All residents have the ability to be affected. Therefore, an initial audit was conducted by the DON or designee on 6/6/25 to ensure all residents have appropriate photo identification in the medical record. Any negative findings were addressed immediately. LPN responsible for the error was educated on medication rights to include how to identify a resident on 6/6/25 by the DON. Per policy, a discipline was also issued to the LPN responsible by the DON on 6/6/25 to prevent recurrence. Audits for medication errors were completed by RCS weekly between 6/6/25 and 6/25/25 with no identified errors. All nurses were reeducated by 7/14/25 by the DON or designee on medication pass policy and procedure to include when a nurse is unable to verify resident identification with the medical record picture, they must ask the resident their name and get a response prior to administering the medication. If the resident does not respond, they are to get assistance from other staff members. Medication pass observations of 5 nurses per week for 4 weeks will be conducted by the DON or designee to ensure no significant medication errors occur. Any negative findings will be addressed immediately. The DON is responsible for ongoing compliance. Results of audits will be reviewed at QAPI for adjustments as needed.
Medication Administration Errors: Crushing ER Tablets and Missed Dose
Penalty
Summary
A medication administration deficiency occurred when a nurse crushed and administered extended release (ER) tablets of potassium chloride and verapamil to a resident, contrary to manufacturer guidelines and accepted standards of practice, which specify that ER tablets should not be crushed. The nurse stated that the resident was unable to swallow whole pills and believed the resident also crushed pills at home. However, there was no evidence that the physician had been consulted regarding alternative formulations or the appropriateness of crushing these medications. Additionally, the nurse failed to administer a prescribed multivitamin (PreserVision AREDS) in the morning as ordered, citing unavailability on the medication cart. The facility's medication error rate was calculated at 10.7%, with three errors identified out of 28 opportunities during observation. The errors affected one resident who had a history of swallowing difficulties, as documented in a hospital discharge summary, which recommended crushing pills only if they were crushable. The nurse and another staff member later confirmed that ER tablets are generally not to be crushed, and medication information sources suggested considering liquid alternatives for residents with swallowing difficulties.
Plan Of Correction
Resident #5 was assessed by RCS on 6/26/25 with no ill effects related to medications being crushed or missed vitamin administration. MD was notified with orders to change medications to crushable form and to discontinue the PreserVision AREDS as she was on a multivitamin with minerals on 6/26/25 by the floor nurse. By 7/14/25, all residents with a need for medications to be crushed will be audited by RCS to ensure medications ordered were able to be crushed. Any negative findings will be addressed. An initial audit of all residents' medication administration records will be completed by RCS to ensure medications are administered as ordered. Any negative findings will be addressed. By 7/14/25, LPN #100 was educated by RCS related to crushing medications, forms that cannot be crushed, and administering all medications as ordered. All nurses will be educated by 7/14/25 by the DON or designee on medication administration to include crushing medications, medications that are not crushable, and administering all medications as ordered. Audit of 5 residents per week who require medications to be crushed will be completed weekly for 4 weeks by the DON or designee to ensure medications ordered are allowed to be crushed. Medication pass observations will be conducted by the DON or designee for 5 nurses per week for 4 weeks to ensure proper medication administration. Any negative findings will be addressed immediately. The DON or designee will complete medication pass audits for 5 nurses per week for 4 weeks to ensure all medications are appropriately ordered and administered. The DON will be responsible for ongoing compliance. Results of audits will be reviewed at QAPI for adjustments as needed.
Failure to Develop Behavioral Care Plan for Resident on 1:1 Supervision
Penalty
Summary
A deficiency was identified when the facility failed to develop and implement a comprehensive, person-centered care plan to address a resident's behavioral issues, specifically following an incident involving inappropriate sexual behavior. The resident in question had a history of medical conditions including diabetes mellitus, stroke with ataxia, depression, and anxiety, and was admitted with intact cognition. After an incident where the resident made a gyration motion in another resident's doorway, the facility placed the resident on one-on-one (1:1) supervision per physician order, and this supervision continued for several days as documented in health status notes. Despite the ongoing 1:1 supervision and the resident's behavioral concerns, a review of the resident's care plan revealed that there were no documented interventions or care plans addressing the resident's behaviors or the need for 1:1 supervision. The lack of a behavioral care plan was confirmed by the MDS Coordinator, who acknowledged that such a plan should have been created given the circumstances. The facility was also aware of a pending court hearing for sexual misconduct involving the resident prior to admission, but this information did not result in a behavioral care plan being developed. The deficiency was discovered during a complaint investigation, which included review of the facility's self-reported incident, medical records, and staff interviews. The investigation also noted that the facility conducted an internal investigation into the allegation of sexual abuse, which was ultimately unsubstantiated. However, the failure to create a behavioral care plan for the resident, despite clear evidence of behavioral issues and the implementation of 1:1 supervision, constituted noncompliance with regulatory requirements for comprehensive care planning.
Plan Of Correction
Resident #11 was discharged from the facility prior to survey visit so the care plan/intervention was unable to be completed. However, on 6/18/2025, the MDS nurse and administrator educated the social service director on the importance of behavior care plans. She was shown the focus, goal, and adding interventions. A new care plan library was created on 6/15/2025 to streamline the process. With no other residents on a 1:1, there are no like residents to audit. Behavioral care plans on all similar/like residents will be audited by the MDS nurse twice a week for two weeks, then once a week for two weeks, and the results will be reviewed in QAPI. Social Services and MDS coordinator completed audits of like residents from 6/18/2025 to 7/9/2025.
Significant Medication Error Due to Transcription Mistake
Penalty
Summary
A deficiency occurred when a resident with diagnoses including atrial fibrillation, protein calorie malnutrition, dementia, depression, and transient ischemic attacks was prescribed Diltiazem 180 mg daily by their primary care provider. However, facility staff transcribed the order incorrectly, entering Dilantin 180 mg instead of Diltiazem into the resident's medication orders. As a result, the resident received Dilantin 180 mg rather than the intended Diltiazem on the following day. The error was identified through a review of the medical record, medication administration record, and the facility's medication error form, which confirmed the transcription mistake. The facility's policy required medications to be administered as prescribed, but this was not followed in this instance, leading to the administration of the wrong medication to the resident.
Plan Of Correction
Resident was assessed for changes in condition and any side effects from the medication and none were noted. Assessment was completed by RN unit manager and evaluated by LPN staff nurses on 4/25/25. No new interventions needed. The physician was notified on 4/25/25 and no new orders provided. There was no change in the resident's condition. The facility DON and/or designee completed an audit of orders for patients on Dilantin and/or Diltiazem to ensure that orders are correct. The audit was completed on 6/26/25. All nurses in the facility will be educated on ensuring that appropriate medication is picked from the drop-down box in the EMR and to be aware of look-alike names such as Dilantin and Diltiazem. Education will be completed by DON and/or designee and will be completed by 7/10/25. The DON and/or designee will audit new medication orders on 2-3 residents per unit weekly for 4 weeks. The results of the audit will be forwarded to the QAPI Committee to determine next steps.
Failure to Address and Resolve Resident Council Concerns in a Timely Manner
Penalty
Summary
The facility failed to address and resolve resident concerns raised during Resident Council meetings in a timely manner, as evidenced by repeated documentation of unresolved issues in the council minutes over several months. Concerns included call lights not being answered promptly, requests for an additional smoking break, cold showers in a specific wing, and staff speaking rudely to residents. These issues were consistently brought up in meetings from January through May, with no documented resolution or satisfactory response provided to the residents. Interviews with residents who held leadership roles in the Resident Council revealed ongoing dissatisfaction with the administration's handling of their complaints. The residents reported that their requests, such as having a resident take meeting minutes and meeting without staff present, were not accommodated. They also expressed frustration that their concerns about staff behavior, call light response times, and environmental issues like shower temperature had persisted for months without resolution. Staff interviews confirmed that the concerns raised by residents were not being resolved in a timely manner. The Activities Director acknowledged that resident training to take minutes had not been completed, and the Administrator confirmed that issues such as call light response, staff rudeness, and environmental complaints remained unresolved. The facility's policy required documentation and follow-up on resident concerns, but the process was not effectively implemented, as evidenced by the lack of resolution and ongoing resident dissatisfaction.
Plan Of Correction
maintain ongoing compliance LNHA will audit Resident Council Minutes and Concern forms weekly X4, then monthly x2 to ensure concerns are being resolved timely and appropriately. Results of the audits will be forwarded to the facility QAPI committee for further review and recommendation. F600 Urbana Health and Rehab wishes to point out to any person who reviews this document that we do not necessarily agree with the citations with which we were cited. However, the law requires us to prepare a plan of correction for the citations regardless of whether we agree with them or not. Thus, we have prepared such a plan as noted below. Please note though, that this plan does not constitute an admission that the citations are either legally or factually correct. This plan of correction is not meant to establish any standard of care, contract, obligation, or position, and Urbana Health and Rehab reserves all rights to raise all possible contentions and defenses in any civil or criminal action or proceeding. Please accept 07/30/25 as the facility's allegation of compliance date. The facility failed to ensure residents were safe from abuse, affecting one resident #24. Step 1 Resident #24 was assessed and no negative findings. Resident assessment completed on 6/11/25 by NP. STNA #240 was removed from duty and suspended, personnel file for STNA #240 was reviewed for background check, along with 5 other random staff personnel files, no concerns were identified. Audit completed on 6/6/25. Step 2 To identify other residents that have the potential to be affected, on 6/6/25 the Social Services initiated interviews of those residents able to be interviewed regarding abuse, completing the interviews on 6/6/25 with no negative findings. DON completed skin check on 6-6-25 for non-verbal and cognitively impaired resident with no negative findings. Step 3 To prevent this from recurring, NHA started in house
Medication Error Rate Exceeds 5% Due to Administration Errors
Penalty
Summary
The facility failed to maintain a medication error rate below five percent during a medication pass observation, resulting in a calculated error rate of 6.67%. Two residents were directly affected by medication administration errors. For one resident with a history of chronic obstructive pulmonary disease, osteoporosis, pneumonia, and paroxysmal atrial fibrillation, the LPN administered Senna Plus 8.6-50 mg instead of the ordered Sennoside 8.6 mg. The error was confirmed by the LPN during an interview. Another resident, diagnosed with chronic diastolic heart failure, depression, vascular dementia, paroxysmal atrial fibrillation, and hypertension, received Potassium Chloride ER 20 MEQ in crushed form, contrary to the extended-release medication's administration guidelines. The RN confirmed that the Potassium Chloride ER was crushed and administered in applesauce. Facility policy requires staff to verify correct medication, dose, route, and administration method for each resident, which was not followed in these instances.
Plan Of Correction
F759 Facility observed medication administration error rate of 6.75% affecting residents #43 and #15, when LPN administered Senna Plus to resident #43 instead of ordered Senna and RN crushed potassium chloride for resident #15. Step 1: The facility RN #204 immediately notified the PCP with no new orders on 6/4/25. Residents #43 was assessed by the facility DON with no negative findings and resident #15 was assessed by RN #204 without negative effects observed on 6/4/25. The LPN #257 and RN #204 were immediately educated by the facility DON on medication administration principles as well as medication error prevention. Completed on 6/5/25. Step 2: All residents have the potential to be affected by medication error rate of 6.75%. Step 3: To prevent this from recurring the DON or designee will educate licensed nursing personnel on principles of proper medication administration, including medications that can/cannot be crushed and medication error prevention as well as having updated medication administration competencies. Completed on 7/11/25. Step 4: To monitor and maintain ongoing compliance, the DON or designee will complete medication administration audits 2x per week x4 weeks then 2x per month x2 months. Audits will begin on 7/14/25. The results of the audits will be forwarded to the facility QAPI committee for further review and recommendations. F760 Facility failed to prevent significant medication administration error for resident #15, when RN #204 crushed potassium chloride for resident #15. Step 1: The facility RN #204 immediately notified the PCP; no new orders. The RN #204 assessed resident #15 without negative effects observed. The RN #204 was immediately educated by the DON on medication administration principles as well as medication error prevention with special focus on medications that cannot be crushed. Completed on 6/5/25. Step 2: This has the potential to affect residents that require medications being crushed. The DON will review medication lists for residents that require mechanically altered medications on 7/10/25. Step 3: To prevent this from recurring the DON or designee will educate licensed nursing personnel on principles of proper medication administration and medication error prevention with special focus on medications that cannot be crushed. Completed on 7/11/25. Step 4: To monitor and maintain ongoing compliance, the DON or designee will complete medication administration audits 2x per week x4 weeks then 2x per month x2 months. Audits will begin on 7/14/25. The results of the audits will be forwarded to the facility QAPI committee for further review and recommendations.
Unpalatable and Improperly Prepared Food Served to Residents
Penalty
Summary
The facility failed to prepare palatable food for residents on regular consistency textured diets, as evidenced by multiple observations and interviews. During a lunch meal, several residents received popcorn shrimp that had a white, hard coating and was not browned, making it difficult to chew. Residents who received the shrimp either struggled to eat it or removed it from their mouths due to its unappetizing texture and appearance. Interviews with these residents confirmed that the shrimp was unappetizing and difficult to chew, resulting in their inability to consume the meal. Further investigation revealed that the shrimp was prepared in an oven rather than a deep fryer, which was the appropriate method for this product. The cook confirmed that the facility did not have a deep fryer, leading to the shrimp remaining white and the coating becoming harder. The registered dietitian verified that the shrimp should have had a golden brown appearance and a coating that was easily chewed. Review of the facility's food production and safety policy indicated that foods are to be prepared by methods that maintain, develop, and enhance flavor, which was not followed in this instance.
Plan Of Correction
F804 Urbana Health and Rehab wishes to point out to any person who reviews this document that we do not necessarily agree with the citations with which we were cited. However, the law requires us to prepare a plan of correction for the citations regardless of whether we agree with them or not. Thus, we have prepared such a plan as noted below. Please note though, that this plan does not constitute an admission that the citations are either legally or factually correct. This plan of correction is not meant to establish any standard of care, contract, obligation, or position and Urbana Health and Rehab reserves all rights to raise all possible contentions and defenses in any civil or criminal action or proceeding. Please accept 07/30/25 as the facility's allegation of compliance date. The facility failed to provide residents on a regular diet with palatable food affecting residents 20, 39, 35, 5, 28, 2, 34, 12, 33, 198, 38, 8, 17, 27, 43, 29, 3, 13, 32, 22, 10, 26, 31, 25, 24, 7, 23, and 37. Step 1: Dietary Manager provided identified residents alternate menu items at their request. This was completed on 6/2/25. Step 2: Dietary Manager to audit current food supply to ensure we have ability to prepare the items properly for the best outcomes in taste and presentation. Audit completed to be by 6/30/25. Dietary manager will adjust weekly order to ensure menu items can be prepared by the kitchen appliances. Step 3: RRD to provide education on 6/18/25 to Dietary Manager to order alternative items when a specific way of preparation is unavailable at the facility. Step 4: To monitor and maintain ongoing compliance, RRD/Designee will audit menu and preparation process weekly X4, then monthly x2 to ensure that menu items are being prepared properly with the equipment Urbana kitchen has available. Results of the audits will be forwarded to the facility QAPI committee for further review and recommendation. --- F812 Urbana Health and Rehab wishes to point out to any person who reviews this document that we do not necessarily agree with the citations with which we were cited. However, the law requires us to prepare a plan of correction for the citations regardless of whether we agree with them or not. Thus, we have prepared such a plan as noted below. Please note though, that this plan does not constitute an admission that the citations are either legally or factually correct. This plan of correction is not meant to establish any standard of care, contract, obligation, or position and Urbana Health and Rehab reserves all rights to raise all possible contentions and defenses in any civil or criminal action or proceeding. Please accept 7/30/25 as the facility's allegation of compliance date. The facility failed to prepare food in a sanitary manner affecting 45 residents that received food from the facility kitchen. Observation 1: DM did not have arm coverings on while preparing food and she has a diagnosis of psoriasis. Observation 2: Cook #250 failed to wear gloves nor did she sanitize her hands after touching her face when reassembling the food processor. Step 1: Regional Dietitian educated DM on dress and personal hygiene and instructed to don a jacket and/or arm coverings, completed 6/4/25. Step 2: Regional Dietitian educated Cook #250 on handwashing in the kitchen, handling and storage of equipment and utensils, which included information on avoiding handling equipment that will come in contact with food, the drying of wet equipment, and the use of disposable gloves in the kitchen. Handwashing competencies.
Food Preparation and Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure food was prepared and served in a sanitary manner, affecting 45 residents who received food from the kitchen. Observations revealed that a diet manager with a noncommunicable skin condition on her forearms, characterized by white flakes and reddened skin, performed food preparation, service, and dishwashing duties without consistently covering the affected skin areas. Despite acknowledging the need to cover the flaky skin, the diet manager was observed multiple times with exposed forearms while handling food and washing dishes, and even when a jacket was worn, the sleeves were pushed up, leaving the skin exposed. Facility policy and state code require food employees to keep hands and exposed portions of arms clean and to wear protective coverings when necessary. Additionally, a cook was observed preparing pureed foods while engaging in unsanitary practices, such as rubbing her forehead and partially exposing her hair from under a hairnet during food preparation. The cook did not sanitize her hands after touching her face and hair, and she reassembled a food processor with her bare hands without ensuring the equipment was dry before use. The cook confirmed these actions during interviews. Facility policies require staff to avoid touching food-contact surfaces of cleaned equipment and to wear hair restraints that fully cover hair, but these standards were not followed during the observed food preparation processes.
Plan Of Correction
Completed 6/2/25 by Regional Dietitian. Step 2 The potential to affect all residents. Cognitive residents interviewed for adverse effects in last 30 days, non-verbal or cognitive impaired residents had medical records review with look back of 30 days, to be completed by 7/15/25. Step 3 All dietary staff to be educated by the RRD/designee on Facility policies "Food and Nutrition, Personnel and Training" and "Food and Nutrition, Sanitation and Infection Control" by 6/30/25. Step 4 To monitor and maintain ongoing compliance, RRD/designee will audit 1 dish washing process daily, weekly x4, then monthly x2 to ensure proper sanitation and infection control practices are being adhered to. Results of the audits will be forwarded to the facility QAPI committee for further review and recommendation.
Failure to Perform Hand Hygiene During Medication Pass and Meal Delivery
Penalty
Summary
Facility staff failed to perform proper hand hygiene during medication administration and meal tray delivery, resulting in a deficiency under infection prevention and control standards. During a medication pass, a registered nurse dropped several medications onto the top of a medication cart, which was not clean, and then used her bare, ungloved hand to pick up the medications and place them into a medication cup. The nurse then crushed the medications, mixed them with applesauce, and administered them to a resident with severe cognitive impairment and multiple chronic conditions, including heart failure and atrial fibrillation. Additionally, the dietary manager was observed delivering lunch trays to three different residents without performing hand hygiene between each delivery. The dietary manager entered each resident's room, removed the food tray lid, touched items on the tray and the food delivery cart, and exited the room without using the hand sanitizer dispensers that were available in each room. The dietary manager confirmed during an interview that she did not wash her hands or use hand sanitizer between meal tray deliveries, acknowledging awareness of the proper procedure but stating she did not often deliver trays. A review of the facility's hand hygiene policy indicated that employees are required to use alcohol-based hand rub or wash hands after touching a patient's environment. The observed failures to follow this policy during both medication administration and meal tray delivery directly contributed to the cited deficiency in infection prevention and control.
Plan Of Correction
F880 The facility failed to ensure proper infection control measures when: A) The RN #204 dropped medication for resident #15 on the medication cart during medication administration, then placed medication in a medication cup. B) The Dietary Manager #208 assisted with passing meal trays on the B-front hall without performing proper hand hygiene during tray pass for residents #98, #5, and #99. Step 1: The facility DON immediately educated A) the RN #204 on proper maintenance of infection control practices during medication administration and B) the Dietary Manager #208 on proper hand hygiene practices while passing meal trays. Hand Hygiene competencies were completed on both individuals as well. Completed on 6/10/25. Step 2: This has the potential to affect residents #15, #98, #5, #99; The DON will assess the identified residents #5 and #15 for potential effects on 7/10/25. Unable to assess #98 and #99 as these residents are not identified on the resident identifier list provided by the ODH Surveyors. Step 3: To prevent this from recurring, the DON or designee will educate A) licensed nurses on proper infection control principles during medication administration and B) staff that assist with meals on proper hand hygiene during the meal process. Completed on 7/11/25. Step 4: To monitor and maintain ongoing compliance, the DON or designee will audit A) maintenance of proper infection control practices during medication administration 2x per week x4 weeks then 2x per month x2 months and B) use of proper hand hygiene during tray pass 3x per week x4 weeks then monthly x2 months. Audits will begin 7/14/25. The results of the audits will be forwarded to the facility QAPI committee for further review and recommendations.
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