Arc At Cincinnati
Inspection history, citations, penalties and survey trends for this long-term care facility in Cincinnati, Ohio.
- Location
- 4001 Rosslyn Drive, Cincinnati, Ohio 45209
- CMS Provider Number
- 365044
- Inspections on file
- 41
- Latest survey
- February 10, 2026
- Citations (last 12 mo.)
- 38
Citation history
Health deficiencies cited at Arc At Cincinnati during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, dependence for mobility, and a history of left femur fracture reported an unwitnessed fall and developed left leg and knee pain with swelling. An NP assessed the resident, documented pain and limited ROM in the left leg, but initially entered STAT imaging orders for the wrong limb, leading to X-rays of the right hip and knee that only showed arthritis. Nursing documentation of the fall was absent, and assessment notes contained contradictions about the left leg findings. Orders for X-rays of the left hip and knee were written the following day, along with oral pain medications and a Lidocaine patch, but the left-sided imaging was not completed until several days later, when a suspected distal femur fracture was finally identified. The resident was then transferred to the hospital, where a bicondylar distal femur fracture was confirmed and treated surgically with ORIF. Surveyors determined the facility failed to provide timely treatment of the fracture, resulting in actual harm to the resident.
A resident with a history of repeated falls and multiple comorbidities had a care plan that included non-skid strips on the floor beside the bed as a fall prevention intervention. During surveyor observation, the resident’s bedside area lacked these non-skid strips. A CNA, maintenance staff, and the DON each confirmed that non-skid strips were not in place, and maintenance reported that none were available in the facility. This failure to implement the care-planned intervention occurred despite a facility policy requiring comprehensive person-centered care plans to be developed and implemented.
A resident with multiple care needs and a care plan requiring two-person assistance for all personal care was provided a bed bath by a single CNA. During care, the resident experienced a leg spasm, fell from the bed, and sustained fractures in both legs. Staff interviews confirmed that care was routinely provided by only one CNA, contrary to the documented care plan and facility policy.
A resident with multiple complex medical conditions who was dependent on staff for mobility did not attend scheduled outside medical appointments due to failures in scheduling and arranging transportation. Confusion and poor communication between nursing staff and the transportation coordinator led to missed appointments, with no documentation that transportation was arranged or that appointments were attended, despite physician orders and facility policy requiring such arrangements.
A resident who required two staff for bathing was left unattended by only one staff member, resulting in a fall and fractures to both legs. Other deficiencies included a resident keeping a prohibited electric coffee pot in their room, medications left at the bedside without proper orders or labeling, and a room with a loose metal chair rail and splintered wood, all of which were unaddressed by staff and posed safety hazards.
A resident with chronic pain and opioid dependence missed multiple doses of prescribed methadone due to pharmacy dispensing issues, prescription diagnosis errors, and delays in obtaining new prescriptions or prior authorizations. This led to increased pain, withdrawal symptoms, and emergency room visits. Staff interviews revealed inconsistent medication reordering practices and inadequate documentation, resulting in actual harm to the resident.
Staff conducted verbal shift reports at the nurses' station where residents could overhear protected health information, including diagnoses and medications. Multiple residents with intact cognition reported overhearing confidential details, and an LPN confirmed that this practice occurred and constituted a HIPAA violation. The DON stated that private areas were available for such reports, and facility policy required confidentiality, but these procedures were not followed.
Several nurses did not receive required training on abuse, neglect, and exploitation during orientation or annually, as mandated by facility policy. Employee file reviews and staff interviews confirmed missing documentation of this training, despite expectations set by facility leadership and policy requirements. This deficiency had the potential to affect all residents in the facility.
Surveyors identified expired medications stored in medication rooms and carts, as well as missing and incomplete temperature monitoring for medication refrigerators. An LPN and the DON indicated unclear staff responsibilities and inconsistent training regarding these duties, resulting in expired drugs being accessible and temperature logs not being maintained as required by facility policy.
Staff failed to follow infection control protocols by discarding used towels on the shower room floor and allowing shared use of unlabeled personal care items among residents. Additionally, two residents with respiratory conditions had their nebulizer and CPAP equipment left uncovered and improperly stored, despite staff awareness of correct procedures. Both the DON and Administrator confirmed expectations for individual labeling and proper storage, but these practices were not consistently followed.
The facility did not maintain ongoing communication with dialysis providers for two residents requiring hemodialysis. Staff interviews and record reviews showed that information was not consistently sent to or received from the dialysis center, and required communication sheets were not regularly used. This resulted in a lack of documentation and exchange of critical care information between the facility and the dialysis provider.
Three residents experienced significant medication errors when staff failed to administer medications as ordered, including not updating an eye drop order after an optometrist visit, giving an antipsychotic at the wrong time of day, and missing doses of an antiplatelet medication without documentation or physician notification. Nursing staff and the DON confirmed that these errors resulted from missed order updates and transcription mistakes.
A resident with chronic pain and opioid dependence was prescribed methadone, but nursing staff signed the MAR as if the medication was administered on several occasions when it was not, as confirmed by the absence of narcotic sheet documentation and staff interviews. The resident also reported missed doses due to pharmacy supply issues, and facility leadership acknowledged that this resulted in inaccurate medical records.
A resident with multiple chronic conditions was found unresponsive after an unwitnessed fall, and staff did not complete a required post-fall investigation as outlined in facility policy. Interviews with the DON, ED, ADON, and an RN confirmed the omission, resulting in a deficiency related to fall management.
A resident with cognitive impairment and multiple medical conditions underwent several room changes without proper documentation of the reasons or written notification to the resident and their representative. Staff interviews and record reviews confirmed the absence of required notifications and documentation.
Staff failed to consistently recheck and notify providers about abnormal blood pressure readings for a resident with multiple chronic conditions. On two occasions, the resident had significantly high and low blood pressure readings without follow-up or provider notification, contrary to facility policy and staff expectations as confirmed by interviews with nursing and medical staff.
A resident with multiple risk factors for skin breakdown did not receive required weekly skin assessments or consistent turning and repositioning, as documented by gaps in CNA records. When new pressure ulcers developed, there were delays and incomplete documentation of physician-ordered wound care. Staff interviews confirmed that assessments and interventions were not completed as ordered, resulting in the resident developing advanced stage pressure ulcers and experiencing actual harm.
A registered nurse left a resident's EMR containing confidential health information open and facing the hallway, making it visible to others while administering medications. The resident had multiple diagnoses and moderate cognitive impairment. This action was not in accordance with the facility's policy on medical record confidentiality.
An LPN administered Lorazepam and Modafinil, both controlled substances, to a resident with multiple medical conditions without verifying the medication count or signing out the medications in the controlled substance log, contrary to facility policy requiring proper documentation and accountability for controlled substances.
A nurse failed to administer two prescribed medications to a resident with multiple chronic conditions because the medications were unavailable, resulting in a medication error rate of 7.7% during observed medication passes. This exceeded the regulatory limit of 5% and was identified as a deficiency during the survey.
Surveyors observed that staff failed to follow infection control protocols during medication administration and wound care. An RN did not wear an isolation gown while assisting with wound care for a resident on EBP, and two nurses handled medications improperly—one by placing pills directly into bare hands, and another by picking up a dropped pill with a gloved hand and not performing hand hygiene between residents.
A resident with a history of bipolar disorder and schizophrenia was discharged from a facility without a 30-day notice and was initially sent to a homeless shelter, which refused him due to past behaviors. The facility did not attempt to find alternative placement and relied on a caseworker's plan, leading to the resident being taken to multiple hospitals before being admitted. The facility's policy on discharge was not followed.
The facility failed to prevent and treat pressure ulcers in residents, leading to the development of avoidable stage III pressure ulcers. Despite physician orders for interventions like heel protectors and a low air loss mattress, these were not implemented timely. The lack of a quick reference system for staff and failure to follow the facility's policy on skin assessment contributed to the issue.
The facility's phone system malfunctioned, preventing communication with staff and affecting all 84 residents. Observations over several days showed repeated failed attempts to reach personnel, with calls redirected to a generic message without options to transfer. The Administrator and Receptionist confirmed the issue, which was reported by a family member.
The facility failed to serve meals at palatable temperatures, affecting nearly all residents. During a meal service observation, food temperatures dropped significantly by the time they were served, with chili mac at 96°F, cornbread at 92°F, and milk at 50°F. Residents confirmed their meals were cold and bland, and the Dietary Manager acknowledged the issue, despite a policy to monitor food temperatures.
The facility failed to ensure a safe and homelike environment, affecting 23 residents. Observations revealed damaged drywall in a resident's room and multiple ceiling tiles with brown stains in the therapy gym and common areas, indicating potential water damage. These conditions were confirmed by the Maintenance Director.
A facility failed to implement its policy on injuries of unknown origin when a resident with severe cognitive impairment was found with scratches on her face. Initial documentation by an LPN was struck out by the Interim DON, who claimed the injury did not occur as described. Despite the facility's policy requiring immediate reporting and investigation, the incident was not properly addressed, leading to a deficiency.
A resident with severe cognitive impairment was found with scratches on her face, but the facility failed to report the injury of unknown origin to the state agency in a timely manner. Despite documentation by an LPN and witness statements from CNAs, the interim DON struck out the records, claiming the incident did not occur. The facility's policy required immediate reporting of such incidents, leading to a deficiency citation.
A resident with severe cognitive impairment was found with scratches on her face, but the facility failed to investigate the injury thoroughly. Despite initial documentation by an LPN and notifications to the physician and family, the interim DON struck out the records, claiming incorrect information. Interviews confirmed the injuries, but the facility did not adhere to its policy for investigating such incidents.
A resident admitted with multiple health conditions did not receive their prescribed medications on the evening of admission and the following morning. Despite the availability of some medications in the facility's Pyxis system, they were not administered, and the physician was not notified of the missed doses. The facility's policy on medication errors was not followed, as no incident report or nursing notes were completed.
A resident with severe cognitive impairment and multiple medical conditions was inappropriately restrained with a sheet by an STNA to prevent falls. The resident exhibited aggressive behavior and attempted to get out of the wheelchair, leading to the unauthorized use of the sheet as a restraint. The incident was documented and confirmed through staff interviews and observations.
The facility failed to update a resident's fall care plan with current interventions, despite the resident being at risk for falls and using a low bed and fall mats. This deficiency was confirmed through observations and staff interviews, revealing non-compliance with the facility's fall risk management policy.
Delayed and Incorrect Imaging Orders Resulting in Untimely Treatment of Femur Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely and accurate treatment of a resident’s left leg fracture following a reported unwitnessed fall. The resident had multiple diagnoses, including prior fractures of the left femur, ischemic cardiomyopathy, cerebral infarction, type II diabetes, and heart failure, and was care planned as being at risk for pain with interventions to evaluate the effectiveness of pain interventions. The resident had severely impaired cognition, verbal behaviors, and was dependent on staff for toileting, mechanical lift transfers, and bed mobility. On the date of the incident, the nurse practitioner (NP) acutely evaluated the resident after reports of a possible fall out of bed, with the resident stating he rolled out of bed onto the floor on his right side with knees colliding. There was no nursing documentation of a fall or change-in-plane status. The NP’s documentation regarding the left leg was contradictory, noting both no crepitus or difficulty with passive range of motion (ROM) and that the resident reported pain with passive ROM and did not participate in active ROM. The NP documented that STAT imaging was ordered and gave verbal orders for acetaminophen and a Lidocaine patch, with a plan to re-evaluate the resident in the morning. Later that afternoon, a registered nurse documented that the resident reported an unwitnessed fall on the previous shift and complained of left knee pain with apparent swelling. The RN notified the NP, who assessed that the resident was unable to participate in ROM to the left leg due to pain and placed new orders for an X-ray to the left leg, a one-time dose of acetaminophen, and a Lidocaine patch to the left leg. However, the actual physician orders entered on that date were for a STAT X-ray of the right hip and a Lidocaine patch to the right posterior hip, along with acetaminophen. X-rays completed that evening were of the right knee and right hip, both showing only modest arthritis and osteoarthritis, respectively. The next day, an untimed progress note documented left knee swelling related to the unwitnessed fall and referenced the right hip X-ray findings. New orders were then placed for X-rays of the left hip and left knee, as well as oral anti-inflammatory medication, a muscle relaxer, and a Lidocaine patch to the left posterior hip for pain. Despite the orders for left hip and knee imaging being written the day after the initial evaluation, the X-rays of the left knee and hip were not completed until two days later. When performed, the imaging showed the left knee was highly suspicious for a minimally displaced distal femoral metaphyseal fracture, while the left hip showed only mild degenerative changes without acute fracture or dislocation. The NP later documented reviewing the left-sided X-ray results and arranged for the resident to be sent to the hospital for further evaluation of a suspicious, non-confirmed fracture of the left leg. Hospital records showed the resident was admitted and treated for a closed bicondylar fracture of the left distal femur with open reduction and internal fixation. The resident reported having fallen out of bed on the left side while at the facility but could not provide more information due to baseline dementia, and the hospital was unable to obtain further details from facility staff. Interviews confirmed that the NP acknowledged placing the initial orders for the wrong limb and that the facility’s medical director was not informed of the alleged fall, the fracture requiring surgery, or the incorrect orders until a later date. The facility’s policy on attending physician responsibilities required appropriate and timely medical orders and treatments to enable safe, effective continuing care. Surveyors concluded that the facility failed to ensure timely treatment of the resident’s left leg fracture, resulting in actual harm. The sequence of events included an unwitnessed fall without nursing documentation, contradictory assessment notes, incorrect initial imaging orders for the right side instead of the left, and a delay of several days before the correct left-sided imaging was completed and the fracture identified. This failure affected one resident reviewed for care post fall out of a facility census of 89.
Failure to Implement Care-Planned Non-Skid Floor Strips for Fall Prevention
Penalty
Summary
The deficiency involves the facility’s failure to implement a care-planned fall prevention intervention for a resident identified as being at risk for falls. The resident had multiple diagnoses, including multiple rib fractures, unspecified bipolar disorder, recurrent major depressive disorder, unspecified anxiety disorder, chronic pain syndrome, repeated falls, and stage IV chronic kidney disease. An annual MDS assessment documented that the resident was cognitively intact, had no behaviors, did not reject care, and did not wander. The resident’s care plan, dated 08/14/24, identified fall risk related to refusing environmental modifications, self-medicating, alcohol use, use of mobility devices, and clutter in the room. Among the listed interventions were a cushion in the wheelchair, anti-roll backs to the wheelchair, encouraging use of the call light, a new bed/mattress, education on appropriate footwear, encouraging the resident to keep the bed in the lowest position, non-skid strips to the floor next to the bed, and family decluttering the room. Surveyor observation on 01/27/26 at 12:07 P.M. showed that the resident did not have non-skid strips on the floor beside the bed, despite this being a care-planned intervention. A CNA confirmed at the same time that there were no non-skid strips at the bedside. Later that day, a maintenance staff member verified that the resident did not have non-skid strips on the floor in the room and stated that non-skid strips would have to be ordered because none were available in the facility. On 01/28/26, the DON also confirmed that the resident did not have non-skid strips at the bedside as specified in the care plan. Review of the facility’s Comprehensive Person-Centered Care Plans policy, dated March 2022, indicated that each resident was to have a comprehensive care plan developed and implemented to meet physical, psychological, and functional needs. This deficiency was cited under a complaint investigation and was a recite to a prior annual survey.
Failure to Follow Two-Person Assistance Care Plan Results in Resident Fall and Fractures
Penalty
Summary
The facility failed to implement person-centered care planned interventions for a resident who was dependent on staff for all aspects of personal care, including bathing and bed mobility. The resident, who had diagnoses such as absolute glaucoma, muscle weakness, difficulty walking, and required total assistance, had a care plan specifying that two staff members were required for all care. Despite this, a single CNA provided a bed bath without assistance, during which the resident experienced a leg spasm, fell from the bed, and sustained fractures in both legs. The care plan and MDS documentation clearly indicated the need for two-person assistance, but this intervention was not followed. Interviews with staff confirmed that the resident was always cared for by one CNA, despite the care plan's directive. The CNA involved stated that she never received help from other staff members when providing care to this resident. The incident resulted in the resident being transported to the hospital and not returning to the facility. Facility policy required staff to follow care planned interventions and to implement measures to prevent falls, but these were not adhered to in this case.
Failure to Arrange and Document Transportation for Scheduled Medical Appointments
Penalty
Summary
The facility failed to ensure that a resident was taken to scheduled outside medical appointments, as required by physician orders and the resident's care plan. The resident in question was admitted with multiple complex diagnoses, including paraplegia, autonomic dysreflexia, neuromuscular bladder dysfunction, anxiety disorder, chronic pain syndrome, and major depressive disorder. The resident was dependent on staff for all mobility needs and required stretcher transportation due to being bedbound. Upon admission, the resident had existing appointments scheduled and orders for additional appointments, with instructions for staff to arrange transportation. Despite these requirements, a review of the medical record and interviews with staff revealed that the necessary appointments were not scheduled or attended. The process for arranging appointments and transportation involved multiple staff members, including nurses and the transportation coordinator, but there was confusion and lack of clear responsibility. Nurses were responsible for scheduling appointments and notifying the transportation coordinator, who would then arrange transportation. However, conflicting information, missed communications, and lack of documentation led to appointments not being made or attended. Staff interviews confirmed that there were ongoing issues with communication between nursing and transportation staff, resulting in missed appointments. Further review showed no documentation that the resident attended the scheduled appointments or that transportation was arranged. The Director of Nursing and the Administrator confirmed that there was no evidence in the records of appointments being made or attended, and attempts to verify appointments with outside providers were unsuccessful. The facility's policy required assistance with arranging transportation, but this was not carried out as needed for the resident.
Failure to Provide Adequate Supervision and Maintain a Safe Environment
Penalty
Summary
The facility failed to provide adequate supervision and assistance for a resident who was dependent on two staff members for bathing. Despite care plan interventions specifying the need for two staff during all care, only one staff member was present when the resident experienced a leg spasm, fell from the bed, and sustained fractures in both legs. The staff member involved reported that she routinely provided care alone, as no one would assist her, and the resident confirmed that only one staff member was present during the incident. Facility leadership and documentation confirmed the resident's dependence on staff for all care and the expectation that care plans be followed. The facility also failed to ensure the environment was free from accident hazards for several residents. One resident was found to have a plugged-in electric coffee pot in their room, which was against facility policy due to the risk of burns or fire. Staff and leadership interviews confirmed that such appliances were not permitted, and the presence of the coffee pot had not been reported or addressed. Another resident had expired and unlabeled medications, including a bottle of nasal spray and a cup of white cream, left at the bedside without proper orders or assessment for self-administration. Staff acknowledged that medications should not be left at the bedside and that the resident did not have orders for self-administration. Additionally, a resident's room was observed to have a loose metal chair rail with sharp edges and splintered wood, creating a physical hazard. The maintenance director and DON confirmed that these conditions had not been reported and posed a risk of injury. The facility's failure to maintain a safe environment and to follow policies regarding supervision, medication administration, and environmental hazards resulted in actual harm and placed multiple residents at risk.
Failure to Provide Ordered Pain Medication Resulting in Actual Harm
Penalty
Summary
The facility failed to ensure that ordered pain medication, specifically methadone, was available for administration to a resident with chronic pain syndrome and opioid dependence. The resident missed multiple doses of methadone over several days due to issues with pharmacy dispensing, prescription diagnosis errors, and delays in obtaining new prescriptions or prior authorizations. Documentation showed that the resident missed a total of nine doses over three days, resulting in increased pain and withdrawal symptoms, which led the resident to call 911 and be transferred to the emergency room for treatment. Medical record review and staff interviews revealed that the resident had a history of chronic pain, recent surgeries, and opioid dependence, and was prescribed methadone three times daily. Despite this, there were repeated instances where the medication was not available due to the pharmacy's inability to fill prescriptions with an opioid dependence diagnosis, insurance issues, and delays in obtaining updated prescriptions from the provider. Staff interviews indicated inconsistent practices in reordering medications, lack of timely follow-up with the pharmacy or provider, and inadequate documentation regarding missed doses and communication with the provider. The facility's own policy required that pain medications be administered as ordered and that staff monitor for withdrawal symptoms and communicate with the provider if pain or side effects were not controlled. However, the resident experienced actual harm, including increased pain and withdrawal symptoms, due to the facility's failure to ensure the availability of methadone. The deficiency affected at least one resident and was substantiated by medical records, staff and resident interviews, and pharmacy documentation.
Failure to Protect Resident Health Information During Shift Reports
Penalty
Summary
Staff failed to maintain the confidentiality of residents' personal and medical records by conducting verbal shift reports in areas where other residents could overhear protected health information. Multiple residents with intact cognition reported overhearing details about other residents' diagnoses and medications during staff conversations at the nurses' station. One resident stated that she and others became aware of confidential medical information due to these discussions, and another resident, a former nurse, confirmed that she could hear health information during staff shift reports. A staff LPN acknowledged that shift reports were held at the nurses' station and admitted that residents could overhear protected health information, recognizing this as a HIPAA violation. The DON stated that private areas were available for such reports and did not expect staff to discuss confidential information within earshot of residents. Facility policy required staff-to-staff communication, such as shift reports, to be conducted outside the hearing range of residents and the public, but this was not followed, resulting in a breach of confidentiality for all residents in the facility.
Failure to Provide Required Abuse, Neglect, and Exploitation Training to Nursing Staff
Penalty
Summary
The facility failed to ensure that four nursing staff members received required training on abuse, neglect, and exploitation during orientation and annually, as mandated by facility policy. Employee file reviews showed that three nurses hired within the past two years had no documented evidence of having completed abuse/neglect training within the last 12 months. Additionally, a recently hired nurse had no documentation of receiving this training at all. These findings were confirmed through staff interviews, where the Director of Nursing, Administrator, and Human Resources Director all acknowledged the expectation that staff complete required in-services and that management should monitor compliance. However, the Human Resources Director was unable to explain why the required abuse training was missing for these staff members. The facility's policy on abuse prevention and reporting, updated in 2018, requires all new employees to receive training on abuse policies during orientation and mandates annual training for all staff. The policy specifies that training must cover definitions of abuse, neglect, and exploitation, reporting requirements, and appropriate interventions. The lack of documented training for these four nurses represents non-compliance with both facility policy and regulatory requirements, with the potential to affect all residents in the facility, which had a census of 92 at the time of the review.
Expired Medications and Inadequate Refrigerator Temperature Monitoring
Penalty
Summary
The facility failed to ensure expired medications were discarded and did not maintain proper monitoring of medication refrigerator temperatures. During observations, surveyors found 25 expired heparin lock flush solutions with expiration dates ranging from 03/2023 to 07/2022 in the medication room, as well as expired Solosite wound gel, enema saline laxative, and zinc oxide ointment on the medication cart. All expired items were unopened but accessible for use. Additionally, one medication refrigerator lacked a thermometer, and temperature logs for both medication refrigerators on two units showed significant gaps in daily monitoring and documentation, with several days and even weeks missing entries. Interviews with nursing staff and the DON revealed confusion and inconsistency regarding responsibility for checking medication refrigerators and monitoring for expired medications. The night shift was reportedly responsible for these tasks, but there was uncertainty about staff training and clear assignment of duties. Facility policy required nursing staff to maintain medication storage areas and to contact the pharmacy for instructions on handling outdated medications, but these procedures were not consistently followed, as evidenced by the presence of expired medications and incomplete temperature monitoring.
Infection Control Failures in Shower Room and Respiratory Equipment Storage
Penalty
Summary
Staff failed to maintain proper infection prevention and control practices in the facility's shower rooms and in the storage of respiratory equipment. Observations revealed that used towels were discarded on the shower room floor, and large bottles of shower supplies and hairbrushes were not designated for individual resident use. Multiple staff interviews confirmed that unlabeled personal care items were used by multiple residents, and staff were unsure of the ownership of certain items. Both the Director of Nursing and the Administrator acknowledged that each resident was expected to have their own labeled bath supplies, and that sharing such items posed an infection control concern. Additionally, the facility did not ensure proper storage of respiratory equipment for two residents with significant respiratory needs. One resident, in a persistent vegetative state with a tracheostomy and chronic respiratory failure, had a nebulizer machine and accessories left uncovered on the over-bed table between uses, rather than being stored in a plastic bag as required. Staff interviews confirmed knowledge of the correct storage procedure, but it was not followed due to oversight. The Director of Nursing and Administrator both stated that respiratory equipment should be covered when not in use. Another resident with COPD, asthma, and obstructive sleep apnea used a CPAP machine, but the CPAP mask was repeatedly observed lying uncovered on the resident's dresser rather than being stored in a plastic bag. Staff interviews confirmed that CPAP masks were expected to be stored in bags, but the facility did not have a formal policy for this practice. The Director of Nursing and Administrator both stated their expectation for proper storage, but this was not consistently implemented.
Failure to Ensure Ongoing Communication with Dialysis Providers
Penalty
Summary
The facility failed to ensure ongoing communication with dialysis providers for two residents who required hemodialysis. Both residents had diagnoses including end stage renal disease and were receiving dialysis three times a week. Review of their medical records and care plans indicated that staff were directed to encourage attendance at dialysis appointments, but there was no documentation of communication between the facility and the dialysis center. Staff interviews revealed that information was not consistently sent with residents to the dialysis center, and when residents returned, the facility typically did not receive or review information from the dialysis center, except occasionally for laboratory work. Nurses reported that communication sheets were not being used regularly, and the dialysis center confirmed they had not received information from the facility for several months. The Director of Nursing stated that nurses were responsible for completing and sending dialysis communication sheets with residents for every treatment, and that returned sheets should be uploaded to the electronic medical record and placed in the paper chart. However, this process was not being followed, as evidenced by the lack of documentation and staff statements. Facility policy required arrangements with the contracted dialysis provider to include how information would be exchanged, but this was not occurring, resulting in a deficiency related to the management and communication of dialysis care for residents.
Failure to Administer Medications as Ordered Resulting in Significant Medication Errors
Penalty
Summary
The facility failed to ensure that medications were administered as ordered, resulting in significant medication errors affecting three of six residents reviewed. For one resident with a diagnosis of allergic rhinitis and severely impaired vision, a physician's order for prednisolone acetate eye drops was changed to be administered only in the right eye each morning following an optometrist visit. However, the medication administration records showed that staff continued to administer the drops in both eyes, and the new order was not transcribed or updated in the records. Interviews with nursing staff and the Director of Nursing confirmed that the order change was missed and not implemented as required. Another resident with chronic viral hepatitis C, opioid dependence, and HIV had a physician's order for quetiapine 50 mg to be administered nightly. Upon admission, the medication was incorrectly entered into the medication administration record to be given in the morning instead of at night. This error persisted for several days until the order was corrected. Staff interviews revealed that the error occurred due to oversight during the transcription of hospital orders, and there was no documentation of adverse effects during the period the medication was administered at the wrong time. A third resident with acute respiratory failure, ventricular tachycardia, and atherosclerotic heart disease had a physician's order for clopidogrel bisulfate (Plavix) 75 mg daily. The medication administration records indicated that the medication was not administered on several specified dates, with no documentation or physician notification regarding the missed doses. Staff interviews confirmed that the medication should not have been held without appropriate clinical justification or documentation. Facility policy required medications to be administered as prescribed and within the specified time frame, which was not followed in these cases.
Inaccurate MAR Documentation for Controlled Substance Administration
Penalty
Summary
The facility failed to ensure accurate documentation on the Medication Administration Record (MAR) for a resident with a history of chronic pain syndrome and opioid dependence. The resident was prescribed methadone three times daily for pain management. Review of the MAR for October and November revealed that methadone was signed as administered on several occasions, but there was no corresponding Controlled Drug Record (narcotic sheet) to indicate the medication was available or actually given on those dates and times. Interviews with nursing staff confirmed that they had signed the MAR indicating administration of methadone when, in fact, the medication was not given, attributing the errors to accidental documentation. The resident also reported that there were multiple instances when the facility was unable to obtain methadone from the pharmacy. Facility policy required that medications be administered as prescribed and that staff document administration accurately, including signing the MAR only after giving the medication. The Director of Nursing and the Administrator both confirmed that signing the MAR for medications not administered results in inaccurate medical records. The deficiency was identified through record review, staff and resident interviews, and policy review, and was investigated under a specific complaint number.
Failure to Conduct Post-Fall Investigation
Penalty
Summary
The facility failed to conduct a post-fall investigation for a resident who was found unresponsive on the bathroom floor following an unwitnessed fall. Medical record review showed that the resident, admitted with diagnoses including congestive heart failure, chronic obstructive pulmonary disease, and schizoaffective disorder, did not have documentation of an investigation into the cause of the fall. Staff interviews with the DON, ED, ADON, and an RN confirmed that no post-fall investigation was completed, despite facility policy requiring staff to investigate falls to determine underlying causes and implement appropriate interventions. This deficiency was identified during a review of three residents for falls, with a facility census of 91 residents.
Failure to Notify Resident and Representative of Room Changes
Penalty
Summary
The facility failed to properly notify a resident and the resident’s representative of multiple room changes, as required. Medical record review for a resident with diagnoses including dementia, spinal stenosis, cervical spine injury, neuromuscular dysfunction, bipolar disorder, and a history of opioid and alcohol abuse, revealed that the resident was cognitively impaired and dependent on staff for activities of daily living. The resident experienced room changes on three separate occasions, but there was no documentation in the medical record regarding the reasons for these moves or evidence that the resident or their representative had been notified in writing prior to the changes. Interviews with the facility Administrator and Social Services Director confirmed the absence of documentation for both the reasons for the room changes and the required notifications. Additionally, the resident’s representative confirmed that she had not been informed of the room changes. This lack of notification and documentation was identified during a complaint investigation and affected one of three residents reviewed for room changes.
Failure to Monitor and Report Abnormal Blood Pressure Readings
Penalty
Summary
Facility staff failed to appropriately monitor and respond to abnormal blood pressure readings for a resident with chronic obstructive pulmonary disease, chronic kidney disease, and hypertension. Medical record review showed that on two separate occasions, the resident had significantly abnormal blood pressure readings—one low (91/40) and one high (203/99)—without documentation of a recheck or notification to a physician or provider. Interviews with staff revealed inconsistent practices regarding the rechecking of abnormal blood pressures and provider notification, with one LPN stating she only rechecks if time allows and does not notify providers, while an RN described a protocol of rechecking and notifying based on symptoms. The DON confirmed that staff are expected to recheck abnormal blood pressures within two hours and notify providers, regardless of symptoms. Further review of facility policy indicated that any blood pressure reading above 140/90 is considered hypertension and below 100/60 is hypotension, and that abnormal readings should be reported to a physician and documented at different times of the day. The physician interviewed confirmed that staff should recheck and notify providers if abnormal readings persist. The deficiency was identified during a complaint investigation and affected one resident out of 15 reviewed for blood pressure monitoring, with a facility census of 94 residents.
Failure to Prevent and Manage Pressure Ulcers Resulting in Actual Harm
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevention for a resident with multiple risk factors, including diabetes mellitus type 2, cerebral infarction, vascular dementia, and major depressive disorder. The resident's care plan identified a high risk for skin breakdown due to impaired mobility, incontinence, and impaired cognition, with interventions such as barrier ointment, frequent weight shifting, nutritional monitoring, and a low-air loss mattress. Despite these interventions, there was no documentation of required weekly skin assessments for the entire month of January, and certified nursing assistant (CNA) documentation showed extensive gaps in turning and repositioning the resident as required. Further review revealed that when new wounds were identified on the resident's sacrum and left buttock, there were delays and inconsistencies in implementing and documenting physician-ordered wound care treatments. The Treatment Administration Record (TAR) showed missing or incomplete documentation for several days, and progress notes did not reflect the completion of wound care as ordered. Additionally, shower sheets were not accurately completed, failing to indicate the condition of the resident's skin. The lack of timely and thorough skin assessments and wound care allowed the resident's pressure ulcers to progress to advanced stages, including a stage IV ulcer and an unstageable ulcer. Interviews with facility staff, including the Director of Nursing (DON) and the Wound Nurse Practitioner (WNP), confirmed that required assessments and interventions were not completed as ordered. The WNP stated that the pressure ulcers were pressure-related and should have been avoided with proper turning, repositioning, and timely incontinence care. Facility policy and national guidelines emphasize the importance of regular skin assessments, prompt intervention, and thorough documentation, all of which were not followed in this case, resulting in actual harm to the resident.
Failure to Secure Resident's Electronic Medical Record
Penalty
Summary
A deficiency occurred when a registered nurse left a resident's electronic medical record (EMR) open and visible in a hallway while administering medications in the resident's room. The EMR contained private and confidential health information, which was accessible to other staff and residents passing by. The resident involved had diagnoses including diabetes mellitus type two, vascular dementia, and major depressive disorder, and was assessed as having moderate cognitive impairment. The facility's policy required that medical records be kept confidential and only disclosed to authorized persons with the resident's consent, but this policy was not followed in this instance.
Failure to Account for and Document Controlled Substance Administration
Penalty
Summary
The facility failed to ensure that controlled substances were properly accounted for and signed out after administration. During an observation, an LPN administered Lorazepam 0.5 mg and Modafinil 100 mg, both schedule IV controlled substances, to a resident without verifying the medication count prior to administration and without signing out the medications from the controlled substance log. The LPN confirmed in an interview that she did not check the controlled medication counts or document the administration in the controlled substance log as required. The resident involved had diagnoses including cerebral infarction, generalized anxiety disorder, peripheral vascular disease, and chronic respiratory failure, and required substantial assistance with activities of daily living. Facility policy required that medications, especially controlled substances, be prepared, administered, and recorded by the same licensed nurse, with documentation on both the medication administration record and the individual controlled substance record. These procedures were not followed during the observed medication pass.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as required by regulation. During medication administration, a nurse did not provide two prescribed medications—Stress B/Zinc Oral tablet and Famotidine—to a resident because the medications were unavailable at the time of administration. This omission was confirmed by direct observation and staff interview. The affected resident had multiple diagnoses, including cerebral infarction, generalized anxiety disorder, peripheral vascular disease, gastroesophageal reflux disorder, and chronic respiratory failure, and required significant assistance with daily activities. A review of medication administration for four residents revealed that out of 26 medications administered by three nurses, two were omitted, resulting in a medication error rate of 7.7%. The facility's policy requires medications to be administered according to physician orders and outlines steps to be taken in the event of a medication error. The observed omissions and resulting error rate exceeded the acceptable threshold, constituting a deficiency as identified during the survey.
Infection Control Lapses During Medication Administration and Wound Care
Penalty
Summary
Surveyors identified multiple failures in infection prevention and control practices involving three residents. For one resident with diabetes, vascular dementia, and impaired mobility, a registered nurse assisted with wound care without donning an isolation gown, despite the resident being on Enhanced Barrier Precautions (EBP) due to chronic wounds. The facility's policy required the use of gowns and gloves during wound care for residents under EBP, but this protocol was not followed, as confirmed by the nurse during interview. In two other cases, medication administration practices did not adhere to infection control standards. One nurse administered medications by popping pills directly into his bare hands before placing them in a pill cup for a resident with moderate cognitive impairment. Another nurse picked up a dropped medication from the cart with a gloved hand and administered it to a resident with significant ADL dependence, then proceeded to administer medications to another resident without performing hand hygiene. These actions were inconsistent with the facility's hand hygiene policy, which requires hand cleaning before and after direct resident contact.
Failure to Ensure Safe and Orderly Discharge
Penalty
Summary
The facility failed to ensure a safe and orderly discharge for a resident, identified as Resident #90, who was admitted for surgical after-care following knee surgery and had a history of bipolar disorder and schizophrenia. The resident was initially discharged to a homeless shelter at the request of a caseworker, but the shelter refused to accept him due to his past behaviors, including setting fires. Consequently, the resident was returned to the facility and later discharged again to a hospital, which had previously discharged him, without a confirmed placement. The facility's management was unaware of the resident's violent incidents during his hospital stay prior to admission, as these were not communicated in the hospital notes shared with the facility. Despite the resident not exhibiting violent behaviors while at the facility, the caseworker insisted on discharging him due to his history. The facility did not provide a 30-day discharge notice or attempt to find alternative placement, relying instead on the caseworker's plan, which ultimately led to the resident being taken to multiple hospitals before being admitted. Interviews with facility staff and the caseworker manager revealed that the resident was improperly placed in the facility and that the caseworker should not have taken responsibility for the resident's discharge. The facility's policy on notice of transfer and discharge was not followed, as the resident was not given a 30-day notice, and the discharge was not conducted in a safe and orderly manner, as required by the policy.
Failure to Prevent and Treat Pressure Ulcers in Residents
Penalty
Summary
The facility failed to adequately assess and monitor the skin conditions of residents, leading to the development of avoidable, facility-acquired pressure ulcers. Resident #75, who was admitted without pressure ulcers but was at risk due to conditions such as dementia and diabetes, developed multiple stage III pressure ulcers on the right heel, right flank, and sacrum. Despite physician orders for interventions like heel protectors and a low air loss (LAL) mattress, these were not implemented in a timely manner, contributing to the progression of the ulcers. The facility's lack of a quick reference system for staff to access care interventions further exacerbated the issue. Resident #05, who was also admitted without pressure ulcers, developed a stage III pressure ulcer on the sacrum. The facility failed to notify the physician or document the skin breakdown in a timely manner, delaying appropriate treatment. The resident was at risk for pressure ulcers due to conditions such as a recent hip replacement and impaired mobility. Despite orders for a LAL mattress, it was not put in place until months after the ulcer was identified, indicating a significant lapse in implementing necessary preventive measures. Interviews with facility staff, including the Interim Director of Nursing and various nurses, revealed a lack of awareness and documentation regarding the necessary interventions for pressure ulcer prevention and treatment. The facility's policy on skin condition assessment and monitoring was not followed, as evidenced by the absence of weekly skin assessments and timely physician notifications. The facility's failure to implement physician-ordered interventions and conduct regular skin assessments resulted in the development and progression of pressure ulcers in residents who were initially admitted without such conditions.
Phone System Malfunction Affects Resident Communication
Penalty
Summary
The facility failed to maintain a functional phone system, which had the potential to affect all 84 residents residing in the facility. Observations from November 13 to November 19, 2024, revealed 15 unsuccessful attempts to reach facility personnel via the phone system. Each attempt resulted in a message stating, 'Hello, you have reached the ARC of Cincinnati. It is our pleasure to serve you today. Please leave a message and we will be happy to return your call as soon as possible. Thank you and have a good day.' There was no option to transfer to an individual, department, or nursing unit. The Administrator learned of the phone system's malfunction on November 17, 2024, and the Receptionist confirmed the issue had been ongoing since at least November 14, 2024, when a family member reported the inability to reach staff.
Failure to Serve Meals at Palatable Temperatures
Penalty
Summary
The facility failed to ensure that food was served at a warm and palatable temperature, affecting nearly all residents except two who did not receive food from the facility's kitchen. During an observation of the meal service, it was noted that the dinner meal, which included chili mac, cornbread, salad, green beans, and carrots, was initially prepared at appropriate temperatures. However, by the time the food was served to the residents, the temperatures had significantly dropped, with the chili mac at 96 degrees Fahrenheit, cornbread at 92 degrees Fahrenheit, and milk at 50 degrees Fahrenheit. The Dietary Manager confirmed these temperatures and acknowledged that the food was not hot and was bland in taste, with an unappealing presentation. Interviews with residents confirmed that their meals were cold and bland, corroborating the observations made by the surveyor and the Dietary Manager. The facility's policy on monitoring food temperatures, dated September 2023, was reviewed and indicated that food temperatures should be monitored to prevent foodborne illness and ensure palatable temperatures. Despite this policy, the deficiency was noted under Complaint Number OH00158984, highlighting a failure in the facility's food service process.
Environmental Deficiencies in Nursing Unit
Penalty
Summary
The facility failed to maintain a safe, functional, and homelike environment for its residents, affecting 23 individuals in the Fountains Nursing Unit. During an observation conducted on November 5, 2024, several deficiencies were noted. Resident #23's room had a significant area of damaged drywall with brown and black discoloration near the window. Additionally, the therapy gym and multiple common areas throughout the unit exhibited ceiling tiles with brown ring stains, indicating potential water damage. These observations were confirmed by the Maintenance Director, highlighting the facility's non-compliance with maintaining a suitable living environment.
Failure to Implement Policy on Injuries of Unknown Origin
Penalty
Summary
The facility failed to implement its policy regarding injuries of unknown origin when a resident was found with injuries. Resident #11, who had severe cognitive impairment and was dependent on staff for toileting and transfers, was found with scratches on her left eyebrow and cheek. The incident was initially documented by LPN #401, who notified the physician and family, and initiated an abuse/neglect screening. However, the documentation was later struck out by the Interim DON, who claimed the injury did not occur as described. The facility's Incidents and Accidents Log showed an entry for the injury, which was also struck out by the Interim DON. Despite the initial documentation and notifications made by LPN #401, the Interim DON and ADON #333 later stated that the injuries described in the progress notes were incorrect. The ADON, who assessed the resident with the previous Administrator, claimed there were no injuries as documented, but offered no further explanation or documentation to support this claim. The facility's policy required immediate reporting and investigation of any incident or suspicion of abuse, neglect, or injuries of unknown origin. However, the facility did not follow this policy when Resident #11 was found with injuries. The Interim DON's decision to strike out the documentation without a thorough investigation or explanation led to a deficiency in the facility's handling of the incident.
Failure to Timely Report Injury of Unknown Origin
Penalty
Summary
The facility failed to timely report an injury of unknown origin involving a resident to the state agency. The resident, who had severe cognitive impairment and was dependent on staff for toileting and transfers, was found with scratches on her left cheek and eyebrow. These injuries were documented by an LPN, who also notified the physician and family, and initiated an abuse/neglect screening. However, the documentation was later struck out by the interim DON, who claimed the incident did not occur as described. The interim DON, who began employment after the incident, struck out all related documentation after being informed by the ADON that the injury did not happen. Despite the initial documentation by the LPN and witness statements from CNAs, the facility did not submit a Self-Reported Incident (SRI) to the state agency in a timely manner. The facility's policy required such incidents to be reported immediately, or within two hours if they involved abuse or serious bodily injury, and within 24 hours otherwise. Interviews with the LPN and CNAs confirmed the presence of the injuries on the resident, contradicting the interim DON and ADON's claims. The facility's failure to report the incident as per policy led to a deficiency being cited under a complaint investigation. The report highlights discrepancies in documentation and communication within the facility's administration regarding the incident.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate an injury of unknown source involving a resident with severe cognitive impairment and multiple diagnoses, including Alzheimer's disease and repeated falls. The incident occurred when the resident was found in another resident's room with scratches on her left cheek and eyebrow. Despite the documentation of the injuries by an LPN and notifications made to the physician and family, the interim DON later struck out the documentation, claiming incorrect information. The interim DON, who started employment after the incident, was informed by the ADON that the injury did not occur, leading to the removal of the documentation. However, interviews with the LPN and CNA who discovered the resident confirmed the presence of the injuries. The facility's policy mandates a thorough investigation of any incident involving injuries of unknown origin, which was not adhered to in this case. The facility's incident log and self-reported incidents did not reflect a timely or thorough investigation of the resident's injuries. The interim DON and ADON's actions contradicted the initial findings and documentation by the LPN, resulting in a deficiency for failing to investigate the injury properly.
Failure to Administer Medications Timely Upon Admission
Penalty
Summary
The facility failed to ensure timely ordering and administration of medications for a resident upon admission. The resident, who was admitted with multiple diagnoses including malignant neoplasm of the lung, hepatic encephalopathy, and diabetes mellitus type II, did not receive physician-ordered medications on the evening of admission and the following morning. The medications included essential treatments such as rosuvastatin, melatonin, mirtazapine, olanzapine, omeprazole, and lactulose, which were not administered as per the physician's orders. The facility's Pyxis system had some of the medications available, yet they were not administered. The Interim Director of Nursing confirmed the oversight and acknowledged that the physician was not notified of the missed doses, nor were nursing notes or incident reports completed. The facility's policy requires immediate notification of the physician and documentation in the event of medication errors, which was not adhered to in this case. The consulting pharmacist indicated that a STAT order could have ensured timely delivery of the medications, but this was not done.
Inappropriate Use of Physical Restraint on Resident
Penalty
Summary
The facility failed to ensure a resident was free from physical restraints, which affected one resident with severe cognitive impairment and multiple medical conditions. The resident was admitted with diagnoses including cerebral infarction, brain stem stroke syndrome, dysphagia, cognitive communication deficit, and hemiplegia. The resident required maximal assistance with daily activities and had no orders for physical restraints or assessments completed for such use. On the day of the incident, the resident was observed being aggressive and attempting to get out of his wheelchair. In response, a State Tested Nurse Aide (STNA) tied a sheet around the resident's waist to prevent him from falling, which was not an appropriate or authorized restraint. The resident continued to exhibit combative behavior, and staff, including a Licensed Practical Nurse (LPN), were involved in trying to manage the situation. The incident was documented in progress notes and an incident report, and it was confirmed that the use of the sheet as a restraint was not ordered or assessed. Interviews with staff and observations confirmed that the resident was restrained with a sheet, which was against the facility's policy on physical restraints and abuse. The facility's Director of Nursing (DON) and other staff were notified of the incident, and it was determined that the restraint was inappropriate. The facility's policy review and personnel files indicated that the STNA involved had been educated on abuse and restraint policies but still used the sheet to restrain the resident.
Failure to Update Fall Care Plan with Current Interventions
Penalty
Summary
The facility failed to ensure a resident's fall care plan was updated with current interventions. This deficiency was identified during a review of Resident #01's chart, which revealed that the resident had severe cognitive impairment and required extensive assistance with various activities of daily living. Despite the resident being at risk for falls and requiring specific interventions such as a low bed and fall mats, these interventions were not documented in the resident's fall care plan. Observations confirmed that the resident was using a low bed and fall mats, but these were not reflected in the care plan. Interviews with the Director of Nursing (DON) and a Licensed Practical Nurse (LPN) verified that the fall mat and low bed were not updated in the resident's fall care plan. The facility's policy on managing falls and fall risk, dated March 2018, mandates that staff identify interventions related to the resident's specific risks to prevent falls and minimize complications. The failure to update the care plan with current interventions represents non-compliance and was investigated under Complaint Number OH00152855.
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Surveyors found that multiple hazardous storage areas, including a closet near medical records, a beauty salon used to store chemical cases, a supply room in one nursing station, a room leading to a smoking area, a housekeeping room near therapy, and a lobby storage room, lacked required self-closing or automatic-closing doors. These conditions did not comply with NFPA 101 requirements for hazardous area enclosure and had the potential to affect all residents and staff in an emergency.
Surveyors found that the facility did not conduct fire drills on every shift each quarter and did not vary drill conditions as required by NFPA 101. Record review showed that one shift lacked a documented drill for an entire quarter, and the pattern of drill times and dates did not demonstrate varied conditions. The Maintenance Director confirmed the incomplete and noncompliant fire drill schedule, which affected all residents and staff emergency preparedness.
Surveyors found that the facility did not maintain clear egress corridors as required by NFPA 101, with a TV/video cart plugged into a corridor outlet and multiple unsecured chairs placed in the hallway near resident rooms and the secured unit dining room, including directly in front of a fire extinguisher. These items projected about 29 inches into an approximately eight-foot-wide corridor and were located in front of the handrail, potentially affecting 28 residents and staff’s ability to assist in an emergency. The Maintenance Director confirmed these corridor obstructions during the survey.
A resident with intact cognition receiving Medicare Part A skilled services for metabolic encephalopathy had services discontinued while benefit days remained, but the facility did not issue the required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN). The Social Services Director later confirmed that no SNF ABN was provided and reported she believed only a Notice of Medicare Non-Coverage (NOMNC) was needed when all skilled services were stopped. This practice conflicted with the facility’s written policy, which required SNF ABNs to be issued when extended care items or services were initiated, reduced, or terminated due to expected non-coverage by Medicare.
Surveyors identified that the facility exceeded the acceptable medication error rate when two residents with type 2 DM received insulin doses that were not administered according to orders or manufacturer instructions. In two separate observations, an LPN administered Novolog and another LPN administered insulin glargine and insulin lispro without priming the insulin pens, and the insulin lispro and Novolog were given after the residents had already consumed a significant portion of their breakfast meals, despite orders for administration before meals. Manufacturer information for both insulin products required priming before each injection to ensure accurate dosing, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and specified time frames.
The facility failed to maintain accurate and complete crash cart audits for multiple full-code residents. Surveyors, accompanied by the DON, found that daily crash cart checks did not include verification of supply expiration dates, and that an extension cord documented as present on several audit dates was not actually in the cart. Audit logs also conflicted with the cart’s contents by indicating that required items such as eye protection, saline, and clear plastic were present when they were not. These findings were inconsistent with the facility’s policy requiring the crash cart to be checked every 24 hours and after each use, with prompt replacement of equipment and supplies.
A resident with chronic respiratory failure on supplemental O2, COPD, and cognitive risk factors was repeatedly documented as non-compliant with the smoking policy, including going out to smoke outside designated times and retaining cigarettes and lighters provided by family. Despite prior assessments identifying this resident as unsafe to smoke without supervision, a later assessment classified the resident as safe to smoke independently without documented rationale or care plan update. The resident subsequently went outside alone with an O2 nasal cannula in place, lit a cigarette, and sustained facial burns when the cannula ignited, as observed by staff and confirmed by EMS and ED records. In a separate case, another cognitively impaired resident with a history of falls had a care-planned intervention for non-skid strips in front of a recliner, but observation and staff confirmation showed the strips were not present, despite remaining on the active fall-risk care plan.
Multiple dependent residents did not receive scheduled showers, bed baths, or shaving as outlined in their care plans and the facility’s routine care policy. One resident recovering from spinal surgery missed numerous scheduled showers over several months. Another resident who relied on staff for self-care repeatedly requested shaving but was not shaved, and visible facial hair was observed after a recent shower. A resident with chronic respiratory failure and a tracheostomy, requiring substantial/maximal assist with personal hygiene, had no documented showers for an extended period and was observed with long facial hair, which staff acknowledged should be removed during bathing or as needed. A cognitively impaired resident with ESRD and CHF, scheduled for twice-weekly showers, had multiple undocumented or missed showers and reported not getting showers despite asking aides who said they lacked time. Another cognitively intact resident with hemiplegia and multiple comorbidities, also scheduled for twice-weekly showers, had several dates where documentation showed no shower/bath/bed bath provided or no entry at all, and she reported feeling unclean and unimportant when her showers were missed.
A resident with an indwelling urinary catheter for urinary retention, and care plan interventions requiring the drainage bag to be properly secured with a dignity cover, was observed seated in a chair with the catheter drainage bag uncovered and containing visible dark yellow urine that could be seen from the hallway. Later, an LPN confirmed the catheter bag was lying directly on the floor without a dignity cover. This situation occurred despite facility policy requiring care to be provided in a manner that respects and enhances each resident’s dignity and personal privacy.
A cognitively intact resident with chronic orthopedic pain had a PRN oxycodone order, but multiple doses were signed out on the narcotic log by an RN without corresponding entries on the MAR or documented pain assessments. A CNA/med tech reported frequent problems with this RN’s narcotic counts and documentation, describing erratic behavior when handling narcotic keys. The resident reported taking oxycodone only once or twice daily and otherwise using Tylenol, which conflicted with the number of oxycodone doses signed out. The facility’s investigation found it was inconclusive whether narcotics were misappropriated or whether there was a failure of documentation, but confirmed there was no evidence that all signed-out doses were administered.
Failure to Maintain Self-Closing Doors for Multiple Hazardous Storage Areas
Penalty
Summary
Surveyors identified a deficiency related to hazardous area protection and door requirements under NFPA 101, 2012 Edition. During facility tours, they observed that multiple hazardous storage areas did not have self-closing or automatic-closing doors as required for hazardous areas such as combustible storage and chemical storage. These areas included a closet next to medical records, a beauty salon being used to store cases of chemicals, a supply room in Station #2, and the room leading to the smoking area in Station #3. On a subsequent tour, surveyors observed additional hazardous areas without self-closing doors. The housekeeping room across from therapy and the lobby storage room were both noted to lack self-closing door mechanisms. The facility census at the time was 59 residents, and the surveyors stated that this deficient practice had the potential to affect all residents and staff's ability to assist in an emergency. The Maintenance Director verified these findings at the time they were observed.
Plan Of Correction
K 0321 This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be admissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as its allegation of substantial compliance as of 06/12/2026 K-0321 Doors with Self-Closing Devices Corrective action for resident/s: 1. The closet door next to medical records was lacking a self-closing door on 5/19/2026. Maintenance director to add self-closing device to closet door next to medical records on or before 06/12/2026 in accordance with applicable code. 2. The beauty salon had chemicals stored in it on 5/19/2026. Maintenance director moved chemicals from beauty salon on 05/20/2026 in accordance with applicable code. 3. The supply room on station 2 was lacking a self-closing door on 5/19/2026. Maintenance director to add self-closing door to supply room on station 2 on or before 06/12/2026 in accordance with applicable code. 4. The room to the smoking area on station 3 was lacking a self-closing door on 5/19/2026. Maintenance director to add a self-closing door to the smoking are on station 3 on or before 06/12/2026 in accordance with applicable code. 4. The housekeeping room across from therapy was lacking a self-closing door on 5/19/2026. Maintenance director to add a self-closing door to the housekeeping room across from therapy gym on or before 06/12/2026 in accordance with applicable code. 5. The lobby storage room was lacking a self-closing door on 5/19/2026. Maintenance director to add a self-closing door to the lobby storage room on or before 06/12/2026 in accordance with applicable code. Identification of other residents who may be affected: LNHA and Maintenance director/designee completed a full facility audit for doors with self-closing devices on 05/26/2026. Any corrective action, including, doors identified as needing self-closures will be added on or before 06/09/2026 in accordance with applicable code. Measures for systemic change: LNHA educated Maintenance Director on 05/26/2026 regarding NFPA 101-2012 sections 19.3.2.1 and 19.3.5.9 specifically regarding doors with self-closing devices. How Corrective Action will be monitored Ongoing "Doors with Self-Closing device audit" to be completed weekly x 2 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 06/12/2026
Failure to Conduct Required Quarterly Fire Drills on All Shifts
Penalty
Summary
The facility failed to conduct fire drills in accordance with NFPA 101, 2012 Edition, sections 19.7.1 through 19.7.1.8, specifically by not holding drills every shift each quarter and not varying drill conditions as required. Record review on 06/09/25 at approximately 10:32 A.M. showed there was no fire drill conducted for the first shift during the third quarter. The documented first-shift fire drills occurred on 01/30/26 at 2:42 P.M., 04/30/26 at 1:51 P.M., and 10/31/25 at 10:58 A.M., indicating a missed quarter. Second-shift fire drills were recorded on 02/26/26 at 5:20 P.M., 06/03/25 at 4:35 P.M., 08/29/25 at 3:46 P.M., and 11/25/25 at 5:09 P.M., and third-shift drills on 02/28/26 at 11:47 P.M., 05/30/25 at 12:18 A.M., 07/22/25 at 11:34 P.M., 09/26/25 at 11:40 P.M., and 12/15/25 at 5:17 A.M. The surveyor determined that drills were not conducted under varied conditions and that the required quarterly drill on each shift was not consistently performed. The Maintenance Director confirmed these findings at the time they were identified, and the deficiency had the potential to affect all 59 residents and staff response in an emergency. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency related to facility-wide emergency preparedness practices and documentation of fire drills.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 05/29/2026 K-0712 Fire Drills Corrective action for resident/s: There were no records of a fire drill for the first shift of the third quarter of 2025. First shift fire drill completed on 5/24/2026 by maintenance director/designee with no findings or corrective action necessary. Identification of other residents who may be affected: On 5/26/2026 Maintenance director/designee completed 100% audit of the scheduled fire drills to ensure a drill is scheduled quarterly each shift with no findings or corrective action necessary. Measures for systemic change: LNHA educated Maintenance Director on 05/26/2026 regarding NFPA 101-2012 section 19.7.1.4 through 19.7.1.7. specifically including fire drill frequency requirements. How Corrective Action will be monitored Ongoing "Fire Drill Audit" to be completed weekly x 2 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 05/29/2026
Obstructed Egress Corridors Due to Equipment and Chairs
Penalty
Summary
The facility failed to maintain required clear egress widths in corridors in accordance with NFPA 101, 2012 Edition, sections 19.2.3.4 through 19.2.3.5 and 7.3.2 through 7.3.2.3, creating projections into the egress corridor that exceeded allowable limits. Surveyors observed that on one day in Station #3, a cart with a television and video equipment was plugged into an outlet in the corridor by room 38, and five activity room chairs were placed in the corridor near the secured unit dining room directly in front of a fire extinguisher. On the following day, surveyors again observed chairs in the Station #3 corridor, with four by room 35 and four by the activities room, and the same television cart still in the corridor; the chairs were not secured. The corridor was approximately eight feet wide, and the projections extended approximately 29 inches into the corridor in front of the handrail. These conditions had the potential to affect 28 residents in the facility and the staff’s ability to assist in an emergency, and the Maintenance Director confirmed the observations at the time of discovery. No specific resident medical histories or conditions were described in the report, only that 28 residents were potentially affected and the facility census was 59.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be subsequent remedial measures and should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 05/29/2026 K-0232 Clear path of egress Corrective action for resident/s: 1. On 05/18/2026 station 3 had a cart with a television parked in the corridor by room 38 that exceeded allowable limits. Maintenance director/designee moved the TV cart into the activity room, out to the corridor on 05/18/2026 in accordance with applicable code. 2. On 5/18/2026 station 3 had 5 chairs in the corridor near the dining room directly in front of the fire extinguisher. Maintenance director/designee moved the chairs into the dining room, out of the corridor on 5/18/2026 in accordance with applicable code. 3. On 5/19/2026 station 3 had 4 chairs by the activity room and 4 by room 35. In addition, the TV cart was in the corridor. The maintenance director/designee moved the chairs and TV cart into the dining room, out of the corridor on 5/19/2026 in accordance with applicable code. Identification of other residents who may be affected: Maintenance director/designee completed a 100% facility audit for clear paths of egress on 5/26/26 with no findings or corrective action necessary. Measures for systemic change: Maintenance Director/designee educated staff on 5/26/2026 regarding NFPA 101-2012 section 19.2.3.4 and 19.2.3.5 specifically including maintaining a clear path of egress. How Corrective Action will be monitored Ongoing "Path of Egress Audit" to be completed weekly x 2 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 05/29/2026
Failure to Issue Required SNF ABN When Discontinuing Medicare Part A Services
Penalty
Summary
The deficiency involves the facility’s failure to issue a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) when Medicare Part A services were discontinued for a resident who still had available benefit days. The resident was admitted with a diagnosis of metabolic encephalopathy and had intact cognition per the Minimum Data Set assessment. The facility’s own SNF Beneficiary Notification Review documented that Medicare Part A skilled services began on 02/11/26 and the last covered day was 03/11/26, and that the facility initiated discharge from Medicare Part A services before the resident’s benefit days were exhausted. Despite this, no SNF ABN was provided to the resident or the resident’s representative. During interviews, the Social Services Director stated that the SNF ABN was issued hours prior to the last covered day but, upon reviewing her files, confirmed that no SNF ABN had actually been issued for this resident. She further explained that she believed an SNF ABN was only required if one skilled service remained and that if all skilled services were being discontinued, only the Notice of Medicare Non-Coverage (NOMNC) needed to be issued. The Administrator, however, stated that a resident should always receive both a SNF ABN and a NOMNC when Medicare Part A services are discontinued and benefit days remain. Review of the facility’s written policy dated 03/28/23 showed that the facility was required to issue SNF ABNs for initiation, reduction, or termination of extended care items or services when Medicare payment was not expected, which did not occur in this case.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as its allegation of substantial compliance as of 05/29/2026 F-0582 Corrective action for resident/s: On 5/14/26 Resident #34 was informed of rights and responsibilities related to Advanced Beneficiary Notice and voiced understanding of information for future reference by administrator. Identification of other residents who may be affected: Any resident receiving skilled services from nursing or therapy services. The Administrator audited all residents who were discharged from skilled services in the past 30 days to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary Notice on 5/29/26. No non-compliance was noted. Measures for systemic change: On 5/14/2026 Business Office Manager, Director of Rehab, Minimum Data Set nurse, Director of Nursing and Social Services Director were educated on proper procedure of issuing of Notice Of Medicare Non Coverage and Advanced Beneficiary Notice by administrator. All upcoming discharges from skilled services will be reviewed weekly at Utilization Review meeting to ensure notices will be delivered timely. How Corrective Action will be monitored: Administrator or designee to complete audits of all residents being discharged from skilled services to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 5/29/26
Insulin Administration Errors and Failure to Prime Insulin Pens
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5%, with surveyors identifying 3 errors out of 28 medication administration opportunities, resulting in a 10.71% error rate. For one resident with type 2 diabetes mellitus and moderate cognitive impairment, the physician’s order directed Novolog insulin 10 units via subcutaneous pen-injector to be given before meals. During an observed medication pass, the LPN administered 10 units of Novolog insulin without priming the pen and did so after the resident had already consumed approximately 50% of the breakfast meal. The LPN later confirmed she did not prime the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer instructions for the Novolog FlexPen specified that an air shot (priming) must be performed before each injection to ensure proper dosing. Another resident, also diagnosed with type 2 diabetes mellitus and with intact cognition, had orders for insulin glargine 35 units subcutaneously twice daily and insulin lispro 20 units subcutaneously before meals, plus 12 units subcutaneously if blood glucose was between 251 mg/dL and 300 mg/dL. During an observed medication administration, an LPN administered 35 units of insulin glargine and 32 units of insulin lispro without priming the insulin pens and after the resident had consumed approximately 90% of the breakfast meal, despite orders for insulin lispro to be given before meals. The LPN later stated she could not remember if she had primed the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer information for insulin lispro stated that the pen must be primed before each injection to confirm insulin delivery and remove air, and that failure to prime could result in too much or too little insulin. The DON confirmed the expectation that insulin be administered as ordered, including priming each pen with two units before dialing the prescribed dose, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and required time frames.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 5/29/2026. F-0759 Corrective action for resident/s: Residents #21 and #22 were assessed and evaluated by nurse and Director of Nursing 5/14/26. Resident #21 and #22 both denied any adverse effects and none were noted upon assessment by the Director of Nursing on 5/14/2026. Notification made to physician on 5/14/2026. LPN # 2 competency Eval on insulin administration with the Director of Nursing completed 5/14/2026. Identification of other residents who may be affected: Diabetic residents on assignment of LPN #2/station 2 have the potential to be affected and were assessed by the DON/Designee on 5/14/26 and found to be within normal limits. Measures for systemic change: All Nurses were educated by the Director of Nursing on the steps for Insulin administration per competency, diabetes clinical protocol policy, Medication and treatment orders policy, administering medications policy, and Obtaining fingerstick Glucose Level policy On 5/14/2026. How Corrective Action will be monitored: Director of Nursing and Assistant Director of Nursing will complete insulin administration audits on 5 nurses. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance: 5/29/2026
Inaccurate Crash Cart Audits and Missing Emergency Equipment
Penalty
Summary
The facility failed to ensure accurate and complete crash cart audits for residents requiring basic life support, affecting eighteen of thirty-five residents who were designated as full code. During an observation of the crash cart with the DON, surveyors found that the daily audit documentation for the month did not include verification of expiration dates for crash cart supplies. Review of the crash cart audit logs showed that an extension cord was documented as being in the cart on multiple dates, but the extension cord was not present in the cart at the time of inspection. Additionally, the audit documentation indicated that required items, including eye protection, saline, and clear plastic, were not present in the crash cart, yet they were documented as being in the cart. The facility’s undated “Emergency Crash Cart” policy stated that the crash cart is to be checked every 24 hours and after every use, and that equipment and supplies are to be noted and replaced promptly, but the observed documentation and contents of the cart did not match these requirements. This deficiency was verified with the DON at the time of the survey and was cited under the requirement that personnel provide basic life support, including CPR, to residents requiring emergency care, subject to physician orders and advance directives, and was investigated under Complaint Number 2687380.
Plan Of Correction
Cridersville Care Center Provider Number:366171 Survey Type: Complaint Survey Survey Date: 04/29/26 This Plan of Correction (PoC) outlines the actions completed by the facility with regards to the deficiency citation. This Plan of correction does not constitute any admission of guilt or liability by the facility and is submitted only in response to the regulatory requirements. Please accept the following as the facility's credible allegation of compliance as of 4/30/26. F678 CPR All Full Code residents #18 have the potential to be affected by the alleged deficiency. On 4/27/26 the DON/ADON re-stocked the crash cart per the inventory sheet for all missing items. Crash cart inventory sheet updated and new one will go into effect on 5/1/26. All licensed nursing staff provided with training related to crash cart inventory being a daily audit review using inventory sheet on 4/27/26 per DON/designee. The DON/designee will conduct clinical rounds and conduct a random audit of crash cart three times per week for 4 (four) weeks to ensure compliance. The results of the audit will be documented. The facility conducted an Ad-Hoc QAPI meeting on 4/27/26 and discussed the alleged deficiency and corrective actions. Date when corrective action will be completed: 4/30/26
Unsafe Smoking Practices with Oxygen and Missed Fall-Prevention Interventions
Penalty
Summary
The deficiency involves the facility’s failure to provide a safe smoking environment, adequate supervision, and appropriate implementation of its smoking policy for a resident who used oxygen and smoked, as well as failure to implement fall-prevention interventions as care planned for another resident. One resident had multiple relevant diagnoses, including chronic respiratory failure with hypoxia, COPD, end-stage renal disease, dependence on supplemental oxygen, diabetes, and necrotizing fasciitis. Her care plans identified impaired visual function, risk for respiratory complications related to a history of smoking, and risk for cognitive decline, with interventions including use of oxygen per order and observation for understanding. A smoking-related care plan created earlier documented that she wished to use smoking products, had been assessed as safe to smoke "with supervision," and was non-compliant with the smoking policy, with family continuing to provide smoking supplies despite education and a verbal warning for non-compliance. Smoking assessments and progress notes showed a pattern of non-compliance and inconsistent classification of this resident’s smoking safety. Multiple smoking observation/assessments completed earlier in March documented that she had no cognitive loss, visual deficits, or dexterity problems but was unsafe to smoke without supervision because she did not return smoking materials and did not follow designated smoke times. Progress notes described her going out to smoke multiple times by herself or with family, including sneaking out next door with a cigarette and going out multiple times in one evening, with staff documenting that she was "reeducated" and that family brought in cigarettes and lighters which she did not return to staff. Despite this history, a smoking assessment completed after a three-day hospital stay assessed her as safe to smoke without supervision, with no documentation explaining how this conclusion was reached or evidence that her care plan was updated accordingly. On the day of the incident, the resident reported she had cigarettes and a lighter on her person after returning from dialysis and stated she "could not find a nurse" and went outside to smoke, saying she "guessed" she forgot she had her oxygen on. A CNA observed her outside and saw a flame coming through the resident’s oxygen nasal cannula tubing, turned off the oxygen tank, removed the tubing, and patted out sparks on the resident’s shirt sleeve. The resident’s face and hands appeared black in color, and EMS documented first-degree burns to the head and face, with the resident stating she lit a cigarette with her nasal cannula on, causing the burn. The hospital record described her face as black from smoke and her lips and mouth as "burnt and charred," with a recommendation for intubation that she refused. The facility’s incident report recorded that she went outside with oxygen on to smoke without notifying staff, that staff witnessed the occurrence as she walked through the dining room door to the courtyard, and that she stated she thought she had turned her oxygen off. The facility’s smoking policy required interdisciplinary evaluation to determine safe versus unsafe smokers, staff maintenance of all smoking paraphernalia for both safe and unsafe smokers, and progressive consequences for policy violations. A separate deficiency involved another resident at risk for falls whose care plan included use of non-skid strips on the floor in front of her recliner as a fall-prevention intervention. This resident had severe cognitive impairment, used a walker and wheelchair, required supervision or touching assistance for transfers and ambulation, and had experienced two or more falls without injury since the prior assessment. The fall-risk care plan, initiated at admission, specified non-skid strips in front of the recliner beginning in November. However, nursing staff interviewed were not familiar with all of the resident’s fall-prevention interventions without checking the record, and observation of the room showed two recliners with no non-skid strips on the floor in front of them. An LPN confirmed that the non-skid strips were not present despite the intervention remaining active in the care plan, and moving the recliners did not reveal any strips. The facility’s fall management policy required identification of hazards and risk factors, implementation of interventions to minimize falls and injuries, and development and implementation of a care plan based on interdisciplinary evaluation, with interventions related to identified risk factors.
Plan Of Correction
Smoking: On 03/21/26 at 3:16 P.M. 911 response was activated for Resident #11 and Medical Director #601 was notified by Registered Nurse (RN) #322. On 03/21/26 at 3:18 P.M. on-call Nurse/Social Services #423 immediately notified the Administrator and Director of Nursing (DON) #304 of the incident involving Resident #11. On 03/21/26 at 3:22 P.M. Emergency Medical Services (EMS) arrived onsite. At 3:30 P.M. Resident #11 was transported to the emergency room. On 03/21/26 at 3:30 P.M. RN #322 completed a smoking re-assessment of Resident #11 assessing the resident to be an unsafe smoker requiring supervision due to failure to remove oxygen prior to entering designated smoking area. On 03/21/26 from 3:38 P.M. through 7:57 P.M. Licensed Practical Nurse (LPN) #337, #336, #335, #338; RN #334, and DON #304 re-assessed residents (who smoke). This included Resident #22, Resident #3, Resident #47, Resident #50, Resident #60, Resident #150, Resident #86, and Resident #10 to determine smoking safety (via smoking assessment). Each resident was re-educated regarding the facility smoking policy and staff verified there were no smoking materials on their person. The residents' smoking materials would be maintained by facility staff and distributed per policy. On 03/21/26 at 4:30 P.M. DON #304 responded to facility and an Ad Hoc (not scheduled) Quality Assurance (QA) meeting was held via telephone with the Administrator, DON #304 and Medical Director #601 to review investigative findings and plan of action. A root cause analysis was completed and determined Resident #11 had smoking materials on her person (believed to be obtained from family without staff knowledge) and failed to remove her oxygen. The QA team discussed a corrective action plan. On 03/21/26 from 5:00 P.M through 03/22/26 at 3:00 P.M. 26 RNs, 13 LPNs, one medical technician (MT), 54 Certified Nursing Assistants (CNA) four activities staff, one central supply staff, 11 dietary staff, 12 housekeeping staff, three laundry staff, one medical records staff, two social designees, two maintenance staff, nine administrative staff, and 19 therapy staff (158 staff at the time of the incident) were provided education regarding the facility smoking policy by DON #304 and the Administrator. This was completed via 1:1, small group in-services or via phone. Newly hired staff would receive education during general orientation regarding the facility's smoking policy. On 03/21/26 at 5:00 P.M. DON #304 completed an audit of all residents who smoke (Resident #22, Resident #3, Resident #47, Resident #50, Resident #60, Resident #150, Resident #86, and Resident #10) to verify smoking evaluations and plans of care accurately reflected the residents' smoking safety needs. The residents were educated on the facility smoking policy, and smoking materials were to be maintained at the nurses' station. An audit was completed which included verification of required safety measures present in designated smoking areas, including an ash can, fire extinguisher, fire blanket, ash trays and no oxygen signs. There were no identified concerns or changes made because of the audits. On 03/21/26 at 8:55 P.M. Resident #11 returned from the ED. LPN #332 verbally educated the resident regarding the facility smoking policy which included the need for supervision, a smoking apron (to be worn) and the facility smoke times. LPN #332 verified no smoking materials were on the resident's person or in her room at this time. On 03/23/26 at 11:00 A.M. the Interdisciplinary Team (IDT) (Administrator, DON #304, Medical Director #601, RN #302, Social Services #427, Social Services #423, DON #300, and Maintenance #436) met in-person to review the plan of action with DON #304/designee to complete weekly monitoring of residents who smoke and designated smoking areas weekly for four weeks with Housekeeping responsible to complete the cleaning. Housekeeping staff were responsible for cleaning ashtrays and the designated smoking area daily. Audits to be reviewed and any further actions required to be directed by the Quality Assurance and Performance Improvement (QAPI) Committee during scheduled meetings. The IDT also reviewed all current smoking assessments and care plans for residents who smoke. Resident #50 required a change in supervision levels with smoking due to cognition levels and her plan of care as well as Resident #11's plan of care was updated to reflect supervision/safety. On 03/23/26 from 3:45 P.M. to 8:55 P.M. Social Services #423 re-educated residents who smoke (Resident #22, Resident #3, Resident #47, Resident #50, Resident #60, Resident #150, Resident #86, Resident #10) and responsible parties, if applicable regarding the facility smoking policy and supervision levels. On 03/23/26 at12:13 P.M. Social Services #427 contacted Resident #11's family member (#602) to schedule a care conference. Family member #602 and Family Member #603 were not available to meet until 03/27/26. On 03/23/26 at 1:00 P.M. staff education related to smoking areas, removal of oxygen prior to entering smoking area and maintaining smoking materials at the nurses' station for residents who smoke was initiated by DON #304 and the Administrator via 1:1, small group in-services or via phone call. Education was completed for all 158 staff by 03/24/26 at 1:00 P.M. Newly hired staff would be educated during general orientation regarding the facility's smoking policy. The facility does not utilize agency staff. On 03/27/26 at 11:00 A.M. a care conference was held with Resident #11 and Family Members #602 and #603, the Administrator, Social Services #423 and Social Services #427. The facility smoking policy was reviewed. The resident and family were informed an involuntary discharge would be initiated should the resident exhibit non-compliance moving forward and supervision would be increased beyond the two-hour standard of care to monitor more closely for non-compliance with the facility smoking policy. Family Member #602 stated he educated his siblings as well. On 04/10/26 at 2:00 P.M. DON #304 initiated education with 26 RNs and 13 LPNs (100% of nurses educated) regarding completion of the smoking evaluation via 1:1, small group in-services, or phone. The education was completed by 6:00 P.M. on 04/10/26. A new resident who smokes must remain supervised until the interdisciplinary team (IDT) reviews and determines smoking safety, at which time the care plan is developed and resident and family education is provided. The communication through the staff would be the care plan. Newly hired staff receive education during general orientation regarding the facility's smoking policy and completion of smoking evaluation via Point Click Care (PCC). On 04/10/26 at 4:29 P.M. DON #304 initiated an order in PCC for the nurse to verify, each shift, that Resident #11's smoking materials were maintained at the nurses' station. On 04/13/26 at 5:30 P.M. DON #304 initiated orders in PCC for nurses to verify, each shift, that all residents who smoke would have smoking materials maintained at the nurses' station. An updated list of smokers included: Resident #60, Resident #50, Resident #11, Resident #86, Resident #113, and Resident #151. On 04/13/26 at 5:45 P.M. DON #304 initiated questionnaires for staff regarding the smoking policy with re-education provided as needed via 1:1 and small group in-services for staff currently in the facility with all staff to be questioned/educated prior to working their next scheduled shift. Falls: On 4/9/26, Maintenance Director placed non-skid strips on the floor in front of Resident #12's recliner. Like Residents are identified as residents who have had a fall within the facility. Utilizing the Fall Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, an audit of falls and appropriate interventions for the past 30 days will be completed by the Director of Nursing or designee to ensure fall interventions are in place per plan of care. This audit along with identified corrections will be completed on or F 0689 before 5/13/26. The Director of Nursing or designee will re-educate licensed nurses and STNA/CNAs on the Fall Management Policy to include fall interventions to be in place per the care plan. This education will be completed on or before 5/13/26. Utilizing the Fall Management Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, the Director of Nursing or designee will complete an audit of new admissions, new readmissions and residents who experience a fall within the last 7 days, weekly for four weeks, beginning 5/14/26 to ensure fall safety interventions are in place per plan of care. Current fall interventions found to not be in place will be corrected with all intervention in place per plan of care. Negative findings to be addressed immediately and negative trends or system wide issues will be reported to the QAPI committee, and the action plan will be adjusted as needed.
Removal Plan
- Activated 911 response for Resident #11 and notified the Medical Director.
- On-call Nurse/Social Services immediately notified the Administrator and DON of the incident.
- EMS arrived onsite and Resident #11 was transported to the emergency room.
- Completed a smoking re-assessment of Resident #11, determining the resident was an unsafe smoker requiring supervision due to failure to remove oxygen prior to entering the designated smoking area.
- Re-assessed all residents who smoke (Residents #22, #3, #47, #50, #60, #150, #86, and #10) to determine smoking safety via smoking assessment.
- Re-educated residents who smoke regarding the facility smoking policy and verified there were no smoking materials on their person.
- Implemented that smoking materials would be maintained by facility staff and distributed per policy.
- Held an ad hoc QA meeting to review investigative findings and plan of action.
- Completed a root cause analysis determining Resident #11 had smoking materials on her person and failed to remove oxygen.
- Developed a corrective action plan.
- Provided facility-wide education to staff on the facility smoking policy.
- Implemented that newly hired staff would receive smoking policy education during orientation.
- Completed an audit of all residents who smoke to verify smoking evaluations and plans of care accurately reflected smoking safety needs.
- Ensured smoking materials were maintained at the nurses’ station.
- Audited designated smoking areas for required safety measures (ash can, fire extinguisher, fire blanket, ash trays, and no-oxygen signs).
- Provided verbal education to Resident #11 on smoking policy (supervision, smoking apron, smoke times).
- Verified no smoking materials were on Resident #11’s person or in her room.
- Conducted an in-person IDT meeting to implement weekly monitoring of residents who smoke and designated smoking areas weekly for four weeks.
- Assigned housekeeping to clean ashtrays and the designated smoking area daily.
- Directed audits to be reviewed by QAPI.
- Reviewed all current smoking assessments and care plans for residents who smoke.
- Updated Resident #50’s supervision level.
- Updated Resident #11’s plan of care to reflect supervision/safety.
- Re-educated residents who smoke and responsible parties (as applicable) regarding the facility smoking policy and supervision levels.
- Contacted Resident #11’s family to schedule a care conference.
- Initiated additional staff education regarding smoking areas, removal of oxygen prior to entering smoking area, and maintaining smoking materials at the nurses’ station.
- Held a care conference with Resident #11 and family to review smoking policy.
- Informed resident/family that involuntary discharge would be initiated for future non-compliance.
- Increased supervision beyond the two-hour standard of care to monitor more closely for non-compliance.
- Provided education to all nurses regarding completion of the smoking evaluation.
- Implemented that new residents who smoke must remain supervised until IDT review determines smoking safety and care plan/education are completed.
- Entered an order in PCC for nursing to verify each shift that Resident #11’s smoking materials were maintained at the nurses’ station.
- Entered orders in PCC for nursing to verify each shift that all residents who smoke have smoking materials maintained at the nurses’ station.
- Initiated staff questionnaires regarding the smoking policy with re-education as needed.
- Required all staff to be questioned/educated prior to working their next scheduled shift.
Failure to Provide Scheduled Bathing and Shaving Assistance for Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide scheduled and needed bathing and shaving assistance to multiple dependent residents in accordance with their care plans, preferences, and the facility’s routine care policy. One resident with spinal stenosis and recent L2–L5 decompression fixation fusion was care planned for substantial/maximal assistance with shower/bath and toileting hygiene and was scheduled for showers on Tuesdays and Fridays. Electronic documentation from early January through early April showed this resident did not receive a shower or bed bath on 11 identified scheduled days, and the DON confirmed these missed bathing events. Another resident with dysphagia and developmental issues, who required assistance with self-care and mobility, reported that she asked staff to shave her but they did not, which bothered her. During an observation following a recent shower, she stated she had not been shaved and that the hair "itched"; small gray hairs were visible on her chin. A CNA confirmed the presence of gray chin hairs and acknowledged the resident needed shaving, stating it would be addressed with the next scheduled shower. A further resident with chronic respiratory failure, tracheostomy status, heart failure, moderate intellectual disabilities, anxiety, depression, and PTSD required substantial/maximal assistance with personal hygiene and had a care plan for assistance with self-care, including personal hygiene. Her shower schedule called for showers on Monday and Thursday nights, with complete shaves for men and women. Review of documentation showed her last recorded shower/bath was nearly a year earlier, with no indication of additional personal hygiene or facial hair removal on that date. Observations on two separate days showed long white hairs on her chin and jaw line, which a CNA later confirmed, stating facial hair removal should occur with baths/showers or as needed. A resident with end stage renal disease, respiratory failure, hyperlipidemia, and congestive heart failure, who had impaired cognition and required partial/moderate assistance with bathing and personal hygiene, was scheduled for showers on Wednesdays and Saturdays. Review of shower documentation from admission through early April revealed no showers provided or refusals documented on at least ten scheduled shower days. In interviews, this resident reported not receiving scheduled showers, was unsure of his shower days, and stated he could use a good scrub down, adding that he had asked aides who told him they did not have time. A CNA explained that shower days appear on shower sheets and in the computer and that CNAs are supposed to document daily, with nurses checking the documentation; the DON verified the resident had not received showers per schedule or preference. Another resident with a fracture of the lower end of the left humerus, hemiplegia and hemiparesis after cerebral infarction, rheumatoid arthritis, hypertensive heart disease, urinary retention, and osteoarthritis was care planned as non–weight bearing to the left upper extremity and requiring substantial/maximal assistance with showering/bathing. Her electronic record showed she was scheduled for showers on Wednesdays and Saturdays. The shower task question "did the resident receive a shower/bath/bed bath?" was documented as "no" on three dates, indicating no shower/bath/bed bath was completed, and left unanswered on three additional dates. The DON confirmed that one missed shower was due to an outside appointment, that on two dates the "no" response meant no bathing of any type occurred, and that on three dates there was no documentation at all. The resident, who was cognitively intact, reported that missing showers made her feel unimportant compared to others and that she did not feel clean when her shower was missed. Facility policy on routine resident care stated that showers, tub baths, and shampoos are to be scheduled according to person-centered care or state guidelines, with additional showers given upon request, but the documented and observed care did not reflect consistent provision of scheduled bathing and shaving for these residents.
Plan Of Correction
1. Resident #5 received a shower by the STNA on 4/13/26. Resident #8 received a shower by the STNA on 4/8/26. Resident #9 received a shower and had their chin shaved by the STNA on 4/14/26. Resident #70 received a shower by the STNA on 4/13/26. Resident #76 received a shower and had their chin shaved by the STNA on 4/15/26. 2. Like residents are identified as residents who need assistance with showering and shaving. Utilizing the Shower Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, an audit of like residents will be completed by the Director of Nursing or designee to ensure that showers and resident shaving are completed. This audit along with identified corrections will be completed on or before 5/13/26. 3. The Director of Nursing or designee will re-educate licensed nurses and STNA's on the Routine Resident Care Policy to include bathing and shaving residents. This education will be completed on or before 5/13/26. 4. Utilizing the Shower Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, the Director of Nursing or designee will complete an audit of 4-6 residents weekly for four weeks, beginning 5/14/26 to ensure that showers and resident shaving are completed. Noncompliance found during audits will be addressed and assistance with showers and/or shaving provided. Negative findings to be addressed immediately and negative trends or system wide issues will be reported to the QAPI committee, and the action plan will be adjusted as needed.
Uncovered Urinary Catheter Drainage Bag Compromises Resident Dignity
Penalty
Summary
The facility failed to maintain a resident’s right to privacy and dignity related to management of an indwelling urinary catheter. A resident admitted with malignant neoplasm of the esophagus and type II diabetes mellitus had a care plan identifying risk for urinary tract infection and catheter-related trauma due to an indwelling catheter for urinary retention. The care plan interventions included ensuring the catheter tubing was secured and the drainage bag was properly secured with a dignity cover in place. Physician orders directed that the resident’s 16 French indwelling urinary catheter be changed every 30 days and as needed, and the comprehensive MDS documented that the resident had an indwelling catheter and was cognitively intact. During observation, the resident was seen seated in a chair with the urinary catheter drainage bag hanging from the chair without a dignity cover, and dark yellow urine was visible in the bag from the hallway. In a later observation and interview, an LPN confirmed that the catheter bag was lying directly on the floor and did not have a dignity cover. Attempts to interview the resident to confirm cognitive status were unsuccessful, as the resident was unable to answer screening questions. Review of the facility’s “Resident Dignity & Personal Privacy” policy stated that the facility should provide care in a manner that respects and enhances each resident’s dignity, individuality, and right to personal property, which was not followed in this instance when the catheter drainage bag was left uncovered and visible.
Plan Of Correction
The Laurels of Athens wishes to have this plan of correction submitted as our written allegation of compliance. Preparation and/or execution of this plan of correction does not constitute admission to nor agreement with, either the existence of, or the scope and severity of, any of the cited deficiencies or conclusions set forth in the statement of deficiencies. This plan is prepared and/or executed to ensure continuing compliance with regulatory requirements. Our alleged date of compliance is 5/13/2026. 1. On 4/6/26, Resident #92's catheter bag was removed from the floor, the bag changed and covered for dignity by the licensed nurse. Resident #92 discharged from the facility on 4/11/26. 2. Like Residents are identified as residents who utilize urinary catheters. An audit will be completed by the Director of Nursing or designee for like residents utilizing the Urinary Catheter Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC to ensure catheter bags are covered for dignity and not laying directly on the floor. This audit along with identified corrections will be completed on or before 5/13/26. 3. The Director of Nursing or designee will re-educate licensed nurses on the Indwelling Urinary Catheter Policy as well as Resident Dignity & Personal Privacy Policy to include privacy covers are in place for urinary catheters and that the catheter is not laying on the floor. This education will be completed on or before 5/13/26. 4. Utilizing the Urinary Catheter Audit Tool which was created on 4/20/26 by the Director of Nursing for purpose of this POC, the Director of Nursing or designee will complete an audit of all residents with catheters weekly for four weeks, beginning 5/14/26 to ensure catheter bags are covered for dignity and not laying directly on the floor. Any catheters found to be touching the floor or uncovered will be removed from the floor, the bag changed and covered for dignity. Negative findings to be addressed immediately and negative trends or system wide issues will be reported to the QAPI committee, and the action plan will be adjusted as needed.
Failure to Prevent Possible Misappropriation and Poor Documentation of PRN Narcotics
Penalty
Summary
The deficiency involves failure to prevent potential misappropriation of a resident’s narcotic medication and failure to ensure accurate documentation of controlled substance administration. A cognitively intact resident with chronic pain related to an internal orthopedic device and left knee pain had an order for oxycodone 5 mg PO every four hours PRN for pain and a care plan directing staff to administer medications as ordered and observe for effectiveness and side effects. The resident’s MDS showed she rated her pain as 7/10 and received opioid medication. However, review of the February MAR and the narcotic log revealed multiple discrepancies between narcotic sign-outs and documented administration. On several occasions, oxycodone doses were signed out on the narcotic log by an RN without corresponding documentation on the MAR. Specifically, oxycodone was signed out on one evening at 9:30 p.m. with no MAR entry, and again on a subsequent night at 1:30 a.m. and 5:30 a.m. with no MAR entries for those times. Another dose was signed out at 9:00 p.m. while the MAR reflected administration at 10:16 p.m., and a later dose at 5:30 a.m. was documented on both the narcotic log and MAR. There was also no documentation of pain assessments before or after PRN opioid administration. These documentation gaps meant there was no evidence that all narcotic doses signed out were actually administered to the resident. Staff interviews further highlighted concerns about the handling of narcotics. A CNA/med tech reported frequently taking the narcotic keys from the RN and described the RN’s behavior as erratic, with repeated problems involving incorrect narcotic counts and missing documentation on both the MAR and narcotic log. The resident stated she did not receive oxycodone more than once or twice a day, preferring to take Tylenol the rest of the time, which conflicted with the number of oxycodone doses signed out. When questioned, the RN gave inconsistent explanations about how often she pulled and administered PRN narcotics and acknowledged struggling with the new system, while also suggesting the resident may have received PRN tizanidine instead of remembering oxycodone. The facility’s investigation concluded that evidence was inconclusive as to whether misappropriation occurred or whether the issue was solely lack of documentation, but confirmed there was no evidence the resident received all doses signed out on the narcotic log.
Plan Of Correction
1. Resident #99 had a Self-Reported Incident submitted and investigated via the EIDC on 3/2/26. The investigation was inconclusive as we could not prove that misappropriation occurred. On 2/24/26, Resident #99 was interviewed and pain assessed by Director of Nursing and resident had no ill effects related to the inconsistent documentation in the medical record as it relates to her controlled substance pain medication. 2. Like Residents are identified as residents who utilize controlled substance PRN pain medications. An audit will be completed by the Director of Nursing or designee for like residents utilizing the Controlled Substance Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC to ensure PRN controlled substance pain medications that are signed off the control sheet are documented in the resident medical record as well. This audit along with identified corrections will be completed on or before 5/13/26. 3. The Director of Nursing or designee will re-educate licensed nurses on the Controlled Substances Policy to include appropriate documentation of controlled substances. In addition, the licensed nurses will be re-educated by the Director of Nursing or designee on the Abuse Prohibition Policy to include misappropriation of resident property. This education will be completed on or before 5/13/26. 4. Utilizing the Controlled Substance Audit Tool which was created on 4/20/26 by the Director of Nursing for the purpose of this POC, the Director of Nursing or designee will complete an audit three controlled substance sheets from each of the nine medication carts for a total of twenty-seven sheets weekly for four weeks, beginning 5/14/26 to ensure PRN controlled substance pain medications that are signed off the control sheet are documented in the resident medical record as well. Inconsistencies noted from the audit will be investigated for misappropriation. Negative findings to be addressed immediately and negative trends or system wide issues will be reported to the QAPI committee, and the action plan will be adjusted as needed.
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