Altercare Of Canal Winchester Post-acute Rc
Inspection history, citations, penalties and survey trends for this long-term care facility in Canal Winchester, Ohio.
- Location
- 6725 Thrush Drive, Canal Winchester, Ohio 43110
- CMS Provider Number
- 366367
- Inspections on file
- 27
- Latest survey
- April 21, 2026
- Citations (last 12 mo.)
- 25 (1 serious)
Citation history
Health deficiencies cited at Altercare Of Canal Winchester Post-acute Rc during CMS and state inspections, most recent first.
The deficiency centers on multiple residents for whom staff failed to recognize and respond to changes in condition and to implement ordered treatments. A resident with diabetes and multiple comorbidities became markedly lethargic with critically high BG, but nursing staff did not complete or document full VS, did not perform comprehensive ongoing assessments, and limited BG checks to scheduled insulin times despite continued lethargy and reported diarrhea. Another cognitively impaired, incontinent resident went eight days without a documented BM despite a bowel protocol requiring action after three days, with no evidence of nursing assessment, PRN laxative use, or provider notification, and CNAs and supervisors later reported they were unaware of the prolonged constipation. Additional residents did not receive ordered medications: one with CHF and HTN never received losartan ordered on a hospital after-visit summary because the admitting nurse failed to transcribe the order, and another with glaucoma and cataracts went more than six months without scheduled ophthalmic drops ordered by an ophthalmologist, as the orders were not entered and only unused PRN drops were on the MAR. A further resident with recent UTI, sepsis, and stroke had ongoing nausea, abdominal pain, poor intake, and loose stool treated with Zofran, but there was no documentation that the MD/NP was notified or that a change-in-condition assessment was completed.
A resident with cognitive impairment and a history of urinary retention was discharged from the hospital with an indwelling catheter and orders for catheter care. After a urology visit where the catheter was removed and the resident passed a voiding trial, facility staff did not obtain or enter updated orders, left prior catheter-care orders active, and later documented providing catheter care even though the catheter had been removed. At some point, the catheter was reinserted without documented physician orders or a comprehensive assessment, and staff inconsistently monitored and recorded urinary output, with only two documented outputs over nearly two weeks. A later order to remove the catheter and discontinue related orders was not carried out. The resident subsequently developed hypotension and abnormal drainage with pus and blood from the catheter, and hospital evaluation revealed a severely distended bladder, hydronephrosis, and a malpositioned Foley catheter balloon in the urethra, with diagnoses including UTI, sepsis, and acute kidney injury attributed to catheter-related obstruction.
The facility failed to maintain sufficient nursing staff and clear staffing plans, resulting in delayed call light responses, missed ADL care, and incomplete treatments for multiple residents. Residents and families reported long waits for assistance, especially at night and on weekends, with some residents lying in urine for hours, not receiving scheduled showers, and being left without proper bedding or repositioning. Staff confirmed that halls were sometimes staffed with only one CNA despite several residents requiring mechanical lifts, and that lifts were at times performed by a single staff member contrary to policy. Nurses described heavy treatment loads across multiple halls, leading to missed wound care and, in some cases, documentation that treatments were completed when they were not. One resident with complex wounds did not receive ordered daily leg dressings, another dependent resident was bathed only twice in 18 days, and a resident with a urinary catheter continued to have catheter care documented after the catheter had been removed by a urologist, with later orders to remove the catheter not carried out promptly. High staff turnover and miscommunication contributed to these care and documentation failures.
The facility experienced frequent turnover in the administrator and DON positions and lacked effective administrative systems to ensure adequate staffing and oversight of resident care. Residents and families reported chronic understaffing, long call light response times, missed showers, and lack of assistance with turning and repositioning, while staff confirmed that halls were often staffed with only one CNA and that mechanical lifts were sometimes done by a single staff member. Due to this lack of consistent oversight, multiple residents experienced serious care failures, including delayed response to acute changes in condition, unmanaged constipation progressing to stercoral colitis, inadequate management of CHF, wounds, UTIs, and glaucoma, insufficient ADL assistance, missed or incomplete pressure ulcer treatments, unrecognized significant weight loss, and deficiencies in infection prevention and control practices.
Multiple dependent residents did not receive necessary ADL assistance with bathing, nail care, personal hygiene, and eating as outlined in their care plans and facility policy. Several residents with cognitive impairment, hemiplegia, dysphagia, and other serious conditions went extended periods with only one or two baths or showers, or had no documented bathing at all, despite a twice‑weekly bathing expectation. Some residents were repeatedly observed with long fingernails and visible brown or dark material underneath, even though nail care was ordered with showers and a facility nail‑care policy required cleaning and trimming. One resident who was dependent for eating and at risk for altered nutrition was not offered a dinner tray during an observed meal service and therefore received no feeding assistance at that meal, despite an order for a mechanical soft diet with thin liquids. Staff interviews and record reviews confirmed missed or undocumented showers, lack of nail care, and failure to offer a meal, affecting multiple residents who relied on staff for ADLs.
The facility failed to maintain accurate medical records for multiple residents, including one cognitively intact resident whose ordered Modafinil was never received from the pharmacy, yet several nurses documented administering it on the MAR without corresponding controlled-substance tracking. A resident with severe cognitive impairment and hemiplegia had fewer showers than scheduled, while the DON later completed multiple shower sheets in a CNA’s initials and another CNA signed for a shower she did not provide. Another resident had a urinary catheter removed by an outside urologist, but nurses continued to chart catheter care on the TAR and no progress notes or physician orders reflected the catheter removal or discontinuation of catheter care. A resident with chronic bilateral leg wounds had dressings dated several days old despite daily treatment orders, while an LPN admitted charting treatments as done when they were not. A newly admitted resident with dementia and a hip wound had missing documentation for ordered Oxybutynin doses, TED hose use, catheter care, and dressing changes over several days, with the Regional Nurse Consultant confirming the lack of documented completion.
Surveyors found that the facility failed to consistently implement its infection prevention and control program. A resident with C. diff was not placed on contact precautions at admission, and later a CNA entered the room wearing only gloves despite posted instructions to use gown and gloves. Another resident placed on droplet precautions for respiratory symptoms was visited by an MDS nurse who did not wear a mask or gloves, even though signage required both. During incontinence care for a different resident, two CNAs changed gloves multiple times without performing hand hygiene between changes, contrary to facility policy. In addition, two newly admitted residents did not receive TB skin testing as required: one had no TB test documented within the policy-required timeframe, and another had an ordered Mantoux test that was neither signed off on the MAR nor explained in the record.
A resident with dementia and multiple medical conditions, including urinary retention requiring an indwelling catheter, was observed seated in a wheelchair in a common TV lounge wearing a hospital gown with the urinary drainage bag hanging uncovered from the wheelchair, leaving urine visible to others passing by. A Regional Corporate Nurse confirmed the bag was uncovered and in view. Facility policy required that urinary drainage bags be kept in a privacy bag or decorative drainage bag that does not expose urine contents, but this was not followed, resulting in a failure to maintain the resident’s dignity.
A resident with dementia, glaucoma, and cataracts had long-standing scheduled orders for Brimonidine and Latanoprost eye drops, consistent with an ophthalmology visit summary and a care plan goal to prevent negative consequences of vision loss. The physician orders were later changed from scheduled to PRN administration, but review of the EMR and nursing notes showed no documentation that the resident’s representative was informed of this change. In an interview, the representative stated she was upset about not being notified, and a regional nurse consultant confirmed there was no evidence that either the resident or the representative had been informed, resulting in a cited deficiency related to failure to ensure the resident and representative were fully informed about changes in treatment.
The facility failed to properly document, investigate, and resolve grievances from residents and families. Concern logs contained only minimal information and listed resolution dates without supporting documentation. A cognitively intact resident dependent on staff for toileting reported long delays in call light response and remaining wet with urine despite a logged concern about response time. A family member’s complaint about a resident’s daily routine and another family’s report of missing clothing were logged, but there was no evidence in the records of investigation or follow-up, and required concern forms were not completed. Staff interviews showed confusion over responsibility for handling grievances and confirmed the absence of a policy for non–missing-item concerns.
The facility failed to develop and implement timely baseline care plans and to provide summaries of those plans to residents or their representatives. One newly admitted resident had no baseline care plan within 48 hours. Another resident with multiple fractures, dementia, and heel wounds had detailed hospital AVS instructions for wound care, positioning, and hip precautions, but the baseline care plan only addressed an ID band and COVID-19 infection risk, omitting skin assessment, wound care, hip precautions, and personal care needs. A third resident admitted with a Stage III sacral pressure ulcer and multiple comorbidities had a baseline care plan marked as not applicable for wound care, with no pressure-ulcer interventions until days later, and no documented provision of a baseline care plan summary to the resident or a representative. The facility’s care planning policy required a baseline care plan within 48 hours but did not address providing a summary to residents or representatives.
A resident with multiple comorbidities and a stage 3 sacral pressure ulcer on admission did not receive timely and complete pressure ulcer care and prevention. The baseline care plan omitted any wound care interventions, and a comprehensive pressure ulcer care plan was delayed by 10 days. Although a physician ordered sacral wound care with Triad twice daily, documentation showed the treatment was not started for three days. There were no orders or care plan directions for turning/repositioning until 10 days after admission, and the plan did not specify frequency. A pressure redistribution mattress was not ordered until several days after admission and was applied later. These actions and omissions occurred despite a facility policy requiring risk identification, repositioning at least every two hours, and use of pressure redistribution mattresses as indicated.
A resident with multiple medical conditions, moderately impaired cognition, and a history placing her at risk for falls had a care plan requiring dycem in her wheelchair, non-skid strips on one side of the bed, and use of glasses as fall-prevention measures. Over several observations, surveyors found the resident in bed and in a wheelchair in common areas without glasses, without dycem in the wheelchair, and without non-skid strips on the bed, despite the facility’s fall-prevention policy requiring staff to ensure such safety interventions are in place. These findings were confirmed with a regional nurse consultant.
A resident with multiple comorbidities, dysphagia, and cognitive impairment was admitted and initially refused to be weighed, but staff made no further documented attempts to obtain weights despite an order for weekly weights and a facility policy requiring an admission weight and ongoing monitoring. Staff relied on a hospital weight while diet orders and texture modifications were made, and a dietitian note referenced the hospital weight and recommended a protein supplement for a sacral wound. When the resident was eventually weighed, the result showed an 11.8% loss from the hospital weight, yet no reweigh was completed within 24 hours and no dietitian evaluation of the significant loss was documented, contrary to the facility’s weight/reweigh policy.
A resident with multiple chronic conditions, cognitive impairment, and documented daily pain was admitted with orders for PRN Tylenol and every-shift pain assessments, along with a baseline care plan directing staff to monitor verbal and non-verbal pain signs and medicate per orders. Facility records showed that required pain assessments were repeatedly not completed on several shifts, and when pain scores of three and four were documented, there was no evidence that any pharmacologic or non-pharmacologic pain interventions were offered or provided. The resident’s family later reported the resident had been in pain and unwell, and increased pain complaints were eventually reported to an NP, but the Regional Nurse Consultant confirmed that pain relief was not offered at admission or when pain was documented, contrary to the facility’s pain assessment and management policy.
A resident admitted with a hip fracture and multiple chronic conditions had several scheduled medications ordered for pain control, muscle spasms, and other needs, including acetaminophen, celecoxib, baclofen, aspirin, gabapentin, modafinil, and PRN oxycodone. Shortly after admission, staff documented that no medications were available, and the resident was not yet in the pharmacy or provider systems, requiring new entry and prescription processing. MAR review showed that scheduled acetaminophen, aspirin, baclofen, and celecoxib were not administered on the first two days, while the resident reported severe pain. Regional nurse consultants confirmed these medications were not given despite policies directing staff to obtain initial doses from starter stock or an automatic dispensing system and to contact the pharmacy if medications could not be located.
A resident with C. diff was admitted on an ongoing regimen of oral Vancomycin 125 mg every six hours, but the facility failed to administer four scheduled doses because the medication was not available. Nursing staff documented the missed doses on the MAR, yet there was no evidence the physician was notified of the unavailability. The first dose from the facility was not given until the evening of the second day after admission, and the Regional Nurse Consultant confirmed that Vancomycin was not in the starter kit, the pharmacy was not contacted until the following day, and multiple doses were missed.
A resident with multiple stage 4 pressure ulcers and significant comorbidities was not provided with a recommended protein supplement for wound healing, despite a dietician's documented recommendation and care plan update. The recommendation was not communicated to the physician, resulting in no supplement order or administration. The resident experienced notable weight loss, and both the wound physician and the resident's spouse identified nutrition as a key factor in delayed wound healing.
The facility failed to implement a comprehensive pressure ulcer prevention program, resulting in harm to two residents. One resident developed a Stage IV ulcer due to inadequate assessments and interventions, while another did not receive prescribed off-loading boots, increasing their risk of skin breakdown. Staff interviews confirmed the lack of timely interventions and adherence to facility policies.
A facility failed to ensure proper hand hygiene during medication administration and did not implement enhanced barrier precautions (EBP) for residents with chronic wounds. An RN did not perform hand hygiene before or after entering rooms, and EBP was not in place for residents with pressure ulcers. The facility's policies require hand hygiene and EBP for infection control.
A resident with intact cognition and requiring assistance to reposition in bed experienced a 29-minute delay in call light response, despite facility policy requiring a response within three to five minutes. The delay occurred because other aides were busy, affecting one resident in a facility with a census of 61.
The facility failed to maintain the confidentiality of residents' medical records during medication administration. An RN Supervisor left MARs open and unattended, exposing sensitive information to passersby. This affected two residents, both moderately cognitively impaired, with various medical conditions. The Assistant Director of Nursing confirmed that such exposure violated the facility's confidentiality policy.
A resident with severe cognitive impairment and limited mobility did not receive necessary meal setup assistance, despite physician orders and therapy assessments indicating the need. The resident struggled to eat breakfast due to improperly set up meals, highlighting a deficiency in care.
The facility failed to implement fall interventions and conduct timely investigations for three residents, leading to deficiencies in accident prevention and supervision. A resident experienced multiple falls without timely interventions, another was observed with their bed not in the lowest position, and a third had a fall report completed late. These lapses highlight the facility's failure to adhere to prescribed safety measures and policies.
A facility failed to ensure adequate hydration for a resident with severe cognitive impairment, as fluids were not consistently provided and no hydration care plan was in place. Another resident experienced significant weight loss, which was not addressed by the facility, and dietary needs were not accurately assessed or met. Additionally, a third resident was not weighed monthly as required, with no documentation of refusal or notification to the physician, leading to deficiencies in monitoring nutritional status.
A facility failed to document nonpharmacological interventions before administering PRN Lorazepam to a resident with dementia and anxiety. Despite multiple administrations over a month, interventions were only documented once. The DON confirmed the lack of required documentation.
A resident with a history of dysphagia and other medical conditions experienced a delay in receiving speech therapy services after a diet change due to swallowing difficulties. Despite documentation of the issue, the SLP was not informed until over two months later, revealing a communication breakdown in the facility's protocol for notifying therapy staff.
A resident's prescribed narcotics were misappropriated due to altered medication inventory logs and poor documentation. An agency RN was suspected of taking the medications, as discrepancies occurred during their shifts. The resident did not report any missed doses, but a pharmacy audit revealed a missing card of Hydrocodone-Acetaminophen.
A facility failed to timely investigate a misappropriation allegation involving a resident's Hydrocodone-Acetaminophen medication. Discrepancies in the medication inventory log and a pharmacy audit revealed missing narcotics, with RN suspected but unreachable. The facility's delayed response violated its policy requiring immediate reporting and investigation of such incidents.
Failure to Monitor Changes in Condition and Implement Ordered Treatments
Penalty
Summary
The deficiency involves multiple failures to provide timely assessment, monitoring, and treatment in accordance with physician and NP orders, resident condition changes, and established facility policies. One resident with diabetes, chronic kidney disease, multiple sclerosis, seizures, and prior stroke became very lethargic with a critically elevated blood glucose of 522 mg/dL. The RN notified the CNP, who ordered lispro insulin and close monitoring for 24 hours, but the RN did not obtain or document a full set of vital signs at the time of the acute change, nor did staff perform comprehensive assessments as the resident remained lethargic. Subsequent blood glucose checks were delayed and limited to scheduled insulin times, and there was no documented ongoing monitoring of vital signs or physical assessments overnight despite continued lethargy and reports of diarrhea. Another resident, cognitively impaired and incontinent of bowel, had a care plan and bowel protocol requiring daily bowel documentation and intervention if no bowel movement occurred within three days. Documentation showed a small bowel movement on one date, followed by no recorded bowel movements for eight consecutive days. During this period, there was no evidence in the nursing notes that staff recognized or addressed the absence of bowel movements, no documentation that the PRN laxative protocol was used after the initial doses weeks earlier, and no indication that the physician or CNP was notified of prolonged constipation. CNAs and nursing supervisors later reported they were unaware the resident had gone that long without a bowel movement. Additional deficiencies included failures in medication management and implementation of specialist and hospital orders. One resident with CHF and hypertension was ordered losartan on a hospital after-visit summary, but the admitting nurse did not transcribe this order into the electronic record, and the medication was never started or documented as discontinued, despite a care plan intervention to administer medications as ordered. Another resident with glaucoma and cataracts had ophthalmology orders for scheduled brimonidine, latanoprost, and dorzolamide-timolol eye drops that were not entered and implemented for more than six months; during that time, the resident only had PRN eye drop orders that were not administered. A further resident admitted after treatment for UTI, sepsis, and cerebral infarction had documented nausea, stomach pain, poor intake over 48 hours, and loose stool, with Zofran given, but there was no evidence that the physician or NP was notified of these ongoing symptoms or that a change in condition assessment was completed. Across these cases, the surveyors identified that staff did not consistently follow the facility’s change in condition policy requiring adequate assessment, vital sign monitoring, and timely provider notification when residents exhibited significant changes such as lethargy, diarrhea, prolonged constipation, or ongoing gastrointestinal symptoms. The records showed gaps in documentation of assessments, vital signs, and provider communication, as well as failures to recognize and act on abnormal findings or prolonged absence of bowel movements. The facility also did not ensure that hospital and specialist orders were accurately transcribed and implemented, resulting in residents not receiving ordered cardiac and ophthalmologic medications over extended periods.
Failure to Follow Catheter Orders and Monitor Output Resulting in Catheter-Related Harm
Penalty
Summary
The deficiency involves the facility’s failure to follow physician and urology orders regarding an indwelling urinary catheter, failure to develop and implement a comprehensive and individualized care plan for catheter management, and failure to consistently monitor and document urinary output for a cognitively impaired resident. The resident was admitted without a catheter and was initially continent of bladder, requiring staff assistance with toileting. After an episode of urinary retention and UTI, the resident was hospitalized, treated with antibiotics, and discharged back to the facility with a urinary catheter in place, with orders for catheter care twice daily that were carried out from mid‑July through mid‑August. On a subsequent outpatient urology visit, the urologist determined the resident was no longer in urinary retention, documented only 30 ml in the bladder, and removed the catheter, indicating a suprapubic catheter would be preferable if retention recurred. No new physician orders reflecting catheter removal were entered into the facility record on that date, and the existing catheter care orders remained active. That evening, catheter care was not documented, but starting the next day, multiple nurses documented providing catheter care despite the catheter having been removed at the urology office. Within days, the resident again had a urinary catheter in place, but there were no physician orders in the record to reinsert it, no documentation of a comprehensive assessment supporting reinsertion, and no evidence of communication with the physician or urologist to obtain such orders. The CNP later documented that the catheter had been removed at urology and “somehow” had been reinserted, and indicated that orders were given to remove the catheter, but no corresponding physician orders were entered on those dates. A physician order was eventually written to remove the catheter and discontinue associated orders, but this order was not carried out, and catheter care orders remained active for several more days. During the period after the urology visit, staff documented catheter care but failed to consistently monitor and record urinary output from the catheter, with only two output values recorded over nearly two weeks, despite facility policy requiring accurate daily output records and monitoring for abnormal volume or appearance. Vital signs remained stable until a later date when the resident’s blood pressure dropped. A bladder scan order was entered and a scan documented, but the record lacked documentation explaining the clinical rationale for the scan. Later that morning, staff found the resident non‑responsive, pale, and with beige, creamy drainage and pus and blood noted at the penile meatus and in the catheter bag. The resident was sent to the hospital, where imaging showed a severely distended bladder with hydronephrosis and a malpositioned Foley catheter balloon inflated in the membranous urethra, requiring removal and repositioning. Hospital records attributed sepsis, acute kidney injury, and bladder outlet obstruction with hydronephrosis to the catheter‑related obstruction, and the resident required ICU care before eventually stabilizing and being discharged to another facility with hospice. Interviews with multiple RNs and LPNs who had provided care indicated they believed the resident had a catheter in place the entire time and denied knowledge of any orders to remove it or any complications or monitoring concerns related to catheter output. They also denied reinserting the catheter or obtaining orders for reinsertion. A CNA recalled that on one day shortly after the urology visit, the nurse may have noticed the catheter was not present and assumed the resident had pulled it out, and vaguely recalled that the nurse on duty might have reinserted it, though the identified nurse denied doing so. The CNP confirmed that review of call logs showed no calls from the facility to the physician office to obtain reinsertion orders after the urology visit, and that she had raised concerns about this issue with the facility. The Regional Nurse Consultant confirmed there was no documentation of a comprehensive assessment supporting catheter reinsertion, no evidence explaining the need for the later bladder scan, inconsistent monitoring of urinary output, and that the physician order to remove the catheter was not completed as ordered. Facility policies required proper handling of telephone orders and accurate monitoring and documentation of urine volume and appearance, but these were not followed for this resident.
Insufficient Staffing Leading to Delayed Care, Missed Treatments, and Documentation Failures
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff to meet residents’ needs and to ensure timely, complete care and accurate documentation. On the initial survey day, staffing consisted of one medication tech, one RN, three LPNs, and five CNAs for 57 residents. The facility assessment identified that 27.9% of residents were clinically complex and that the facility was responsible for a full range of care and services, but the staffing assessment did not specify the number of staff needed per shift. Resident council minutes over multiple months documented ongoing concerns about delayed call light response, lack of aides for showers, aides using phones instead of assisting residents, and staff hiding to avoid work. A CNP reported that her provider group had repeatedly met with the management company about concerns for resident care and attributed some challenges to staffing turnover. Multiple residents and family members reported that the facility was understaffed, especially on nights and weekends, resulting in long delays in call light response and missed care. One resident stated there was often only one aide at night for two halls and that call lights could take over 30 minutes to be answered. Another resident reported waiting up to five hours for a call light to be answered and noted that a staff member transferred him alone with a mechanical lift. A family member reported finding a resident lying on a mattress with no sheet and not being turned, repositioned, or gotten up. Other residents reported that there were not enough staff, that call lights took a long time to be answered, and that on afternoons and weekends response times could be one to two hours. In a special resident council meeting, residents described having to help other residents who were sliding out of chairs because no staff were present and tracking their own shower schedules because showers were not being provided as planned. Staff interviews corroborated that staffing levels were often inadequate and that required care could not be completed. LPN supervisors and CNAs reported that at times there was only one aide on a hall with multiple residents requiring mechanical lifts, and that mechanical lifts were sometimes performed by a single staff member despite facility policy requiring two staff. Staff stated that when there were call-offs, they were expected to work short, leading to missed showers, inability to turn and reposition residents or provide incontinence care every two hours, and delayed call light response. Nurses reported that heavy treatment loads and being responsible for multiple halls made it difficult to complete all ordered treatments and medications. One CNA stated that staffing had only recently improved with a new DON, and that previously there were not enough staff to safely transfer dependent residents with two staff as required. Specific resident records and observations showed missed treatments and inadequate hygiene care linked to staffing and workload. One resident with morbid obesity, diabetes, heart failure, and chronic bilateral lower extremity wounds had physician orders for daily leg dressings, but surveyors observed dressings dated four days prior, and the treatment record showed missed or undocumented treatments in March and April. The LPN responsible for one missed treatment day stated the hall had a heavy treatment load and she was too busy to complete the dressings; another LPN admitted documenting that treatments were done on two days when they were not, explaining that working two halls and admissions made it difficult to complete all treatments and that she typically signed off treatments before actually doing them. Another resident, incontinent and dependent for toileting and transfers, reported waiting 2–4 hours for call light response, lying in urine for long periods, and not being gotten up at his preferred time, with aides attributing delays to insufficient help; this resident required a mechanical lift, and facility policy required two staff for such transfers. Additional record review showed a resident who was dependent for showers and incontinent of bowel and bladder received only one bed bath and one shower over an 18-day period, despite the regional nurse consultant confirming residents were to be bathed twice weekly and no evidence of additional baths or showers was found. Another resident with metabolic encephalopathy, benign prostatic hyperplasia, and a cognitive communication deficit had a urinary catheter placed for urinary retention and UTI, with catheter care documented as provided for weeks. After a urology visit determined the catheter was no longer needed and it was removed, no new orders were entered to discontinue catheter care, and TAR entries showed catheter care continued to be signed off by multiple nurses even though the catheter was not present. Later, orders were written to remove the catheter and associated orders, but the TAR showed the catheter was not removed over several days and catheter care orders remained. The resident was eventually sent to the hospital with decreased level of consciousness, confusion, and pus and blood at the penile meatus. Nurses interviewed stated the catheter had been in place the entire time they cared for the resident and were unaware of orders to remove it or any complications, while the CNP cited high staff turnover and miscommunication as concerns during that period. Overall, the survey findings showed that insufficient and unstable staffing, combined with lack of a specific staffing plan, led to delayed call light responses, incomplete ADL care, missed or falsified treatments, unsafe one-person mechanical lift transfers, inadequate bathing, and failures in communication and documentation regarding catheter management for multiple residents.
Administrative Instability and Inadequate Oversight Leading to Widespread Care Failures
Penalty
Summary
The deficiency involves the facility’s failure to be administered in a manner that enabled effective and efficient use of resources to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Surveyors identified frequent turnover in key leadership positions, including five administrators since June 2023 and seven DONs since June 2025, with no additional information provided by current leadership to demonstrate effective administrative systems. The facility assessment documented that 27.9% of residents were clinically complex and that the facility provided a wide range of required services, but the staffing assessment was not specific regarding the number of staff needed to meet residents’ total care needs. Resident council minutes over multiple months documented ongoing concerns about delayed call light response, lack of CNA availability for showers, and CNAs using phones instead of assisting residents. Residents and families reported repeated concerns related to inadequate staffing and delayed care. Multiple residents stated that there were not enough staff, especially at night and on weekends, and that call lights could take from 30 minutes to several hours to be answered. One resident reported waiting five hours for a call light to be answered, and another resident’s family member reported finding the resident lying on a mattress with minimal bedding and no staff coming in to turn, reposition, or get the resident up. In a special resident council meeting, residents described having to help other residents who were sliding out of chairs because staff were not present, and one resident kept a personal calendar of showers because the shower schedule was not being followed. Staff interviews corroborated these concerns, with LPN supervisors and CNAs reporting that there were often only one or very few CNAs on certain halls or shifts, making it difficult to complete showers, incontinence care, turning and repositioning, and timely call light response. Staff also reported that mechanical lift transfers were sometimes performed by one person despite the requirement for two staff. As a result of the lack of consistent and necessary administrative oversight and frequent leadership changes, multiple care and treatment failures were identified across several regulatory areas. One resident with lethargy and a critically elevated blood glucose had delayed reassessment and continued limited intake, later becoming unresponsive and requiring hospital admission with diagnoses including severe sepsis with septic shock, acute encephalopathy, acute kidney injury, hyperglycemia, urinary tract infection, and hypernatremia, and subsequently returned with hospice and later died. Another resident, cognitively impaired and requiring substantial assistance with toileting and assessed as incontinent, had no documented bowel movement for several days, was later hospitalized, and was found on CT scan to have a moderately stool-distended rectal vault with developing stercoral colitis, requiring disimpaction and an 11-day hospital stay; this same resident also had deficiencies in implementation of urinary catheter orders and individualized catheter care planning. Additional findings included failures to ensure treatments for conditions such as CHF, vascular wounds, UTIs, and glaucoma; failures to provide necessary ADL care for residents unable to perform self-care, including assistance with eating, nail care, and bathing/showering; failures to provide ordered pressure ulcer care; failures in accurate and timely weight monitoring leading to an undetected significant weight loss; and failures in the infection prevention and control program for multiple residents. The administrator job description indicated responsibilities for supporting recruitment and retention to lower turnover and developing a strong management team, but the survey findings showed that these administrative functions were not effectively carried out.
Failure to Provide Required ADL Assistance With Bathing, Nail Care, and Eating
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary assistance with activities of daily living (ADLs)—including bathing, nail care, personal hygiene, and eating—to multiple dependent residents, as required by their care plans and facility policy. One resident with cerebral infarction, dysphagia, diabetes, morbid obesity, sepsis, osteoarthritis, memory problems, and total dependence for showers and personal hygiene received only one bed bath and one shower over an 18‑day stay, despite a facility expectation of twice‑weekly bathing. Another resident with hemiplegia, dysphagia post‑stroke, aphasia, memory problems, and total dependence for bathing and personal hygiene was observed on several days with a very dry bottom lip and later with long fingernails containing a dark substance underneath. Although his care plan called for assistance with all ADLs, nail care, hair shampooing with showers, and oral care twice daily, the CNA who provided his shower documented no nail care and confirmed that his nails were not cleaned or trimmed. A resident with hemiplegia, hemiparesis, cognitive communication deficit, reduced mobility, cerebral infarction, severe cognitive impairment, and dependence on staff for eating, personal hygiene, transfers, and bathing was not offered a dinner meal during a continuous observation of the hall dining service, and therefore did not receive feeding assistance at that meal. A CNA stated that no residents refused dinner, while the resident confirmed she was not offered a tray but said she would have refused if it had been offered; the Administrator asserted that the CNA had offered the meal and that the resident refused. The same resident’s care plan identified risk for altered nutrition status and required that her ordered mechanical soft diet with thin liquids be provided, and that she receive assistance with ADLs and scheduled showers. Review of shower documentation and the shower schedule showed she received six showers over a period when ten were scheduled, and staff confirmed she did not refuse showers and that all showers would be documented. Additional residents were found with unmet ADL needs related to grooming and hygiene. One resident with cerebral infarction, muscle weakness, vascular dementia, moderate cognitive impairment, and dependence on staff for personal hygiene had long fingernails with brown substance caked underneath on multiple observations, despite a care plan approach to provide nail care with showers; the resident stated he preferred short, clean nails, and staff confirmed he did not refuse care. Another resident with COPD, metabolic encephalopathy, diabetes, depression, CHF, hypertension, fibromyalgia, cognitive communication deficit, severe cognitive impairment, incontinence, and dependence for showers and substantial assistance with hygiene was repeatedly observed over several days with long fingernails and brown substance underneath, despite a facility nail care policy requiring cleaning and trimming to maintain well‑being. A discharged resident with multiple fractures, osteoporosis, COPD, and chronic respiratory failure, who required supervision or touching assistance with bathing and was frequently incontinent, had no documented baths or showers during her stay, which the Administrator confirmed. A further resident with impaired cognition and moderate assistance needs for bathing, toileting, and mobility received showers only every other week according to facility records, and the Regional Nurse Consultant confirmed she received only one shower per week, even though she had declined some offers, resulting in less frequent bathing than the facility’s twice‑weekly expectation. Overall, record reviews, observations, interviews, and policy review showed that seven residents who were unable to carry out ADLs did not consistently receive necessary care and services to maintain good nutrition, grooming, and personal hygiene. Deficiencies included missed or undocumented showers and baths, lack of nail care despite visible buildup under long nails, failure to provide ordered diet and feeding assistance at a meal, and inadequate attention to oral and lip care, all in residents whose care plans and assessments documented dependence on staff for these ADLs and a facility standard of twice‑weekly bathing and routine nail care.
Inaccurate and Falsified Clinical Documentation for Medications, Treatments, and Care
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records and documentation for multiple residents, including inaccurate medication administration records, falsified treatment and shower documentation, and lack of integration of external provider orders into the record. For one resident with multiple sclerosis, osteonecrosis, osteoarthritis, fatigue, and PTSD, the physician ordered Modafinil 200 mg twice daily to promote wakefulness. The MAR showed repeated entries that the Modafinil was unavailable on several dates, but also showed it as administered on multiple other dates. A progress note documented that the resident’s medications were not at the facility, the pharmacy did not have the resident in its system, and the provider had to be contacted to enter the resident. Later, the Regional Nurse Consultant confirmed with the pharmacy that the Modafinil was never received by the facility, yet five nurses had documented that they administered it, despite the absence of the medication and any controlled-substance tracking documentation. Another resident with hemiplegia, cognitive communication deficit, reduced mobility, and cerebral infarction had a care plan requiring assistance with ADLs and scheduled showers. The shower schedule showed ten scheduled showers over a defined period, but the medical record reflected only six completed showers. The shower book initially showed an additional shower, but later review revealed multiple shower sheets for additional dates all completed in the same handwriting, with the same CNA initials, and without nurse signatures. The DON admitted to filling out several of these shower sheets herself and initialing them with a CNA’s initials after calling the CNA at home to ask if showers had been given. Another CNA confirmed that she signed a shower sheet for a shower she did not provide, after the DON approached her and suggested she sign based on having only assisted with a transfer to a shower chair. These actions resulted in shower documentation that did not accurately reflect the care actually provided. For a resident with metabolic encephalopathy, BPH, need for assistance with personal care, and cognitive communication deficit, urology notes documented that the resident no longer required a urinary catheter after a successful voiding trial, and the catheter was removed. Despite this, the TAR showed ongoing documentation by multiple nurses that catheter care was provided twice daily after the catheter had been removed. The nursing progress notes contained no record of the urology appointment, catheter removal, or discontinuation of catheter care orders, and the physician orders were not updated to discontinue catheter care until later. The Regional Nurse Consultant confirmed that the urologist’s after-visit summary was not available in the medical record at the time, that catheter care orders were not discontinued when the catheter was removed, and that there were no orders to reinsert the catheter after removal. Another resident with morbid obesity, diabetes, heart failure, and chronic bilateral lower extremity wounds had physician orders for daily wound care to both legs. Observation showed that the dressings on both legs were dated four days prior, even though the orders required daily changes. The TAR, however, showed that treatments were documented as completed on two of those days by an LPN supervisor. In interview, the LPN admitted documenting that the leg treatments were completed when they were not, explaining that workload issues and working multiple halls contributed, and that she typically signed off treatments before doing rounds and did not go back to correct the record when treatments were not done. A newly admitted resident with orthopedic aftercare needs, a recent fall with fracture, pain, dementia, osteoarthritis, hypertension, GERD, and an indwelling urinary catheter had admission orders for bilateral thigh-high TED hose for three weeks, Oxybutynin 5 mg twice daily, daily catheter care, and a daily dressing change to the right hip. Review of the MAR and TAR showed that the evening doses of Oxybutynin on two days were not documented as administered, the TED hose were not documented as on for the first three days, catheter care was not documented for the first three days, and the right hip dressing change was not documented on two consecutive days. The Regional Nurse Consultant verified that these medications and treatments were not documented as completed. Across these residents, the survey findings show multiple instances where documentation did not accurately reflect the care and services actually provided, in violation of the facility’s own policy requiring accurate flagging and documentation when medications or treatments are withheld, refused, unavailable, or not given as scheduled.
Failure to Implement Transmission-Based Precautions, Hand Hygiene, and TB Screening
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective infection prevention and control program, including proper use of transmission-based precautions and adherence to hand hygiene and tuberculosis (TB) screening policies. One resident with acute and subacute infective endocarditis and a recent diagnosis of Clostridioides difficile (C. diff) was admitted with a PICC line and an active treatment plan for C. diff. Hospital records showed this resident had been placed on Contact plus precautions in the hospital, and the facility’s own admission nursing note documented the C. diff diagnosis and IV antibiotic therapy. Despite this, the resident was not placed on contact precautions upon admission, and a physician’s order for contact precautions was not obtained until the day after admission. During the initial facility tour, no contact precaution signage was posted outside the resident’s room, and the Regional Nurse Consultant later confirmed the resident should have been on contact precautions at admission. After contact precautions were ordered and signage was posted, staff still failed to follow the required personal protective equipment (PPE) practices. A CNA entered the C. diff-positive resident’s room wearing only gloves, despite a sign indicating contact precautions and the need for both gown and gloves. While in the room, the CNA adjusted the resident’s position, raised the bed, moved the bedside table, and removed juice glasses, then exited the room without having worn a gown. The CNA stated she did not know the resident was on contact precautions, even though the sign was present, and the Regional Nurse Consultant confirmed staff were required to wear a gown when entering that room. In a separate incident, another resident was placed on droplet precautions due to a cough and pending testing for influenza and RSV, with a physician’s order and a sign instructing staff to wear a mask and gloves. An MDS nurse entered this resident’s room without a mask or gloves and later acknowledged she had not followed the sign, explaining she had mistaken the droplet precaution sign for enhanced barrier precautions. Additional deficiencies were identified in hand hygiene and TB screening practices. During observed incontinence care for another resident, two CNAs performed perineal care, including cleansing areas with visible smears of bowel movement, and changed gloves twice without performing hand hygiene between glove changes. Both CNAs later verified they had not washed their hands between glove changes, contrary to the facility’s Hand Washing-Hygiene policy, which requires hand hygiene after removing gloves. The facility also failed to complete TB screening in accordance with its policies for two newly admitted residents. One new admission had no documentation that a TB skin test was completed within 48 hours of admission, as required by the facility’s Tuberculosis Screening policy. Another resident had a physician’s order for a Mantoux step one TB test, but the MAR showed no nurse sign-off and no documentation explaining why the test was not administered, and progress notes contained no information about the missing test. The Regional Nurse Consultant confirmed there was no documented evidence that this TB test had been given.
Uncovered Urinary Catheter Bag Exposed in Common Area
Penalty
Summary
The facility failed to treat a resident with respect and dignity related to management of an indwelling urinary catheter. The resident, admitted on 04/03/26 with diagnoses including orthopedic aftercare, fall with fracture at home, pain, dementia, osteoarthritis, and hypertension, had a physician’s order dated 04/06/26 for an indwelling urinary catheter for urinary retention/possible bladder outlet obstruction, with catheter care to be provided every shift. On 04/06/2026 at 9:59 A.M., the resident was observed in the TV lounge area in a wheelchair wearing a hospital gown, with the urinary catheter drainage bag hanging from the wheelchair uncovered and the urine visible, while other residents and staff passed through the area. At 10:01 A.M., a Regional Corporate Nurse confirmed that the catheter bag was uncovered and in view. Review of the facility’s undated “Catheter Care, Urinary” policy showed staff were required to ensure the urinary drainage bag was kept in a privacy bag or a decorative drainage bag that did not expose the urine contents, which was not followed in this instance. This deficiency demonstrates noncompliance investigated under Complaint Number 2596634.
Failure to Notify Resident Representative of Change in Ophthalmic Medications
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s representative of a change in the resident’s ophthalmic medication regimen. The resident had multiple diagnoses including cognitive communication deficit, aphasia, dementia, bilateral open-angle glaucoma, bilateral age-related cataracts, and vitreous degeneration of the right eye. The care plan, initiated in 2018, identified the resident as being at risk for decreased visual function due to cataracts, with goals to prevent negative consequences of vision loss and approaches that included administering medications as ordered and obtaining ophthalmology consultations as needed. A quarterly MDS assessment showed a Brief Interview for Mental Status score of 06, indicating severe cognitive impairment. The resident had long-standing physician orders for Brimonidine eye drops twice daily and Latanoprost eye drops once daily, consistent with an ophthalmology after-visit summary that specified Brimonidine 0.2% twice daily and Latanoprost 0.005% at bedtime. On a later date, the physician orders for both Brimonidine and Latanoprost were changed from scheduled administrations to as-needed (PRN) medications for glaucoma. Review of the nursing progress notes for the period surrounding this change showed no documentation that the resident’s representative was notified of this alteration in treatment. During an interview, the resident’s representative reported being upset that she had not been informed when the eye drops were changed from scheduled to PRN. A Regional Nurse Consultant confirmed there was no evidence that either the resident or the resident’s representative had been notified of the medication change. This lack of notification formed the basis of the cited deficiency, which was investigated under two complaint numbers.
Failure to Document and Resolve Resident and Family Grievances
Penalty
Summary
The facility failed to honor residents' rights to voice grievances without reprisal and to make prompt efforts to resolve those grievances, as required by its own policies and regulatory expectations. Review of the facility’s Concern Tracking Logs showed that entries only included the date, resident name, general nature of concern, department, and a listed date of resolution, without specific details of the concerns or documented follow-up. For three residents reviewed, there was no documented evidence of investigation or resolution beyond the brief log entries. One resident, who was cognitively intact and always incontinent of bowel and bladder and dependent on staff for toileting, had a concern logged about response time on a specific date, with the same date listed as the resolution date. However, the resident later reported waiting 2–4 hours for call lights to be answered and lying in urine for long periods, and there was no documentation showing how his concern had been addressed or resolved. A second resident’s daughter submitted a concern regarding the resident’s daily routine, which was logged with a resolution date the following day, but the medical record contained no documentation of the concern or any resolution. The resident was transferred to the hospital the next day due to a change in condition and did not return, and there was no documented evidence of follow-up on the grievance. For a third resident, a family concern about missing clothes was logged with a resolution date, but there was no Resident Concern Form completed and no evidence of an investigation, despite a facility policy requiring prompt investigation, documentation on a Resident Concern Form, and follow-up by the Social Services Director. Interviews with the Social Services Coordinator and the Administrator revealed conflicting understandings of who was responsible for handling missing item reports and concerns, that no concern forms had been completed for these three residents, and that the facility lacked a policy for following up on resident concerns that were not related to missing items.
Failure to Develop and Communicate Timely Baseline Care Plans on Admission
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement baseline care plans within 48 hours of admission and to provide a summary of those plans to residents or their representatives. One newly admitted resident with diagnoses including orthopedic aftercare, fall with fracture, pain, dementia, osteoarthritis, hypertension, and GERD had no baseline plan of care in the medical record within 48 hours of admission. The Regional Corporate Nurse confirmed that a baseline plan of care had not been developed for this resident within the required timeframe. Another resident was admitted with multiple serious conditions, including displaced fracture of the anterior wall of the right acetabulum, Alzheimer’s disease, vascular dementia, peripheral vascular disease, multiple vertebral compression fractures, chronic embolism and thrombosis, fractures of the right pubis and left humerus, abdominal aortic aneurysm, gallbladder and bile duct disease, hyperosmolality and hypernatremia, and bilateral artificial hip joints. The hospital after-visit summary contained detailed instructions for heel wound care, pressure relief, positioning, and hip precautions, including not crossing legs and frequent repositioning. However, the resident’s care plan, last revised two days after admission, only addressed an identification wristband and risk for infection due to COVID-19 and did not include the heel wounds, skin assessment findings, hip precautions, or information on resident background, preferences, or personal care needs. Progress notes around admission were sparse and did not document these needs, and the Regional Nurse Consultant confirmed the absence of skin assessment documentation and hip precaution interventions in the baseline care plan and medical record. A third resident was admitted with cerebral infarction, dysphagia, diabetes, morbid obesity, sepsis, bipolar disorder, anxiety disorder, hypertension, osteoarthritis, and peripheral vascular disease, and had impaired short- and long-term memory, oriented to self only. An initial wound grid documented admission with a Stage III sacral pressure ulcer, but the baseline care plan, with an observation date matching admission, was marked “not applicable” for wound care and contained no interventions related to pressure ulcers. A comprehensive care plan for pressure ulcers was not implemented until several days after admission. A “Meet and Greet” form was signed by Social Services, noted the resident was unable to sign, and lacked a representative’s signature or any description of what was discussed. There was no evidence that a summary of the baseline care plan was provided to the resident or a representative. The Regional Nurse Consultant confirmed that the initial clinical assessment and baseline care plan did not identify the pressure ulcer or required care, and that the nurse likely made an error due to multiple admissions that day. The facility’s care planning policy required a baseline care plan within 48 hours but did not address providing a summary of the baseline plan to residents or representatives.
Failure to Timely Implement and Document Pressure Ulcer Treatment and Prevention
Penalty
Summary
The deficiency involves the facility’s failure to provide timely and complete pressure ulcer care and prevention for a resident admitted with a stage 3 sacral pressure ulcer. The resident had multiple diagnoses including cerebral infarction, dysphagia, diabetes, morbid obesity, sepsis, bipolar disorder, anxiety disorder, hypertension, osteoarthritis, and peripheral vascular disease, and was incontinent of bowel and bladder with impaired short- and long-term memory and orientation to self only. On admission, the resident had a documented stage 3 sacral pressure ulcer measuring 0.6 x 0.3 x 0.2 cm, yet the baseline care plan, completed days later, marked wound care as not applicable and contained no interventions related to pressure ulcers. A comprehensive pressure ulcer care plan was not implemented until 10 days after admission. Although a physician ordered sacral wound care with normal saline cleansing and Triad application twice daily and as needed on the admission date, the TAR showed no evidence that this treatment was initiated until three days later. The record further showed that the resident required substantial/maximal assistance with turning and was always incontinent, but there were no physician’s orders for turning/repositioning and no care plan or profile card addressing turning/repositioning until 10 days after admission, and even then the plan did not specify the frequency of repositioning. A pressure redistribution mattress was not ordered until three days after admission and was documented as applied the following day, after the resident refused to get up. The facility’s own pressure injury policy required identification of residents at risk, implementation of preventive interventions such as repositioning at least every two hours, and use of pressure redistribution mattresses as indicated. The Regional Nurse Consultant confirmed that the initial assessment and baseline care plan failed to identify the existing pressure ulcer or required care, that the treatment was not provided for three days after being ordered, and that turning/repositioning was not included in the resident’s care plan during that period.
Failure to Implement Care-Planned Fall-Prevention Interventions
Penalty
Summary
The deficiency involves the facility’s failure to ensure that fall-prevention interventions identified in a resident’s care plan were consistently implemented. The resident had diagnoses including aphasia, hypertension, major depression, insomnia, anemia, cerebral infarction, anxiety, and a history of embolism, with a quarterly MDS showing moderately impaired cognition and functional limitations requiring varying levels of assistance with ADLs and incontinence care. The resident’s fall plan of care, initiated due to confusion/altered mental status, history of falls, and use of antidepressants, included specific interventions: dycem in the wheelchair, non-skid strips on the right side of the bed, bright-colored tape on the call light, and encouraging the resident to wear glasses. Surveyor observations over multiple days showed that these planned interventions were not in place. On several occasions, the resident was observed in a wheelchair in common areas and in bed without wearing glasses, and without dycem present in the wheelchair. When the resident was observed in bed, there were no non-skid strips on the right side of the bed as required by the care plan. These missing interventions were confirmed during an interview with the Regional Nurse Consultant, and the facility’s Fall Prevention policy stated that staff will ensure safety interventions are in place for each resident to reduce the risk of falls. This established that the facility did not follow its own policy or the resident’s fall-prevention care plan.
Failure to Monitor and Reweigh Resident After Significant Weight Loss
Penalty
Summary
The deficiency involves the facility’s failure to accurately and timely monitor a resident’s weight, resulting in an undetected and unevaluated significant weight loss. The resident was admitted with multiple diagnoses including cerebral infarction, dysphagia, diabetes, morbid obesity, sepsis, bipolar disorder, anxiety disorder, hypertension, osteoarthritis, and peripheral vascular disease. On admission, the resident refused to be weighed, and the admission assessment documented this refusal. A physician’s order was in place for weekly weights for four weeks, but there was no evidence of further attempts to obtain weights between admission and a later date, and no additional refusals were documented. The facility’s policy required a weight within 24 hours of admission and prohibited use of hospital weights in lieu of actually weighing the resident. Subsequent orders changed the resident’s diet texture and thickened liquid consistency, and the MDS assessment showed the resident had short- and long-term memory problems and required substantial/maximal assistance with eating. A dietary note documented a hospital weight of 220 lbs, variable intake, and a sacral wound, and recommended a protein supplement for wound healing, which was ordered by the physician. When the resident was finally weighed, the weight was 194 lbs, reflecting a 26-lb (11.8%) decrease from the hospital weight. There was no evidence that this significant loss triggered a reweigh within 24 hours as required by policy, and no dietitian evaluation of the significant weight loss was documented. A nurse practitioner later documented that the resident was minimally responsive with additional neurologic signs and the resident was sent to the hospital and did not return. The regional nurse consultant confirmed the lack of interim weight attempts, lack of reweigh after the significant loss, and lack of evaluation of that loss.
Failure to Provide Ordered Pain Assessment and Management for a Resident with Chronic Pain
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate pain management for Resident #93, who was admitted with multiple significant diagnoses including cerebral infarction, dysphagia, diabetes, morbid obesity, sepsis, bipolar disorder, anxiety disorder, hypertension, osteoarthritis, thoracic spine pain, and peripheral vascular disease. On admission, the clinical assessment documented impaired short- and long-term memory, orientation only to self, daily pain with a pain level of three on a 0–10 scale, and non-verbal expressions of pain, yet there was no evidence that any pain relief interventions were offered or provided. The baseline care plan set a goal to promote the resident’s comfort over 30 days and included approaches such as monitoring verbal and non-verbal pain signs, working with therapy for pain control, medicating per orders based on pain indications, and reporting unrelieved pain to the physician. Physician orders dated 01/24/26 included Tylenol 1000 mg every six hours as needed and an order to assess pain every shift using a 0–10 pain scale. Record review showed that every-shift pain assessments were not consistently completed as ordered: they were missing on several night shifts in January and February and on one day shift in January. When pain assessments were documented, they showed pain levels of three and four on specific shifts, but there was no evidence that the resident was offered or given any interventions for pain relief in response to these findings. A nursing note documented that the resident’s daughter reported the resident had been in pain, nauseous, and not feeling well during a visit, although the resident did not express pain at the time of the subsequent assessment and was oriented only to person, which the daughter stated was her new baseline. Later, increased complaints of pain were reported to the nurse practitioner, who ordered scheduled Tylenol and subsequently assessed the resident and ordered transfer to the hospital after the resident was noted to be minimally responsive with tremors. The Regional Nurse Consultant confirmed that the resident was assessed on admission with a pain level of three without any evidence that pain relief was offered, that every-shift pain assessments were not completed as ordered, and that nothing was offered or given when pain was identified on the MAR. The facility’s pain policy required assessment, monitoring, treatment, and evaluation of pain, and treatment of residents identified as experiencing pain in accordance with their care plan, including use of non-pharmacological interventions when appropriate.
Failure to Provide Ordered Pain and Other Medications for New Admission
Penalty
Summary
The deficiency involves the facility’s failure to ensure ordered medications were available and administered to meet a resident’s needs. A cognitively intact resident with multiple sclerosis, osteonecrosis of the left femur, unilateral primary osteoarthritis of the left hip, fatigue, PTSD, and a recent hip fracture was admitted in the evening and had multiple pain, muscle relaxant, and other medications ordered to start on the day of admission. These included acetaminophen (in two strengths and dosing schedules), celecoxib for pain, baclofen for muscle spasms, gabapentin for pain, aspirin, modafinil, and PRN oxycodone for pain. A progress note documented that shortly after admission the resident did not have medications at the facility, and when staff contacted the pharmacy and the provider’s system, the resident was not yet in either system. The nurse then worked to have the resident entered as a new admission and to obtain a new prescription and status update from the pharmacy. Review of the Medication Administration Record (MAR) showed that on the first and second days, there were “x” marks in place of nurse initials for scheduled acetaminophen doses, aspirin, baclofen, and celecoxib, indicating the medications were not administered. Additional MAR review showed the resident was documented as having 10/10 pain on one day and 6/10 pain the following day. Regional nurse consultants confirmed that there was no indication the resident received acetaminophen or aspirin on the first two days and that these medications would be expected to be available from house stock, and also confirmed the resident did not receive celecoxib or baclofen on those days. Facility policies stated that to avoid delaying patient care, initial doses should be obtained from starter supply or an automatic dispensing machine, and that if a medication with an active order could not be located, staff should search other areas and contact the pharmacy or use the starter box, but the documentation showed the ordered medications were not available or administered as required.
Failure to Provide Ordered Vancomycin for C. diff Treatment
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors and that medications were administered in accordance with physician orders. A resident with a recent hospital diagnosis of Clostridioides difficile (C. diff) had been started on oral Vancomycin 125 mg every six hours in the hospital, with treatment intended to continue through a specified end date. Upon admission to the facility, the physician ordered Vancomycin 125 mg every six hours for 37 doses. The resident’s record showed bowel incontinence on multiple occasions shortly after admission. The facility’s medication administration record listed scheduled Vancomycin doses at four specific times each day. Review of the medication administration record revealed that four scheduled Vancomycin doses were not given, with nursing staff documenting that the medication was not available. The missed doses occurred during the first two days after admission, and the first dose administered by the facility was not given until the evening of the second day. The times for administration were changed on the second day, but there was no evidence that the physician was notified that the ordered Vancomycin was unavailable. The Regional Nurse Consultant confirmed that Vancomycin was not in the facility’s starter kit, that the pharmacy was not contacted to supply the medication until the second day after admission, and that the resident missed four doses of the antibiotic with no documented physician notification.
Failure to Implement Care Planned Nutritional Supplementation for Wound Healing
Penalty
Summary
The facility failed to implement care planned interventions for nutritional supplements for a resident with multiple stage 4 pressure ulcers and significant comorbidities, including hemiplegia, chronic kidney disease, and obesity. Upon admission, the resident was identified as being at high risk for skin breakdown and poor nutritional intake, and the care plan included recommendations for nutritional assessment and supplementation to support wound healing. The dietician specifically recommended a protein supplement (prosource) to aid in wound healing, and this intervention was documented in the care plan. Despite the dietician's recommendation and the care plan update, there were no physician orders for the recommended supplement, and the intervention was not implemented. The dietician's recommendation was communicated via email to the Administrator, DON, and ADON, but the message was not relayed to the resident's physician. As a result, the physician was unaware of the recommendation and did not order the supplement. The resident experienced significant weight loss over a short period, and both the resident and her spouse expressed concern that the weight loss was contributing to poor wound healing. The wound physician also identified nutrition as the primary barrier to wound healing for this resident. Interviews with facility staff confirmed that the breakdown in communication led to the failure to implement the recommended nutritional intervention. The facility's policy required that dietician referrals and recommendations for supplements be administered in accordance with physician orders, but this process was not followed. The deficiency was identified through observation, interviews, and record review, and it affected one resident reviewed for wounds.
Failure to Implement Pressure Ulcer Prevention Program
Penalty
Summary
The facility failed to develop and implement a comprehensive and individualized pressure ulcer prevention program, resulting in harm to two residents. Resident #216, who was at risk for pressure ulcer development and dependent on staff for activities of daily living, developed an unstageable pressure ulcer on the sacrum, which later progressed to a Stage IV ulcer. The resident was admitted with intact skin, and the facility did not implement adequate interventions to prevent the development of the ulcer or identify it in a timely manner. The admitting nurse did not thoroughly assess the resident's buttocks area, and a second skin assessment was not completed as required by facility policy. Resident #213, who was at moderate risk for skin breakdown due to impaired mobility and cognitive challenges, did not receive the necessary interventions to prevent pressure ulcers. Despite physician orders for off-loading boots to be used while the resident was in bed, observations revealed that the boots were not in place during multiple checks. The resident's family expressed concerns about the lack of support boots, and staff confirmed the need for these interventions due to the resident's high risk of skin issues. Interviews with facility staff, including the Director of Nursing and a Regional Nurse Consultant, confirmed the lack of timely interventions and assessments for both residents. The facility's policies on pressure injury prevention and admission skin assessments were not followed, contributing to the development and progression of pressure ulcers in these residents. The facility's failure to adhere to its own policies and implement necessary preventive measures led to the deficiencies identified in the report.
Inadequate Hand Hygiene and EBP Implementation
Penalty
Summary
The facility failed to ensure appropriate hand hygiene during medication administration for Resident #105. The RN Supervisor #207 did not perform hand hygiene before preparing medications or after exiting the resident's room. This was confirmed through observation and interviews with the RN Supervisor and the Assistant Director of Nursing. The facility's hand hygiene policy requires hand hygiene before direct contact with residents, before preparing or handling medications, and after contact with residents or inanimate objects. The facility also failed to implement and follow enhanced barrier precautions (EBP) for Residents #2, #19, and #104. For Resident #104, the RN Supervisor did not perform hand hygiene before entering or after exiting the room, despite the presence of an EBP sign. The resident's care plan required EBP due to a chronic wound, and the facility's policy mandates frequent hand hygiene and the use of gowns and gloves during high-contact care activities. Resident #2 had a stage three pressure ulcer but did not have EBP in place, as observed over several days. The Director of Nursing confirmed that EBP should have been implemented. Similarly, Resident #19 had a stage three pressure ulcer, but EBP was not in place until after the surveyor's observation. The facility's policy on EBP requires the use of PPE and signage for residents with chronic wounds to prevent the transmission of multidrug-resistant organisms.
Delayed Response to Call Light
Penalty
Summary
The facility failed to address the needs of a resident in a timely manner, as evidenced by a 29-minute delay in responding to a call light. The resident, who had intact cognition and required substantial or maximal assistance to reposition in bed, triggered the call light because she was uncomfortable and needed help adjusting her position. Despite the facility's policy stating that call lights should be answered within three to five minutes, the call light remained unanswered for 29 minutes. An STNA eventually responded, explaining that other aides were busy assisting other residents. This incident affected one resident out of a facility census of 61.
Confidentiality Breach During Medication Administration
Penalty
Summary
The facility failed to ensure the confidentiality of residents' medical records during routine medication administration, affecting two residents. During the medication administration process, the Registered Nurse (RN) Supervisor left the medication administration records (MAR) open and unattended on the computer screen, making sensitive information visible to passersby. This occurred while the RN was obtaining blood pressure readings for the residents, which was required before administering medications. The information exposed included medication details, scheduled timings, residents' dates of birth, and room numbers. The incident involved two residents, both of whom were moderately cognitively impaired. One resident had a medical history including metabolic encephalopathy, vascular dementia, hypertension, pneumonia, and gastro-esophageal disease, while the other had osteoarthritis, cognitive communication deficit, bradycardia, and acute kidney failure. The RN Supervisor confirmed that the medical records were visible to the public during the medication administration process. The Assistant Director of Nursing also acknowledged that residents' medical records should not be visible or accessible to the public, as per the facility's confidentiality policy.
Failure to Provide Meal Setup Assistance
Penalty
Summary
The facility failed to provide necessary meal setup assistance to a resident with limited range of motion, resulting in a deficiency. Resident #213, who was admitted with severe cognitive impairment and multiple fractures, required setup assistance with eating due to her limited mobility and strength in both upper extremities. Despite physician orders and occupational therapy assessments indicating the need for assistance, the resident did not receive the required help during meals. On the morning of the observation, Resident #213 was seen struggling to eat her breakfast because her meal was not properly set up. She had difficulty cutting her food and removing lids due to her limited arm movement. A nursing assistant denied that any residents, including Resident #213, required meal assistance, which was confirmed as incorrect by the Regional Nurse Consultant. This lack of assistance directly contributed to the resident's inability to perform activities of daily living independently.
Failure to Implement Fall Interventions and Timely Investigations
Penalty
Summary
The facility failed to ensure fall interventions were in place for three residents, leading to deficiencies in accident prevention and supervision. Resident #2 experienced multiple falls, with the facility failing to implement timely and appropriate interventions. Despite orders for a low bed and a fall mat, these were not consistently in place, and neurological assessments were incomplete. The fall investigation for an incident on 09/05/24 was not completed until 09/23/24, indicating a delay in addressing the resident's fall risk. Resident #38 was observed with his bed not in the lowest position, contrary to physician orders and care plan interventions aimed at reducing fall risk. This oversight was confirmed by a nursing assistant, highlighting a lapse in adherence to prescribed safety measures. The facility's policy on fall investigation was not effectively followed, as assessments and interventions were not consistently implemented. Resident #205 had a fall on 09/21/24, with the fall report not completed in a timely manner. The resident's care plan identified a high risk for falls, yet interventions such as non-skid strips were not promptly implemented. The Director of Nursing confirmed the delay in completing the fall report and implementing preventive measures, further underscoring the facility's failure to adequately address fall risks and ensure resident safety.
Deficiencies in Hydration and Nutrition Monitoring
Penalty
Summary
The facility failed to ensure adequate hydration for Resident #38, who had severe cognitive impairment and required assistance with eating. Observations over several days revealed that the resident was frequently without fluids in various locations, including the activities room, dining room, and in bed. Interviews with staff confirmed that fluids were not consistently provided, and there was no hydration care plan in place for the resident, despite the facility's policy to pass fluids once a shift and as needed. Resident #2 experienced a significant weight loss of 6.2% within six days, which was not addressed by the facility. The resident, who was on hospice care and had a stage three pressure ulcer, had dietary needs that were not accurately assessed or met. The Registered Dietitian failed to recognize the weight change and did not make necessary dietary recommendations, such as supplements, to address the resident's increased protein needs due to the pressure ulcer. The facility's policy required addressing weight loss within a week, but this was not followed, and the physician and dietitian were not notified of the weight loss. Resident #19 was not weighed monthly as required, and there was no documentation of the resident refusing weights or the physician being notified of such refusals. The resident had a history of refusing care, but this was not documented, and the facility failed to ensure that the resident's weight was monitored according to policy. The lack of documentation and communication regarding the resident's refusal to be weighed contributed to the deficiency in monitoring the resident's nutritional status.
Failure to Document Nonpharmacological Interventions Before PRN Medication
Penalty
Summary
The facility failed to ensure that nonpharmacological interventions were attempted and documented before administering 'as needed' anxiety medication to a resident. This deficiency was identified during a review of the medical records and interviews. The resident in question had a range of diagnoses, including senile degeneration of the brain, unspecified dementia, and anxiety disorder, among others. The resident's care plan included the use of psychotropic medications, specifically an antidepressant and an antianxiety medication, with interventions requiring physician and pharmacist review for potential dosage reduction and monitoring for side effects. The resident had a physician's order for Lorazepam, an antianxiety medication, to be administered as needed. The Medication Administration Record (MAR) showed that Lorazepam was administered multiple times over a period of approximately one month. However, documentation of nonpharmacological interventions was only present for one instance, despite the medication being administered on numerous occasions. The Director of Nursing confirmed that nonpharmacological interventions were not documented as required, indicating a lapse in following the established protocol for medication administration.
Failure to Provide Timely Speech Therapy Services
Penalty
Summary
The facility failed to ensure that a resident received timely speech therapy services following a change in their nutritional condition. The resident, who had a history of chronic obstructive pulmonary disease, hemiplegia, dysphagia, diabetes, and a gastrostomy tube, was noted to have difficulty swallowing a mechanically altered diet. As a result, the resident's diet was downgraded to a pureed diet until a speech language pathologist (SLP) could provide a recommendation. However, despite the change in diet and the resident's swallowing issues being documented, there was no evidence of evaluation or treatment by the SLP from the time of the diet change until over two months later. Interviews with facility staff revealed a breakdown in communication and process. The SLP was not made aware of the resident's swallowing issues and diet change until much later, indicating a failure in the facility's protocol for notifying therapy staff of such changes. The Director of Nursing (DON) explained that the usual process involved the nurse entering the diet change order, which the DON would then print and provide to therapy during the next morning meeting. However, the order from July was missed, leading to the delay in the resident receiving necessary speech therapy services.
Misappropriation of Resident's Narcotics
Penalty
Summary
The facility failed to prevent the misappropriation of a resident's prescribed narcotics, specifically Hydrocodone-Acetaminophen. The resident, who was cognitively intact and on a scheduled pain medication regime, did not report any missed doses or pain. However, discrepancies were found in the controlled medication inventory log, with entries being altered and made illegible without proper documentation or signatures indicating who made the changes. This affected one resident out of three reviewed for misappropriation. The issue was identified when a pharmacy audit revealed poor documentation and a missing card of Hydrocodone-Acetaminophen. The audit was conducted after staff attempted to refill the resident's prescription and were informed it was too early, indicating that the medication should still have been available in the facility. The investigation pointed to an agency RN as the suspected perpetrator, who had signed the medication inventory log during the shifts when the discrepancies occurred. Attempts to contact the RN for clarification were unsuccessful. The facility's investigation involved reviewing witness statements and contacting the staffing agency. A police report was filed, and the facility determined that the RN was responsible for the missing medications based on the timing of the medication delivery and the altered narcotic sheet documentation. The facility's policy defined misappropriation as the wrongful use of a resident's belongings without consent, which was applicable in this case.
Delayed Investigation of Medication Misappropriation
Penalty
Summary
The facility failed to timely investigate an allegation of misappropriation involving a resident's medication. Resident #21, who was cognitively intact and on a scheduled pain regimen, was affected by this incident. The resident's medical record indicated a prescription for Hydrocodone-Acetaminophen, which was documented as administered without any concerns of missing doses. However, discrepancies were found in the controlled medication inventory log, with altered entries and missing documentation of who made these changes. The issue came to light when a pharmacy audit revealed poor documentation and a missing card of Hydrocodone-Acetaminophen. The Director of Nursing reached out to the staffing agency regarding RN #122, who was suspected of misappropriating the narcotics. Despite attempts to contact RN #122, the agency was unable to reach her. The facility's investigation, initiated after the pharmacy audit, was delayed, and the missing medication was reported to the police. Interviews with staff and review of the facility's policy on misappropriation highlighted a delay in reporting and investigating the incident. The policy required immediate reporting of misappropriation allegations to the Administrator, with an investigation to be completed within five working days. The deficiency was identified under Complaint Number OH00155403, indicating non-compliance with the facility's policy and procedures.
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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.
A cognitively intact resident with behavioral issues, including physical aggression and noncompliance with care, was in a secured unit and was observed tapping on the window/door. A dietary aide, despite being told by a CNA and an RN not to enter the secured unit and that the resident’s assigned aide could assist, went onto the unit and interacted with the resident, including offering to buy a soda after seeing money in the resident’s hand. The resident struck the aide in the face, and the aide responded by punching the resident in the face; a CNA reported hearing the aide say, “I will hit you again,” and then observed the resident bleeding. The resident was later found at the hospital to have an open mandibular fracture and non-restorable teeth requiring extraction, and the facility’s investigation and policy definitions led to the incident being substantiated as staff-to-resident physical abuse.
A resident with severe cognitive impairment, osteoporosis, and total dependence for transfers was being moved from bed to wheelchair with a mechanical lift when CNAs reported that an undersized sling and a forceful pull on the lift caused the resident to fall feet‑first from the sling, with staff catching the upper body while both legs struck the floor and one leg bent behind. Witnesses heard a loud pop and observed immediate pain, bruising, swelling, and deformity of the leg, yet the responding LPN did not complete a thorough musculoskeletal assessment, did not document a fall, and the physician and resident representative were not promptly informed of a suspected injury. Through the night and into the next day, staff and the roommate reported the resident crying out in pain and an obviously abnormal leg, but nursing notes only reflected intermittent acetaminophen administration without clear pain documentation, and the physician was contacted primarily about yelling and behavior. Mobile X‑rays obtained later showed a displaced distal femur fracture, which was not reviewed until the following day, when hospital imaging confirmed a closed displaced comminuted femur fracture and a hand fracture. The facility’s internal investigation was incomplete and inaccurate, with leadership denying a fall, preparing a single typed statement minimizing the event, and having multiple staff sign it despite later testimony that the statement was false and that staff were told not to discuss the incident.
Surveyors found multiple instances of improper food storage and labeling, including undated and unlabeled opened dairy products, beverages, and prepared foods in the main walk-in cooler and freezer, as well as a serving scoop left resting directly on stored pasta. Additional issues included covered but undated pre-poured juices, milk, and thickened beverages in a reach-in cooler used for tray line, and a nurses' station refrigerator containing a dated bag of a resident’s food from over a week prior and three undated half-sandwiches. In a resident’s personal refrigerator, staff confirmed three undated bags of grapes with visible mold. These conditions did not comply with facility policies requiring cold foods to be stored off the floor, wrapped or covered, labeled, dated, and for resident refrigerators to be monitored daily with unsafe or moldy food discarded.
Surveyors found unsanitary kitchen conditions, including a dirty tray holding clean pitchers, soiled storage carts containing clean dishware and disposables, and multiple trays of open juice in a reach-in refrigerator that were unlabeled and undated. In a walk-in refrigerator, they observed a bag of bologna marked only with a freeze date, lacking a thaw or use-by date, and appearing slimy and discolored. Observation of the high-temp dishwasher showed rinse temperatures below the 180°F minimum required for hot water sanitizing, and review of several months of temperature logs revealed repeated sub-minimum wash and rinse temperatures and numerous missing entries. Facility policies required dishwashing to meet specified temperature standards and all refrigerated foods to be covered, labeled, and dated with a use-by date, but these requirements were not consistently followed.
Surveyors found that the facility did not maintain a safe, clean, and homelike environment as required by its policy. In one shared bedroom, wallpaper was peeling in several areas, including behind each bed, below a window, and near baseboards, and a black substance was present around the base of the toilet. A CNA confirmed these conditions. In addition, three cracked or broken light covers were observed in a hall restroom. These environmental issues affected two residents and had the potential to affect all residents.
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
Staff-to-resident physical abuse resulting in jaw fracture and tooth loss
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from staff-to-resident physical abuse, resulting in serious injury. A dietary aide entered a secured unit where a cognitively intact resident with a history of behavioral issues, including physical aggression and noncompliance with care and medications, was located. The resident had been tapping or knocking on the window/door of the secured unit, drawing the attention of the dietary aide. Multiple staff, including a CNA and an RN, told the dietary aide not to go onto the secured unit, noting that the resident’s assigned aide could assist and that the resident had been agitated the previous day. Despite these instructions, the dietary aide went onto the secured unit. Witness statements and interviews indicate that upon entering the unit, the aide interacted with the resident, including offering to buy the resident a soda after seeing the resident holding money. According to staff statements and the aide’s own account, the resident then struck the aide in the face. The aide responded by punching the resident in the face. A CNA on the unit reported stepping between the two to attempt to deescalate the situation and then calling for the nurse due to the resident’s aggression. The CNA also reported hearing the aide tell the resident, “I will hit you again,” and then observed that the resident was bleeding. Following the punch, the resident was noted by staff to be bleeding from the nose and mouth. The resident was assessed by nursing and subsequently transported to the hospital. Hospital records documented that the resident sustained an open fracture of the right jaw, with a loose right lateral mandibular incisor and bleeding from the socket at the fracture site. The resident’s remaining 11 teeth were extracted because they could not be restored. A police report documented that staff reported the incident as an assault in which a staff member punched a resident after the resident had punched the staff member. The facility’s policy defined abuse as the willful infliction of injury resulting in physical harm, including physical abuse such as hitting and punching, and the facility substantiated that the dietary aide had physically abused the resident.
Failure to Ensure Safe Mechanical Lift Transfer, Timely Assessment, and Pain Management After Traumatic Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure safe mechanical lift transfers, adequate assessment, timely physician and representative notification, and appropriate pain management for a severely cognitively impaired, non‑ambulatory resident who required a mechanical lift with two‑person assistance for all transfers. The resident had multiple relevant diagnoses, including vascular dementia, osteoarthritis, a right hip prosthesis, chronic kidney disease, and a history of fractures and osteoporosis/osteopenia. On the morning of 04/22/26, during a mechanical lift transfer from bed to wheelchair, multiple CNAs reported that the sling appeared too small, the lift was pulled forcefully from under the bed, and the resident fell feet‑first out of the sling, with staff catching her upper body while both legs hit the floor and one leg bent behind her. A loud popping sound was heard, the resident screamed and cried out in pain, and witnesses observed immediate bruising, swelling, and apparent misalignment of the left knee/leg. Despite this, the nurse who responded did not perform a complete head‑to‑toe or range‑of‑motion assessment focused on the leg, and the incident was not documented as a fall from the lift. Following the incident, nursing staff actions and documentation were incomplete and inconsistent with the resident’s presentation. Progress notes on 04/22/26 documented only a skin tear to the left forearm and a head‑to‑toe assessment with no new areas, and there were no notes describing a fall, leg injury, or significant pain. Multiple CNAs and the resident’s roommate reported that the resident cried out in pain throughout the night and that her left leg appeared swollen, bruised, and deformed, yet nursing notes from the night shift only recorded administrations of acetaminophen without documenting the reason for administration, pain assessment findings, or any musculoskeletal concerns. One RN reported being asked to look at the resident on 04/22/26, noting swelling of the left leg but performing no further assessment. The physician was not notified within one hour of a suspected musculoskeletal injury as required by facility policy, and the resident’s representative was not informed that the resident had fallen from the mechanical lift. On 04/23/26, staff continued to report the resident’s ongoing pain and abnormal leg appearance, but the physician was contacted only about increased yelling and behavior, with a focus on agitation and prior hip/groin pain history rather than a new traumatic event. The DON later documented that a loud popping noise occurred during a Hoyer lift transfer with three staff present and that no abnormalities or signs of pain were noted, and the physician was asked to order bilateral hip and knee X‑rays as a precaution, without documenting a fall. Mobile X‑rays were obtained on 04/23/26, but the results, which showed a displaced distal femur fracture on a limited lateral view, were not reviewed until 04/24/26. Only then was the fracture acknowledged and discussed with the physician and resident representative. Subsequent hospital evaluation identified a closed displaced comminuted supracondylar fracture of the left femur and a distal fifth metacarpal fracture of the left hand. The facility’s internal investigation was incomplete and inaccurate: the DON denied a fall on 04/22/26, prepared a single typed statement describing only a popping sound while the resident was suspended over the bed, and had multiple staff sign it, even though at least two CNAs and an agency DON later reported that the statement was false and that staff felt intimidated and were told not to talk about the incident. The facility also failed to adequately manage the resident’s pain following the injury. Although the MAR shows acetaminophen administrations on 04/22/26 and early 04/23/26, there was no associated documentation of pain scores or clinical rationale in the progress notes for some doses, and staff interviews and the roommate’s account described the resident crying out in pain whenever touched and throughout the night. The physician later stated he was under the impression the fracture was non‑displaced and that, because the resident was bedbound, he did not feel she needed pain medication, and he was unaware of the severity of the femur fracture or the additional hand fracture. Overall, the facility did not follow its own physician communication policy for falls with musculoskeletal deformity or leg pain, did not perform and document thorough assessments at the time of the incident and during the subsequent night, did not promptly review diagnostic imaging, and did not conduct a complete, accurate investigation into the circumstances of the mechanical lift transfer and resulting injuries.
Improper Food Storage and Labeling in Facility and Resident Refrigerators
Penalty
Summary
Surveyors identified a failure to store food in accordance with professional standards and facility policy, creating the potential for foodborne illness for nearly all residents who received food from the kitchen. In the walk-in cooler, they observed multiple items that were opened and partially used without any open dates, including two cartons of heavy whipping cream, bins of individually poured and covered beverages, and a tray of covered fruit cocktail bowls. A large pan of pasta with ground meat was stored with the serving scoop resting directly on the food, covered with plastic wrap and not dated. A cart in the cooler held a 22-quart container of dark liquid with no label or date, and a pink plastic pitcher resting directly on the cart surface, which was coated with a dark unidentified material. A box of bacon was stored directly on the floor. The Director of Dietary Services confirmed the presence of undated, unlabeled, and improperly stored food items in the walk-in cooler. In the walk-in freezer, surveyors found an unsealed and undated bag of frozen chicken breasts and an unsealed and undated bag of pork pizza topping, which the Director of Dietary Services also confirmed. The reach-in cooler used for tray line contained a variety of pre-poured juices, milk, thickened beverages, and tea that were covered but not dated. At a nurses' station refrigerator, surveyors observed a plastic bag of food labeled with a resident’s name and dated more than a week earlier, along with three half-sandwiches wrapped in plastic without dates; the LPN present verified these findings. In a resident’s personal refrigerator, three undated bags of grapes with visible mold were found, and a CNA confirmed the grapes were moldy and undated. Facility policies required cold foods to be stored at least six inches above the floor, wrapped or in covered containers, labeled, and dated, and required resident refrigerators to be monitored daily, with food appropriately labeled and unsafe or moldy food discarded. These practices were not followed, resulting in the cited deficiency under the complaint investigation.
Unsanitary Kitchen Practices and Improper Dishwashing Temperatures
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service operations related to unsanitary kitchen conditions, improper food labeling and dating, and failure to operate the dishwasher according to manufacturer and policy requirements. During an initial kitchen tour, they observed a plastic tray holding clean pitchers with a brown-like substance on it, and three open, three-shelf carts with crumbs and debris on the shelves where clean insulated plate lids and sleeves of disposable bowls, cups, and lids were stored. Multiple trays of juice in a reach-in refrigerator were open, unlabeled, and undated. In the walk-in refrigerator, surveyors found a plastic bag of bologna with only a freeze date and no thaw or use-by date; the bologna appeared slimy and lighter in color. The facility census was 67, with one resident identified as not receiving meals from the kitchen, and the deficiency was noted as having the potential to affect all residents receiving food from the kitchen. Surveyors also observed the high-temperature dishwasher in use and recorded a wash temperature of 168°F and rinse temperatures of 160°F, 176°F, 178°F, 178°F, and 178°F over five cycles, despite the machine label and facility policy requiring a minimum wash temperature of 150°F and a minimum rinse temperature of 180°F for hot water sanitizing. A staff member confirmed the dishwasher had not been running earlier that morning, verified it was a high-temperature machine that should rinse at a minimum of 180°F, and acknowledged the observations regarding the dirty tray, soiled carts, unlabeled juice, and improperly dated bologna. The staff member stated that items in the reach-in refrigerator were normally prepped the night before and asserted that the bologna always had that color before discarding it. Review of the dishwasher temperature logs for January through April 2026 showed repeated failures to meet required wash and rinse temperatures and numerous instances of missing documentation. In January, multiple wash temperatures were below the 150°F minimum, and several meals lacked recorded wash and rinse temperatures. February logs showed at least one sub-minimum wash temperature and many missing wash and rinse entries for various meals. March logs included at least one meal with no documented wash or rinse temperatures. April logs documented several wash temperatures below 150°F and rinse temperatures below 180°F, along with multiple days and meals where wash and/or rinse temperatures were not recorded at all. Facility policies on sanitation, kitchen infection control, and food receiving and storage required dishwashing to meet temperature and sanitation standards and refrigerated foods to be covered, labeled, dated, and used, frozen, or discarded by their use-by date, which was not consistently followed according to the survey findings.
Environmental Maintenance and Cleanliness Deficiencies in Resident Room and Common Restroom
Penalty
Summary
Surveyors identified that the facility failed to maintain a safe, clean, comfortable, and homelike environment as required by its “Homelike Environment” policy. Observation of a shared bedroom for Residents #46 and #56 showed wallpaper peeling from the wall in multiple locations, including behind each resident’s headboard, below the window, and near the baseboards. In the same room’s bathroom, a black substance was observed around the base of the toilet. During an interview conducted concurrently with these observations, CNA #175 confirmed the presence of the peeling wallpaper and the black substance around the toilet base. Further observation with CNA #175 in the C hall restroom revealed that three light covers in that restroom were cracked or broken. The facility’s written policy, revised in February 2021, states that residents are to be provided with a safe, clean, comfortable, and homelike environment. The conditions observed in the residents’ bedroom, bathroom, and the C hall restroom were inconsistent with this policy and affected two identified residents, with the potential to affect all residents in the facility.
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