Altercare Of Nobles Pond, Inc
Inspection history, citations, penalties and survey trends for this long-term care facility in Canton, Ohio.
- Location
- 7006 Fulton Drive, Nw, Canton, Ohio 44718
- CMS Provider Number
- 366298
- Inspections on file
- 24
- Latest survey
- March 19, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Altercare Of Nobles Pond, Inc during CMS and state inspections, most recent first.
A resident with multiple medical conditions, including metabolic encephalopathy and Generalized Anxiety Disorder, was started on BuSpar 10 mg BID following a psychiatric evaluation, but the responsible party was not properly informed of this new psychotropic medication order. Nursing notes lacked documentation of the psychiatrist’s assessment or any notification to the responsible party, even though the MAR showed the resident received two doses. The responsible party later reported learning of the medication only during an in-person visit and expressed concern due to the resident’s prior adverse reactions to psychotropic drugs. Conflicting accounts from two ADONs about when and how the responsible party was notified, combined with the absence of required documentation, demonstrated noncompliance with the facility’s policy on notifying and documenting changes in a resident’s condition or treatment.
A resident with impaired ability to perform ADLs and requiring assistance with toileting reported that her bedpan smelled terrible and was not cleaned by staff after use. During observation, surveyors found two unlabeled, unbagged orange bedpans in the bathroom, one in the toilet bowl and one on the floor between the wall and toilet, both with apparent barrier cream residue. A CNA confirmed the bedpans were stored inappropriately, demonstrating a failure to maintain a clean, comfortable, and homelike environment consistent with the facility’s resident rights policy.
The facility failed to provide appropriate and timely care in several areas. A resident with urinary retention, a Foley catheter, and ongoing hematuria continued to receive an anticoagulant while experiencing large blood clots and low Hgb, with delayed practitioner response and no documented timely family notification, until critically low labs led to hospital transfer. Another resident with a right hip arthroplasty had a hip dressing in place but no wound care orders or care plan interventions. A third resident with a stage 4 pressure ulcer also had an undocumented and untreated skin tear on the posterior inner thigh, despite a dated dressing being present. A fourth resident with obesity, DM, and cardiac monitoring needs had multiple missed daily weights despite a physician order and care plan interventions, with no documentation explaining the omissions.
Two residents did not receive consistent, professionally managed pressure ulcer care. One resident was admitted with a wound noted on assessment, but for weeks the only documented wound was a skin tear, there were no wound-care orders, and facility staff denied any buttock wounds despite a family photo and an outside RN’s documentation of open buttock areas and a stage 1 coccyx ulcer. Another resident with a care-planned stage 4 sacral pressure injury and specific MD orders for Aquacel AG and foam dressings every other day had multiple missed or unrecorded treatments on the TAR, and reported that dressings were not changed consistently and that only two nurses regularly performed the care. The regional RN verified the missing treatment entries, while the ADON, who stated an outside wound center managed the wound, was unaware of the missed treatments, contrary to the facility’s wound care policy requiring adherence to professional standards of practice.
A resident with acute kidney failure, kidney stones, UTI, moderate cognitive impairment, and severe left hip osteoarthritis experienced inadequate pain management when PRN acetaminophen and later PRN oxycodone were not used or escalated in a timely and consistently effective manner. On one occasion, the resident was documented as yelling with pain rated 9/10, initially receiving only Tylenol because narcotics were noted as not due, and although oxycodone was later increased and administered, the resident was again observed yelling in pain that same afternoon. A family member reported the resident screaming in pain on another day, being told that Tylenol would not be available for some time, and that the nurse would not call the NP or physician, instead waiting for the NP’s next visit and only leaving a log-book message. These events occurred despite facility policies requiring prompt physician notification for changes in condition and pain management consistent with professional standards.
A resident with multiple comorbidities, including DM, CKD, morbid obesity, and mobility impairment, had a PRN order for Hydroxyzine Pamoate 25 mg. The consulting pharmacy later recommended discontinuation of this drug, and the physician signed to discontinue it, but nursing staff continued to administer the medication and the order remained active on the MAR for several weeks afterward. This resulted in the resident receiving doses of Hydroxyzine despite the documented decision to stop the medication, contrary to facility policy requiring medications to be administered in accordance with prescriber orders.
A resident without documented psychiatric diagnoses or anxiety symptoms was started on BuSpar and Trazodone following a psychiatric evaluation that relied on the resident’s self-reported sadness, anxiety, and sleep issues, while depression was still being ruled out. Nursing notes did not document the psychiatrist’s assessment or the new psychotropic orders on the day they were made, and there was no clear documentation that the responsible party was notified when BuSpar was initiated. The MAR showed BuSpar was entered and administered twice before being discontinued, and the responsible party later reported not understanding why the medications were started and expressed concern due to the resident’s prior adverse reactions to psychotropics. Interviews with ADONs revealed inconsistent accounts of when and how the responsible party was informed and showed that the rationale for Trazodone was not discussed, contrary to facility policy requiring immediate notification and documentation when there is a change in the resident’s status or treatment.
Surveyors found that food items were stored without required labels or dates, the oven was not kept clean, and a dietary aide handled ready-to-eat food with bare hands, all in violation of facility policies. These deficiencies had the potential to affect nearly all residents receiving food from the kitchen.
Multiple residents did not receive physician-ordered fortified nutritional treats or their preferred food and beverage items during meals, including cases where allergies and dietary orders were not accommodated. Staff and resident interviews, as well as direct observation, confirmed that meal trays were missing required supplements and selected items, and that substitutions were made without honoring resident preferences.
A resident with multiple medical conditions and intact cognition was unable to summon assistance because the call light in their room was not working due to the cord being pulled out of the wall. The resident, who was at risk for falls and required help with transfers, was observed needing assistance and reported the issue. Facility policy required timely response to call lights, but the malfunction prevented the resident from receiving needed support.
A resident with hemiplegia and muscle weakness did not consistently receive a physician-ordered left palm protector as required to prevent skin breakdown and deformity. Observations and staff interviews revealed the device was not always in place during the day, and some CNAs were unaware of the correct timing for its removal. The facility also lacked a policy on palm protector use.
A resident who required tube feeding due to dysphagia and gastrostomy status was given a different enteral formula than what was ordered by the physician, despite the correct formula being available in the facility. Staff did not obtain physician or dietitian approval for the substitution, and facility policy requiring administration of prescribed enteral nutrition was not followed.
A resident with type 1 diabetes and significant physical limitations did not receive consistent staff assistance with carbohydrate counting or insulin pump operation as ordered, resulting in missed or incorrect insulin administration. Staff lacked training on the insulin pump, care plans were not updated to reflect current interventions, and documentation of insulin boluses and carbohydrate counts was incomplete, leading to significant medication errors.
A resident with multiple chronic conditions experienced a fall that was inconsistently documented in the facility's records. Two separate incident reports were created for the same event, both marked as falls with injury, yet both stated there was no injury or pain, despite clinical notes indicating a head abrasion and thigh pain. Staff interviews confirmed discrepancies in the documentation and notification times, and the DON acknowledged the reports did not match.
A resident with multiple medical conditions and a fall risk was unable to summon assistance because the call light in their bathroom was not working due to the cord being pulled out of the wall. The resident attempted to use the call light for help with positioning, but it failed to activate the electronic message board, contrary to facility policy requiring timely response to call lights.
A long-term care facility failed to protect residents from the misappropriation of narcotic medications, affecting several residents. Discrepancies in medication administration records and narcotic count sheets led to missing medications. Incidents included missing oxycodone for a resident post-discharge, premature destruction of another resident's medication, and false documentation of narcotic waste by an LPN. These deficiencies highlight lapses in medication management and documentation procedures.
Failure to Notify Responsible Party of New Psychotropic Medication Order
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s responsible party was fully informed of and understood a change in the resident’s medication regimen. A resident admitted with metabolic encephalopathy, peripheral vascular disease, urinary tract infection, kidney calculus, and osteonecrosis of the left femur underwent an admission psychiatric evaluation by a consulting psychiatrist, who diagnosed Generalized Anxiety Disorder and ordered BuSpar 10 mg orally twice daily. The nursing progress notes for the period surrounding this evaluation contained no documentation of the psychiatrist’s assessment or of any notification to the resident’s responsible party about the new BuSpar order. The MAR showed the BuSpar order was entered and that the resident received two doses. The facility’s policy required immediate notification of the resident and authorized representative, with documentation in the medical record, when there was a change in the resident’s mental, physical, or psychosocial status. The resident’s responsible party reported that the facility started the resident on BuSpar and Trazodone for reasons unknown to her, and that she did not learn about the BuSpar until a nurse mentioned it during a visit. She stated the resident had previously experienced adverse reactions to psychotropic medications and that she did not want him on medications that cross the blood-brain barrier. One ADON stated she believed another ADON had notified the responsible party by phone and that she later met in person with the responsible party to discuss the BuSpar order, acknowledging the resident received two doses before discontinuation. The other ADON, however, stated she did not notify the family by phone, that all communication with the responsible party was in person, and that she discussed the BuSpar order with the responsible party at the next in-person visit and believed the resident did not receive any doses. There was no documentation in the medical record of timely notification to the responsible party about the initiation of BuSpar, contrary to facility policy.
Failure to Maintain Clean and Homelike Environment for Bedpan-Dependent Resident
Penalty
Summary
Surveyors identified that the facility failed to maintain a clean and homelike environment for Resident #58. The resident was admitted on 11/04/25 with diagnoses including need for personal care, difficulty walking, muscle weakness, and repeated falls, and had a care plan dated 01/21/26 indicating an impaired ability to perform or participate in ADLs, with interventions to assist with toileting and provide incontinence care as needed. During an interview and observation on 03/16/26 at 11:40 A.M., the resident reported that her bedpan smelled terrible and that staff did not clean the bedpan after use. At that time, two unlabeled and unbagged orange bedpans were observed in the bathroom, one inside the toilet bowl and one on the floor between the wall and toilet, both appearing to have barrier cream residue on them. At 11:42 A.M., CNA #615 confirmed that the two bedpans were stored inappropriately. Review of the facility’s resident rights policy dated 05/01/25 stated the facility would make every effort to assist each resident in exercising their rights to be treated with respect, kindness, and dignity. This deficiency was cited under Complaint Number 2807084. The deficiency centers on the facility’s failure to ensure that the resident’s bedpan was cleaned after use and that bedpans were properly labeled, bagged, and stored, resulting in a bathroom environment that was not clean, comfortable, or homelike as required by the facility’s own resident rights policy.
Failure to Provide Timely Medical Response, Wound Management, and Ordered Daily Weights
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate medical treatment and timely response to a change in condition for a resident with hematuria and anemia, as well as failures in wound care management and completion of ordered daily weights for other residents. One resident with acute kidney failure, urinary retention, and a Foley catheter had ongoing hematuria and blood clots while receiving Eliquis. Laboratory results showed low red blood cell and hemoglobin levels, and nursing notes documented large blood clots and bloody drainage from the penis on multiple occasions. Although nursing staff paged the nurse practitioner and notified the urologist, there were significant delays in response to the change in condition, and the medical record lacked evidence of timely family notification. The resident continued to receive Eliquis through multiple days of documented bleeding and low hemoglobin until an order was finally obtained to hold the anticoagulant and repeat labs, after which a critically low hemoglobin prompted transfer to the emergency department. Another deficiency involved a resident admitted with a displaced right femur fracture and right hip arthroplasty who had a dressing to the right hip but no corresponding wound care orders or care plan interventions. Observation confirmed the presence of a right hip dressing without any documented wound care orders in the medical record. The DON confirmed that the resident did not have orders or a care plan for wound care and interventions related to the right hip surgical site, despite the presence of a dressing. A further deficiency concerned a resident with a history including surgical aftercare for digestive system surgery, muscle weakness, and malignancies of the liver and colon, who had a documented stage 4 pressure ulcer but also had an additional skin tear on the left posterior inner thigh. The quarterly MDS did not reflect the skin tear, and the physician orders contained no assessments or treatments for this wound. During wound care observation, a dressing dated several days earlier was noted on the left posterior inner thigh, and the DON confirmed that the medical record did not contain documentation of or orders to treat this skin tear, contrary to the facility’s wound care policy requiring verification of physician orders for wound procedures. Additionally, the facility failed to obtain daily weights as ordered for another resident with morbid obesity, type II diabetes mellitus, and cardiac-related monitoring needs. This resident had an order for daily weights and a care plan that included monitoring for edema and obtaining vital signs as ordered. Review of treatment administration records showed multiple missed daily weights in both February and March, with no documentation in the progress notes explaining why the weights were not completed. An LPN confirmed that some of the required daily weights had not been obtained as ordered, despite the facility’s policy that residents’ weights be monitored and recorded in the electronic medical record to evaluate nutritional status within the parameters of their medical condition.
Failure to Provide and Document Consistent Pressure Ulcer Care
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate care and treatment for existing pressure ulcers and to prevent new ulcers from developing for two residents. One resident was admitted with multiple medical conditions, including peripheral vascular disease and osteonecrosis, and the admission assessment and baseline care plan noted the presence of a wound without documenting its location. From admission through several weeks, nursing progress notes contained no documentation of any wounds other than a skin tear, and there were no physician orders for wound care. Despite this, the resident’s responsible party reported pressure wounds on the buttocks, provided a photograph showing two open reddened areas near the gluteal fold, and stated that the facility was not providing wound care. A urology RN later documented two open skin areas on the left medial buttock and a stage 1 pressure ulcer on the coccyx when the resident presented for a procedure, while facility nursing leadership and staff continued to deny the presence of any buttock wounds beyond the documented skin tear. The second resident had an existing care plan for a sacral pressure injury related to impaired mobility, urinary incontinence, and cancer, with interventions including performing ordered treatments and completing preventive measures. The resident’s MDS indicated cognitive intactness, need for assistance with rolling, frequent urinary incontinence, a colostomy, and one stage 4 pressure ulcer. Physician orders specified cleansing the sacrum with soap and water, patting dry, filling the wound and undermining with Aquacel AG rope, and applying a foam dressing every other day and as needed. However, review of the Treatment Administration Records showed multiple dates in two consecutive months when the ordered sacral wound treatments were not recorded as completed. The resident with the sacral pressure ulcer reported that dressings were not being changed consistently and attributed the development of the wound to not being repositioned, though she was unsure whether it originated in the facility or the hospital. She further stated that only two nurses regularly changed her sacral dressing. The regional RN confirmed the missing treatment entries on the TAR, and the ADON, who indicated that an outside wound center managed the resident’s wound care and had recently changed the treatment frequency, was unaware that treatments were not being completed and suggested agency nursing staff usage as a possible factor. The facility’s own wound care policy required that wound care be provided using professional standards of practice, which was not followed as evidenced by the lack of documented and consistently provided wound care for both residents’ pressure ulcers.
Failure to Provide Timely and Effective Pain Management for a Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate pain management for a resident with multiple medical issues, including acute kidney failure, kidney stones, urinary tract infection, and primary osteoarthritis of the left hip. The resident had moderate cognitive impairment and reported pain in multiple areas, including his hip, arms, legs, and teeth. Physician orders initially included PRN acetaminophen 325 mg every four hours for pain, which was later discontinued, and then PRN oxycodone 2.5 mg every eight hours for pain. Documentation showed that on one date the resident received acetaminophen for a pain level of six, which was not effective, followed by another dose that was effective. An orthopedic note documented the resident’s left hip pain and the plan for further interventions, including urology and dental evaluations. On another date, the resident’s pain escalated significantly. At approximately midday, the resident was documented as yelling out with pain rated 9/10. At that time, narcotics were noted as “not due,” and Tylenol was administered while the NP was notified. Shortly thereafter, the NP ordered an increase in oxycodone to 5 mg every eight hours PRN, and a dose was administered. The MAR and controlled drug record indicated that the oxycodone dose was effective at a later assessment, with the resident resting; however, an observation later that same afternoon found the resident in bed yelling out that he was in pain. The ADON later stated she did not hear the resident if he hollered out after the oxycodone administration. Family interviews revealed additional concerns about pain management on an earlier date. A family member reported that the resident was screaming in pain and that staff told her Tylenol would not be available for another 40 minutes. The family member stated she had to locate staff to assist the resident and provide pain medication, and that the LPN on duty said the NP would not be in until the next day and would not address the resident’s pain, and that the nurse would not call the physician. The LPN later confirmed she was aware of the family’s concerns, gave Tylenol, did not recall if the resident was hollering in pain, and did not call the NP because the NP preferred to see residents in person for narcotic pain medications, instead leaving a message in the log book for the physician. These actions and inactions occurred despite facility policies requiring notification of the physician and representative upon changes in condition and administration of pain medications in accordance with professional standards of practice.
Failure to Timely Implement Pharmacy and Physician Discontinuation of PRN Hydroxyzine
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely implementation of pharmacy recommendations to discontinue a medication after physician approval. A resident admitted with diagnoses including a displaced right humerus fracture, gait and mobility abnormalities, type II diabetes mellitus, morbid obesity, and chronic kidney disease had a physician order dated 01/27/26 for Hydroxyzine Pamoate 25 mg to be given orally once daily as needed. The five-day admission MDS showed a BIMS score of 10, indicating moderate cognitive impairment, and documented that the resident was receiving a diuretic, opioid, antiplatelet, and antidepressant. On 02/16/26, the consulting pharmacy recommended discontinuation of Hydroxyzine Pamoate 25 mg, and on 02/20/26 the physician reviewed and agreed with this recommendation, signing to discontinue the medication. Despite the physician’s discontinuation decision, review of the February and March 2026 MARs showed that the Hydroxyzine Pamoate order remained active and the medication continued to be administered. The MAR for February 2026 documented administration of Hydroxyzine Pamoate 25 mg on 02/25/26, and the March 2026 MAR documented administrations on 03/06/26 and 03/11/26. The order itself was not discontinued until 03/16/26. During an interview on 03/17/26, the Regional Nurse confirmed that the pharmacy recommendation to discontinue the medication was made on 02/16/26, the physician signed to discontinue it on 02/20/26, but the medication continued to be given on the above dates and the order remained in place until mid-March. Facility policy on medication administration stated that medications are to be administered in accordance with prescriber orders, which did not occur in this case.
Failure to Ensure Appropriate Indication and Notification for New Psychotropic Medications
Penalty
Summary
The facility failed to ensure a resident’s drug regimen was free from unnecessary medications by not establishing and documenting appropriate indications for new psychotropic drugs. A resident admitted with metabolic encephalopathy, peripheral vascular disease, urinary tract infection, kidney calculus, and osteonecrosis of the left femur had no documented history of generalized anxiety disorder, depression, or other psychiatric conditions in the medical record. Review of progress notes over several days showed no signs or symptoms of anxiety and no documentation of referral to psychiatric services. During an admission psychiatric evaluation, the consulting psychiatrist documented the resident’s self-reported sadness, depression, poor sleep, anxiety, and restlessness, diagnosed generalized anxiety disorder, ordered BuSpar 10 mg orally twice daily for anxiety, and Trazodone 25 mg orally every evening while depression was still being ruled out and not listed as a confirmed diagnosis. The nursing documentation did not reflect the psychiatrist’s assessment or the new orders for BuSpar and Trazodone on the date they were made, and there was no documentation of notification of the resident’s responsible party regarding the initiation of BuSpar. The MAR showed the BuSpar order was entered the day after the psychiatric evaluation, and the resident received two doses before discontinuation. The responsible party later reported that the medications were started for an unknown reason, stated the resident had prior adverse reactions to psychotropic medications, and did not want medications that cross the blood-brain barrier. Interviews with the ADONs revealed conflicting accounts about whether and when the responsible party was notified of the new orders, with one ADON stating she did not notify the family by phone and that all communication was in person, and acknowledging that nothing was discussed regarding the rationale for Trazodone. The facility’s policy required immediate notification of the resident and authorized representative, consultation with the practitioner, and documentation in the medical record when there is a change in mental, physical, or psychosocial status, which was not consistently followed in this case.
Deficient Food Storage, Sanitation, and Handling Practices
Penalty
Summary
Surveyors observed multiple deficiencies in the facility's food storage, preparation, and service practices. During a kitchen tour, open bags of cake mix and instant mashed potatoes were found in the dry goods storage room without labels or dates indicating when they were opened. In the walk-in freezer, frozen french toast sticks and an opened bag of biscuits were also found without labels or dates. Additionally, the oven in the preparation area had visible food residue and splatter, indicating it was not maintained in a clean and sanitary condition. During lunch meal service, a dietary aide was seen handling a deli sandwich with bare hands, removing it from a sandwich bag and placing it on a plate for a resident, contrary to facility policy requiring glove use for food handling. Facility policies reviewed by surveyors specified that all open food items must be labeled with the opened date, expiration date, and food item name, and that gloves must be worn when handling food. These deficiencies had the potential to affect 68 out of 69 residents who received food from the kitchen, with one resident not affected due to being NPO (nothing by mouth).
Failure to Provide Physician-Ordered Supplements and Honor Resident Meal Preferences
Penalty
Summary
The facility failed to provide meals that accommodated resident allergies, physician-ordered supplements, and stated preferences for multiple residents. For one resident with COPD, failure to thrive, and dementia on hospice, the physician ordered a regular diet with a four-ounce fortified nutritional treat at lunch. However, observation revealed that the fortified treat was not included on the lunch tray, and this omission was confirmed by both a CNA and review of the meal ticket. Another resident with systemic lupus and recent significant weight loss had a physician order for a regular diet with no bananas or seafood due to allergies and a daily fortified nutritional treat at lunch. Observation and interviews confirmed that the fortified treat was missing from the lunch tray, despite being indicated on the meal ticket. Additional deficiencies were observed regarding resident meal preferences. One resident with anorexia and moderate cognitive impairment was supposed to receive apple juice according to the meal ticket but was instead given cranberry juice and, on another occasion, lemonade. These errors were verified by both staff and the resident, who expressed dissatisfaction with the incorrect beverage. Another resident with chronic respiratory failure and muscle wasting selected specific breakfast items, including a hash brown patty and cranberry juice, but did not receive the hash brown and was given orange juice instead. Staff confirmed the kitchen had run out of hash browns. A further resident with COPD and moderate cognitive impairment also did not receive a selected hash brown patty for breakfast, as the kitchen had run out. Across these cases, the facility did not consistently provide food and beverages according to physician orders, resident allergies, and stated preferences, as evidenced by direct observation, record review, and staff interviews. These failures affected five of six residents reviewed for food and drink, out of a facility census of 69.
Failure to Ensure Functioning Call Light for Resident Needing Assistance
Penalty
Summary
A deficiency was identified when a resident with diagnoses including pancytopenia, diabetes mellitus, and atherosclerotic heart disease, and who exhibited intact cognition, was observed needing assistance and reported that the call light was not working. The resident's care plan indicated a risk for falls and included an intervention to encourage the use of the call light for transfer and ambulation assistance. During observation and interview, it was confirmed that the call light did not activate the electronic message board, and further inspection revealed the call light cord was pulled out of the wall, rendering it nonfunctional. The facility's policy required timely response to call lights to meet residents' needs.
Failure to Implement Physician-Ordered Palm Protector for Resident with Limited Mobility
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident's left palm protector was implemented as ordered to prevent skin breakdown and deformity. The resident, who had a history of hemiplegia and hemiparesis following a cerebral infarction affecting the left non-dominant side, muscle weakness, and vascular dementia, had a physician's order for a left palm protector to be applied in the morning and removed at bedtime, with skin integrity checks twice daily. Documentation in the medical record indicated the palm protector was applied as ordered, and the care plan included this intervention. However, during observation, the resident was found with a contracted left hand and no palm protector in place, and the resident confirmed that the device was supposed to be worn during the day. A CNA also confirmed the palm protector was not in place as ordered and applied it at that time. Further interviews revealed that staff were not consistently aware of the timing for removal of the palm protector, with one CNA stating she was unaware it was to be removed at bedtime. Additionally, the facility did not have a policy regarding the use of palm protectors.
Failure to Administer Prescribed Enteral Feeding Formula
Penalty
Summary
A deficiency occurred when a resident with a history of dysphagia, aphasia, and gastrostomy status, who was dependent on staff for activities of daily living and received the majority of their nutrition and hydration via tube feeding, was not provided the prescribed enteral feeding formula. The physician's order specified continuous administration of Isosource 1.5 at 55 ml per hour, but instead, Vital 1.5 formula was administered. This substitution was observed during a survey, and the medication administration record indicated the feeding was signed as administered according to the order, despite the actual formula being different. Interviews with nursing and dietary staff confirmed that no physician order or dietitian consultation had been made to authorize the substitution of the enteral formula. The supply room was found to have the prescribed Isosource 1.5 formula available at the time of the incident, and the medical records coordinator was unable to explain why the incorrect formula was used. Facility policy required that enteral nutrition be administered as prescribed, in accordance with professional standards, which was not followed in this instance.
Failure to Ensure Proper Insulin Pump Management and Carbohydrate Counting
Penalty
Summary
The facility failed to ensure that a resident with type 1 diabetes mellitus, spastic quadriplegic cerebral palsy, and a recent right humerus fracture received proper assistance with insulin pump management and carbohydrate counting as ordered by the physician. The resident was dependent on staff for all activities of daily living, including eating, and was unable to independently calculate or enter carbohydrate counts into the insulin pump due to physical limitations. Despite physician orders specifying that staff should assist with carbohydrate counts and insulin pump operation, there was no evidence in the medical administration records that this assistance was consistently provided across multiple meals and days. Staff interviews revealed a lack of knowledge and training regarding the resident's insulin pump and carbohydrate counting. Several nurses and LPNs admitted they were unfamiliar with the insulin pump's operation, did not know they were responsible for providing carbohydrate counts, or relied on the resident to guide them through the process. Documentation showed that staff did not consistently record carbohydrate counts or verify that insulin boluses were administered as ordered. Additionally, there was a transcription error regarding insulin dosage, and the nurse involved was unaware of the correct dose to administer, further contributing to medication errors. The resident's care plan did not reflect current physician orders related to carbohydrate counting and insulin pump management. The facility did not provide staff education on the use, care, or maintenance of the insulin pump, nor did it assess the resident for self-administration of medication. The lack of updated care plans, staff training, and proper documentation led to significant medication errors, including missed or incorrect insulin administration and inadequate monitoring of blood glucose levels.
Inaccurate Documentation of Fall and Investigation
Penalty
Summary
The facility failed to accurately document the details of a fall and the subsequent fall investigation for one resident. The medical record review revealed inconsistencies in the documentation of the fall event, including conflicting dates and times of the incident, discrepancies in the reporting of injuries, and inconsistent notification times for the nurse practitioner and resident representative. Two separate fall investigation reports were completed for the same incident, both indicating the fall was classified as 'with injury,' yet both reports stated there was no injury and no pain. Additionally, the progress note from the nurse practitioner described a small abrasion on the back of the resident's head and right thigh pain, which was not reflected in the fall investigation reports. The care plan identified the resident as being at risk for falls due to multiple medical conditions and medications, but the documentation of the actual fall event and related assessments was not consistent or accurate. The resident involved had multiple diagnoses, including osteoarthritis, atrial fibrillation, diabetes, COPD, bipolar disorder, hypertension, and impaired mobility. The resident self-reported the fall, stating she hit her head and hurt her arm, but the incident reports did not document these injuries. Interviews with facility staff confirmed the existence of two incident reports for the same event and acknowledged that the information in the reports did not match. The Director of Nursing confirmed that the fall was classified as a fall with injury, despite the incident reports indicating otherwise, and explained that the duplication occurred because the first report was accidentally closed before completion.
Non-Functioning Call Light in Resident Bathroom
Penalty
Summary
A deficiency was identified when a resident, admitted with pancytopenia, diabetes mellitus, and atherosclerotic heart disease, was found to have a non-functioning call light in their room. The resident, who was assessed as having intact cognition and was at risk for falls, reported using the call light to request assistance for positioning prior to lunch, but the device did not work. Observation confirmed that the call light failed to activate the electronic message board, and further inspection with the Administrator revealed the call light cord was pulled out of the wall, rendering it inoperable. The facility's policy required timely response to call lights to meet resident needs, but this was not met in this instance.
Misappropriation of Narcotic Medications in LTC Facility
Penalty
Summary
The facility failed to protect several residents from the misappropriation of narcotic medications, affecting five residents who were prescribed such medications. The incidents involved discrepancies in medication administration records (MAR) and narcotic count sheets, leading to missing medications. For instance, Resident #70's oxycodone was reported missing after discharge, prompting a facility-wide search and drug testing of nurses, which returned negative results. Similarly, Resident #22's narcotic medication was found to be destroyed prematurely, with the facility unable to verify the receipt of medications due to missing records. Resident #21 experienced issues with medication administration documentation, where an LPN failed to record the administration of narcotic medication in the MAR, leading to a policy violation write-up. Resident #64's records showed discrepancies between the MAR and the narcotic sheets, with more administrations recorded on the narcotic sheets than in the MAR. This was discovered during routine medication audits, indicating a lack of proper documentation and accountability. Resident #71's case involved an LPN who falsely documented the wasting of narcotic medication, claiming a witness who later denied involvement. This led to the termination of the LPN and further investigation by the facility. The facility's policies on medication administration and narcotic handling were not adequately followed, resulting in these deficiencies. The incidents highlight lapses in the facility's procedures for narcotic medication management and documentation.
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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.
Trusted data from CMS and state health departments
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