Aurora Manor Special Care Cent
Inspection history, citations, penalties and survey trends for this long-term care facility in Aurora, Ohio.
- Location
- 101 S Bissell Rd, Aurora, Ohio 44202
- CMS Provider Number
- 365844
- Inspections on file
- 29
- Latest survey
- April 9, 2026
- Citations (last 12 mo.)
- 14 (1 serious)
Citation history
Health deficiencies cited at Aurora Manor Special Care Cent during CMS and state inspections, most recent first.
A cognitively intact but quadriplegic resident with MS, incontinence, and a history of behavioral symptoms was physically abused by a CNA during incontinence care. Video showed the CNA entering without knocking while the resident slept, roughly rolling him, striking his face and upper body multiple times, throwing and forcefully holding a pillow over his face, and continuing care in a rough manner. The next morning the resident reported being punched in the nose and handled "like a rag doll"; staff and police noted dried blood and nasal deviation, and hospital imaging confirmed multiple nasal fractures and a perforated nasal septum. The facility’s investigation, based on video review and interviews, substantiated that physical abuse had occurred.
A resident with MS, quadriplegia, depression risk, incontinence, and documented rejection-of-care behaviors was involved in an incident where video showed a CNA entering the room without knocking, roughly repositioning the resident during incontinence care, striking him multiple times, throwing and forcefully holding a pillow over his face, and continuing care while the resident appeared to react. The CNA later reported that the resident had been verbally aggressive and spitting at her during care, and an RN confirmed the resident became verbally aggressive and refused care later that night. Despite these reports and facility policies requiring assessment and monitoring of residents with behaviors that might lead to conflict or neglect, and immediate interventions when behaviors could harm others, the RN did not assess or formally report the resident’s aggressive behaviors, resulting in a failure to assess the resident following reported aggressive behaviors in the setting of a substantiated abuse incident.
A resident with dementia, chronic venous insufficiency, muscle weakness, and a prior pelvic fracture was identified as high fall risk and care-planned for non-skid socks and two-person assist for transfers, yet the fall/safety care plan was not updated after PT discharge and was inconsistently implemented. The resident sustained an unwitnessed fall in her room and was found on the floor barefoot, despite non-skid socks being a listed intervention, with no clear explanation in the fall investigation and no timely witness statement from the assigned CNA. Later the same day, a CNA transferred the resident alone from wheelchair to bed, contrary to the care plan, causing a severe skin tear when the resident’s leg scraped the wheelchair leg rest; the resident, on warfarin, required hospital care and was diagnosed with a pelvic fracture and multiple skin tears. Facility investigations lacked complete root cause analyses and did not reconcile MDS findings, therapy recommendations, and care-plan directives with the care actually provided.
A resident with multiple sclerosis, chronic respiratory failure with hypoxia, and a tracheostomy had provider orders and a care plan requiring oxygen via trach collar at 5 L/min, with oxygen tubing and disposable respiratory supplies to be changed weekly and equipment cleaned weekly. Facility policy also required weekly changes of oxygen tubing, masks, and cannulas with documentation in the EHR. During observation, the resident was in bed receiving oxygen via trach mask, and the oxygen tubing in use was dated several weeks earlier, which a CNA verified, showing the tubing had not been changed weekly as ordered and as required by facility policy.
A resident with cognitive impairment and total incontinence received incontinence care during which a CNA placed supplies on an uncleaned bedside table without a barrier and failed to perform hand hygiene after glove removal, contrary to facility policy.
The facility failed to ensure resident rooms were clean and sanitary, affecting five residents. Observations showed grimy floors, unswept areas, and unclean bathrooms. Residents reported that rooms were not cleaned daily, and the Housekeeping Manager confirmed staffing shortages. The facility's policy required daily cleaning, which was not consistently followed.
A resident was involved in a physical altercation with another resident, resulting in a bruise. Despite facility policy, the family was not notified of the incident. The event was not documented or reported to the administration until days later, leading to a deficiency in care.
Two residents in an LTC facility were involved in a physical altercation, resulting in one resident being punched and bruised. Despite the incident being witnessed by CNAs, it was not documented or reported to the Ohio Department of Health until ten days later. The facility's staff failed to follow the abuse policy, which required immediate reporting and investigation, leading to a deficiency in protecting residents from abuse.
Two residents with chronic conditions were involved in a physical altercation after a verbal dispute, resulting in a bruise on one resident's forehead. The incident was witnessed by CNAs but was not reported or documented until days later, leading to a deficiency due to the facility's failure to follow its abuse policy and protocol.
Two residents with chronic conditions were involved in a physical altercation, resulting in one resident sustaining a bruise. The incident was witnessed by CNAs but was not reported to the Ohio Department of Health until ten days later. The facility failed to document the incident, monitor behavior contracts, and follow the abuse policy, leading to a deficiency investigation.
Two residents were involved in a verbal and physical altercation, resulting in one resident being punched and bruised. Despite facility policy requiring immediate investigation of abuse allegations, the incident was not reported or investigated until several days later. Staff and resident interviews confirmed the altercation and the delay in response, leading to non-compliance.
A resident with multiple health issues did not have a stat Basic Metabolic Panel (BMP) completed as ordered by a Nurse Practitioner due to a hemolyzed specimen. The facility failed to reschedule the test, as confirmed by interviews with the NP and DON. This deficiency was identified during a complaint investigation.
An Administrator failed to treat a resident with dignity and respect, as evidenced by yelling and threatening behavior. The resident, who had no cognitive impairment and multiple health conditions, reported feeling inappropriately treated. Witnesses, including an LPN and a Regional RN, confirmed the Administrator's actions, which included yelling, gesturing, and threatening to evict the resident.
A resident with multiple health conditions reported that the Administrator yelled and threatened to evict her, which was witnessed by an LPN. The incident was reported to the former DON but not to the regional team, delaying the investigation. The facility's policy requires immediate reporting and investigation within five days, which was not followed, leading to non-compliance.
The facility failed to notify physicians when residents did not receive their prescribed insulin or have their blood sugar levels checked due to unavailability of medication or testing strips. This affected five residents with type II diabetes mellitus, and the lapses were confirmed by staff interviews.
The facility failed to administer insulin as ordered for five residents with type II diabetes mellitus due to the unavailability of glucometer strips needed to check blood sugar levels. This resulted in missed insulin doses on multiple occasions. Staff interviews and observations revealed that the strips were later found in the facility, indicating a failure in inventory management and communication.
A resident with a history of substance use disorder was not adequately assessed or provided with individualized care interventions to prevent a drug overdose. The resident was found unresponsive and later pronounced dead due to acute intoxication by Alprazolam, Fentanyl, and Gabapentin. The facility failed to implement increased monitoring or supervision to address the resident's substance abuse history, leading to a fatal outcome.
The facility failed to ensure that a resident's medications were administered as ordered. The resident, with diagnoses including anxiety disorder and multiple fractures, had physician orders for Lexapro, Ferrous Sulfate, and Lovenox. A review of the medication administration records revealed no evidence that these medications were administered as ordered. An LPN confirmed that the morning medications were not administered as required. This deficiency was investigated under Complaint Number OH00152414.
Physical abuse of dependent resident during incontinence care
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively intact, totally dependent resident from physical abuse by a CNA during incontinence care. The resident had multiple sclerosis, quadriplegia, muscle weakness, dysphagia, incontinence of bowel and bladder, hearing loss, and a history of behavioral symptoms including rejection of care and use of profanity toward staff. His care plan required staff to face him when speaking, obtain his attention, speak clearly, explain all procedures before beginning care, approach in a calm and relaxed manner, re-direct when he was resistive, ensure he felt safe, and, if he became resistive, leave briefly and re-approach. He was dependent for all ADLs, including toileting and personal hygiene, and required staff assistance for incontinence care. On the night of the incident, facility video footage showed the CNA entering the resident’s room around 11:35 P.M. without knocking while the resident was asleep. The CNA lowered the bed, removed the sheets, lifted the resident’s gown, and opened his incontinence brief while he was still asleep. At approximately 11:37 P.M., she rolled him onto his left side toward the wall, placed a new brief, and then rolled him back onto his back in a rough manner, causing him to quickly fall onto the mattress. At about 11:38 P.M., the video showed the CNA making a swift, swinging motion with both hands toward the resident’s face, with enough force that the resident’s body and mattress shook. She then stood over him, pointed her finger at his face, appeared to touch his face with enough force to shake his body, and continued to hover over him while pointing and moving her mouth as if speaking. The video further showed the CNA slapping the resident with an open palm to his upper chest and/or face, again causing his body and pillow to shake, and then using a closed fist to hit his right upper shoulder, chest, and/or face while the wall partially blocked the view of his head. She threw a pillow at his upper chest and face, left it there, and then covered both his body and the pillow on his face with a sheet. She subsequently hit him in the chest with the pillow and held the pillow with force over his face for approximately two seconds before removing her hand but leaving the pillow on his face while raising the head of the bed. A nurse was later seen approaching and entering the room, and the CNA appeared to be wiping the resident’s face. The next morning, the resident reported to his family member and facility staff that a night-shift aide had been rough with him, had thrown him around “like a rag doll,” and had punched him in the nose after he asked her to take it easy. Staff and police observed dried blood under his right nostril and a deviation of his nose, and hospital imaging confirmed multiple nasal fractures and a perforated nasal septum. The facility’s investigation, including review of the video and interviews, substantiated that physical abuse by the CNA had occurred.
Failure to Assess Resident After Reported Aggressive Behaviors in Context of Abuse Incident
Penalty
Summary
The deficiency involves the facility’s failure to assess a resident following reported aggressive behaviors, in the context of an abuse incident. The resident involved had multiple complex medical conditions, including multiple sclerosis, quadriplegia, muscle weakness, falls, failure to thrive, and dysphagia. His care plans documented hearing loss, risk for altered mood related to depression and medical diagnoses, incontinence of bowel and bladder, and self-care deficits requiring assistance with ADLs and mechanical lift transfers. A quarterly MDS assessment showed intact cognition, dependence for eating, toileting, bathing, and personal hygiene, incontinence of bowel and bladder, and behaviors that included rejection of care. On one evening, video footage showed a CNA entering the resident’s room without knocking while the resident was asleep, lowering the bed, removing sheets, and exposing and opening the resident’s incontinence brief while he remained asleep. The CNA was observed rolling the resident roughly, causing him to fall quickly onto the mattress, and then making a swift, swinging motion with both hands toward his face, with enough force that the resident’s body and mattress shook. The CNA then stood over the resident, pointed at him, appeared to touch his face with enough force to slightly shake his body, and continued to point at him while her mouth moved as if speaking. She slapped the resident with an open palm to his upper chest and/or face, again causing his body and pillow to shake, and used a closed fist to hit his right upper shoulder, chest, and/or face, though the exact area was obscured by the wall. The video further showed the CNA throwing a pillow at the resident’s upper chest and face, leaving it there while covering him and the pillow with a sheet, then striking him in the chest with the pillow and holding the pillow with force over his face for approximately two seconds before removing her hand but leaving the pillow on his face as she raised the head of the bed. Later, an RN approached and entered the room after the CNA had been seen wiping the resident’s face; the CNA pointed at or on the resident’s mouth and held up a cloth when it appeared the resident spit at her. The CNA’s written statement claimed she had provided routine care, denied treating the resident roughly or hitting him, and reported that the resident had used racial slurs, derogatory language, and spit at her during care at multiple times that night, including an instance when a nurse entered to help de-escalate and another when a nurse advised discontinuing care. The RN’s statement confirmed the resident was calm and cooperative earlier in the evening, and later verbally aggressive and refusing care, but documented that staff remained calm and professional. A progress note by the former DON documented that the resident had increased behaviors, including cursing at staff during care. In a subsequent telephone interview, the former DON stated that the RN should have assessed the resident for the aggressive behaviors reported by the CNA and should also have reported those behaviors accordingly. Facility policies on resident abuse and behavior management required assessment, care planning, and monitoring of residents with needs and behaviors that might lead to conflict or neglect, including those with a history of aggressive behaviors, and required immediate implementation of keep-safe interventions and provider notification when residents present with behaviors that will harm others. Despite the CNA’s reports of escalating verbal aggression and spitting, there was no documented assessment of the resident’s aggressive behaviors by the RN as expected under these policies, which constituted the failure cited in this deficiency. The facility’s self-reported incident documented that the resident’s family reported the CNA had handled the resident roughly and that he had been hit in the nose during care. Upon assessment, the resident was found with a small amount of blood under his nostril and an apparently deviated nose, and he was transported to the hospital where he was admitted with multiple facial fractures. The facility’s investigation, including review of video footage, led to a determination that abuse had occurred. The deficiency specifically addresses that, in the context of these events and the resident’s documented behavioral issues, the facility failed to ensure the resident was assessed following reported aggressive behaviors, contrary to its own abuse prevention and behavior management policies. This deficiency was investigated under Complaint Number 2806407 and was based on interview, record review, policy review, and video camera footage. The cited non-compliance centers on the lack of appropriate assessment and reporting of the resident’s aggressive behaviors after they were reported by staff, in a resident with known behavioral symptoms and complex medical and psychosocial needs, as required by the facility’s policies for prevention and identification of abuse and for behavior management.
Failure to Implement and Update Individualized Fall and Transfer Safety Measures
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a comprehensive, effective, and individualized fall management program for a resident identified as high risk for falls. The resident was admitted with diagnoses including chronic venous insufficiency, osteoarthritis, dementia, muscle weakness, and a healing pubic fracture. A fall risk assessment identified the resident as high risk, and the care plan noted impaired safety awareness and deterioration in ADLs related to chronic venous stasis. Interventions included encouraging non-skid socks as tolerated and, later, providing two-person assistance for transfers and use of a manual wheelchair with one-person assist for mobility. The admission and subsequent MDS assessments documented severely impaired cognition and dependence or substantial/maximal assistance needs for transfers, toileting, and bed mobility. Despite these identified risks and documented needs, the facility did not update or consistently implement the resident’s fall and safety care plan in line with current functional status and therapy recommendations. A PT discharge summary indicated the resident generally required minimal assistance for functional tasks and safety cueing, and recommended limited assistance for safety due to high fall risk and cognitive deficits. However, no changes were made to the fall/safety plan of care after therapy discharge. Later MDS assessments continued to show the resident as dependent for transfers, but the care plan was not revised to reconcile these findings with therapy recommendations, and the DON confirmed the care plan had not been updated following PT discharge. On one night, the resident experienced an unwitnessed fall in her room. She was last seen in bed and later found on the floor, sitting on her buttocks, barefoot, with a left elbow skin tear. The fall investigation documented that all fall interventions were in place, yet also noted the resident was barefoot, without explaining why non-skid socks, which were a care-planned intervention, were not in use. No witness statement was obtained from the CNA assigned to the resident that shift, and the root cause analysis attributed the fall to the resident being old, confused, and unbalanced, without addressing the missing non-skid socks or other specific environmental or supervision factors. Later that same day, the resident sustained a severe skin tear during a transfer from wheelchair to bed. An incident investigation and CNA statement revealed that a CNA, working alone, transferred the resident and the resident’s leg scraped against the wheelchair leg rest, causing immediate and significant bleeding. The resident was on warfarin and required hospital evaluation, where she was diagnosed with a closed nondisplaced pelvic fracture and multiple skin tears. The DON confirmed that the care plan in place required two-person assistance for transfers, but only one CNA performed the transfer. The incident investigation for the skin tear did not include a root cause analysis. Interviews also showed inconsistencies in staff recall and documentation, including the assigned CNA not recalling the fall and the absence of timely, complete witness statements. These actions and omissions demonstrate the facility’s failure to implement and individualize fall and accident prevention measures as required by the resident’s assessed needs and care plan. Additional documentation and interviews highlighted further discrepancies between assessed needs, care plan directives, and actual care provided. The DON and MDS nurse confirmed that MDS data indicated the resident was dependent for transfers, which the MDS nurse equated with a two-person assist, while therapy had recommended minimal assistance with safety cueing. The care plan was not updated to reflect or reconcile these differing assessments, and the CNA who performed the transfer alone stated she believed she could transfer the resident by herself due to the resident’s weight, without referencing the care plan requirements. The facility’s fall prevention and management policy required assessment of fall risks, implementation of preventive measures, and review and investigation of all falls, but the investigations for both the fall and the transfer-related injury lacked complete root cause analyses and did not fully address why care-planned interventions, such as non-skid socks and two-person transfers, were not followed.
Failure to Change and Date Oxygen Tubing Weekly for Tracheostomy Resident
Penalty
Summary
The deficiency involves the facility’s failure to follow its own policy and physician orders for weekly oxygen tubing changes for a resident receiving oxygen via tracheostomy. The resident had significant medical conditions including multiple sclerosis, chronic respiratory failure with hypoxia, tracheostomy status, encephalitis, and encephalomyelitis, and had orders for oxygen via tracheostomy collar at five liters per minute to maintain oxygen saturation above 90%. The orders and care plan specified that oxygen tubing and disposable respiratory supplies were to be changed weekly and that the oxygen concentrator and filter were to be cleaned weekly. The facility’s oxygen administration policy also required that tubing, masks, and cannulas be changed weekly and documented in the EHR. During an observation, the resident was seen in bed receiving oxygen via a tracheostomy mask, and the oxygen tubing in use was dated nearly four weeks earlier. A CNA confirmed the tubing date as 12/25/25 at the time of observation on 01/20/26, indicating that the tubing had not been changed according to the weekly schedule. This failure to change and date the oxygen tubing as required constituted non-compliance with the facility’s policy and the resident’s care plan and orders for equipment management and infection control.
Infection Control Lapse During Incontinence Care
Penalty
Summary
During incontinence care for Resident #42, who had diagnoses including cerebral palsy, high blood pressure, Alzheimer's disease, and a history of falls, staff failed to follow infection control standards. The resident was cognitively impaired, fully dependent on staff for toileting, and always incontinent of bowel and bladder. Observation revealed that a Certified Nurse Aide (CNA) placed care supplies directly onto the bedside table without cleaning the surface or using a barrier. Additionally, after removing soiled gloves, the CNA retrieved additional supplies and donned new gloves without performing hand hygiene, contrary to the facility's hand hygiene policy, which requires hand hygiene immediately after glove removal. These findings were confirmed through staff interview and policy review.
Failure to Maintain Clean and Sanitary Resident Rooms
Penalty
Summary
The facility failed to maintain a clean and sanitary environment in resident rooms, affecting five out of eight residents reviewed for physical environment. Observations revealed significant cleanliness issues, including a black grimy buildup on the floor of one resident's room, unswept floors with dirt and paper in another, and a buildup of dust and dirt in a third resident's room. Additionally, one room had a plastic bag, paper towels, and an empty wipes container on the floor, with food and debris under the bed. Another room had dried food and drink on the floor, with a bathroom that had a brown wet liquid around the toilet base and a brown paper towel soaking up the wetness. Interviews with residents confirmed that their rooms were not cleaned daily, as required by the facility's housekeeping policy. The Housekeeping Manager acknowledged that resident rooms should be cleaned daily, including sweeping, mopping, and cleaning high-touch areas and bathrooms. However, it was revealed that only one housekeeper was working on the day of the observations, and there was no second shift housekeeper. The facility's policy outlined specific cleaning tasks, but these were not consistently performed, leading to the observed deficiencies.
Failure to Notify Family of Resident's Change in Condition
Penalty
Summary
The facility failed to notify the family of Resident #11 about a change in her condition after an incident of physical abuse. Resident #11, who was not responsible for herself and had her sister listed as her responsible party, was involved in an altercation with another resident, Resident #26, which resulted in a bruise above her left eyebrow. The incident occurred near the central nurse's station and was witnessed by two CNAs. Despite the facility's policy requiring notification of the family and physician in the event of a change in condition, Resident #11's family was not informed of the incident until much later. The incident was not documented or reported to the responsible party or the facility administration until several days after it occurred. Interviews with staff and the resident's sister confirmed that the family was not informed of the physical altercation and resulting injury. The facility's policy on notifying family members of changes in condition was not implemented, leading to a deficiency in the care provided to Resident #11.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect two residents, Resident #11 and Resident #26, from abuse, as evidenced by a physical altercation between them. Resident #11, who was alert and oriented with a BIMS score of 15, had a history of chronic diastolic congestive heart failure, chronic obstructive pulmonary disease, and dysthymic disorder. She was dependent on staff for activities of daily living (ADLs) and had a care plan in place to monitor her mood and behaviors. Resident #26, with a BIMS score of 10 indicating cognitive impairment, had diagnoses including chronic obstructive pulmonary disease, cirrhosis of the liver, and bipolar disorder. He also required staff assistance for ADLs and had a care plan to monitor his mood and behaviors. On the day of the incident, a verbal altercation between Resident #11 and Resident #26 escalated into a physical confrontation, resulting in Resident #26 punching Resident #11 in the head, causing bruising above her left eyebrow. The altercation was witnessed by CNAs #856 and #900, who reported differing accounts of the incident. Despite the altercation occurring on 11/04/24, it was not documented or reported to the Ohio Department of Health until 11/14/24. The facility's staff, including LPN #872 and ADON #849, failed to document or report the incident in a timely manner, and the investigation was not initiated immediately. The facility's policy required immediate reporting and investigation of all allegations of abuse, but this was not followed. The Administrator confirmed that the incident was reported late, and staff did not monitor the residents for compliance with their behavior contracts. The failure to document and report the incident promptly, as well as the lack of monitoring, contributed to the deficiency in protecting the residents from abuse.
Failure to Implement Abuse Policy in Resident Altercation
Penalty
Summary
The facility failed to implement its abuse policy for an incident involving two residents, resulting in a deficiency. Resident #11, who has chronic diastolic congestive heart failure, chronic obstructive pulmonary disease, and dysthymic disorder, and Resident #26, who has chronic obstructive pulmonary disease, cirrhosis of the liver, and bipolar disorder, were involved in a physical altercation. The incident occurred after a verbal altercation, where Resident #11 made hand gestures near Resident #26, leading to Resident #26 physically contacting Resident #11's face, causing a bruise above her left eyebrow. The incident was witnessed by two CNAs, but it was not reported or documented until several days later. The facility's failure to report and document the incident promptly, as well as to monitor the residents for compliance with behavior contracts, contributed to the deficiency. The Administrator was not informed of the incident until ten days after it occurred, resulting in a late self-reported incident to the Ohio Department of Health. The facility's abuse policy, which requires immediate investigation and reporting of all allegations and incidents of abuse, was not followed, leading to non-compliance with the policy and protocol.
Failure to Report Resident Abuse Timely
Penalty
Summary
The facility failed to report an allegation of abuse to the State Agency, affecting two residents. Resident #11, who had chronic diastolic congestive heart failure, chronic obstructive pulmonary disease, and dysthymic disorder, was involved in a physical altercation with Resident #26, who had chronic obstructive pulmonary disease, cirrhosis of the liver, and bipolar disorder. The incident occurred on 11/04/24, when Resident #11 and Resident #26 had a verbal altercation that escalated into physical violence, resulting in Resident #11 sustaining a bruise above her left eyebrow. Certified Nursing Assistants (CNAs) #856 and #900 witnessed the altercation, with Resident #26 punching Resident #11 in the head. Despite the severity of the incident, the facility did not report the altercation to the Ohio Department of Health until 11/14/24, ten days after it occurred. The Administrator confirmed that staff failed to document the incident, monitor the residents for compliance with behavior contracts, and follow the abuse policy and protocol. The facility's Ohio Resident Abuse Policy, revised in July 2024, mandates the immediate reporting of all allegations and incidents of abuse, which was not adhered to in this case. This deficiency was investigated under Complaint Number OH00159817.
Delayed Investigation of Resident Altercation
Penalty
Summary
The facility failed to ensure a timely and thorough investigation of an abuse allegation involving two residents. Resident #11, who was alert and oriented, was involved in a verbal and physical altercation with Resident #26, who had cognitive impairment. The incident occurred on 11/04/24, but the investigation was not initiated until 11/18/24, after the facility's administration was informed on 11/14/24. This delay in response was contrary to the facility's policy, which mandates immediate investigation of all abuse allegations. Resident #11 was admitted with diagnoses including chronic diastolic congestive heart failure and dysthymic disorder, and was dependent on staff for activities of daily living. She had a behavioral contract to avoid Resident #26. On the day of the incident, Resident #11 was observed with bruising above her left eye and scapula area. The altercation reportedly involved Resident #11 making hand gestures and contact with Resident #26, who then punched her, resulting in a bruise above her left eyebrow. Witnesses, including CNAs, confirmed the physical altercation. Resident #26, admitted with chronic obstructive pulmonary disease and bipolar disorder, had a care plan that included checks to prevent harm to others. Despite this, the incident log did not reflect the physical abuse incident until 11/15/24, and the Self-Reported Incident was dated 11/14/24. Interviews with staff and residents confirmed the altercation and the delay in reporting and investigating the incident. The facility's policy required immediate investigation, which was not adhered to, leading to non-compliance under Complaint Number OH00159817.
Failure to Complete and Report Ordered Laboratory Services
Penalty
Summary
The facility failed to ensure that a resident's physician-ordered laboratory services were completed and reported as required. The resident, who had diagnoses including cirrhosis of the liver, obesity, chronic pain, heart failure, and pulmonary edema, was seen by a Nurse Practitioner due to congestion and not feeling well. The Nurse Practitioner ordered a stat Basic Metabolic Panel (BMP) and a chest x-ray. However, the BMP specimen collected was hemolyzed, rendering it unusable, and the facility did not reschedule the test. Interviews with the Nurse Practitioner and the Director of Nursing confirmed that the facility should have followed up on the stat BMP and rescheduled the test after the initial specimen was found to be inadequate. The facility's policy on Resident Change in Condition required the nurse to address emergency care and gather the most recent labs for the physician, which was not adhered to in this case. This deficiency was identified during the investigation of a complaint.
Administrator's Inappropriate Conduct Towards Resident
Penalty
Summary
The facility Administrator failed to treat a resident in a dignified and respectful manner, as evidenced by multiple accounts of inappropriate behavior. The resident, who had no cognitive impairment and was diagnosed with anxiety disorder, major depressive disorder, congestive heart failure, chronic obstructive pulmonary disease, hypertension, and type two diabetes mellitus, reported that the Administrator yelled at her and argued with her. This incident was corroborated by a Licensed Practical Nurse (LPN) who witnessed the Administrator yelling and gesturing at the resident near the nurses' station. Further interviews and signed statements confirmed the Administrator's inappropriate conduct. A Regional Registered Nurse (RN) stated that the Administrator was verbally inappropriate and threatened to evict the resident from the facility. The resident's signed statement indicated that the Administrator asserted her authority and threatened eviction. The LPN's signed statement also confirmed the Administrator's actions and described them as a bad choice of words and uncalled for. This deficiency was investigated under Complaint Number OH00155871.
Failure to Timely Report Alleged Abuse by Administrator
Penalty
Summary
The facility failed to ensure timely reporting of an abuse allegation involving Resident #21, who had diagnoses including anxiety disorder, major depressive disorder, congestive heart failure, chronic obstructive pulmonary disease, hypertension, and type two diabetes mellitus. The incident involved the Administrator allegedly yelling at and threatening Resident #21, which was witnessed by an LPN. The LPN reported the incident to the former Director of Nursing, but it was not communicated to the regional team, resulting in a delay in the investigation. The facility's policy requires immediate reporting of abuse allegations and completion of investigations within five working days. However, the incident involving the Administrator was not reported in a timely manner, leading to non-compliance with the facility's abuse policy. The deficiency was identified during a complaint investigation, affecting one resident out of the 56 in the facility census.
Failure to Notify Physician of Missed Insulin Administration
Penalty
Summary
The facility failed to notify the physician of residents not receiving medications as ordered, specifically insulin for diabetes management. This deficiency affected five residents who did not receive their insulin or have their blood sugar levels checked as prescribed. The medical records for these residents showed missed doses and lack of blood sugar monitoring, with reasons such as 'drug/item unavailable' and 'no testing strips available' noted in the medication administration records (MAR). However, there was no documentation that the physicians were informed of these missed medications and checks. Resident #1, diagnosed with type II diabetes mellitus and end-stage renal failure, did not receive insulin or have his blood sugar checked on a specific date due to the unavailability of the drug/item. Similarly, Resident #3, who also has type II diabetes mellitus, missed multiple doses of insulin and blood sugar checks over two days due to the unavailability of testing strips. In both cases, the physician was not notified of these lapses in care. Other residents, including Resident #8, Resident #24, and Resident #55, also experienced similar issues where their insulin was not administered, and blood sugar levels were not checked as ordered. The reasons for these lapses included the unavailability of testing strips and other unspecified reasons. Interviews with the Regional Nurse and an LPN confirmed that the physicians were not notified about these missed medications and checks, highlighting a systemic issue in the facility's communication and medication administration processes.
Significant Medication Errors Due to Unavailability of Glucometer Strips
Penalty
Summary
The facility failed to administer medications as ordered by physicians, resulting in significant medication errors for five residents diagnosed with type II diabetes mellitus. These residents did not receive their prescribed insulin due to the unavailability of glucometer strips needed to check their blood sugar levels. This issue was observed on multiple occasions, affecting the residents' ability to manage their diabetes effectively. For instance, Resident #1 did not receive insulin on 05/05/24 at 9:30 P.M. because their blood sugar was not checked, and the medication administration record (MAR) noted that the drug was unavailable. Similar issues were noted for Residents #3, #8, #24, and #55, who also missed their insulin doses due to the same reason. Interviews with staff confirmed these lapses in medication administration, and it was revealed that glucometer strips were later found in the facility, indicating a failure in proper inventory management and communication among staff members. Resident #3's medical record showed that they missed their insulin doses on 05/05/24 at 9:00 P.M. and 05/06/24 at 7:30 A.M. due to the unavailability of testing strips. Resident #8 also did not receive their insulin at bedtime on 05/05/24 for the same reason. Resident #24 missed four insulin doses between 05/04/24 and 05/06/24 because their blood sugar was not checked, and no insulin was administered. Resident #55 did not have their blood sugar checked and missed insulin doses at dinner and bedtime on 05/05/24. Observations on 05/09/24 revealed that the medication storage room and medication carts had sufficient supplies of insulin needles and glucometer strips, suggesting that the issue was not a lack of supplies but rather a failure in locating and utilizing them. Interviews with the facility's staff, including the Regional Nurse and the Administrator, highlighted communication breakdowns and inadequate inventory management as contributing factors to the medication errors. The Administrator confirmed that LPN #306 had reported the unavailability of glucometer strips and had attempted to contact management without success. The Administrator instructed LPN #306 to check the central supply and medication room, but the nurse was unable to find the strips. This deficiency represents non-compliance investigated under Complaint Number OH00153676.
Failure to Prevent Drug Overdose in Resident with Substance Use Disorder
Penalty
Summary
The facility failed to ensure that a resident with a history of substance use disorder was adequately assessed and provided with comprehensive and individualized care interventions to prevent a drug overdose. Resident #65, who had a history of substance abuse, was admitted to the facility for short-term placement following a motor vehicle accident. Despite the resident's history of substance abuse, the facility did not include increased monitoring or supervision in the resident's care plan to address the risk of relapse or overdose. The resident's medical record and care plans lacked interventions to address substance abuse history, and there was no evidence of increased supervision of visitors who might provide drugs to the resident. On the day of the incident, the resident was found unresponsive in their room and later pronounced dead due to acute intoxication by Alprazolam, Fentanyl, and Gabapentin. The resident had not received their morning medications, and the nurse on duty had not assessed the resident until finding them unresponsive. The coroner's report and police investigation revealed evidence of drug use in the resident's room, including a white powdery substance and drug paraphernalia. Interviews with facility staff confirmed that the resident's substance abuse history was known, but no specific interventions were implemented to prevent a potential overdose. The facility's failure to assess and implement appropriate interventions for Resident #65's substance use disorder resulted in the resident's death due to a drug overdose. The facility did not provide adequate supervision or monitoring to prevent the resident from obtaining and using drugs, leading to a fatal outcome. The deficiency was identified during a complaint investigation, highlighting the facility's non-compliance with ensuring resident safety and preventing accidents related to substance abuse.
Failure to Administer Medications as Ordered
Penalty
Summary
The facility failed to ensure that Resident #65's medications were administered as ordered. Resident #65, who was admitted with diagnoses including anxiety disorder, other psychoactive substance abuse, and multiple fractures, had physician orders for Lexapro, Ferrous Sulfate, and Lovenox. A review of the medication administration records (MARS) from 08/01/23 to 08/21/23 revealed no evidence that these medications were administered as ordered. An interview with LPN #813 confirmed that the morning medications were not administered as required. The facility's General Dose Preparation and Medication Administration policy, revised on 01/01/13, mandates that staff verify the correct medication, dose, route, rate, time, and resident each time a medication is administered. This deficiency was investigated under Complaint Number OH00152414.
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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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