Ayden Healthcare Of Waterville
Inspection history, citations, penalties and survey trends for this long-term care facility in Waterville, Ohio.
- Location
- 8885 Browning Drive, Waterville, Ohio 43566
- CMS Provider Number
- 365617
- Inspections on file
- 38
- Latest survey
- March 19, 2026
- Citations (last 12 mo.)
- 31
Citation history
Health deficiencies cited at Ayden Healthcare Of Waterville during CMS and state inspections, most recent first.
Unsafe Food Storage and Unsanitary Kitchen Conditions: The facility failed to keep kitchen and food storage areas sanitary and to store food properly. Surveyors observed heavy dust buildup on vents, ceilings, and walls in food prep, dish, and serving areas; liquid eggs stored on the floor of the walk-in cooler; opened, undated pasta in dry storage; undated and unlabeled refrigerated items; and an opened cup of ice cream in the freezer. An DS was also observed cooking ground beef without a hair net.
Infection prevention failures were observed involving Legionella control, urinary catheter care, PPE use, and hand hygiene. The facility was not documenting water temperatures or tracking flushes in vacant areas, and a resident’s Foley drainage bag was found on the floor. For another resident with a urinary catheter, a CNA provided incontinence care without a gown despite EBP signage requiring gloves and gown for high-contact care, the catheter bag was again left on the floor, and an LPN performed finger stick blood glucose checks on two residents without gloves or hand hygiene between residents.
A resident with parkinsonism, dementia, schizophrenia, depression, and functional dependence was found in bed with a red pull-cord call light positioned near the shoulder, but she could not pull it. Observation showed she could not lift one arm and had very limited use of the other hand, and a CNA confirmed she was unable to activate the current device. The CNA stated soft-touch call lights were available but could not be used on that hall because of the outlet type.
Failure to provide scheduled bathing: A resident who was cognitively intact, dependent for all ADLs, and had multiple complex medical conditions did not receive bed baths twice weekly as scheduled. The resident reported missed bathing care, shower sheets showed multiple missed baths and two extended gaps without documentation, and the DON confirmed the resident did not refuse care and that there was no documentation supporting the missed baths.
Failure to monitor psychotropic medication side effects for two residents. One resident with PTSD and insomnia had orders for Ativan PRN and mirtazapine, and another resident with schizoaffective disorder and a history of TBI had orders for divalproex and mirtazapine. Both residents were cognitively intact, but their care plans did not direct monitoring for psychotropic side effects, and no active physician orders were in place for that monitoring; the DON verified the monitoring was not completed.
Unsafe discharge without required notice: A resident with epilepsy, TBI, severe cognitive impairment, and ongoing behavioral symptoms was sent with her husband to an ER after staff-directed aggression escalated. The hospital did not admit her, the facility then refused readmission, and the resident was ultimately taken home. The record showed no discharge notice or appeal rights were provided before the discharge, and the facility’s own policy allowed discharge only under limited circumstances.
A resident with hemiplegia, aphasia, impaired cognition, and dependence for transfers and mobility was identified as at risk for skin breakdown, with orders for bilateral protective boots and a care plan calling for pressure reduction devices. Observations showed the boots left off the resident while she sat in a reclining wheelchair, and one heel resting on the wheelchair footpad before staff later applied the boots.
A resident with dementia, RA, disc degeneration, and neuropathy received frequent PRN oxycodone for pain, but the record showed no evidence that non-pharmacological interventions were attempted before the doses were given. The care plan included trying non-medication interventions if the resident allowed, and an LPN confirmed that such interventions should be attempted before administering PRN pain medication.
Failure to Individualize Trauma-Informed Care Plans: Three residents with documented trauma histories, including sexual abuse, violent crime exposure, and PTSD from military history, had care plans that listed only general trauma-informed interventions. The DON confirmed the plans did not identify resident-specific triggers or include interventions tailored to avoid those triggers, and one resident’s plan also lacked trauma-specific triggers despite a history of sexual abuse.
Medication Given Outside Ordered BP Parameters: A resident with dementia, HTN, and anxiety had a physician order for midodrine HCl only when SBP was less than 100 mmHg, but MAR review showed multiple doses were given when BP readings were above the ordered parameter. The UM confirmed the medication was administered outside the ordered instructions on multiple occasions.
Medication storage was not secured for a resident receiving HD. Staff found the resident's HD binder and medication pouch in a tote bag in the resident's room, and CNA confirmed the medications were inside the notebook before bringing it to an LPN at the med cart. The LPN found a midodrine HCl card with seven tablets and placed the notebook in a locked drawer; the facility policy required drugs and biologicals to be stored in locked compartments.
Failure to Obtain and Communicate Diagnostic Test Results: A resident with respiratory failure, depression, anxiety, pneumonia, neurogenic bladder, spinal cord infarction, HTN, and GI hemorrhage had a bone biopsy rescheduled and then went out of the facility, but the chart contained no biopsy results. The resident’s representative said January test results were never communicated, and the DON confirmed the facility had not obtained or shared the bone biopsy results with the MD or representative; the Administrator stated there was no policy for obtaining or notifying about diagnostic test results.
Incomplete Documentation of Dialysis Provider Communication: A resident with dementia, heart disease, and ESRD received offsite HD three times weekly, and the care plan called for communication with dialysis staff and the physician. Although staff reported ongoing email and phone contact with the HD clinic, the resident’s medical record only documented limited communication, and the ongoing exchange of information was not routinely recorded.
A resident who was fully dependent on staff for ADLs, including personal hygiene, was observed with significant unshaved facial hair despite being scheduled and documented as having received showers. Staff interviews revealed that facial hair was not shaved due to reluctance to use facility razors, resulting in inadequate grooming care in violation of facility policy.
The facility failed to maintain a clean and homelike environment, affecting all 72 residents. A resident reported unclean conditions in his restroom and soiled bed linens, which were confirmed by a housekeeping assistant. Another resident's room was found dirty, as verified by an LPN. Additionally, the carpet in a hallway was stained and dirty, with food pieces ground into it, as confirmed by an STNA.
A cognitively impaired resident with dementia and wandering behaviors exited the facility without staff observation. An LPN found the resident outside and returned her to the facility. Despite the incident, the facility did not report it to the state agency as required by their policy. Interviews confirmed the incident, and the corporate director questioned the need for reporting, highlighting a failure to adhere to reporting policies.
A resident with dementia and a history of elopement exited the facility unsupervised due to inadequate supervision and staff oversight. Despite interventions in place, staff failed to notice the resident's exit, and the door alarm was not effectively responded to. The resident was found outside by an LPN on a smoke break and was safely redirected back inside.
A facility failed to effectively control a bed bug infestation affecting a resident with severe cognitive impairment. Despite exterminator treatments, bed bugs persisted due to the resident's family bringing contaminated items from their infested home. Staff confirmed the ongoing issue, and observations revealed evidence of bed bug activity in the resident's room.
The facility failed to document meal intakes as recommended by the dietician and outlined in the care plans for two residents, leading to a deficiency in maintaining their nutritional status. Both residents had missing meal intake documentation on several specified dates, despite having care plans that required monitoring and interventions to address their nutritional needs.
Unsafe Food Storage and Unsanitary Kitchen Conditions
Penalty
Summary
The facility failed to ensure food was prepared and stored in a safe manner and failed to maintain the kitchen environment in a sanitary manner. During observation, significant dust buildup was found on the ceiling vent and surrounding ceiling over the coffee area, juice dispenser, toaster, and preparation area, as well as on the ceiling vents over the clean dish end of the dishwasher and over the clean plate stack for meal service. Dust buildup was also observed on the wall above the steam oven and on the wall along the meal tray line near the clean plates for meal service, and the Dietary Supervisor verified these conditions. Additional observations found a box of multiple cartons of liquid eggs stored on the floor of the walk-in cooler, two large bags of pasta opened and undated in dry storage with one bag open to air, one cup of cottage cheese and six small cups of ranch salad dressing undated and unlabeled in the reach-in cooler, and an opened cup of ice cream in the reach-in freezer with the lid not fully covering the ice cream. The Dietary Supervisor verified the storage issues and removed or discarded some of the items. The supervisor was also observed cooking ground beef without wearing a hair net, and verified the hair net was not being worn at that time.
Infection Prevention Failures With Legionella Monitoring, Catheter Care, PPE, and Hand Hygiene
Penalty
Summary
The facility failed to implement its infection prevention and control program in several areas. Review of the facility’s Legionella risk management plan showed that control measures included reviewing and removing long plumbing runs and dead ends, or otherwise regularly flushing the system, and storing water above 140 degrees Fahrenheit to kill Legionella bacteria. However, the last documented flush of vacant room water was on 03/12/24, no water temperature logs were provided, and the Director of Maintenance confirmed the facility was not recording water temperatures and was not tracking or logging flushes. The CDC Legionella guidance reviewed by surveyors described the need for a water management program team, system description, identification of growth areas, control measures, intervention steps, and documentation of activities. Resident #13 had diagnoses including morbid obesity, neuromuscular dysfunction of the bladder, and a right femur fracture, and was cognitively intact and dependent on staff for all ADLs. The resident had an indwelling Foley catheter and care plan interventions included catheter care every shift, emptying the bag every shift and as needed, and keeping the Foley catheter to straight drain. During observation, the resident’s urinary catheter drainage bag was laying on the floor and up against the bottom bedrail while the bed was in a low position. The CNA confirmed the bag was on the floor and stated staff could not figure out where to hang it when the bed was in the lowest position. The facility’s urinary catheter policy stated catheter tubing and drainage bags are to be kept off the floor. Resident #2 was cognitively intact and had an indwelling urinary catheter, including a suprapubic catheter order. The revised care plan did not direct the use of enhanced barrier precautions for the suprapubic catheter, and there was no order for EBP. During observation, a CNA provided incontinence care, including peri-care and changing the resident’s brief, while wearing gloves but no gown. The CNA confirmed a gown was not worn, and staff stated they believed a gown was not needed because wound care was not being provided. The EBP sign on the room door directed staff to wear gloves and gown for high-contact care activities such as changing briefs and device care or use of a urinary catheter. In a separate observation, the resident’s catheter drainage bag was again lying on the floor with no barrier between the bag and the floor until a CNA hung it on the side of the bed. In another event, an LPN obtained finger stick blood glucose levels for two residents without wearing gloves and without performing hand hygiene before or after the checks, and the DON and LPN confirmed this occurred. The facility’s hand hygiene policy required hand hygiene before and after direct contact with residents.
Resident Unable to Activate Call Light
Penalty
Summary
The facility failed to ensure Resident #7 was provided a call light that accommodated the resident's needs. Resident #7 was admitted with diagnoses including unspecified parkinsonism, acute respiratory failure with hypoxia, paranoid schizophrenia, major depressive disorder, suicidal ideations, dementia, and anxiety disorder. The significant change MDS dated 01/06/26 showed a BIMS score of 11, indicating moderate cognitive impairment, and the resident was dependent on others for eating, oral hygiene, toileting, showering/bathing, upper and lower body dressing, and personal hygiene. The revised care plan dated 12/09/25 identified self-care deficits, risk for alteration in mood and behavior related to schizophrenia and auditory hallucinations, and risk for falls related to debilitation and weakness. During observation and interview on 03/17/26 at 8:40 A.M., Resident #7 was lying awake in bed with a red pull-cord call light attached near her shoulder. When asked if she could pull the cord, the resident shook her head no. She was unable to lift her right arm, could only partially open the fingers of her left hand, and was unable to pull the string. During interview, CNA #651 stated the resident had limited movement in the left arm, no movement in the right arm, and a contracted left hand, and verified the resident was unable to use the current call light device. The CNA also stated the facility had soft touch call light devices that the resident could use, but they could not be used on that hall because of the outlet type.
Failure to Provide Scheduled Bathing
Penalty
Summary
The facility failed to ensure that Resident #46 was bathed according to his scheduled preference of twice weekly. Resident #46 was admitted with diagnoses including chronic respiratory failure, alveolar hypoventilation, morbid obesity, neurogenic bladder, hypertension, dependence on ventilator, COPD, asthma, type 2 diabetes mellitus, depression, and anxiety. The annual MDS assessment showed he was cognitively intact, had no behaviors or refusals of care, and was dependent for all ADLs and transfers, with bowel incontinence and a urinary catheter in place. The resident stated he did not receive bathing care twice a week as scheduled. Review of shower sheets showed missed bed baths on multiple dates, including 01/04/26, 01/14/26, 01/18/26, 02/08/26, and 02/22/26, as well as two separate two-week periods when no baths were documented. The DON confirmed the resident was scheduled for bathing on Wednesdays and Sundays, that he did not refuse bathing, and that there was no documentation supporting the missed bed baths. The DON also stated the facility standard was to offer bathing two times per week.
Failure to Monitor Psychotropic Medication Side Effects
Penalty
Summary
The facility failed to ensure adequate monitoring for psychotropic medication effectiveness, side effects, and adverse effects for two residents reviewed for unnecessary medications. One resident had diagnoses including unspecified head injury, PTSD, and psychophysiologic insomnia, was cognitively intact with a BIMS score of 15, and had care plan interventions focused on anxiety, environmental stimulation, reassurance, and psychiatric referral. The resident’s medication orders included Ativan 0.5 mg twice daily as needed for anxiety and mirtazapine 7.5 mg at bedtime for sleep, but there were no physician orders initiated to monitor psychotropic medication side effects, and the care plan did not direct monitoring for those effects. The second resident had diagnoses including aphasia, hemiplegia and hemiparesis following cerebral infarction, schizoaffective disorder, and a history of traumatic brain injury. The resident’s quarterly MDS showed a BIMS score of 15, with depression noted during the look-back period and no behaviors at the time of assessment, while the care plan identified risks for behavior symptoms and mood changes related to depression, bipolar disorder, and antidepressant and antipsychotic medications. Medication orders included divalproex sodium 125 mg twice daily and mirtazapine 7.5 mg at bedtime, but there were no orders entered to monitor psychotropic medication side effects. The DON stated the facility used a house order for monitoring side effects, that the order was not active for these residents, and later verified that monitoring for psychotropic medication side effects had not been completed.
Unsafe discharge without required notice
Penalty
Summary
The facility failed to ensure a resident was provided a safe and appropriate discharge. Resident #84 was admitted with diagnoses including epilepsy, traumatic brain injury, anxiety disorder, mood disorder, depression, tracheostomy status, and thyroiditis. The resident’s MDS showed a BIMS score of zero, indicating she was rarely or never understood, and a staff assessment noted short- and long-term memory problems. She required moderate assistance with toilet use, bathing, and dressing, and her care plan identified cognitive impairment, risk for falls, and mood and behavior concerns, including crying, yelling for help, repeated questioning, and removing her clothes and walking in the hallway. Progress notes showed the resident’s behaviors were directed toward staff and included hitting, kicking, throwing items, and hitting the medication cart against the wall. The record did not show behaviors directed toward other residents or herself. The DON documented that she was notified the resident was out of control, had hit a nurse, and police were called. The DON emailed the physician stating the facility was not equipped for the resident’s behaviors and asked about psychiatric placement options. The physician responded that a psychiatric facility with neurology onsite was needed, but she did not know of one that met that need, and suggested the resident’s husband take her to an ER with a psychiatric center. The resident was sent to a local hospital with her husband, but the hospital did not admit her. The facility then determined the resident could not return because she was considered a harm to herself and others, despite the record showing her behaviors were directed toward staff. The resident’s husband reported the hospital would not admit her and that he had no place to take her. The facility provided the husband with the resident’s medications and belongings, and the resident ultimately went home with her husband. The medical record contained no documentation that the facility provided the resident or her husband with a discharge notice or appeal rights before the discharge. The facility policy stated residents could remain in the facility except when the resident or responsible party requested discharge, payment was not being made, or the health and safety of the individual or other residents were endangered.
Failure to Follow Ordered Heel Offloading Measures
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was not ensured for one resident reviewed for pressure ulcers. Resident #11 was admitted with diagnoses including hemiplegia and hemiparesis, aphasia, and anxiety. The annual MDS showed impaired cognition, dependence on staff for transfers and mobility, and risk for skin breakdown, with no pressure ulcers at the time of assessment. The care plan identified risk for impaired skin integrity related to ADL needs, incontinence, and frail/thin skin, and included pressure reduction devices as needed. The physician order directed bilateral protective boots to be used per wound care and removed for hygiene and skin care. Observations showed Resident #11 in an adjustable reclining wheelchair with the offloading boots left on a dresser behind the television, and the resident stated she would allow staff to put the boots on. Later, the resident was observed in the wheelchair with a blanket covering her body, legs, and feet, and she stated she could not move her legs independently. A CNA stated the resident had been transferred from bed to wheelchair on the previous shift and that the boots were intended for use while in bed. During continued observation, the resident’s legs were crossed at the ankle and one heel was resting on the wheelchair footpad, which the CNA confirmed. The boots were not on the resident until later that day. The weekly body audit noted no skin breakdown.
Failure to Attempt Non-Pharmacological Pain Interventions Before PRN Oxycodone
Penalty
Summary
The facility failed to ensure non-pharmacological interventions were attempted before administering as-needed pain medication for one resident reviewed for pain. Resident #63 was admitted on 04/02/25 with diagnoses including dementia, rheumatoid arthritis, disc degeneration, and neuropathy. The quarterly MDS dated 12/24/25 indicated the resident had intact cognition, received as-needed pain medications, and did not receive non-medication interventions for pain. The care plan, initiated 04/03/25, identified the resident as at risk for alteration in comfort due to complaints of pain, generalized pain, and gastroesophageal reflux disease, and included an intervention for staff to attempt non-pharmacological interventions if the resident allowed. The physician ordered oxycodone HCl 5 mg by mouth every six hours as needed for pain on 11/21/25. The February 2026 MAR showed the resident received 59 doses of oxycodone HCl, and the March 2026 MAR showed 28 doses through 03/17/26 at 4:00 P.M. Review of the medical record found no evidence that non-pharmacological interventions were provided before these as-needed doses in February and March 2026. An LPN confirmed during interview that non-pharmacological interventions should be attempted before administering as-needed pain medication, and concurrent review of the record confirmed no evidence that the resident received such interventions prior to the oxycodone doses.
Failure to Individualize Trauma-Informed Care Plans
Penalty
Summary
The facility failed to ensure resident-specific interventions were implemented to address residents’ histories of trauma for three residents reviewed for trauma-informed care. For one resident with diagnoses including dementia, bipolar disorder, and depression, the care plan identified trauma related to sexual abuse and included general interventions such as reassurance, comfort measures, social interaction, and referral to psychiatric or counseling services, but the DON, an LPN, and the Social Service Director confirmed the care plan did not include trauma-specific triggers or interventions to address or avoid those triggers. For another resident with diagnoses including morbid obesity, neuromuscular dysfunction of the bladder, and a right femur neck fracture, the care plan identified a history of trauma related to being in a situation/environment and being a victim of a violent crime, but the documented interventions were general and did not identify any trauma triggers. For a third resident with diagnoses including an unspecified head injury, PTSD, and psychophysiologic insomnia, the care plan addressed trauma-related PTSD from military history with general interventions such as building trust, observing for anxiety, decreasing environmental stimulation, and providing reassurance, but it contained no resident-specific PTSD triggers. The DON verified that the care plans for these residents did not contain specific triggers and that the interventions were not resident-specific.
Medication Given Outside Ordered BP Parameters
Penalty
Summary
Medications were not administered per physician order for Resident #63, who was admitted on 04/02/25 with diagnoses of dementia, hypertension, and anxiety. The MDS assessment dated 12/24/25 indicated the resident had intact cognition. A physician order dated 08/29/25 directed midodrine HCl 2.5 mg by mouth every eight hours for hypotension, with instructions to give the medication only for SBP less than 100 mmHg. Review of the February 2026 MAR and March 2026 MAR showed multiple administrations of midodrine HCl when the resident's BP readings were above the ordered SBP parameter, including readings of 124/50, 117/58, 125/72, 163/59, 104/76, 108/62, 106/69, 106/54, 126/57, 108/74, and 143/51 mmHg. During interview on 03/19/26 at 9:13 A.M., the Unit Manager confirmed the medication was given outside the ordered parameters on each of those dates.
Medication Storage Not Secured
Penalty
Summary
Medications were not stored in a secure manner. Based on observation, staff interview, medical record review, and policy review, the facility failed to ensure that medications were stored in locked compartments. This affected one resident reviewed for hemodialysis and related care in a census of 76. The cited concern involved Resident #9, who had diagnoses including dementia, heart disease, and end stage renal disease, and whose MDS assessment indicated intact cognition and dialysis use. Resident #9 had a physician order for midodrine HCl 10 mg to be given in the afternoon every Monday, Wednesday, and Friday and sent with the resident to dialysis. Staff observed the resident's HD communication binder in a tote bag in the resident's room, and the tote bag was zipped closed on the recliner. With the resident's permission, the binder was opened and a medication pouch was found inside it. CNA #644 confirmed medications were inside the notebook, and the notebook was then carried to an LPN at the medication cart. The LPN observed a medication card for midodrine HCl 10 mg containing seven tablets and placed the notebook in a locked drawer of the medication cart. The facility policy stated that drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light, and humidity controls.
Failure to Obtain and Communicate Bone Biopsy Results
Penalty
Summary
The facility failed to ensure diagnostic testing results were obtained and communicated in a timely manner for one resident (#44) reviewed for diagnostic testing. Resident #44 was admitted with diagnoses including respiratory failure, depression, anxiety, pneumonia, neurogenic bladder, acute infarction of the spinal cord, hypertension, and gastrointestinal hemorrhage. The annual MDS assessment showed the resident was cognitively impaired, had functional range of motion limitations in both upper and lower extremities, and was dependent for all care and transfers. The medical record showed a progress note dated 01/20/26 indicating a bone biopsy had been rescheduled for 02/03/26, and a note dated 02/03/26 indicated the resident was out of the facility. The record contained no results from the bone biopsy scheduled on 02/03/26. The resident representative stated on 03/16/26 that diagnostic testing results completed in January 2026 had not been communicated. The DON confirmed on 03/18/26 that the bone biopsy results had not been obtained by the facility or communicated to the physician and resident representative. The Administrator stated on 03/19/26 that the facility did not have a policy for obtaining diagnostic testing results or notifying the physician and family representative of those results.
Incomplete Documentation of Dialysis Provider Communication
Penalty
Summary
The facility failed to ensure that Resident #9’s medical record was complete by not documenting ongoing communication with the resident’s dialysis provider. Resident #9 was admitted with diagnoses including dementia, heart disease, and end stage renal disease, and the MDS indicated the resident had intact cognition and received dialysis. The record also included a physician order for offsite hemodialysis three times weekly and as needed, and the care plan identified dialysis on Mondays, Wednesdays, and Fridays with interventions to check for new orders after dialysis and maintain communication with dialysis staff and the physician. Review of the record showed only limited documentation of communication between the facility and the hemodialysis clinic in nursing progress notes, despite staff stating there was ongoing contact by email and telephone. The HD clinic’s letterhead document noted the resident was receiving emergency HD treatments in the area and required travel through the area during hours before and after curfew. Interviews with the RN, LPN, DON, and Unit Manager confirmed the resident’s dialysis care involved routine communication with the clinic, but the ongoing exchange of information was not routinely documented in the resident’s medical record.
Failure to Provide Adequate Assistance with Personal Hygiene for Dependent Resident
Penalty
Summary
A resident with chronic respiratory failure, tracheostomy status, ventilator dependence, quadriplegia, and COPD was identified as being severely cognitively impaired and fully dependent on staff for all activities of daily living (ADLs). The resident's care plan required total assistance for ADLs, including personal hygiene. According to the facility's shower schedule and documentation, the resident received showers as scheduled. However, during observations, the resident was noted to have significant facial hair growth on the upper lip and chin, with hair measuring one to two inches in length and extending beyond the lip line and nearly touching the tracheostomy dressing. Staff interviews confirmed that although the resident was showered, facial hair was not shaved because staff were reluctant to use the facility's razors on the resident's face. The facility's policy required that residents unable to perform ADLs independently receive necessary services to maintain grooming and personal hygiene. Despite this, the resident did not receive adequate assistance with shaving, resulting in a failure to meet the facility's own standards for ADL care and personal hygiene.
Facility Fails to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, sanitary, and homelike environment, affecting all 72 residents. Resident #64, who was cognitively intact, reported that the toilet and toilet riser in his restroom were covered with feces, and his bed linens were soiled. These observations were confirmed by a Housekeeping Assistant. Resident #64 had multiple medical conditions, including malignant neoplasm of the esophagus, diabetes mellitus type two, and morbid obesity. Additionally, Resident #59, who was moderately cognitively intact, reported that her room was not kept clean, which was verified by an LPN who observed dirt on the floor. Furthermore, the carpet in the 300 Hall was observed to be stained and dirty with food pieces ground into it, a condition confirmed by an STNA who stated that this was the usual state of the area. The facility's policy on providing a clean and homelike environment was not adhered to, as evidenced by these findings.
Failure to Report Elopement Incident of Cognitively Impaired Resident
Penalty
Summary
The facility failed to report an incident of potential neglect related to the elopement of a cognitively impaired resident to the state agency. The incident involved a resident with multiple diagnoses, including dementia and severe cognitive impairment, who was noted to have wandering behaviors. On the day of the incident, the resident was observed closing fire doors and was later found outside the facility by an LPN during her smoke break. The resident was brought back inside without any staff having observed her exit the building. Despite the incident, the facility did not submit a Self-Reported Incident (SRI) to the state agency as required by their policy. Interviews with staff confirmed the resident's exit and return to the facility. The facility's policy mandates that alleged violations of neglect be reported immediately to the administrator, state agency, and other required agencies, with a thorough investigation and reporting of results within five working days. However, the facility did not adhere to this policy, as evidenced by the lack of an SRI for the incident. The corporate director questioned the need for reporting, indicating a gap in understanding or adherence to the facility's policies on reporting potential neglect.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to provide adequate supervision to prevent the elopement of a resident identified as at risk for wandering and elopement. Resident #3, who had a history of elopement and was diagnosed with dementia and other cognitive impairments, was able to exit the facility unsupervised. The resident's care plan included interventions for elopement risk, such as completing an elopement risk assessment and monitoring behavior, but these measures were not effectively implemented. On the day of the incident, Resident #3 was observed closing fire doors and pacing the hallway, indicating anxiety. Despite these behaviors, the resident was not adequately supervised, and staff failed to notice when the resident exited the building. The door alarm was found to be in working order, but staff did not hear it or respond in time to prevent the elopement. The resident was eventually found outside by an LPN who was on a smoke break and was able to redirect the resident back into the facility. Interviews with staff revealed lapses in supervision and communication. An LPN was supposed to be monitoring the hallway but did not see or hear the resident leave. Another staff member, an STNA, arrived late and heard the alarm but did not see the resident outside. A housekeeper also heard a beeping noise but did not recognize it as an alarm. These oversights contributed to the resident's unsupervised exit from the facility, highlighting a failure to ensure a safe environment for residents at risk of elopement.
Ineffective Pest Control Program for Bed Bugs
Penalty
Summary
The facility failed to maintain an effective pest control program for bed bugs, affecting a resident who was severely cognitively impaired and dependent on staff for all activities of daily living. The resident's medical record indicated that bed bug precautions were in place due to previous findings of bed bugs, and it was noted that the resident's family, who visited often, had a bed bug infestation at home. Despite treatments by an exterminator, the facility did not address the source of the infestation, allowing the family to continue visiting and bringing potentially contaminated items into the facility. Interviews with staff, including a housekeeper, LPN, and STNA, confirmed the presence of bed bugs in the resident's room and highlighted the facility's inadequate response to the issue. Staff reported that the exterminator's treatments were ineffective due to the ongoing introduction of bed bugs by the resident's family. Observations in the resident's room revealed evidence of bed bug activity, such as red-brown specks on the bed sheet, identified as bed bug droppings. The exterminator's records showed multiple treatments for bed bugs, yet live bed bugs were consistently found during inspections.
Failure to Document Meal Intakes
Penalty
Summary
The facility failed to document meal intakes as recommended by the dietician and outlined in the care plans for two residents, leading to a deficiency in maintaining their nutritional status. Resident #35, who had severe cognitive impairment and was dependent on staff for eating, had no meal intake documentation on several specified dates. The resident was extremely underweight, and the care plan included interventions such as adding enhanced foods to every meal, assisting with feeding, and providing supplements. Despite these interventions, the facility did not consistently document the resident's meal intakes, as verified by the Director of Nursing (DON). Similarly, Resident #61, who was cognitively intact but required supervision for meals, also had missing meal intake documentation on several specified dates. The resident had significant weight loss and was recommended to receive house shakes and have meal intakes monitored. The care plan included monitoring meal intakes and offering substitutes if less than 75% of a meal was consumed. However, the facility failed to document meal intakes consistently, as confirmed by the DON. This deficiency was investigated under Complaint Number OH00152780.
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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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