Bethesda Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Fremont, Ohio.
- Location
- 600 N Brush St, Fremont, Ohio 43420
- CMS Provider Number
- 365510
- Inspections on file
- 26
- Latest survey
- April 2, 2026
- Citations (last 12 mo.)
- 17
Citation history
Health deficiencies cited at Bethesda Care Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and multiple chronic conditions required assistance with all ADLs. The resident’s daughter requested facility policies related to medication administration and bed alarms to support her participation in the care planning process, but the facility did not provide them. Facility leadership acknowledged that the request was not fulfilled, citing ongoing revisions to the policies and concerns about distributing outdated versions, and there was no existing policy governing how requested facility policies should be provided to residents or their representatives.
The facility failed to accurately code MDS assessments for several residents receiving respiratory services. Three residents with chronic respiratory conditions and orders for AVAPS, a non-invasive ventilation mode aligned with BiPAP, were incorrectly coded on the MDS as receiving invasive mechanical ventilation, despite observations showing no invasive ventilator use and RAI guidance limiting that code to closed-system ventilation via endotracheal tube or tracheostomy. Another resident with a history of acute respiratory failure, COPD, and other comorbidities was documented in progress notes and by an LPN and the DON as receiving continuous oxygen via nasal cannula, yet had no physician order for oxygen, no care plan addressing oxygen therapy, and an MDS that indicated no oxygen use, contrary to facility policy requiring accurate, comprehensive resident assessments.
Surveyors found that the facility failed to provide adequate, individualized activities for all residents on the memory care unit. The activity calendar showed only repetitive offerings such as juice, news, and table talk daily, with a single weekly morning stretch. Observations revealed multiple residents sitting in the dining room or in recliners with only television music and no structured or spontaneous activities, and an activity aide distributed word searches only to residents at the table, not to those in recliners. A CNA reported that residents were not offered mental stimulation between scheduled activities. The activity aide stated that a blind resident was not offered adapted activities, and that two other residents who wandered or became easily agitated were also not offered activities, despite facility policy requiring diverse, adapted programming.
Surveyors found that a soiled linen room on a memory care hall was left unlocked and did not require a code for entry, allowing unrestricted access. A CNA was observed opening the door without using a code, and the BOM confirmed the room was unsecured. Inside, an unlocked cabinet above the sink contained multiple medications and a chemical product, including antifungal powder and cream, moisture barrier cream, and an all-purpose spill clean-up absorbent, all labeled to be kept out of reach of children. The facility had identified multiple cognitively impaired, independently mobile residents on this hall who could have been affected, despite a written policy requiring hazardous areas, devices, and equipment to be identified and addressed to ensure safety and mitigate accident hazards.
The facility failed to follow its infection prevention and control policies when staff did not consistently use PPE or perform hand hygiene for a resident on contact precautions and during meal tray delivery to multiple residents. A resident with complex medical conditions, including osteomyelitis and a wound infection requiring IV antibiotics via a PICC line, had an order for single-room isolation with contact precautions and signage requiring hand hygiene and use of gloves and gowns. Despite this, a CNA, a social services assistant, and an LPN entered the room and provided care or services, including PICC access and tray delivery, without donning the required PPE or performing hand hygiene. The same CNA also delivered meal trays to three additional residents without hand hygiene between rooms while touching bedside tables, a resident, and personal items, contrary to facility hand hygiene policy.
The facility failed to maintain a clean, orderly, and homelike environment on the Memory Care unit, where wall carpet and wallpaper were peeling, air vents near the nurse’s station were visibly soiled, and a ceiling tile was missing after remodeling. Peeling paint was also observed at the nurse’s station, and multiple lights in the dining/common area were flickering and only partially illuminated. These conditions were confirmed by several LPNs, an RN, and a receptionist, and did not meet the facility’s own policy requiring a well-maintained environment with adequate lighting and homelike characteristics.
A resident with Parkinson’s disease and hypertension exhibited decreased alertness and lethargy during OT, repeatedly falling asleep and needing verbal cues to stay awake, and later was noted by an LPN to be so lethargic that a dose of cyclobenzaprine was held, yet there was no documentation that a physician was notified of these changes or the held medication. Subsequently, CNAs reported the resident was breathing differently, and an LPN found the resident unresponsive, initiated full code, and EMS later pronounced death. The DON and Medical Director both confirmed that the physician or on-call NP should have been notified whenever the resident had a change in condition.
A cognitively intact resident with multiple chronic conditions had a PRN order for Oxycodone for severe pain, but the MAR reflected only a few documented administrations while the resident reported primarily using Tylenol and not having taken Oxycodone in a long time. In contrast, the controlled drug record showed numerous Oxycodone removals from the narcotic lock box, most signed out by an LPN, without corresponding MAR entries. A drug test for the resident was negative for opiates and Oxycodone, and the resident stated she had not needed stronger pain medication recently, while the LPN claimed each signed-out dose had been requested and given. Another LPN reported that the LPN in question was not signing narcotics out properly and that required narcotic counts were not completed at cart handoff, leading to unaccounted doses and suspected misappropriation of the resident’s narcotic medication.
Two residents who were cognitively impaired and required supervision or assistance with ADLs did not receive complete morning personal hygiene care as outlined in their MDS assessments, care plans, and the facility’s ADL policy. One resident with multiple chronic conditions, including dementia and muscle weakness, was observed in the dining area with disheveled hair after the POA reported that hair and teeth had not been brushed, and the assigned CNA confirmed these tasks were not done. Another resident with dementia and chronic kidney disease was observed on two occasions with unkempt hair at the dining table, and the CNA first expressed uncertainty about assignment, then acknowledged the resident was on her assignment and that morning ADL care, including hair brushing, had not been completed.
Two residents experienced lapses in ordered care and monitoring when staff failed to obtain and document required vital signs and skilled assessments, did not follow physician orders for respiratory monitoring and skin breakdown, did not document or consistently monitor newly identified skin and labial lesions, and did not notify a physician or NP of significant changes in condition, including lethargy and refusal to get out of bed. One resident was documented as receiving oxygen without an order, had no vitals recorded for several days despite skilled status, and had medications held for lethargy and hypotension without corresponding provider notification in the record, culminating in an unresponsive episode requiring EMS. The second resident returned from a gynecology visit with written orders for sitz bath treatments for a labial cyst, but the facility failed to enter or implement these orders or add related care plan interventions until the resident’s representative supplied the necessary sitz bath equipment, delaying the ordered treatment.
A resident with heart failure, DMII, and COPD, who was cognitively intact and care planned for pain management, had a PRN order for Oxycodone 5 mg, two tablets every six hours for pain rated 6–10. Review of the MAR showed Oxycodone administrations, including for pain levels below the ordered range, while the controlled drug record showed multiple removals of Oxycodone from the narcotic lock box that were not documented on the electronic MAR. A facility self-reported incident revealed that an LPN repeatedly signed out controlled substances on the narcotic record but failed to document their administration in the MAR, resulting in inaccurate controlled medication documentation for this resident and potentially others receiving opioids.
A resident with multiple serious health conditions had a signed DNR CC-A advanced directive and a corresponding physician order, but the care plan incorrectly documented the resident as full-code, listing interventions for full resuscitation. The DON confirmed the care plan did not match the resident's documented code status, contrary to facility policy requiring alignment with advance directives.
A resident with complex medical conditions had a signed Advance Directives Form indicating DNR CC-A, but the physician order listed the resident as full code for two months before being corrected. The DON confirmed the mismatch between the resident's documented wishes and the code status order, contrary to facility policy.
A resident with multiple complex medical conditions did not receive several ordered doses of Magnesium Gluconate because the medication was not available, despite facility policy requiring timely receipt of medications. This was confirmed through MAR review and DON interview.
Surveyors found that injectable medications, including insulin and semaglutide pens, were not labeled with the date opened, expiration date, or resident name as required. An LPN confirmed that these medications, which were for two residents on the 100-hall, were missing necessary labeling, contrary to facility policy and supplier guidelines.
A registered nurse did not don a gown while performing a dressing change for a resident on enhanced barrier precautions (EBP) due to wounds, despite clear CDC signage and facility policy requiring gown use for high-contact care activities. The resident had multiple complex medical conditions and severe cognitive impairment. The nurse confirmed the omission during interview, resulting in non-compliance with infection prevention protocols.
A resident with epilepsy did not receive prescribed seizure medications at an LTC facility, resulting in continual tonic-clonic seizures and hospitalization. The facility failed to notify the physician of the medication lapse and seizure activity. The resident's mother was misinformed about medication availability, and critical medications were not administered, leading to a severe health episode.
The facility failed to ensure that STNAs had required evaluations completed. One STNA hired in November did not have an annual evaluation, and another hired in December lacked a 90-day evaluation. The Administrator and DON confirmed the absence of these evaluations, which are mandated by facility policy.
The facility failed to maintain clean and appropriate flooring, affecting fifteen residents in the memory care unit. Observations revealed sticky yellowish residue on the linoleum floor near the nurses' station and dining room, which were sticky and covered with dust and debris. An LPN and housekeeping staff confirmed the persistent issue, attributing it to old wax residue and inadequate cleaning methods.
The facility failed to honor the room temperature preferences of two residents, both of whom were cognitively intact and reported their rooms were too hot. Maintenance staff confirmed that residents could not control the cooling in their rooms, and temperatures were verified to be higher than the residents' preferred levels.
The facility failed to complete neurology checks on a resident with an unwitnessed fall, despite the policy requiring a focused neurological assessment after such incidents. The DON confirmed the checks were not done and the policy lacked specific timing for these assessments.
The facility failed to ensure that a resident's portable oxygen tank was sufficiently supplied with available oxygen. The resident, who required oxygen therapy for chronic respiratory failure and COPD, was observed with an empty portable oxygen tank. Staff interviews revealed that there were no alarms for portable oxygen tanks, and staff were expected to check them frequently.
The facility failed to maintain accurate physician orders and assess a dialysis access site for a resident with end-stage renal disease. Despite having a permacatheter in the chest for dialysis, the medical record lacked documentation and care instructions for it. The resident's non-functional arm fistula was incorrectly monitored, and the LPN was unaware of the chest catheter.
The facility failed to ensure timely psychiatric follow-up for a resident with multiple mental health diagnoses who exhibited significant behavioral changes and expressed suicidal ideation. Despite the resident's request to see a counselor, there was a 22-day delay in psychiatric intervention, and no additional assessments or care plan updates were made during this period.
The facility failed to ensure that insulins were dated when opened and that expired insulins were discarded. This deficiency was observed in the medication storage for three residents, with opened and undated insulin pens and vials, and one insulin pen dated beyond its expiration date. These observations were verified by LPNs during the survey.
The facility failed to appropriately store used soiled bed pans in a shared bathroom, affecting a resident with multiple diagnoses. The resident reported that bed pans were often left on the floor, on the back of the toilet, or in the sink, leading her to use the community bathroom for personal hygiene. Staff interviews confirmed the issue and noted that facility policy requires bed pans to be cleaned and stored in a bag.
Failure to Provide Requested Facility Policies to Resident Representative
Penalty
Summary
The deficiency involves the facility’s failure to provide a resident’s representative with requested facility policies necessary to support participation in the person-centered care planning process. The resident involved was admitted on 08/12/24 and had multiple diagnoses, including chronic kidney disease stage IIIA, hypertension, hyperlipidemia, polyneuropathy, osteoarthritis, dementia, hypothyroidism, chronic pain, generalized muscle weakness, cardiac murmur, amnesia, photokeratitis, and dermatitis. The most recent quarterly MDS assessment showed a BIMS score of three, indicating severe cognitive impairment, and documented that the resident required at least limited assistance with all activities of daily living, including eating, hygiene, toileting, dressing, transferring, and ambulation. Between 03/30/26 and 04/02/26, interviews with family and staff revealed that the resident’s daughter requested facility policies related to medication administration and bed alarms, but the facility did not provide them. In an interview on 04/01/26 with the Administrator, the Regional Director of Operations, and the Regional Director of Clinical Services, facility leadership confirmed that the daughter had requested these policies and that they were not provided. During the exit conference on 04/02/26, the Regional Director of Operations again acknowledged that the request was not fulfilled and explained that the facility did not provide the policies because they were undergoing revisions and the facility could not ensure distribution of updated versions. Review of facility policies further showed there was no policy addressing the provision of facility policies to residents or their representatives upon request.
Inaccurate MDS Coding for Ventilator and Oxygen Therapy Services
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate completion of the Minimum Data Set (MDS) for multiple residents, particularly in the coding of respiratory services and oxygen therapy. For three residents with diagnoses including chronic obstructive pulmonary disease, obstructive sleep apnea, and dependence on a respirator/ventilator, quarterly or annual MDS assessments were coded to indicate use of an invasive mechanical ventilator. Physician orders for these residents specified use of average volume-assured pressure support (AVAPS), described as ventilator/volume targeted pressure support with detailed settings and daily use requirements. However, observations of these residents during the survey showed them in wheelchairs or in their rooms without invasive mechanical ventilation in place. Further clarification from the state RAI/OASIS Education Coordinator and reference to NIH StatPearls identified AVAPS as a form of non-invasive ventilation most closely aligned with BiPAP, which should be coded as BiPAP on the MDS rather than as invasive mechanical ventilation. The RAI manual instructions for coding invasive mechanical ventilation specify that it applies to residents receiving closed-system ventilation via endotracheal tube or tracheostomy, or those being weaned from such devices, and explicitly state not to code this item when the ventilator is used only as a substitute for BiPAP or CPAP. Despite this, the MDS nurse confirmed that the three residents’ MDS assessments were coded as receiving invasive mechanical ventilation, stating that he believed the MDS manual directed him to do so. The facility also failed to accurately assess and document oxygen therapy for another resident with diagnoses including acute respiratory failure with hypoxia, COPD, heart failure, hypertension, type 2 diabetes, and generalized anxiety disorder. This resident’s quarterly MDS indicated that oxygen therapy was not required, and multiple care plans over several months did not include oxygen therapy. Physician orders during the review period contained no order for oxygen administration. In contrast, progress notes on multiple dates documented that the resident was receiving oxygen via nasal cannula, and an LPN confirmed the resident was on 2 L/min oxygen without a corresponding physician order, believing it to be as-needed and longstanding. The DON verified that the resident had been receiving oxygen therapy for an extended period without a physician order, that oxygen was not included in the care plan, and that the MDS assessment was inaccurate regarding oxygen use, contrary to the facility’s policy requiring comprehensive assessments and attestation to MDS accuracy.
Failure to Provide Adequate, Individualized Activities on Memory Care Unit
Penalty
Summary
The deficiency involves the facility’s failure to provide activities that met the needs and cognitive capabilities of residents on the memory care unit, affecting 24 residents. Review of the March 2026 memory care activity calendar showed that scheduled programming for one week consisted only of “juice and news” and “table talk” every day, with “morning stretch” offered only once weekly. Observations on multiple days showed residents sitting in the dining room with only music playing on the television and no other structured or spontaneous activities provided, despite the facility’s policy stating that memory care programming would offer a diverse variety of events throughout the day, with activities adapted and modified based on resident abilities and dementia progression. On one observed morning, five residents were seated around the dining room table with only television music available. On another morning, seven residents were seated in the dining room with only television music until an activity aide began distributing word searches to residents at the table, while three other residents remained in recliners in front of the television and were not offered any activity. A CNA from agency who frequently worked on the memory care unit stated there were no activities for residents and confirmed residents were not offered mental stimulation between scheduled activities. The activity aide reported that one resident was blind and therefore was not offered activities beyond sitting next to the aide, acknowledged that this resident should be offered alternative activities, and stated that two other residents who wandered or became easily agitated were also not offered activities, and in one case the aide did not know the resident’s name.
Unsecured Soiled Linen Room with Accessible Medications and Chemicals on Memory Care Hall
Penalty
Summary
Surveyors identified a deficiency related to accident hazards and inadequate supervision when they observed that the soiled linen room on the 200 Memory Care hall was unlocked and did not require a code for entry, allowing unrestricted access. A CNA was seen opening the soiled linen room door without entering a code, confirming that the door was not secured. During an interview, the Business Office Manager confirmed the door did not require a code and was unlocked, and further verified that an unlocked cabinet above the sink inside this room contained multiple medications and a chemical product, including antifungal powder (miconazole nitrate 2%), two tubes of antifungal cream (miconazole nitrate 2%), moisture barrier cream (12% zinc oxide and 1% dimethicone), and Spill Magic all-purpose spill clean-up absorbent powder, all labeled to be kept out of reach of children. The facility had identified 10 cognitively impaired and independently mobile residents on the 200 hall who could have been affected by this unsecured access to medications and chemicals. Review of the facility’s policy titled “Hazardous Areas, Devices, and Equipment,” revised July 2023, showed that the facility’s stated practice was that all hazardous areas, devices, and equipment would be identified and addressed appropriately to ensure resident safety and mitigate accident hazards to the extent possible, which was not followed in this instance.
Failure to Follow Contact Precautions and Hand Hygiene During Resident Care and Meal Delivery
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program by not ensuring proper use of personal protective equipment (PPE) and hand hygiene for a resident on contact precautions and for multiple residents during meal tray delivery. One resident with multiple medical conditions, including Type 2 diabetes mellitus, chronic kidney disease, osteomyelitis, and a wound infection of the left lower extremity requiring IV antibiotics via a PICC line, had a physician’s order for single room isolation with contact precautions. The resident’s door displayed a contact isolation sign instructing staff and visitors to perform hand hygiene and don gloves and a gown before entering. Despite this, the resident reported that staff were not using the required PPE when entering her room. Surveyor observations confirmed multiple instances of noncompliance with contact precautions for this resident. A CNA delivered a breakfast tray into the resident’s room, placed it on the bedside table next to the bed, and did not perform hand hygiene or don any PPE before entering, which the CNA later confirmed. A social services assistant entered the same resident’s room to assist with her needs without performing hand hygiene or donning the required PPE, and acknowledged this during interview. Additionally, an LPN was observed sitting on the resident’s bed and accessing the resident’s PICC line without wearing a gown as required for contact precautions, and confirmed she had not donned a gown. Training records showed that both the CNA and LPN had previously received in-service education on contact precautions and PPE use. The facility also failed to ensure appropriate hand hygiene during meal tray delivery for four residents. A CNA was observed delivering breakfast trays to four residents, including the resident on contact precautions, without performing hand hygiene between residents. During these deliveries, the CNA touched bedside tables in each room, touched one resident directly, and handled a water cup and personal belongings on another resident’s bedside table. The CNA confirmed she did not perform hand hygiene while passing the breakfast trays. Facility policy on handwashing/hand hygiene required staff to perform hand hygiene before and after direct contact with residents and after contact with objects in the immediate vicinity of residents, but this was not followed during the observed tray pass. This deficiency was investigated under two complaint numbers.
Failure to Maintain Clean, Well-Maintained, and Homelike Memory Care Environment
Penalty
Summary
Surveyors found that the facility failed to provide a comfortable and homelike environment on the Memory Care (MC) unit, potentially affecting all 24 residents residing there. On one observation, wall carpet on the MC unit was peeling and unsightly, wallpaper between resident rooms was peeling, two air vents near the nurse’s station were visibly soiled, and a ceiling tile near the nurse’s station was missing. A licensed practical nurse confirmed the peeling and unsightly wall carpet and wallpaper, and a registered nurse confirmed the dirty air vents and missing ceiling tile, stating the tile had not been replaced following recent remodeling on the unit. On a subsequent observation, paint at the nurse’s station on the MC unit was noted to be peeling, which was confirmed by another LPN. On another day, three lights in the MC dining/common area were observed to be flickering and only partially illuminated, and an LPN and a receptionist confirmed the lights were flickering and not fully functioning. Review of the facility’s “Quality of Life - Homelike Environment” policy, dated May 2017, showed the facility is to provide a clean, orderly, and well-maintained environment with adequate lighting and homelike characteristics, which was not met in these observed conditions.
Failure to Notify Physician of Resident’s Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to notify the physician in a timely manner when a resident experienced a change in condition. The resident, who had diagnoses including Parkinson’s disease and essential hypertension, was admitted and later discharged on the dates noted in the record. An Occupational Therapy (OT) treatment note documented that the resident had decreased alertness and lethargy during an evaluation, was constantly falling asleep, and required verbal cues to stay awake. There was no evidence in the medical record that the physician was notified of this change in condition. The facility’s policy on charting and documentation required that changes in the resident’s condition and any unusual findings be documented in the medical record. A nursing progress note recorded that an LPN held the resident’s cyclobenzaprine 10 mg tablet because the resident was lethargic and unable to stay awake for conversation, with the resident stating, “I’m just tired.” There was no documentation that the physician was notified of this change in condition or of the held medication. Later, another nursing note indicated that CNAs alerted an LPN that the resident was breathing differently; when the LPN returned to the room, the resident was unresponsive, and full code procedures were initiated, with EMS later calling time of death. The DON confirmed there was no documentation of physician notification on the dates when OT identified a change in condition and when the LPN held the medication, and stated the physician should have been notified on those dates. The Medical Director also stated that staff should notify the physician or on-call NP any time there is a change in condition and confirmed that if the resident was presenting with lethargy and hypotension, the on-call physician should have been called immediately.
Suspected Misappropriation and Poor Documentation of PRN Narcotic Medication
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from misappropriation of narcotic medication and to ensure accurate documentation of controlled substances. A cognitively intact resident with diagnoses including congestive heart failure, end-stage heart failure, Type II diabetes, and COPD had a physician’s PRN order for Oxycodone 5 mg, two tablets every six hours for pain rated six to ten. The resident’s care plan noted a potential for altered comfort and directed that she be educated to request pain medication before pain became severe. Medication Administration Records showed only three documented administrations of Oxycodone over two months, all noted as effective, while the resident reported using Tylenol for phantom limb pain and stated she had not taken Oxycodone in quite some time. In contrast, the Controlled Drug Administration Record showed multiple removals of Oxycodone doses from the secured narcotic lock box for this resident on several dates and times that were not reflected as administered on the MAR. The facility’s review identified unaccounted doses of Oxycodone that had been signed out but not documented as given. An internal investigation and self-reported incident determined that, of 41 PRN Oxycodone sign-outs for this resident, one nurse signed for 35 of the removals, often twice during a shift, while the resident’s drug test was negative for opiates and Oxycodone. The resident, who was confirmed cognitively intact via a BIMs score of 15, stated she had not needed stronger pain medication in a long time. Staff interviews further described documentation and handling issues with controlled substances. One LPN reported that another LPN was not signing narcotics out properly, had forgotten to sign out two narcotic pills, and that they failed to count narcotics together before a cart handoff. The nurse in question stated that each time she signed the medication out, it was requested by the resident and administered, despite the lack of corresponding MAR entries and the resident’s statements and negative drug test. The facility’s abuse, neglect, exploitation, and misappropriation policy defined misappropriation as the deliberate misplacement, exploitation, or wrongful use of a resident’s belongings without consent, and the facility concluded that the available evidence regarding the suspected misappropriation of the resident’s Oxycodone was inconclusive but suspected.
Failure to Provide Required ADL and Personal Hygiene Assistance
Penalty
Summary
The deficiency involves the facility’s failure to provide required Activities of Daily Living (ADL) care, including personal hygiene, to dependent residents as outlined in their MDS assessments and care plans. One resident with hypertensive chronic kidney disease, hypertension, dementia without behavioral disturbance, muscle weakness, and aortic ectasia required supervision or touching assistance for personal hygiene and partial or moderate assistance for showering and bathing per a quarterly MDS. The resident’s care plan documented a self-care deficit related to weakness and cognitive impairment, with interventions for staff to assist with ADLs as needed and to report changes in participation. On the morning of the survey, the resident’s POA reported that the resident’s hair and teeth had not been brushed before breakfast, and observation confirmed the resident’s hair was disheveled while seated in the dining room. The CNA assigned to the resident verified she had not brushed the resident’s hair or teeth during morning personal hygiene care. Another resident, admitted with unspecified dementia, major depressive disorder, and chronic kidney disease, was documented on a quarterly MDS as cognitively impaired and requiring supervision or touching assistance with ADLs. The resident’s care plan identified an ADL self-care deficit related to disease process, with interventions to assist with ADLs as needed and to report improvement or decline in participation. On two separate observations, the resident was seen sitting at the dining room table with hair sticking out on one side, appearing unkempt, indicating morning care was incomplete. During an interview, a CNA initially stated uncertainty about who was responsible for the resident’s care, then acknowledged the resident was on her assignment, confirmed the resident’s hair was unbrushed, and that the resident required assistance with ADLs. The facility’s ADL policy stated that appropriate care and services would be provided for residents unable to carry out ADLs independently, which was not followed in these instances.
Failure to Monitor Changes in Condition and Implement Ordered Treatments for Two Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate treatment and care according to orders, resident preferences, and goals, including failure to follow up on skin breakdown, document skilled assessments and vital signs, notify the physician of changes in condition, and implement physician orders after an office visit. For one resident, admitted with diagnoses including Parkinson’s disease, essential hypertension, dorsalgia, and a history of thoracic spine fracture, the record showed that vital signs were obtained on admission and once later that evening, but no further vital signs were documented during the remainder of the stay despite the resident being a skilled resident who, per the DON, should have had skilled assessments with vitals twice daily. Skilled documentation entries were missing on multiple days, and when present, did not include vital signs. The physician progress note relied on outdated vital signs, and the resident was documented as receiving oxygen via nasal cannula without any corresponding physician order for oxygen. Further review showed that the physician had ordered monitoring of lung sounds, pulse rate, and pulse oximetry before and after nebulizer and incentive spirometry treatments, with documentation of setup and monitoring time each shift. The Treatment Administration Record reflected only the setup time and lacked any documentation of lung sounds, pulse, or pulse oximetry as ordered. A nurse’s note documented that a urine specimen was obtained by straight catheterization and that an open area was observed on the right abdominal fold and groin extending to the outer right hip, as well as a raised area on the left outer labia. The areas were cleansed and treated with a barrier product, and the nurse stated the nurse practitioner was notified; however, there was no documentation on the Treatment Administration Record of ongoing monitoring of these open or raised areas. Later, the same nurse documented holding a dose of Cyclobenzaprine because the resident was lethargic and difficult to arouse, but there was no documented notification to the physician or NP regarding this change in condition. On the morning of the resident’s death, staff administered morning medications without documenting vital signs, and EMS records indicated the nurse reported the resident had presented with lethargy and hypotension that morning and that medications were withheld due to this, which was not reflected in the facility’s documentation. The deficiency also includes failure to implement physician orders following an office visit for another resident with multiple diagnoses including diverticulosis, anemia, obstructive sleep apnea, atrial fibrillation, sick sinus syndrome, and unspecified hemorrhoids. Gynecology visit notes documented a diagnosis of a labial cyst and orders for sitz bath treatments. A subsequent facility physician progress note referenced that the labial cyst was being managed by gynecology with recommendations to continue sitz baths. However, there were no corresponding physician orders or care plan interventions in the facility record for sitz bath treatments. The resident reported that the facility did not have the necessary equipment and that sitz baths did not begin until her representative provided a sitz bath basin and Epsom salt, at which point she reported improved comfort. Staff interviews confirmed that sitz baths were not initiated until weeks after the order and that the treatments ordered by gynecology were not implemented in a timely manner. Facility policies on charting, documentation, and medication and treatment orders stated that records should facilitate communication about resident condition and that treatment orders should be implemented consistent with safe and effective order writing, but the documented practices for these two residents did not align with those policies. Family and staff interviews further described events surrounding the first resident’s decline. The resident’s family reported difficulty reaching the resident by phone and stated that when they did speak with her, she said something was not right and that she was going to be sent to the emergency room, but the family did not hear from the facility until after the resident was pronounced dead. The family also reported that during a prior visit the resident had been hallucinating, which they reported to nursing staff, but they were never informed of any physician response. A CNA reported that on the morning of the resident’s death the resident refused to get out of bed, which was not normal for her, and that this was reported to the LPN. The DON confirmed that vital signs were not obtained for several days, that staff were not monitoring the documented open abdominal and groin areas or the raised labial area, that oxygen was used without an order, and that ordered monitoring for incentive spirometry was not documented. The medical director confirmed that staff should notify the physician or on-call NP for any change in condition. These documented omissions and failures in assessment, monitoring, documentation, and implementation of orders for both residents formed the basis of the cited quality of care deficiency.
Failure to Accurately Document Controlled Medication Administration
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate documentation of controlled medication administration for a resident receiving PRN opioid therapy. The resident, admitted with diagnoses including congestive heart failure, end-stage heart failure, Type II diabetes mellitus, and COPD, had intact cognition per a quarterly MDS and a care plan identifying potential for altered comfort with an intervention to request pain medication before pain became severe. A physician’s order directed Oxycodone HCl 5 mg, two tablets every six hours PRN for pain levels of 6–10. However, review of the MAR showed that Oxycodone was documented as administered on specific dates and times, including for pain levels of 4 and 8, and noted as effective, which did not consistently align with the ordered pain parameters. Further review of the controlled drug administration record showed multiple instances where Oxycodone 5 mg, two tablets, were signed out of the secured narcotic lock box for the resident on various dates and times that were not reflected on the electronic MAR. A facility self-reported incident identified that an LPN had signed for narcotics on the controlled drug administration record but failed to document administration in the electronic MAR. The facility’s review determined that this nurse failed to properly document the administration of controlled substances on multiple occasions and shifts, affecting the accuracy of medication documentation for this resident and potentially for other residents receiving opioid medications.
Care Plan Failed to Reflect Resident's DNR Status
Penalty
Summary
The facility failed to ensure that a resident's care plan accurately reflected their documented code status. Medical record review for a resident with multiple complex diagnoses, including chronic kidney disease, heart disease, and dependence on renal dialysis, showed that the resident had a signed Advanced Directives form indicating a Do Not Resuscitate Comfort Care-Arrest (DNR CC-A) status. This directive was also supported by a physician's order. However, the resident's care plan listed interventions for full resuscitative measures, including CPR and calling 911, which contradicted the resident's documented wishes and physician order. During an interview, the DON confirmed that the resident's care plan did not match the signed Advanced Directives form or the physician's order, and that the resident was care planned as a full-code instead of DNR CC-A. Facility policy requires that care plans be consistent with residents' documented treatment preferences and advance directives. This discrepancy was identified during a review of care planning for three residents, affecting one resident, and was investigated under a specific complaint number.
Failure to Ensure Code Status Orders Match Advance Directives
Penalty
Summary
The facility failed to ensure that a resident's code status orders accurately reflected their wishes as documented in their Advance Directives Form. Specifically, a cognitively intact resident with multiple complex medical diagnoses, including chronic kidney disease, heart disease, and diabetes, had a signed Advance Directives Form indicating a preference for Do Not Resuscitate Comfort Care-Arrest (DNR CC-A). Despite this, the physician order in the medical record listed the resident as full code from the time of admission until two months later, at which point the order was changed to DNR CC-A. This discrepancy was confirmed through medical record review and interview with the Director of Nursing, who acknowledged that the resident's code status order did not match the documented advance directive for a significant period. The facility's policy requires that advance directives be respected and that the plan of care be consistent with the resident's documented treatment preferences, but this was not followed in this case.
Failure to Provide Ordered Medication Due to Unavailability
Penalty
Summary
The facility failed to ensure that routine medications were supplied and administered as ordered for a resident. Specifically, a resident with multiple complex medical diagnoses, including chronic kidney disease, diabetes, sepsis, and other serious conditions, had a physician's order for daily Magnesium Gluconate 250 mg due to hypomagnesemia. Review of the electronic medication administration record (MAR) showed that the resident did not receive several doses of this medication on multiple dates because it was not available in the facility. This was confirmed by both the MAR and the Director of Nursing (DON), who verified the missed doses. Facility policy requires that medications and related products are received from the pharmacy on a timely basis and that accurate records of medication orders and receipt are maintained. Despite this policy, the resident experienced repeated missed doses of the ordered medication over a period of weeks, as documented in the MAR and verified by staff interview. The deficiency was identified during a review of pharmacy services and was investigated under two complaint numbers.
Failure to Label and Date Injectable Medications
Penalty
Summary
Surveyors observed that the facility failed to ensure proper labeling and dating of injectable medications for two residents who were prescribed injectable medications and resided on the 100-hall. During an inspection of the medication storage cart with an LPN, a Lantus SoloStar Pen containing insulin glargine was found with approximately 60 units remaining, but it was not labeled with the date it was opened or its expiration date. The LPN confirmed at the time of observation that the pen was missing these required labels. According to the medication supplier guidelines, Lantus insulin pens expire 28 days after first use or removal from refrigeration. Additionally, two Ozempic (semaglutide) pens were found in the same medication cart, both lacking labels indicating the resident's name, the date opened, or the expiration date, despite being labeled by the manufacturer for single patient use only. The LPN confirmed that neither pen was labeled appropriately. Facility policy and supplier guidelines require that medications with shortened expiration dates, such as these injectables, be labeled with the date opened and the new expiration date to ensure medication purity and potency. The failure to follow these procedures resulted in the cited deficiency.
Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
A deficiency was identified when a registered nurse (RN) failed to follow enhanced barrier precautions (EBP) during wound care for a resident. The resident, who had multiple complex medical diagnoses including cerebral infarction, BPH, Barrett's esophagus, GI hemorrhage, atrial fibrillation, dementia, and was dependent on a wheelchair, had a physician order for EBP due to wounds. The resident's cognition was severely impaired, as indicated by a BIMS score of 05. A CDC-published sign was posted at the resident's doorway, instructing all staff to clean their hands and wear gloves and a gown for high-contact care activities, including wound care. Despite these clear instructions, observation revealed that the RN entered the resident's room and began a dressing change without donning a gown. The RN confirmed during an interview that she had not put on a gown prior to starting the procedure. Review of the facility's policy on transmission-based precautions indicated that staff are to follow CDC recommendations and posted signage regarding the use of personal protective equipment (PPE). This failure to adhere to established infection prevention protocols resulted in non-compliance with the facility's infection prevention and control program.
Failure to Administer Seizure Medications Leads to Resident's Hospitalization
Penalty
Summary
The facility failed to ensure that a resident with epilepsy received their prescribed seizure medications, leading to a serious incident. The resident, who had a history of epilepsy and other medical conditions, was admitted to the facility but did not receive their prescribed medications, including Lyrica, lacosamide, and Risperdal. This oversight resulted in the resident experiencing continual tonic-clonic seizures, which required emergency medical intervention and transfer to a hospital's neurological ICU. The deficiency was further compounded by the facility's failure to notify the physician about the resident not receiving their medications and the subsequent seizure activity. The resident's mother, who was the primary caregiver, was assured by the facility that all necessary medications were available, but this was not the case. The resident's condition deteriorated, and despite the mother's efforts to provide medication from home, the facility did not have the necessary medications on hand, nor did they promptly address the situation with the physician. The facility's documentation and communication failures were evident in the lack of recorded doses of critical medications and the absence of timely physician notification. The resident's medical records showed discrepancies in medication orders and administration, contributing to the resident's severe condition. The facility's policies on medication administration and change in resident condition were not followed, leading to the resident's critical health episode.
Removal Plan
- Resident #76 was transferred to the hospital for seizure like activity.
- Upon review of the medical record, the DON identified that Resident #76 did not receive his scheduled Lyrica, lacosamide and Risperdal. A self-imposed plan of correction (SIPOC) was completed.
- SIPOC included review of resident charts who had been admitted within the last 30 days by the DON/Designee, to ensure all physician's orders were transcribed correctly and are administered per order, and all resident medications are available to be administered at the facility.
- Facility nurses were educated by the DON/designee regarding medication order transcription as well as documentation of medication administration, including medications not available and on order from pharmacy, physician notification, and alternate medication administration and representative (RP) notifications.
- The Medical Director was notified via AD Hoc Quality Assurance Review. Review of processes for medication transcription, medication administration and notification of medications not available to physicians and RP.
- The DON completed education to all licensed nurses regarding admission order transcription and obtaining medications from the pharmacy.
- All residents admitted within the last 30 days were reviewed by the DON and/or the Assistant Director of Nursing (ADON), to ensure all orders were transcribed accurately and all medications were available for administration and no discrepancies were identified.
- The DON/Designee will complete a comprehensive medication order review of all admissions/readmissions within 24 hours to verify accuracy of order transcription and availability of medication for administration.
- The facility has had three admissions (Resident #40, Resident #72, and Resident #75), and all medication orders were audited to be accurate and ensure medication availability.
- New admissions and readmissions will continue to be reviewed for transcription accuracy and availability of medications for 4 weeks and reviewed with Quality Assurance and Performance Improvement (QAPI) for compliance.
- Education was initiated by Staff Development Coordinator (SDC) #158 with licensed nurses on Seizures: Clinical Protocol, Assessment and Recognition.
- An Ad hoc Policy Review was held with the Administrator, DON, Regional Director of Clinical Services (RDCS) #103, and the Medical Director to confirm the systems implemented and reviewed to ensure that residents receive medications as ordered by the physician and to meet their total care needs.
- The DON and the ADON verified all prescribed medications for current residents have been transcribed accurately. Current orders were verified for all residents with no discrepancies identified.
- All residents were assessed by the DON, the ADON, and/or Infection Preventionist (IP) Registered Nurse (RN) #176. Four residents were noted to have a change in condition and physicians/physician assistants were notified per policy and orders received as indicated.
- All licensed nurses were re-educated by the DON and/or SDC #158 on the policies and procedures for Admission Assessment and Follow Up: Role of the Nurse, Reconciliation of Medications on Admission, Administering Medications, Change in Resident's Condition or Status, and the procedure for obtaining medications from pharmacy if not available.
- Previously initiated seizure education was also completed at this time. Education to include 13 licensed nurses. Agency staff will be educated upon arrival for and prior to their scheduled shift. All newly hired licensed nurses will be educated at the time of orientation.
- An Ad hoc Resident Council meeting was held with Activities Director #115 and the DON to review the process for obtaining medications and change in resident condition notification.
- The DON/Designee will complete a comprehensive medication order review of admission/readmission charts within 24 hours of admission/readmission.
- Medication orders will be verified for accurate transcription and implementation of medications, and proper medication administration of ordered medications.
- The DON/Designee will complete ongoing auditing of medical records to ensure changes in condition are reported per policy. Ad hoc education will be completed as indicated.
- Admission and readmission orders will be reviewed for transcription and receipt of medications from pharmacy for 4 weeks and reviewed by QAPI for continued compliance.
- Review of all resident medication availability and administration will continue 5 times/week for 4 weeks with QAPI review for compliance.
Failure to Complete Required STNA Evaluations
Penalty
Summary
The facility failed to ensure that State tested Nursing Assistants (STNAs) had evaluations completed as required. Specifically, the employee file for STNA #555, who was hired on 11/11/22, did not contain an annual performance evaluation. Additionally, the employee file for STNA #557, who was hired on 12/18/23, lacked a 90-day performance evaluation. The Administrator confirmed that these evaluations were not completed, and the Director of Nursing (DON) verified the absence of these evaluations. The facility policy, revised on 07/01/12, mandates that employee performance evaluations for all non-exempt staff be reviewed prior to the 90th day of employment and annually.
Failure to Maintain Clean and Appropriate Flooring
Penalty
Summary
The facility failed to ensure the flooring was maintained in a clean and appropriate condition, affecting fifteen residents in the memory care unit. Observations revealed irregular areas of sticky yellowish residue on the linoleum floor near the nurses' station and dining room, which were sticky and covered with dust and debris. Staff, residents, and visitors were observed walking through these affected areas. An LPN confirmed that the floor was always sticky and that dirt from the carpet or shoes gets stuck to these areas despite daily mopping. A housekeeping staff member indicated that the sticky areas might be from old wax residue and that the flooring needs to be treated with an auto-scrubber, which is not used in this hallway. The facility's policy states that all residents have a right to a safe, clean, comfortable, and homelike environment, and that housekeeping and maintenance services should maintain a sanitary, orderly, and comfortable interior.
Failure to Honor Resident Preferences for Room Temperature
Penalty
Summary
The facility failed to ensure resident preferences for room temperatures were honored, affecting two residents. Resident #39, who is cognitively intact and has multiple diagnoses including type II diabetes and chronic obstructive pulmonary disease, reported that her room was too hot and humid. Despite her request to lower the temperature to 68 degrees Fahrenheit, she was informed that the law required room temperatures to be maintained between 71 and 81 degrees Fahrenheit. Maintenance staff confirmed that residents could not control the cooling in their rooms, and the temperature in Resident #39's room was verified to be 74 degrees Fahrenheit using a portable temperature gun. Similarly, Resident #40, who is also cognitively intact and has multiple diagnoses including chronic diastolic heart failure and major depressive disorder, reported that her room was too hot and that her oscillating fan was broken. Despite her hospice staff's efforts to get her a new fan, the room temperature remained uncomfortable. Maintenance staff confirmed that the thermostat in Resident #40's room read 77 degrees Fahrenheit, but a portable thermometer gun showed it was actually 79 degrees. The resident's oxygen concentrator and the inability to open the window contributed to the increased room temperature. The facility's policy on resident rights and dignity was reviewed, revealing that the facility must promote an environment that enhances the quality of life for each resident, recognizing their individuality.
Failure to Complete Neurology Checks After Unwitnessed Fall
Penalty
Summary
The facility failed to complete neurology checks on a resident with an unwitnessed fall, as per facility policy. Resident #29, who was cognitively intact and had a diagnosis of a right femur fracture, experienced an unwitnessed fall. The medical record review revealed that no neurology checks were completed following the fall, despite the facility's policy indicating that a focused neurological assessment is necessary after a fall if the resident may have sustained a head injury. The Director of Nursing confirmed that the neurology checks were not completed and that the facility policies did not specify when these checks should be conducted.
Failure to Ensure Sufficient Oxygen Supply for Resident
Penalty
Summary
The facility failed to ensure that portable oxygen tanks were sufficiently supplied with available oxygen for resident use. This deficiency affected one resident who was reviewed for oxygen use. Resident #267, who was admitted with chronic respiratory failure and COPD, was observed sitting in the common area with an empty portable oxygen tank. The oxygen tank gauge was on the red refill line, indicating no oxygen remained. The Director of Nursing verified that the portable oxygen tank was empty at the time of observation. The resident's medical record indicated that they required oxygen therapy to maintain an oxygen reading of 90% or above, and the care plan included the use of oxygen as ordered. An interview with an LPN revealed that Resident #267 preferred to be in the common area and that all staff were responsible for monitoring the portable oxygen tank when they passed by. The LPN stated that there were no alarms for portable oxygen tanks, and staff had to check them frequently. The facility's policy on oxygen administration indicated that oxygen tanks might need frequent replacement. Despite this policy, the portable oxygen tank for Resident #267 was found empty, indicating a failure to monitor and replace the oxygen tank as needed.
Failure to Maintain Accurate Physician Orders and Assess Dialysis Access Site
Penalty
Summary
The facility failed to maintain accurate physician orders and accurately assess a dialysis access site for Resident #30, who required dialysis. The resident had a history of end-stage renal disease, type II diabetes mellitus, major depressive disorder, primary glaucoma, legal blindness, hyperparathyroidism, and peripheral vascular disease. Despite having a permacatheter in the left upper chest for dialysis since at least August 2023, the medical record lacked documentation of the permacatheter and its care. The facility's records incorrectly indicated that the resident's left arm fistula was being used and monitored, even though it was non-functional and not in use. The resident confirmed that dialysis was being performed through the chest catheter, and the Director of Nursing (DON) verified the absence of relevant documentation and physician orders for the permacatheter care. Additionally, the facility's Treatment Administration Record (TAR) showed inconsistent and inaccurate documentation regarding the assessment of the resident's fistula. The records indicated that the thrill and bruit were checked each shift, but there were multiple instances where the assessment was either marked as non-applicable or not completed. The Licensed Practical Nurse (LPN) responsible for the resident's care was unaware of the chest catheter and continued to check the non-functional left arm fistula. The facility's policy on dialysis care required a care plan to address the access site, including monitoring for infection and bleeding, which was not followed in this case.
Failure to Ensure Timely Psychiatric Follow-Up
Penalty
Summary
The facility failed to ensure timely psychiatric follow-up for a resident experiencing an exacerbation of mood symptoms. Resident #33, who had a history of multiple mental health diagnoses including Parkinson's disease, dementia, major depressive disorder, and bipolar disorder, exhibited significant behavioral changes and expressed suicidal ideation. Despite these alarming symptoms and a request to see a counselor, the resident did not receive timely psychiatric intervention. The resident was admitted to acute inpatient psychiatry for stabilization from 01/30/24 to 02/16/24, but after discharge, there were no documented behaviors until 04/23/24 when the resident again expressed suicidal thoughts and requested to see a counselor. However, the resident did not receive a psychiatric follow-up until 05/15/24, 22 days after the initial request. Observations of Resident #33 on multiple occasions revealed the resident sitting alone, physically distant from others, and displaying a flat, emotionless affect. The resident's care plan included interventions for socially inappropriate behaviors and the use of psychotropic medications, but there was no evidence of additional assessments, ongoing behavior monitoring, or interventions to address the resident's feelings of not being welcome at the facility and feeling the world would be better off without him. The Social Services Assistant confirmed that no updated care plan interventions, increased monitoring, or assessments were completed until the psychiatric services visit on 05/15/24. The facility's policy on Behavioral Health and Mental Health Services, dated December 2016, mandates that residents displaying or diagnosed with a mental disorder receive appropriate treatment and services to correct the assessed problem or attain the highest practicable mental and psychosocial well-being. However, the facility failed to adhere to this policy, resulting in a significant delay in psychiatric follow-up for Resident #33, who was experiencing severe mood symptoms and suicidal ideation.
Failure to Date and Discard Expired Insulins
Penalty
Summary
The facility failed to ensure that insulins were dated when opened and that expired insulins were discarded. This deficiency was observed in the medication storage for three residents. Specifically, an insulin pen labeled for one resident and a multi-dose vial labeled for another resident were found opened and undated. Additionally, an insulin pen for a third resident was found opened and dated beyond its expiration date. These observations were verified by Licensed Practical Nurses (LPNs) during the survey. The medical records for the three residents involved revealed that they all required the use of insulin for diabetes management. The facility's policies on medication storage and expiration dating were reviewed and indicated that opened multi-dose vials should be dated and discarded within 18 days unless otherwise specified by the manufacturer. The manufacturer's recommendations for the Lispro insulin pen stated that it should not be used beyond 28 days after opening. The facility failed to adhere to these guidelines, leading to the observed deficiencies.
Improper Storage of Soiled Bed Pans in Shared Bathroom
Penalty
Summary
The facility failed to ensure used soiled bed pans were stored appropriately in a shared bathroom, affecting one resident. Resident #38, who has diagnoses including COPD, diabetes mellitus type II, high blood pressure, dependence on oxygen, anxiety, schizoaffective disorder, and bipolar disorder, reported that her roommate's bed pans were often left inappropriately in the shared bathroom. The resident mentioned that the bed pans were sometimes left on the floor, on the back of the toilet, upside down draining into the toilet, or in the sink, causing her to use the community bathroom for personal hygiene tasks like brushing her teeth. An observation confirmed the presence of two soiled bed pans on the floor, stacked on top of each other, with visible fecal matter stains and no labeling or plastic bags for containment. Interviews with staff members corroborated the resident's complaints. A State tested Nursing Assistant (STNA) verified the presence of the used bed pans on the floor and confirmed that the facility's policy requires bed pans to be cleaned and stored in a bag. A Licensed Practical Nurse (LPN) stated that there had been no prior complaints from Resident #38 about the issue but acknowledged having seen uncovered bed pans in the past when she worked as an STNA. The facility's policy, as reviewed, mandates that all resident personal items be appropriately labeled and stored in designated areas, and cleaned and disinfected as necessary.
Latest citations in Ohio
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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