Carecore At Margaret Hall
Inspection history, citations, penalties and survey trends for this long-term care facility in Cincinnati, Ohio.
- Location
- 1960 Madison Road, Cincinnati, Ohio 45206
- CMS Provider Number
- 365733
- Inspections on file
- 23
- Latest survey
- April 13, 2026
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Carecore At Margaret Hall during CMS and state inspections, most recent first.
A resident with dementia and multiple comorbidities was found by the NP to have a swollen, dark purple upper lip, with conflicting explanations from the resident and staff and no clear source of injury. The NP ordered ice and directed ongoing monitoring, but there was no documentation that staff monitored the injury or that the resident’s representative was notified. An LPN confirmed she observed the swollen lip, did not inform the family, and did not document the injury, and the DON verified there was no record of representative notification despite facility policy requiring notification for injuries of unknown source.
A resident with dementia and multiple chronic conditions was found by an NP to have a swollen upper lip with dark purple discoloration, with conflicting explanations from the resident and staff and no clear source of injury. Although the NP ordered monitoring of the injury, there was no subsequent documentation by staff of monitoring or assessment in the chart, and the skin assessment did not reflect the lip injury. The DON confirmed that no investigation was conducted, no staff or resident statements were obtained, and no self-reported incident was submitted to the state agency, despite facility policy requiring investigation and reporting of injuries of unknown source.
A resident with dementia and multiple comorbidities was noted by an NP to have a swollen upper lip with dark purple discoloration, with conflicting explanations from the resident and staff about how the injury occurred. Nursing staff reported they did not know the cause, and an LPN who observed the swollen lip did not question the resident, notify the family, or document the injury. Chart review showed no nursing documentation of monitoring the lip as ordered by the NP, no investigation or collection of staff or resident statements, and no self-reported incident filed, despite a facility abuse policy requiring investigation and reporting of injuries of unknown source.
A resident with dementia, multiple chronic conditions, and a gastrostomy tube was found by an NP to have a swollen upper lip with dark purple discoloration and conflicting accounts of how the injury occurred. The NP ordered ice and directed staff to continue monitoring the lip and adjust treatment as needed. However, from that point through the following days, there was no nursing documentation of monitoring the lip, and skin assessments recorded no skin issues other than the feeding tube. The DON and an LPN later confirmed that the swollen, discolored lip and its monitoring were not documented anywhere in the chart aside from the NP’s notes, and the facility did not know how the injury was sustained.
A resident with cognitive deficits, total dependence for ADLs, and incontinence was care planned as being at risk for constipation and had PRN bowel medications ordered, along with an intervention to record daily bowel patterns. For approximately two months, staff failed to document any bowel movements despite a policy requiring shift-by-shift bowel documentation, and the NP was not made aware of the lack of bowel records. During a change in condition, staff focused on respiratory symptoms and did not perform or document an abdominal assessment, even though it was reported the resident had not had a recent bowel movement. The resident was subsequently hospitalized with respiratory failure and was found to have a fecal impaction with concern for stercoral colitis, requiring manual disimpaction, enema, and initiation of a bowel regimen.
Surveyors found that breakfast service did not follow the approved menu or dietary spreadsheets, including required portion sizes and planned items. Instead of the scheduled sausage egg bake, staff routinely served scrambled eggs, toast, and sausage patties, and hot cereal was dished out with a slotted spoon without measuring, resulting in inconsistent portions. The dietary manager acknowledged that casseroles and similar items on the menu were regularly replaced with scrambled eggs and the corresponding breakfast meat due to some residents not eating pork, and that these substitutions were not reviewed with the RD. The RD stated that menus and spreadsheets were expected to be followed and that she should be consulted for any menu changes. The facility identified two residents who did not receive food from the kitchen, and the practice had the potential to affect most residents in the building.
Surveyors found that hot foods and cold beverages were not served at appropriate temperatures during a meal service, with eggs and sausage measured in the 90°F range and milk and juice above 48°F. The Dietary Manager confirmed these temperatures and acknowledged expectations that hot foods be at least 120°F and cold beverages at or below 40°F. Several residents reported receiving cold eggs and sausage, and facility policy identified the temperature range between 41°F and 135°F as a danger zone for potentially hazardous foods such as meats, poultry, eggs, and milk.
Surveyors identified multiple food safety and hygiene failures, including staff with facial hair preparing and handling food without beard restraints, staff entering the kitchen and handling prepared trays without prior handwashing, and improper cleaning of a food thermometer between checking different foods. Inspectors also found improperly labeled and outdated refrigerated items, such as thickened water and cottage cheese, and observed a dropped breakfast tray being reassembled after contact with the floor and then placed on a cart containing clean trays, glasses, condiments, and milk. These issues affected nearly all residents receiving meals from the kitchen.
Surveyors found that kitchen staff did not have access to adequate handwashing facilities while food was being prepared for most residents. One dietary staff member was observed cooking while the front kitchen handwashing sink had no running water, and the back sink lacked soap. The staff member suggested using a pot-filling spigot for handwashing and obtained paper towels from a food preparation area because none were stocked at the front sink. The dietary manager later reported he was unaware the front sink was not working, despite facility policy requiring accessible sinks, soap, and towels.
Surveyors found that the facility failed to provide and document required ADL care for two residents. One resident with Parkinson’s disease, DM2, and spinal stenosis, who was cognitively intact but dependent on staff for bathing, had scheduled showers twice weekly, yet there was no documentation of showers or refusals on multiple scheduled days, confirmed by the DON. Another cognitively intact resident with DM2, Raynaud’s syndrome, osteoarthritis, and significant self-care deficits required substantial/maximal assistance with bathing and personal hygiene; observations showed excessively long and jagged fingernails on two consecutive days. The resident reported requesting nail trimming and not wanting long nails, and a CNA confirmed the condition of the nails and that nail care, typically done with showers or daily care, had not been completed despite notifying the assigned aide and nurse. Facility policy required appropriate hygiene, bathing, and grooming support for residents unable to perform ADLs independently.
The facility failed to maintain accurate and complete medical records and ADL documentation for three residents. One resident with diabetes, Parkinson’s disease, and spinal stenosis had extensive missing documentation over two months for ADLs, continence, behaviors, and meal/fluid intake, despite requiring staff assistance. Another resident with COPD and CHF who died in the facility had no progress note documenting the death, which the DON later confirmed was absent. A third resident with cerebral infarction, anemia, depression, and mood disorder, identified as at risk for constipation and always incontinent per MDS, had no bowel movement documentation for two months, contrary to the care plan requirement for daily bowel movement recording.
Staff failed to follow the facility’s Enhanced Barrier Precautions (EBP) policy when an LPN administered medication via gastrostomy tube to a resident with an enteral tube and wounds, who had been placed on EBP by physician order, without wearing a gown or gloves. The LPN acknowledged awareness that the resident was on EBP and that appropriate PPE should have been used, despite a facility policy stating EBP would be implemented to prevent transmission of multidrug-resistant organisms.
The facility failed to answer phones during nighttime hours, affecting a resident who fell and required assistance. The resident's family had to enter the facility with EMTs due to the inability to reach staff by phone. The night shift supervisor did not report to work, and the phone was left on the reception desk, leading to calls going to voicemail instead of being answered.
A resident with chronic respiratory failure and dementia did not receive timely incontinence care, as required by their care plan. The CNA responsible did not change the resident's incontinence brief for several hours, despite the care plan's directive for changes every two hours. This lapse in care was confirmed during a complaint investigation.
A resident with chronic respiratory failure and dementia, at risk for falls, was transferred using a sit to stand lift by a single CNA, contrary to facility policy requiring two staff members. The resident slid to the floor without injury. The CNA was terminated for violating the policy.
A resident experienced discomfort due to inadequate room temperature, with the heater blowing cold air despite complaints since October. The room temperature was recorded at 68°F, below the facility's policy of 71-81°F. Maintenance attempts were made, but the issue remained unresolved, and a space heater provided by the resident's brother was removed by staff.
A resident with cognitive deficits and a history of cerebral infarction was injured due to improper use of a stand-up lift instead of the recommended Hoyer lift. The resident, on blood-thinning medication, sustained bruising, which was confirmed to be caused by the incorrect transfer method, contrary to the care plan and therapy recommendations.
A resident, dependent on staff for transfers and severely cognitively impaired, was not assisted out of bed despite requesting to do so after breakfast. The resident remained in bed for several hours, and the STNA did not return to assist her, failing to provide timely ADL assistance.
The facility failed to provide adequate pressure ulcer care and prevention for three residents. A resident with a right heel wound did not receive necessary wound treatment as per hospital orders, with no documentation of dressing changes. Two other residents, both at risk for pressure ulcers, were not turned and repositioned as required by their care plans. Observations and staff interviews confirmed these deficiencies.
A facility failed to conduct timely bladder scans and notify the physician for a resident after catheter removal, as per hospital discharge orders. The resident required substantial assistance and had orders for scans every six hours, with catheterization if retaining over 300 ml. No scans were documented for two days, and attempts to catheterize were unsuccessful without physician notification, violating facility policy.
A resident with severe cognitive impairment and multiple diagnoses did not receive medications via the physician-ordered gastrostomy (g-tube) route. The error was observed by the family through a live video camera and reported to the DON. The resident did not experience any negative effects from the incident.
The facility failed to securely store medications, affecting two residents. One resident was left with unsupervised tablets in applesauce, and another had Miralax left at her bedside after refusing to take it immediately. Both instances were against facility policy, which requires physician and care team approval for self-administration.
The facility failed to disinfect a glucose monitoring device after usage and ensure staff completed hand hygiene after removing a wound dressing on a resident in enhanced barrier precautions. These lapses affected multiple residents and were confirmed by staff interviews and observations.
Failure to Notify Resident Representative of Injury of Unknown Origin
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s representative of a change in condition and an injury of unknown origin. A resident with dementia, Type 2 diabetes, peripheral vascular disease, hypertension, depression, incontinence, gastrostomy status, and other comorbidities was admitted with moderate cognitive impairment and required varying levels of assistance with ADLs. On one date, the NP documented that the resident had a swollen upper lip with dark purple discoloration on the inside and outside of the lip. The resident gave one explanation (tripped and hit his lip), while therapy staff reported that a tree limb hit the resident’s face, and nursing staff reported they did not know what happened. The NP ordered ice and directed staff to continue monitoring the swollen lip and adjust the treatment plan as needed. From the date of the NP’s initial assessment of the swollen lip through several days afterward, there was no documentation that staff monitored the swollen lip as ordered. A subsequent skin assessment documented no skin issues, and a later NP note indicated the lip contusion had resolved. Interviews confirmed that the DON could not produce any documentation that the resident’s representative was notified of the swollen, discolored lip. An LPN acknowledged that the resident’s lip was not swollen on one workday but was swollen when she returned the next day, and she verified that she neither notified the family nor documented the swollen lip in the chart. The facility’s abuse policy defined injuries of unknown source and required investigation and notification of the resident representative for such incidents, but there was no documentation that the resident’s representative was notified of this injury of unknown origin.
Failure to Report and Investigate Injury of Unknown Origin
Penalty
Summary
The deficiency involves the facility’s failure to report and investigate an injury of unknown origin for one resident and to notify the state surveying agency as required by policy. The resident was admitted with multiple diagnoses including unspecified dementia with moderate cognitive impairment, Type 2 diabetes mellitus, peripheral vascular disease, hypertension, depression, urinary and fecal incontinence, dysphagia, and other chronic conditions. The admission MDS showed the resident required varying levels of assistance with ADLs but was independent with personal hygiene and rolling in bed. On a documented visit, the nurse practitioner (NP) noted the resident had a swollen upper lip with dark purple discoloration on the inside and outside of the lip. The resident stated he tripped and hit his lip, while therapy staff reported he was hit in the face by a tree limb, and nursing staff reported they did not know what happened. The NP documented that the resident was eating and drinking without difficulty, reported no pain, and had baseline confusion related to dementia. The NP ordered ice and directed staff to continue monitoring the swollen lip and adjust the treatment plan as needed. However, review of the chart from the date of this visit through several days afterward revealed no documentation that staff monitored the swollen lip as ordered. The Director of Nursing (DON) confirmed there was no documentation of the swollen upper lip with dark purple discoloration in the resident’s progress notes or skin assessment, other than the NP’s notes. The DON verified that the facility did not know how the resident sustained the swollen lip, did not complete an investigation, did not obtain resident or staff statements, and did not submit a self-reported incident (SRI) to the state surveying agency for this injury of unknown origin. The facility’s abuse policy required investigation and immediate reporting of all alleged violations, including injuries of unknown source, to the administrator and state surveying agency, and notification of the resident representative, but these steps were not carried out for this incident.
Failure to Investigate and Document Injury of Unknown Origin
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate and document an injury of unknown origin for one resident. The resident had multiple medical conditions, including unspecified dementia with moderate cognitive impairment, Type 2 diabetes, peripheral vascular disease, dysphagia, and incontinence, and required varying levels of assistance with ADLs. On admission skin assessment, only a feeding tube to the abdomen was noted, with no other skin issues. Later, a nurse practitioner (NP) progress note documented that the resident had a swollen upper lip with dark purple discoloration on the inside and outside, while the resident reported tripping and hitting his lip, and other staff reported differing accounts of how the injury occurred. The NP assessed the resident on the date the swollen lip was reported, noting that the resident was eating and drinking without difficulty and denied pain. The NP received conflicting explanations from staff: therapy staff reported that a tree limb hit the resident’s face while outside, the resident stated he tripped and hit his face, and nursing staff reported they did not know what happened. The NP reported notifying the Director of Nursing (DON) and ordered ice for the lip. However, review of the resident’s chart from the date of the NP note through several days afterward revealed no nursing documentation that the swollen lip was monitored as directed by the NP. Further record review and interviews showed that the facility did not document the swollen upper lip with dark purple discoloration in the resident’s progress notes or skin assessment, other than in the NP’s notes. The DON confirmed there was no documentation of the injury in the chart aside from the NP entries, that the facility did not know how the resident sustained the swollen lip, and that no investigation was completed. There were no resident or staff statements related to the injury, no self-reported incident (SRI) was filed for the injury of unknown origin, and the resident’s representative was not notified. An LPN acknowledged seeing the swollen lip after being off duty, did not ask the resident what happened, relied on an unverified report that the resident hit his lip on the bed rail, did not notify the family, and did not document the injury. The facility’s abuse policy required investigation and reporting of all alleged violations and injuries of unknown source, but this was not followed in this case.
Failure to Monitor and Document Swollen, Discolored Lip as Ordered
Penalty
Summary
The deficiency involves the facility’s failure to monitor and document a resident’s swollen upper lip with dark purple discoloration as ordered by the Nurse Practitioner (NP). The resident had multiple medical conditions including unspecified dementia with moderate cognitive impairment, Type 2 diabetes mellitus, peripheral vascular disease, hypertension, dysphagia, and a gastrostomy tube, and required varying levels of assistance with activities of daily living. On 03/16/26, the NP assessed the resident after staff reported a swollen upper lip; the NP observed swelling with dark purple coloration on the inside and outside of the upper lip, noted that the resident was eating and drinking without difficulty, and that the resident denied pain. The NP documented conflicting accounts of how the injury occurred: the resident stated he tripped and hit his lip, therapy staff reported a tree limb hit the resident’s face, and nursing staff reported they did not know what happened. The NP ordered ice and directed staff to continue monitoring the swollen upper lip and adjust the treatment plan as needed. Record review from 03/16/26 to 03/25/26 revealed no documentation that staff monitored the resident’s swollen upper lip as ordered. Skin assessments completed on 03/16/26 at 5:38 p.m. and 10:45 p.m. documented no skin issues other than the gastrostomy tube, and did not mention the swollen, discolored lip. The only documentation of the lip injury in the chart was in the NP’s progress notes dated 03/16/26 and 03/26/26, with the later note indicating the contusion had resolved and the lip had returned to normal. The DON confirmed there was no documentation of the swollen upper lip or its monitoring in the resident’s progress notes or skin assessments, and that the facility did not know how the resident sustained the injury. An LPN who worked on 03/15/26 and 03/16/26 stated the resident’s lip was not swollen on 03/15/26 but was swollen when she returned on 03/16/26, and verified she did not document any information about the swollen lip in the chart.
Failure to Monitor and Document Bowel Function Resulting in Fecal Impaction
Penalty
Summary
The deficiency involves the facility’s failure to monitor and document bowel function for a resident who was care planned as being at risk for constipation. The resident, admitted with diagnoses including cerebral infarction, dysphagia, depression, and mood disorder, had physician orders for PRN milk of magnesia and senna for constipation and a care plan intervention to record bowel movement patterns each day and monitor for complications of constipation. The MDS indicated the resident had moderate cognitive deficits, was dependent for ADLs, and was always incontinent of bowel and bladder. Review of bowel records for December 2025 and January 2026 showed no documented bowel movements, and the DON verified there was no documentation of a bowel movement after 11/19/25, despite a facility policy requiring nursing staff to document bowel movements each shift. On the date of the change in condition, the resident was evaluated with documented signs of fever and shortness of breath, along with other vital signs, but there was no documentation of an abdominal assessment. An LPN reported that when she came on duty, the ADON told her the resident had not had a recent bowel movement and was having respiratory issues; however, the LPN focused on the respiratory concerns when sending the resident to the hospital and did not assess the abdomen. At the hospital, the resident was admitted with acute hypoxic respiratory failure with pneumonia, encephalopathy, hypernatremia, and hyperglycemia, and was found to have a fecal impaction with concern for stercoral colitis. Imaging showed a large ball of stool in the rectum, and the resident required manual removal of the impaction, an enema, and initiation of a bowel regimen. The NP later stated she was unsure if staff had alerted her to the absence of bowel movements and was unaware that bowel movements had not been documented for the resident for two months, despite her expectation that staff document the presence or absence of bowel movements every shift.
Failure to Follow Approved Menus and Portion Sizes for Breakfast Service
Penalty
Summary
The deficiency involves the facility’s failure to follow the planned menu and dietary spreadsheets, including required portion sizes, for multiple residents. On the specified breakfast date, the approved menu called for cereal, toast, and sausage egg bake for residents on regular textured diets, and the dietary spreadsheet specified that all diets were to receive six ounces of cereal, with some diets requiring specific hot cereals. Another spreadsheet for a different date indicated that all diets were to receive a #16 scoop (two ounces) of scrambled eggs when scrambled eggs were on the menu. During observation of breakfast service, surveyors noted that the steam table contained pureed eggs, pureed toast, scrambled eggs, sausage patties, and toast, but no sausage egg bake. For residents on regular diets, the dietary staff member used a four-ounce scoop of scrambled eggs, served one sausage patty, and one slice of toast per plate, and for residents on pureed diets, served a three-ounce scoop of pureed eggs, a two-ounce scoop of pureed toast, and an insulated bowl of hot cereal. Further observation showed that hot cereal was served directly from a pan on the stove using a slotted spoon, with two scoops placed into an insulated bowl, filling it only about halfway, and later a single scoop was served onto a divided plate along with pureed eggs and pureed toast. The dietary staff member confirmed he was using a four-ounce scoop for scrambled eggs and a three-ounce scoop for pureed eggs, and acknowledged that the portion sizes did not match the dietary spreadsheets. He also stated he had always substituted scrambled eggs and the corresponding breakfast meat when casseroles or similar items were on the menu, citing that several residents did not eat pork. The dietary manager confirmed that the egg bake was not prepared because about half of the residents did not eat pork, acknowledged that casseroles and similar items on the menu were routinely replaced with scrambled eggs and the associated breakfast meat, and verified that the hot cereal was not measured and that substitutions had not been discussed with the registered dietitian. The registered dietitian stated her expectation that menus and spreadsheets be followed as planned and that she should be consulted for menu changes, and indicated that the egg bake should have been provided as planned with alternate selections for residents who do not eat pork. The facility identified two residents who did not receive food from the kitchen, and the deficient practice had the potential to affect 76 residents in the facility.
Improper Food and Beverage Temperatures During Meal Service
Penalty
Summary
The facility failed to ensure that food and beverages were served at appropriate, palatable temperatures, affecting the majority of residents who received meals from the kitchen. During observation of a test tray after breakfast trays had been passed, the eggs and sausage were found to be lukewarm and not palatable, with temperatures of 93°F and 93.4°F respectively. The milk, poured from a carton that had been placed on top of the tray cart, measured 48.8°F, and the orange juice measured 51°F. The Dietary Manager confirmed these temperatures and stated his expectation that hot foods should be at least 120°F and that milk and juice should be 40°F or less when served. Interviews with several residents confirmed that their eggs and sausage were cold when they received their trays. The facility’s “Food Preparation and Service” policy, dated April 2019, defined the temperature “danger zone” for food as between 41°F and 135°F, noting that this range promotes rapid growth of pathogenic microorganisms that cause foodborne illness. The policy identified potentially hazardous foods as including meats, poultry, eggs, and milk, and stated that these foods must be maintained below 41°F or above 135°F. The deficiency was identified through observation, staff and resident interviews, and policy review, and was associated with multiple complaint investigations.
Food Safety and Hygiene Failures in Kitchen and Meal Service
Penalty
Summary
The deficiency involves multiple failures in food safety and hygiene practices in the facility’s kitchen and meal service areas, affecting food served to nearly all residents. Surveyors observed several dietary staff and another employee with beards of varying lengths preparing and handling food without wearing required beard restraints, despite facility policy requiring hair restraints to prevent hair from contacting food. One staff member confirmed that beard restraints were not available in the kitchen, and the Dietary Manager acknowledged that employees with facial hair should wear restraints. Additionally, a floor tech entered the kitchen, immediately donned gloves, and began handling prepared breakfast plates without first washing his hands, contrary to facility policies and staff statements that all employees should wash their hands upon entering the kitchen and before handling food. Further observations showed improper handling and storage of food and food-contact equipment. A dietary cook retrieved a food thermometer from a pan containing other utensils, used it to check the temperature of scrambled eggs, then immediately inserted the same uncleaned thermometer into a sausage patty, despite policy requiring food-contact equipment, including thermometers, to be cleaned and sanitized between uses. In the tray line cooling area, surveyors found an open carton of nectar-thickened water past its “best by” date with no opening date, and an opened container of cottage cheese dated well beyond the stated 10-day use period; the Dietitian confirmed all foods should be labeled with open and discard dates, and the Dietary Manager acknowledged these items should have been discarded or used within 10 days. During breakfast tray distribution, staff dropped a tray onto the floor, picked up the items, placed them back on the tray, and then set the soiled tray on top of a cart containing clean meal trays, clean glasses, condiments, and a gallon of milk, which the Dietary Manager confirmed involved placing a dirty tray on a cart with clean items.
Inadequate Handwashing Facilities in Kitchen
Penalty
Summary
The deficiency involves the facility’s failure to ensure kitchen staff had access to adequate, functioning handwashing facilities in the kitchen. Upon entering the kitchen at 8:00 A.M., a surveyor observed a dietary staff member cooking scrambled eggs at the stove. When the surveyor attempted to use the handwashing sink at the front of the kitchen, the water did not flow. The dietary staff member confirmed the sink was not working and directed the surveyor to use the handwashing sink at the back of the kitchen, stating this was where he normally washed his hands. At the back handwashing sink, the surveyor found there was no soap available, which the dietary staff member confirmed, suggesting the surveyor obtain soap from the non-functioning front sink. The dietary staff member then turned on water from a pot-filling spigot that had been pulled over the sink and suggested it could be used for handwashing. There were no paper towels at the front handwashing sink, and the dietary staff member retrieved a roll of paper towels from the food preparation area and handed it to the surveyor. Later, the dietary manager stated he was not aware that the front handwashing sink was not working and verified that hand soap should be available at all kitchen handwashing sinks. The facility census was 78 residents, with 76 receiving food from the kitchen, and the facility’s handwashing policy required that sinks, soap, and towels be readily accessible and convenient for staff use.
Failure to Provide Scheduled Bathing and Needed Nail Care for Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide and document adequate ADL care, specifically bathing, for a resident who was dependent on staff for showers. One resident with Parkinson’s disease, type 2 diabetes mellitus, and spinal stenosis had an MDS showing intact cognition and dependence on staff for bathing, with a care schedule indicating showers on day shift on Wednesdays and Saturdays. Shower documentation for a specified month showed that the resident received showers on several listed dates, but there was no documentation of the resident receiving or refusing showers on three scheduled shower days. The DON confirmed there was no documented evidence that the resident received showers on those dates. The deficiency also includes failure to provide needed grooming care, specifically fingernail trimming, to another cognitively intact resident with type 2 diabetes mellitus, Raynaud’s syndrome, osteoarthritis, and self-care and mobility deficits requiring substantial/maximal assistance with toileting, personal hygiene, and bathing. A progress note documented that the resident refused a bath/shower on one date but allowed nail trimming at that time, with no further documentation of nail care. On observation, the resident’s fingernails were of varying lengths, with several extending about one and one-half inches beyond the nail tip and others jagged and shorter. The resident stated she did not like her nails that long, had asked staff to trim them, and was considering breaking them herself. A CNA confirmed the nails were long and jagged and stated nails are usually trimmed with showers and daily care. On a subsequent observation the next day, the resident’s nails remained untrimmed, and both the resident and the CNA confirmed that nail trimming still had not been done, despite the CNA having informed the assigned aide and nurse the previous day. Facility policy required appropriate support and assistance with hygiene, bathing, and grooming for residents unable to carry out ADLs independently.
Failure to Maintain Accurate and Complete Medical Records and ADL Documentation
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate and up-to-date medical records and documentation for multiple residents. For one resident with type 2 diabetes mellitus, Parkinson’s disease, and spinal stenosis, the MDS showed intact cognition and a need for assistance with ADLs, including eating, bed mobility, transfers, toileting, and bathing. However, documentation survey reports for two consecutive months showed extensive gaps, with no recorded information on bed mobility, bladder and bowel continence and movements, eating, dressing, hygiene, ambulation, transfers, wheelchair/scooter use, toileting, and behaviors. Meal and fluid intake records were blank for numerous specified dates and meals across November and December. The DON confirmed the missing ADL and meal intake documentation for this resident. Another resident, admitted with COPD and congestive heart failure and later discharged due to death, had an MDS indicating intact cognition and a need for substantial/maximal assistance with ADLs. The progress notes for the date of death contained no documentation of the resident’s death, and the DON verified that no note describing the death could be found, despite stating she had been present when the resident died. A third resident, admitted with cerebral infarction, anemia, depression, and mood disorder, had a care plan identifying risk for constipation with interventions requiring daily recording of bowel movement patterns and monitoring for complications. The MDS indicated this resident had moderate cognitive deficits, was dependent for ADLs, and was always incontinent of bowel and bladder. Review of bowel movement records for two months revealed no documentation of bowel movements, and the DON confirmed this lack of documentation.
Failure to Use Required PPE for Resident on Enhanced Barrier Precautions
Penalty
Summary
Facility staff failed to follow the infection prevention and control program by not using required personal protective equipment (PPE) for a resident on Enhanced Barrier Precautions (EBP). The resident was admitted on 01/04/26 with diagnoses including encephalopathy, sleep apnea, heart failure, and severe sepsis, and had no cognitive deficits but required staff assistance with ADLs. A physician’s order dated 01/07/26 placed the resident on EBP due to the presence of an enteral tube and wounds. On 02/09/26 at 9:23 A.M., during observation of medication administration via gastrostomy tube, an LPN provided care without wearing a gown or gloves. In a subsequent interview, the LPN confirmed she was not wearing a gown or gloves, acknowledged the resident was on EBP, and stated she should have donned a gown and gloves prior to administering the medication. Review of the facility’s Enhanced Barrier Precautions policy dated 07/30/25 showed the facility would implement EBP as appropriate for prevention of transmission of multidrug-resistant organisms. These findings demonstrate that, despite an active EBP order and a facility policy requiring implementation of EBP, staff did not consistently wear appropriate PPE while providing care involving an enteral tube to a resident under EBP.
Failure to Answer Phones During Nighttime Hours
Penalty
Summary
The facility failed to ensure that phones were answered during nighttime hours, affecting a resident who required assistance after a fall. The resident, who was cognitively intact and required staff assistance with activities of daily living, was unable to reach the facility staff via telephone. Consequently, the resident's family had to enter the facility with emergency medical technicians because they could not get in touch with the facility. This incident was confirmed by a Licensed Practical Nurse who noted the family's arrival and the lack of phone response. Further investigation revealed that the night shift nursing supervisor did not report to work, and the phone was left on the reception desk instead of being picked up by the night shift nurse supervisor. Observations by the surveyor showed that calls to the facility went directly to voicemail, indicating that calls were not properly forwarded by the front desk staff. The Registered Nurse in charge confirmed that the phone should have been answered directly, especially in emergencies, but the calls were not forwarded correctly, leading to the deficiency.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care for a resident, identified as Resident #36, who was at risk for urinary incontinence and potential impaired skin integrity. The resident, who was cognitively intact and required substantial assistance with toileting, was observed sitting in her room with a noticeable odor of feces. Despite the care plan's directive to check and change the resident frequently, the resident's incontinence brief was not changed for several hours. Observations revealed that the Certified Nursing Assistant (CNA) responsible for the resident did not provide incontinence care between 8:30 A.M. and 1:35 P.M., despite the care plan's requirement for changes every two hours. The CNA confirmed the lapse in care, acknowledging that the resident's brief was not changed as frequently as required. This deficiency was identified during a complaint investigation and affected the quality of care provided to the resident.
Inadequate Supervision During Resident Transfer
Penalty
Summary
The facility failed to ensure the appropriate level of supervision during resident transfers using a sit to stand lift, affecting one resident. The resident, who was admitted with chronic respiratory failure with hypoxia and non-Alzheimer's dementia, was at risk for falls due to impaired mobility. The care plan for the resident was not updated to reflect the use of a sit to stand lift for transfers, despite therapy recommendations. During a transfer from a chair to a bed, the resident slid to the floor, although no injuries were reported. The incident occurred when a Certified Nursing Assistant (CNA) attempted the transfer alone, contrary to the facility's policy requiring two staff members for such procedures. The Director of Nursing confirmed the violation of the policy, which mandates that staff be trained and demonstrate competency in using mechanical lifts. The CNA involved was terminated for not adhering to the facility's policy, which was established to ensure safe resident transfers.
Failure to Maintain Adequate Room Temperature
Penalty
Summary
The facility failed to maintain a satisfactory temperature in the room of Resident #43, who was affected by this deficiency. Resident #43, who was admitted with conditions including [NAME] Syndrome, malnutrition, depression, respiratory disorder, and biliary cirrhosis, was cognitively intact and required assistance with activities of daily living. On observation, the resident was found wearing an oversized house coat and gloves, indicating discomfort due to the cold temperature in her room. The heater in her room was blowing out cold air, and despite her complaints since October 2024, the issue remained unresolved. Maintenance Man #100 had attempted to adjust the heater several times, but the room temperature was recorded at 68 degrees Fahrenheit, which was below the facility's policy of maintaining temperatures between 71 and 81 degrees Fahrenheit. The resident confirmed that a space heater provided by her brother was removed by staff, leaving her without adequate heating. The facility's policy titled Safe and Homelike Environment, updated on the day of the observation, was not adhered to, resulting in an uncomfortable and potentially unsafe environment for the resident.
Improper Use of Lift Leads to Resident Injury
Penalty
Summary
The facility failed to use the proper lift for resident transfers, affecting one resident who required a Hoyer lift for safe transfers. The resident, who had a history of cerebral infarction, hemiplegia, and other medical conditions, was documented in the care plan to need a Hoyer lift with the assistance of two staff members. Despite this, staff used a stand-up lift, which was not recommended by therapy or the care plan, leading to bruising on the resident's rib cage, underarms, and wrist. The resident was on Eliquis, a blood-thinning medication, which increased the risk of bruising. The facility's investigation confirmed that the bruising resulted from the improper use of a stand-up lift instead of the Hoyer lift. Interviews with the Director of Nursing and the Physical Therapy Manager corroborated that the Hoyer lift was the safer option as recommended by therapy, but staff had been using the incorrect equipment, leading to the resident's injuries.
Failure to Assist Resident with ADLs
Penalty
Summary
The facility failed to provide timely assistance with activities of daily living (ADL) for a resident who was dependent on staff for transferring out of bed. The resident, who was severely cognitively impaired and had medical diagnoses including coronary artery disease, heart failure, and cerebrovascular attack, was observed on multiple occasions remaining in bed despite expressing a desire to get up after breakfast. On the morning of the incident, a State tested Nursing Aide (STNA) asked the resident if she wanted to get out of bed after breakfast, to which the resident agreed. However, subsequent observations revealed that the resident remained in bed for several hours, and the STNA did not return to assist her as requested. The STNA later confirmed that she did not get the resident out of bed but did not provide an explanation for her inaction.
Failure to Provide Adequate Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevention for three residents, leading to deficiencies in their care. Resident #18, who was cognitively intact and had a right heel wound, did not receive the necessary wound treatment as per hospital orders after admission. The hospital had instructed to relieve pressure from the heel and maintain a dressing for three days, followed by daily cleansing. However, there were no physician orders or documentation of dressing changes for the right heel from admission through 09/15/24. The Director of Nursing confirmed the lack of treatment and orders for the wound care during this period. Residents #72 and #10, both at risk for developing pressure ulcers, were not turned and repositioned as required by their care plans. Resident #72, who was severely cognitively impaired and dependent on staff for mobility, was observed lying in the same position for several hours without being repositioned. Similarly, Resident #10, who was rarely understood and dependent on staff for mobility, was also observed in the same position for an extended period. Interviews with staff confirmed that these residents were not turned or repositioned as needed, and Resident #10's family reported that staff did not regularly turn her.
Failure to Conduct Bladder Scans and Notify Physician
Penalty
Summary
The facility failed to ensure that bladder scans were completed for a resident following the removal of an indwelling catheter as per hospital discharge orders. The resident, who was cognitively intact and required substantial assistance for toileting and bed mobility, was admitted with orders to have bladder scans every six hours and to be straight catheterized if retaining more than 300 ml of urine. However, the medical record showed no documentation of bladder scans on the first two days following admission, and only two scans were completed on the third day, both indicating significant urine retention. Additionally, the charge nurse was unable to successfully catheterize the resident, and there was no documentation that the physician was notified about the delay in bladder scanning or the unsuccessful catheterization attempt. The Director of Nursing confirmed that the physician was not informed of these issues, which was a violation of the facility's policy requiring prompt notification of changes in a resident's condition to obtain appropriate treatment orders.
Failure to Administer Medications via Ordered Route
Penalty
Summary
The facility failed to ensure medications were administered via the physician-ordered route for one resident. Medical record review for the resident revealed an admission with diagnoses including cerebral infarction, hypertensive cerebral ischemic attack, chronic pain, and hemiplegia and hemiparesis. The resident had severely impaired cognition and was dependent on assistance for daily activities. Physician orders specified that several medications were to be administered via gastrostomy (g-tube). However, on a specific date, the morning medications were given whole instead of via the g-tube, as observed by the resident's family through a live video camera. The incident was reported to the Director of Nursing (DON) by the family, and the physician was notified. The resident did not experience any negative effects from the incident. The facility's policy on administering medication states that medications should be administered in accordance with prescribers' orders. The medication/treatment error report confirmed that the medications were not administered via the ordered route. The DON acknowledged the error and confirmed that the family had notified her of the incident. The documentation was signed by the physician, the nurse who made the error, and the DON. This deficiency was investigated under Complaint Number OH00153089.
Failure to Securely Store Medications
Penalty
Summary
The facility failed to ensure medications were securely stored, affecting two residents. Resident #22, who has diagnoses including cerebral infarction and vascular dementia, was observed with two tablets in applesauce left unsupervised on his bedside table. There was no order or assessment permitting Resident #22 to self-administer medications. Staff interviews confirmed that the medication was left by a nurse who was not present at the time of observation, and the Director of Nursing verified that no medication should be left at the bedside unsupervised. Similarly, Resident #19, who has diagnoses including cerebrovascular disease and dementia, was observed with Miralax left at her bedside after she refused to take it immediately. The LPN left the medication for the resident to take after breakfast, which was confirmed as acceptable by the LPN but later verified as non-compliant by the Director of Nursing. The facility policy states that residents may only self-administer medications if deemed safe by the attending physician and interdisciplinary care planning team, which was not the case for either resident.
Infection Control Deficiencies
Penalty
Summary
The facility failed to disinfect a glucose monitoring device after usage with an appropriate disinfectant, which had the potential to affect two residents residing on the B unit of the second floor who share the glucose monitoring device. Medical record reviews revealed that both residents had diagnoses including type two diabetes mellitus and required blood sugar monitoring multiple times a day. Observations showed that an LPN did not cleanse or disinfect the glucose monitoring device after using it on one resident and before using it on another. The LPN admitted to being unaware of the cleaning requirements related to the glucose monitoring unit, despite the availability of Sani Wipes on the medication cart. The Director of Nursing confirmed that the glucose monitoring device should be cleaned with germicidal wipes between each resident use, as per CDC guidelines and the manufacturer's recommendations. The facility's policy also stated that blood glucose meters intended for reuse should be cleaned and disinfected between resident uses. However, these protocols were not followed, leading to the deficiency. Additionally, the facility failed to ensure staff completed hand hygiene after removing a wound dressing on a resident in enhanced barrier precautions. The resident had a pressure ulcer and required wound care, which included cleansing the wound and applying medi honey ointment and a foam border. During an observation, an RN and an NP donned personal protective equipment but did not follow proper hand hygiene protocols. The RN's gown came into contact with bed linen multiple times, and she exited the room without removing the gown to collect additional dressing supplies. The RN also failed to complete hand hygiene before reapplying gloves and did not change her gown after it brushed against a black uniform jacket hanging on the treatment cart. The RN admitted to not following proper protocols and was unaware that her gown had touched the jacket. The facility's policies for infection control and wound care were not adhered to, leading to potential risks for the residents. The CDC's guidance and the manufacturer's recommendations for cleaning and disinfecting glucose monitoring devices were not followed, and the facility's own policies for hand hygiene and wound care were also neglected. These lapses in protocol contributed to the deficiencies identified during the survey.
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Surveyors found that multiple hazardous storage areas, including a closet near medical records, a beauty salon used to store chemical cases, a supply room in one nursing station, a room leading to a smoking area, a housekeeping room near therapy, and a lobby storage room, lacked required self-closing or automatic-closing doors. These conditions did not comply with NFPA 101 requirements for hazardous area enclosure and had the potential to affect all residents and staff in an emergency.
Surveyors found that the facility did not conduct fire drills on every shift each quarter and did not vary drill conditions as required by NFPA 101. Record review showed that one shift lacked a documented drill for an entire quarter, and the pattern of drill times and dates did not demonstrate varied conditions. The Maintenance Director confirmed the incomplete and noncompliant fire drill schedule, which affected all residents and staff emergency preparedness.
Surveyors found that the facility did not maintain clear egress corridors as required by NFPA 101, with a TV/video cart plugged into a corridor outlet and multiple unsecured chairs placed in the hallway near resident rooms and the secured unit dining room, including directly in front of a fire extinguisher. These items projected about 29 inches into an approximately eight-foot-wide corridor and were located in front of the handrail, potentially affecting 28 residents and staff’s ability to assist in an emergency. The Maintenance Director confirmed these corridor obstructions during the survey.
A resident with intact cognition receiving Medicare Part A skilled services for metabolic encephalopathy had services discontinued while benefit days remained, but the facility did not issue the required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN). The Social Services Director later confirmed that no SNF ABN was provided and reported she believed only a Notice of Medicare Non-Coverage (NOMNC) was needed when all skilled services were stopped. This practice conflicted with the facility’s written policy, which required SNF ABNs to be issued when extended care items or services were initiated, reduced, or terminated due to expected non-coverage by Medicare.
Surveyors identified that the facility exceeded the acceptable medication error rate when two residents with type 2 DM received insulin doses that were not administered according to orders or manufacturer instructions. In two separate observations, an LPN administered Novolog and another LPN administered insulin glargine and insulin lispro without priming the insulin pens, and the insulin lispro and Novolog were given after the residents had already consumed a significant portion of their breakfast meals, despite orders for administration before meals. Manufacturer information for both insulin products required priming before each injection to ensure accurate dosing, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and specified time frames.
A cognitively intact resident with behavioral issues, including physical aggression and noncompliance with care, was in a secured unit and was observed tapping on the window/door. A dietary aide, despite being told by a CNA and an RN not to enter the secured unit and that the resident’s assigned aide could assist, went onto the unit and interacted with the resident, including offering to buy a soda after seeing money in the resident’s hand. The resident struck the aide in the face, and the aide responded by punching the resident in the face; a CNA reported hearing the aide say, “I will hit you again,” and then observed the resident bleeding. The resident was later found at the hospital to have an open mandibular fracture and non-restorable teeth requiring extraction, and the facility’s investigation and policy definitions led to the incident being substantiated as staff-to-resident physical abuse.
A resident with severe cognitive impairment, osteoporosis, and total dependence for transfers was being moved from bed to wheelchair with a mechanical lift when CNAs reported that an undersized sling and a forceful pull on the lift caused the resident to fall feet‑first from the sling, with staff catching the upper body while both legs struck the floor and one leg bent behind. Witnesses heard a loud pop and observed immediate pain, bruising, swelling, and deformity of the leg, yet the responding LPN did not complete a thorough musculoskeletal assessment, did not document a fall, and the physician and resident representative were not promptly informed of a suspected injury. Through the night and into the next day, staff and the roommate reported the resident crying out in pain and an obviously abnormal leg, but nursing notes only reflected intermittent acetaminophen administration without clear pain documentation, and the physician was contacted primarily about yelling and behavior. Mobile X‑rays obtained later showed a displaced distal femur fracture, which was not reviewed until the following day, when hospital imaging confirmed a closed displaced comminuted femur fracture and a hand fracture. The facility’s internal investigation was incomplete and inaccurate, with leadership denying a fall, preparing a single typed statement minimizing the event, and having multiple staff sign it despite later testimony that the statement was false and that staff were told not to discuss the incident.
Surveyors found multiple instances of improper food storage and labeling, including undated and unlabeled opened dairy products, beverages, and prepared foods in the main walk-in cooler and freezer, as well as a serving scoop left resting directly on stored pasta. Additional issues included covered but undated pre-poured juices, milk, and thickened beverages in a reach-in cooler used for tray line, and a nurses' station refrigerator containing a dated bag of a resident’s food from over a week prior and three undated half-sandwiches. In a resident’s personal refrigerator, staff confirmed three undated bags of grapes with visible mold. These conditions did not comply with facility policies requiring cold foods to be stored off the floor, wrapped or covered, labeled, dated, and for resident refrigerators to be monitored daily with unsafe or moldy food discarded.
Surveyors found unsanitary kitchen conditions, including a dirty tray holding clean pitchers, soiled storage carts containing clean dishware and disposables, and multiple trays of open juice in a reach-in refrigerator that were unlabeled and undated. In a walk-in refrigerator, they observed a bag of bologna marked only with a freeze date, lacking a thaw or use-by date, and appearing slimy and discolored. Observation of the high-temp dishwasher showed rinse temperatures below the 180°F minimum required for hot water sanitizing, and review of several months of temperature logs revealed repeated sub-minimum wash and rinse temperatures and numerous missing entries. Facility policies required dishwashing to meet specified temperature standards and all refrigerated foods to be covered, labeled, and dated with a use-by date, but these requirements were not consistently followed.
Surveyors found that the facility did not maintain a safe, clean, and homelike environment as required by its policy. In one shared bedroom, wallpaper was peeling in several areas, including behind each bed, below a window, and near baseboards, and a black substance was present around the base of the toilet. A CNA confirmed these conditions. In addition, three cracked or broken light covers were observed in a hall restroom. These environmental issues affected two residents and had the potential to affect all residents.
Failure to Maintain Self-Closing Doors for Multiple Hazardous Storage Areas
Penalty
Summary
Surveyors identified a deficiency related to hazardous area protection and door requirements under NFPA 101, 2012 Edition. During facility tours, they observed that multiple hazardous storage areas did not have self-closing or automatic-closing doors as required for hazardous areas such as combustible storage and chemical storage. These areas included a closet next to medical records, a beauty salon being used to store cases of chemicals, a supply room in Station #2, and the room leading to the smoking area in Station #3. On a subsequent tour, surveyors observed additional hazardous areas without self-closing doors. The housekeeping room across from therapy and the lobby storage room were both noted to lack self-closing door mechanisms. The facility census at the time was 59 residents, and the surveyors stated that this deficient practice had the potential to affect all residents and staff's ability to assist in an emergency. The Maintenance Director verified these findings at the time they were observed.
Plan Of Correction
K 0321 This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be admissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as its allegation of substantial compliance as of 06/12/2026 K-0321 Doors with Self-Closing Devices Corrective action for resident/s: 1. The closet door next to medical records was lacking a self-closing door on 5/19/2026. Maintenance director to add self-closing device to closet door next to medical records on or before 06/12/2026 in accordance with applicable code. 2. The beauty salon had chemicals stored in it on 5/19/2026. Maintenance director moved chemicals from beauty salon on 05/20/2026 in accordance with applicable code. 3. The supply room on station 2 was lacking a self-closing door on 5/19/2026. Maintenance director to add self-closing door to supply room on station 2 on or before 06/12/2026 in accordance with applicable code. 4. The room to the smoking area on station 3 was lacking a self-closing door on 5/19/2026. Maintenance director to add a self-closing door to the smoking are on station 3 on or before 06/12/2026 in accordance with applicable code. 4. The housekeeping room across from therapy was lacking a self-closing door on 5/19/2026. Maintenance director to add a self-closing door to the housekeeping room across from therapy gym on or before 06/12/2026 in accordance with applicable code. 5. The lobby storage room was lacking a self-closing door on 5/19/2026. Maintenance director to add a self-closing door to the lobby storage room on or before 06/12/2026 in accordance with applicable code. Identification of other residents who may be affected: LNHA and Maintenance director/designee completed a full facility audit for doors with self-closing devices on 05/26/2026. Any corrective action, including, doors identified as needing self-closures will be added on or before 06/09/2026 in accordance with applicable code. Measures for systemic change: LNHA educated Maintenance Director on 05/26/2026 regarding NFPA 101-2012 sections 19.3.2.1 and 19.3.5.9 specifically regarding doors with self-closing devices. How Corrective Action will be monitored Ongoing "Doors with Self-Closing device audit" to be completed weekly x 2 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 06/12/2026
Failure to Conduct Required Quarterly Fire Drills on All Shifts
Penalty
Summary
The facility failed to conduct fire drills in accordance with NFPA 101, 2012 Edition, sections 19.7.1 through 19.7.1.8, specifically by not holding drills every shift each quarter and not varying drill conditions as required. Record review on 06/09/25 at approximately 10:32 A.M. showed there was no fire drill conducted for the first shift during the third quarter. The documented first-shift fire drills occurred on 01/30/26 at 2:42 P.M., 04/30/26 at 1:51 P.M., and 10/31/25 at 10:58 A.M., indicating a missed quarter. Second-shift fire drills were recorded on 02/26/26 at 5:20 P.M., 06/03/25 at 4:35 P.M., 08/29/25 at 3:46 P.M., and 11/25/25 at 5:09 P.M., and third-shift drills on 02/28/26 at 11:47 P.M., 05/30/25 at 12:18 A.M., 07/22/25 at 11:34 P.M., 09/26/25 at 11:40 P.M., and 12/15/25 at 5:17 A.M. The surveyor determined that drills were not conducted under varied conditions and that the required quarterly drill on each shift was not consistently performed. The Maintenance Director confirmed these findings at the time they were identified, and the deficiency had the potential to affect all 59 residents and staff response in an emergency. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency related to facility-wide emergency preparedness practices and documentation of fire drills.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 05/29/2026 K-0712 Fire Drills Corrective action for resident/s: There were no records of a fire drill for the first shift of the third quarter of 2025. First shift fire drill completed on 5/24/2026 by maintenance director/designee with no findings or corrective action necessary. Identification of other residents who may be affected: On 5/26/2026 Maintenance director/designee completed 100% audit of the scheduled fire drills to ensure a drill is scheduled quarterly each shift with no findings or corrective action necessary. Measures for systemic change: LNHA educated Maintenance Director on 05/26/2026 regarding NFPA 101-2012 section 19.7.1.4 through 19.7.1.7. specifically including fire drill frequency requirements. How Corrective Action will be monitored Ongoing "Fire Drill Audit" to be completed weekly x 2 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 05/29/2026
Obstructed Egress Corridors Due to Equipment and Chairs
Penalty
Summary
The facility failed to maintain required clear egress widths in corridors in accordance with NFPA 101, 2012 Edition, sections 19.2.3.4 through 19.2.3.5 and 7.3.2 through 7.3.2.3, creating projections into the egress corridor that exceeded allowable limits. Surveyors observed that on one day in Station #3, a cart with a television and video equipment was plugged into an outlet in the corridor by room 38, and five activity room chairs were placed in the corridor near the secured unit dining room directly in front of a fire extinguisher. On the following day, surveyors again observed chairs in the Station #3 corridor, with four by room 35 and four by the activities room, and the same television cart still in the corridor; the chairs were not secured. The corridor was approximately eight feet wide, and the projections extended approximately 29 inches into the corridor in front of the handrail. These conditions had the potential to affect 28 residents in the facility and the staff’s ability to assist in an emergency, and the Maintenance Director confirmed the observations at the time of discovery. No specific resident medical histories or conditions were described in the report, only that 28 residents were potentially affected and the facility census was 59.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be subsequent remedial measures and should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 05/29/2026 K-0232 Clear path of egress Corrective action for resident/s: 1. On 05/18/2026 station 3 had a cart with a television parked in the corridor by room 38 that exceeded allowable limits. Maintenance director/designee moved the TV cart into the activity room, out to the corridor on 05/18/2026 in accordance with applicable code. 2. On 5/18/2026 station 3 had 5 chairs in the corridor near the dining room directly in front of the fire extinguisher. Maintenance director/designee moved the chairs into the dining room, out of the corridor on 5/18/2026 in accordance with applicable code. 3. On 5/19/2026 station 3 had 4 chairs by the activity room and 4 by room 35. In addition, the TV cart was in the corridor. The maintenance director/designee moved the chairs and TV cart into the dining room, out of the corridor on 5/19/2026 in accordance with applicable code. Identification of other residents who may be affected: Maintenance director/designee completed a 100% facility audit for clear paths of egress on 5/26/26 with no findings or corrective action necessary. Measures for systemic change: Maintenance Director/designee educated staff on 5/26/2026 regarding NFPA 101-2012 section 19.2.3.4 and 19.2.3.5 specifically including maintaining a clear path of egress. How Corrective Action will be monitored Ongoing "Path of Egress Audit" to be completed weekly x 2 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 05/29/2026
Failure to Issue Required SNF ABN When Discontinuing Medicare Part A Services
Penalty
Summary
The deficiency involves the facility’s failure to issue a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) when Medicare Part A services were discontinued for a resident who still had available benefit days. The resident was admitted with a diagnosis of metabolic encephalopathy and had intact cognition per the Minimum Data Set assessment. The facility’s own SNF Beneficiary Notification Review documented that Medicare Part A skilled services began on 02/11/26 and the last covered day was 03/11/26, and that the facility initiated discharge from Medicare Part A services before the resident’s benefit days were exhausted. Despite this, no SNF ABN was provided to the resident or the resident’s representative. During interviews, the Social Services Director stated that the SNF ABN was issued hours prior to the last covered day but, upon reviewing her files, confirmed that no SNF ABN had actually been issued for this resident. She further explained that she believed an SNF ABN was only required if one skilled service remained and that if all skilled services were being discontinued, only the Notice of Medicare Non-Coverage (NOMNC) needed to be issued. The Administrator, however, stated that a resident should always receive both a SNF ABN and a NOMNC when Medicare Part A services are discontinued and benefit days remain. Review of the facility’s written policy dated 03/28/23 showed that the facility was required to issue SNF ABNs for initiation, reduction, or termination of extended care items or services when Medicare payment was not expected, which did not occur in this case.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as its allegation of substantial compliance as of 05/29/2026 F-0582 Corrective action for resident/s: On 5/14/26 Resident #34 was informed of rights and responsibilities related to Advanced Beneficiary Notice and voiced understanding of information for future reference by administrator. Identification of other residents who may be affected: Any resident receiving skilled services from nursing or therapy services. The Administrator audited all residents who were discharged from skilled services in the past 30 days to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary Notice on 5/29/26. No non-compliance was noted. Measures for systemic change: On 5/14/2026 Business Office Manager, Director of Rehab, Minimum Data Set nurse, Director of Nursing and Social Services Director were educated on proper procedure of issuing of Notice Of Medicare Non Coverage and Advanced Beneficiary Notice by administrator. All upcoming discharges from skilled services will be reviewed weekly at Utilization Review meeting to ensure notices will be delivered timely. How Corrective Action will be monitored: Administrator or designee to complete audits of all residents being discharged from skilled services to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 5/29/26
Insulin Administration Errors and Failure to Prime Insulin Pens
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5%, with surveyors identifying 3 errors out of 28 medication administration opportunities, resulting in a 10.71% error rate. For one resident with type 2 diabetes mellitus and moderate cognitive impairment, the physician’s order directed Novolog insulin 10 units via subcutaneous pen-injector to be given before meals. During an observed medication pass, the LPN administered 10 units of Novolog insulin without priming the pen and did so after the resident had already consumed approximately 50% of the breakfast meal. The LPN later confirmed she did not prime the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer instructions for the Novolog FlexPen specified that an air shot (priming) must be performed before each injection to ensure proper dosing. Another resident, also diagnosed with type 2 diabetes mellitus and with intact cognition, had orders for insulin glargine 35 units subcutaneously twice daily and insulin lispro 20 units subcutaneously before meals, plus 12 units subcutaneously if blood glucose was between 251 mg/dL and 300 mg/dL. During an observed medication administration, an LPN administered 35 units of insulin glargine and 32 units of insulin lispro without priming the insulin pens and after the resident had consumed approximately 90% of the breakfast meal, despite orders for insulin lispro to be given before meals. The LPN later stated she could not remember if she had primed the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer information for insulin lispro stated that the pen must be primed before each injection to confirm insulin delivery and remove air, and that failure to prime could result in too much or too little insulin. The DON confirmed the expectation that insulin be administered as ordered, including priming each pen with two units before dialing the prescribed dose, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and required time frames.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 5/29/2026. F-0759 Corrective action for resident/s: Residents #21 and #22 were assessed and evaluated by nurse and Director of Nursing 5/14/26. Resident #21 and #22 both denied any adverse effects and none were noted upon assessment by the Director of Nursing on 5/14/2026. Notification made to physician on 5/14/2026. LPN # 2 competency Eval on insulin administration with the Director of Nursing completed 5/14/2026. Identification of other residents who may be affected: Diabetic residents on assignment of LPN #2/station 2 have the potential to be affected and were assessed by the DON/Designee on 5/14/26 and found to be within normal limits. Measures for systemic change: All Nurses were educated by the Director of Nursing on the steps for Insulin administration per competency, diabetes clinical protocol policy, Medication and treatment orders policy, administering medications policy, and Obtaining fingerstick Glucose Level policy On 5/14/2026. How Corrective Action will be monitored: Director of Nursing and Assistant Director of Nursing will complete insulin administration audits on 5 nurses. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance: 5/29/2026
Staff-to-resident physical abuse resulting in jaw fracture and tooth loss
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from staff-to-resident physical abuse, resulting in serious injury. A dietary aide entered a secured unit where a cognitively intact resident with a history of behavioral issues, including physical aggression and noncompliance with care and medications, was located. The resident had been tapping or knocking on the window/door of the secured unit, drawing the attention of the dietary aide. Multiple staff, including a CNA and an RN, told the dietary aide not to go onto the secured unit, noting that the resident’s assigned aide could assist and that the resident had been agitated the previous day. Despite these instructions, the dietary aide went onto the secured unit. Witness statements and interviews indicate that upon entering the unit, the aide interacted with the resident, including offering to buy the resident a soda after seeing the resident holding money. According to staff statements and the aide’s own account, the resident then struck the aide in the face. The aide responded by punching the resident in the face. A CNA on the unit reported stepping between the two to attempt to deescalate the situation and then calling for the nurse due to the resident’s aggression. The CNA also reported hearing the aide tell the resident, “I will hit you again,” and then observed that the resident was bleeding. Following the punch, the resident was noted by staff to be bleeding from the nose and mouth. The resident was assessed by nursing and subsequently transported to the hospital. Hospital records documented that the resident sustained an open fracture of the right jaw, with a loose right lateral mandibular incisor and bleeding from the socket at the fracture site. The resident’s remaining 11 teeth were extracted because they could not be restored. A police report documented that staff reported the incident as an assault in which a staff member punched a resident after the resident had punched the staff member. The facility’s policy defined abuse as the willful infliction of injury resulting in physical harm, including physical abuse such as hitting and punching, and the facility substantiated that the dietary aide had physically abused the resident.
Failure to Ensure Safe Mechanical Lift Transfer, Timely Assessment, and Pain Management After Traumatic Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure safe mechanical lift transfers, adequate assessment, timely physician and representative notification, and appropriate pain management for a severely cognitively impaired, non‑ambulatory resident who required a mechanical lift with two‑person assistance for all transfers. The resident had multiple relevant diagnoses, including vascular dementia, osteoarthritis, a right hip prosthesis, chronic kidney disease, and a history of fractures and osteoporosis/osteopenia. On the morning of 04/22/26, during a mechanical lift transfer from bed to wheelchair, multiple CNAs reported that the sling appeared too small, the lift was pulled forcefully from under the bed, and the resident fell feet‑first out of the sling, with staff catching her upper body while both legs hit the floor and one leg bent behind her. A loud popping sound was heard, the resident screamed and cried out in pain, and witnesses observed immediate bruising, swelling, and apparent misalignment of the left knee/leg. Despite this, the nurse who responded did not perform a complete head‑to‑toe or range‑of‑motion assessment focused on the leg, and the incident was not documented as a fall from the lift. Following the incident, nursing staff actions and documentation were incomplete and inconsistent with the resident’s presentation. Progress notes on 04/22/26 documented only a skin tear to the left forearm and a head‑to‑toe assessment with no new areas, and there were no notes describing a fall, leg injury, or significant pain. Multiple CNAs and the resident’s roommate reported that the resident cried out in pain throughout the night and that her left leg appeared swollen, bruised, and deformed, yet nursing notes from the night shift only recorded administrations of acetaminophen without documenting the reason for administration, pain assessment findings, or any musculoskeletal concerns. One RN reported being asked to look at the resident on 04/22/26, noting swelling of the left leg but performing no further assessment. The physician was not notified within one hour of a suspected musculoskeletal injury as required by facility policy, and the resident’s representative was not informed that the resident had fallen from the mechanical lift. On 04/23/26, staff continued to report the resident’s ongoing pain and abnormal leg appearance, but the physician was contacted only about increased yelling and behavior, with a focus on agitation and prior hip/groin pain history rather than a new traumatic event. The DON later documented that a loud popping noise occurred during a Hoyer lift transfer with three staff present and that no abnormalities or signs of pain were noted, and the physician was asked to order bilateral hip and knee X‑rays as a precaution, without documenting a fall. Mobile X‑rays were obtained on 04/23/26, but the results, which showed a displaced distal femur fracture on a limited lateral view, were not reviewed until 04/24/26. Only then was the fracture acknowledged and discussed with the physician and resident representative. Subsequent hospital evaluation identified a closed displaced comminuted supracondylar fracture of the left femur and a distal fifth metacarpal fracture of the left hand. The facility’s internal investigation was incomplete and inaccurate: the DON denied a fall on 04/22/26, prepared a single typed statement describing only a popping sound while the resident was suspended over the bed, and had multiple staff sign it, even though at least two CNAs and an agency DON later reported that the statement was false and that staff felt intimidated and were told not to talk about the incident. The facility also failed to adequately manage the resident’s pain following the injury. Although the MAR shows acetaminophen administrations on 04/22/26 and early 04/23/26, there was no associated documentation of pain scores or clinical rationale in the progress notes for some doses, and staff interviews and the roommate’s account described the resident crying out in pain whenever touched and throughout the night. The physician later stated he was under the impression the fracture was non‑displaced and that, because the resident was bedbound, he did not feel she needed pain medication, and he was unaware of the severity of the femur fracture or the additional hand fracture. Overall, the facility did not follow its own physician communication policy for falls with musculoskeletal deformity or leg pain, did not perform and document thorough assessments at the time of the incident and during the subsequent night, did not promptly review diagnostic imaging, and did not conduct a complete, accurate investigation into the circumstances of the mechanical lift transfer and resulting injuries.
Improper Food Storage and Labeling in Facility and Resident Refrigerators
Penalty
Summary
Surveyors identified a failure to store food in accordance with professional standards and facility policy, creating the potential for foodborne illness for nearly all residents who received food from the kitchen. In the walk-in cooler, they observed multiple items that were opened and partially used without any open dates, including two cartons of heavy whipping cream, bins of individually poured and covered beverages, and a tray of covered fruit cocktail bowls. A large pan of pasta with ground meat was stored with the serving scoop resting directly on the food, covered with plastic wrap and not dated. A cart in the cooler held a 22-quart container of dark liquid with no label or date, and a pink plastic pitcher resting directly on the cart surface, which was coated with a dark unidentified material. A box of bacon was stored directly on the floor. The Director of Dietary Services confirmed the presence of undated, unlabeled, and improperly stored food items in the walk-in cooler. In the walk-in freezer, surveyors found an unsealed and undated bag of frozen chicken breasts and an unsealed and undated bag of pork pizza topping, which the Director of Dietary Services also confirmed. The reach-in cooler used for tray line contained a variety of pre-poured juices, milk, thickened beverages, and tea that were covered but not dated. At a nurses' station refrigerator, surveyors observed a plastic bag of food labeled with a resident’s name and dated more than a week earlier, along with three half-sandwiches wrapped in plastic without dates; the LPN present verified these findings. In a resident’s personal refrigerator, three undated bags of grapes with visible mold were found, and a CNA confirmed the grapes were moldy and undated. Facility policies required cold foods to be stored at least six inches above the floor, wrapped or in covered containers, labeled, and dated, and required resident refrigerators to be monitored daily, with food appropriately labeled and unsafe or moldy food discarded. These practices were not followed, resulting in the cited deficiency under the complaint investigation.
Unsanitary Kitchen Practices and Improper Dishwashing Temperatures
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service operations related to unsanitary kitchen conditions, improper food labeling and dating, and failure to operate the dishwasher according to manufacturer and policy requirements. During an initial kitchen tour, they observed a plastic tray holding clean pitchers with a brown-like substance on it, and three open, three-shelf carts with crumbs and debris on the shelves where clean insulated plate lids and sleeves of disposable bowls, cups, and lids were stored. Multiple trays of juice in a reach-in refrigerator were open, unlabeled, and undated. In the walk-in refrigerator, surveyors found a plastic bag of bologna with only a freeze date and no thaw or use-by date; the bologna appeared slimy and lighter in color. The facility census was 67, with one resident identified as not receiving meals from the kitchen, and the deficiency was noted as having the potential to affect all residents receiving food from the kitchen. Surveyors also observed the high-temperature dishwasher in use and recorded a wash temperature of 168°F and rinse temperatures of 160°F, 176°F, 178°F, 178°F, and 178°F over five cycles, despite the machine label and facility policy requiring a minimum wash temperature of 150°F and a minimum rinse temperature of 180°F for hot water sanitizing. A staff member confirmed the dishwasher had not been running earlier that morning, verified it was a high-temperature machine that should rinse at a minimum of 180°F, and acknowledged the observations regarding the dirty tray, soiled carts, unlabeled juice, and improperly dated bologna. The staff member stated that items in the reach-in refrigerator were normally prepped the night before and asserted that the bologna always had that color before discarding it. Review of the dishwasher temperature logs for January through April 2026 showed repeated failures to meet required wash and rinse temperatures and numerous instances of missing documentation. In January, multiple wash temperatures were below the 150°F minimum, and several meals lacked recorded wash and rinse temperatures. February logs showed at least one sub-minimum wash temperature and many missing wash and rinse entries for various meals. March logs included at least one meal with no documented wash or rinse temperatures. April logs documented several wash temperatures below 150°F and rinse temperatures below 180°F, along with multiple days and meals where wash and/or rinse temperatures were not recorded at all. Facility policies on sanitation, kitchen infection control, and food receiving and storage required dishwashing to meet temperature and sanitation standards and refrigerated foods to be covered, labeled, dated, and used, frozen, or discarded by their use-by date, which was not consistently followed according to the survey findings.
Environmental Maintenance and Cleanliness Deficiencies in Resident Room and Common Restroom
Penalty
Summary
Surveyors identified that the facility failed to maintain a safe, clean, comfortable, and homelike environment as required by its “Homelike Environment” policy. Observation of a shared bedroom for Residents #46 and #56 showed wallpaper peeling from the wall in multiple locations, including behind each resident’s headboard, below the window, and near the baseboards. In the same room’s bathroom, a black substance was observed around the base of the toilet. During an interview conducted concurrently with these observations, CNA #175 confirmed the presence of the peeling wallpaper and the black substance around the toilet base. Further observation with CNA #175 in the C hall restroom revealed that three light covers in that restroom were cracked or broken. The facility’s written policy, revised in February 2021, states that residents are to be provided with a safe, clean, comfortable, and homelike environment. The conditions observed in the residents’ bedroom, bathroom, and the C hall restroom were inconsistent with this policy and affected two identified residents, with the potential to affect all residents in the facility.
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