Cedarwood Plaza
Inspection history, citations, penalties and survey trends for this long-term care facility in Cleveland Heights, Ohio.
- Location
- 12504 Cedar Road, Cleveland Heights, Ohio 44106
- CMS Provider Number
- 365033
- Inspections on file
- 38
- Latest survey
- October 14, 2025
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Cedarwood Plaza during CMS and state inspections, most recent first.
Three residents with orders for low sodium or cardiac diets did not receive their prescribed meals, as all residents were served chicken with mushroom gravy instead of the required sautéed mushrooms. This occurred despite clear physician orders and care plans, and was confirmed by staff interviews and observation. The deficiency had the potential to affect additional residents on similar therapeutic diets.
The facility did not ensure that meals were palatable or served at safe, appetizing temperatures due to malfunctioning kitchen equipment, inadequate use of thermal bases, and failure to follow recipes for seasoning. Several residents, including those with complex medical needs, received food that was cold, bland, and not in accordance with their care plans or facility policy.
The facility did not maintain the required holding temperature for mechanical soft chicken during meal service, with food temperatures falling below 135°F and not being reheated as needed. This was due to non-functional kitchen equipment and delayed repair requests, affecting multiple residents on mechanical soft diets.
A resident with an indwelling Foley catheter did not receive catheter care according to standards, as a CNA failed to check for bowel incontinence before care, used unclean surfaces for supplies, did not clean the catheter insertion site properly, and neglected hand hygiene between glove changes. These actions were inconsistent with facility policy and infection control protocols, as confirmed by staff interviews and policy review.
A resident with multiple complex diagnoses experienced a significant, unaddressed weight loss over several months. Despite care plan interventions and facility policy requiring prompt reweighting and monitoring, staff did not timely identify or respond to the resident's declining weight, and nutritional assessments failed to reflect the true extent of the loss. This resulted in continued weight decline and repeated hospitalizations.
A resident with an indwelling catheter did not receive proper infection control during care, as a CNA failed to use clean techniques, placed soiled items on the floor, did not perform hand hygiene or change gloves appropriately, and wore contaminated PPE outside the room, contrary to facility policy. These actions were confirmed by staff interviews and policy review, with the deficiency potentially affecting all residents on the unit.
Surveyors found that the kitchen was not maintained in a clean and sanitary condition, with multiple food items improperly labeled or stored, exposed and freezer-burned meat, and unsanitary equipment and fixtures. These deficiencies had the potential to affect all 104 residents in the facility.
Surveyors observed that the dumpster area was not maintained in a clean and sanitary condition, with significant debris such as used gloves, food containers, and a damaged cardboard box scattered around. The grease barrel was also left open with a stock pot of water on top. These conditions were confirmed by a dietary aide and had the potential to affect all 104 residents.
Several residents received smaller meal portions and did not receive all menu items as specified, with some items substituted or omitted entirely. Staff used incorrect scoop sizes, and some residents did not receive fruit or dessert with their meals. The dietary manager confirmed that substitutions and incorrect portion sizes occurred, affecting multiple residents and potentially impacting all except those who were NPO.
Dietary staff did not adhere to proper food handling protocols, including using a dish cloth to dry silverware instead of air-drying and assembling sandwiches with gloved hands without serving utensils. The dietary manager confirmed these actions were not in line with facility policy, which requires air-drying of equipment and use of utensils to prevent direct hand contact with food. Two residents on NPO status were not affected.
The facility failed to maintain sanitary conditions in food storage and preparation, affecting 111 residents. Observations revealed unlabeled and undated food items, live gnats, and unsanitary conditions in the kitchen, including grime build-up and unclean tray carts. These issues were confirmed by the Dietary Manager.
The facility failed to maintain appropriate food temperatures and palatability, affecting six residents. Observations revealed that while initial food temperatures were acceptable, subsequent monitoring was lacking, resulting in food being served at inadequate temperatures. Residents expressed dissatisfaction, noting that hot foods were served cold and the overall taste was poor.
The facility failed to provide timely incontinence care to two residents, resulting in prolonged periods of discomfort. One resident, with cognitive impairment and mobility issues, was left in a soiled state for over four hours, while another resident, who was cognitively intact but required supervision, was left with saturated sheets for several hours. Staff interviews indicated that residents were checked and changed only twice per shift, contrary to the facility's policy of providing care as needed.
A facility failed to ensure staff wore appropriate PPE during wound care for a resident under Enhanced Barrier Precautions (EBP). The resident, with multiple medical conditions and dependent on staff for ADLs, required EBP due to a heel wound and indwelling devices. Despite facility policy, the RN did not wear a gown during care, acknowledging the oversight. This deficiency was noted during a complaint investigation.
A facility failed to provide a safe environment when an STNA brought an unsecured loaded firearm into the facility. A resident mistakenly took the bag containing the firearm to her room, found it, and hid it under her mattress. The firearm was later recovered by the police. The STNA was terminated for violating the facility's policy on firearms.
Failure to Provide Prescribed Low Sodium/Cardiac Diets to Residents
Penalty
Summary
The facility failed to ensure that three residents received their prescribed two-gram sodium (low sodium) and/or cardiac diets as ordered by their physicians. Medical record reviews showed that these residents had significant diagnoses such as type two diabetes mellitus, chronic obstructive pulmonary disease, congestive heart failure, chronic kidney disease, and hypertensive heart disease, all of which required careful dietary management. Physician orders and care plans for these residents specifically indicated the need for low sodium or cardiac diets, and these requirements were documented in their nutritional assessments and care plans. During a review of the facility's menu and direct observation of meal service, it was found that the lunch menu for a specific day required residents on a two-gram sodium or cardiac diet to receive chicken with sautéed mushrooms instead of mushroom gravy. However, observation of the steam table and tray line revealed that no sautéed mushrooms were available, and all residents, including those on restricted diets, were served chicken with mushroom gravy. Only one resident received a different gravy due to a dislike or allergy, not due to dietary restrictions. Interviews with dietary staff and the dietary consultant confirmed that the correct menu modification for residents on therapeutic diets was not followed, and the error was attributed to oversight. Review of the facility's policy indicated that meals should be checked against the therapeutic diet spreadsheet to ensure accuracy, but this procedure was not followed, resulting in the deficiency. This issue affected three residents directly and had the potential to impact an additional six residents identified as being on similar therapeutic diets.
Failure to Provide Palatable and Properly Heated Meals
Penalty
Summary
The facility failed to ensure that food served to residents was palatable, attractive, and maintained at a safe and appetizing temperature. Observations revealed that the steam table used to keep food warm was not fully operational, with three wells not working and the steamer out of service. As a result, some food items, such as zucchini and onions, were served at temperatures as low as 101.5°F, which is below the facility's policy requirement of at least 135°F for hot foods. Additionally, the zucchini and onions were served without seasoning or margarine, and the noodles were served without the required herbs or margarine, resulting in bland and unappetizing meals. The facility also lacked enough thermal pellet bases to keep all residents' meals warm, using them only for residents on the third floor, while others received only heated plates and dome lids. Interviews with dietary staff and consultants confirmed the issues with food preparation and temperature maintenance. Staff acknowledged that the lack of operational equipment negatively affected their ability to maintain proper food temperatures. During meal service, when the kitchen ran out of noodles and mushroom gravy, trays with thermal pellets were left sitting out while more food was prepared, and these pellets were not reheated before use. Test trays prepared for surveyors confirmed that the food was served at inadequate temperatures and lacked flavor, with the zucchini and onions specifically noted as cold and tasteless, and the noodles as warm but flavorless. Several residents were directly affected by these deficiencies. One resident with a history of chronic kidney disease, weight loss, and other medical conditions reported that meals were not tasteful and described lunch as terrible. Another resident with chronic respiratory failure, diabetes, and heart disease stated that the zucchini lacked flavor and the food was at room temperature. A third resident with cancer, diabetes, and malnutrition risk described the lunch as unappetizing and not warm enough. These findings were corroborated by reviews of medical records, care plans, and facility recipes, which specified the use of seasonings and proper food temperatures that were not followed during the observed meal service.
Failure to Maintain Safe Holding Temperature for Mechanical Soft Chicken
Penalty
Summary
The facility failed to ensure that mechanical soft chicken was held at a safe temperature during lunch service, potentially affecting 18 residents who required a mechanical soft diet. Observations revealed that while most food items were initially cooked to safe internal temperatures, the mechanical soft chicken was found to be at 123.0°F during tray line setup, below the required holding temperature of 135°F. Despite other food items being reheated after low temperatures were identified, the mechanical soft chicken was not reheated and remained on the steam table. Subsequent temperature checks showed the mechanical soft chicken had dropped further to 109.2°F and then 108.7°F, still below the safe threshold, before it was finally reheated after surveyor intervention. Interviews with dietary staff and consultants indicated that several wells of the steam table and the steamer were not fully operational, which had been an ongoing issue for approximately a week and a half. The lack of functioning equipment hindered the facility's ability to maintain safe food temperatures. Documentation from equipment repair companies showed that repairs had not been promptly requested or completed, and there was no evidence that parts were unavailable as previously claimed by staff. The facility's policy required hot foods to be held at or above 135°F, but this standard was not met for the mechanical soft chicken during the observed meal service.
Failure to Perform Proper Catheter and Incontinence Care Increases Infection Risk
Penalty
Summary
A deficiency was identified when staff failed to perform catheter care according to appropriate standards of practice, increasing the risk of contamination and urinary tract infection. Review of a resident's medical record showed the individual had multiple diagnoses, including neuromuscular dysfunction of the bladder, and required an indwelling Foley catheter with care every shift. The care plan specified the need for enhanced barrier precautions and outlined that incontinence care should be provided prior to catheter care if the resident was soiled, to prevent contamination. During direct observation, a CNA did not check for bowel incontinence before starting catheter care and used washcloths that were placed directly on an unclean overbed table without a barrier. The CNA did not use a method to ensure a clean part of the washcloth was used for each stroke, did not use soap, and failed to clean the area around the catheter insertion site or the catheter itself. After incomplete catheter care, the CNA left and re-entered the room, changed only one glove without performing hand hygiene, and then performed incontinence care. The same soiled gloves were used to reposition the catheter tubing and fasten a clean brief, further increasing the risk of contamination. Interviews with staff confirmed that the observed practices did not align with facility policy or standard infection control procedures. Policies required the use of clean basins and washcloths, cleaning from the meatus outward with a clean part of the cloth for each stroke, and performing hand hygiene between glove changes. The failure to follow these procedures was corroborated by staff interviews and review of facility policies, which emphasized the importance of proper hand hygiene and cleaning techniques to prevent infection.
Failure to Timely Address Significant Weight Loss
Penalty
Summary
A deficiency occurred when the facility failed to timely address a significant weight loss in a resident with multiple complex medical conditions, including schizophrenia, severe sepsis with septic shock, adrenocortical insufficiency, depression, and thyrotoxicosis. The resident's care plan identified altered nutritional status and significant weight loss, with interventions such as monitoring intake, providing supplements, and alerting nursing or dietitian staff if intake was inadequate. Despite these interventions, the resident experienced a substantial weight loss over a short period, dropping from 192 pounds to 146 pounds between early May and July, as documented in both facility and hospital records. The facility's records showed that the resident's weight was stable until early May, after which there was a marked decline. The resident was hospitalized for altered mental status, and hospital records confirmed a significant weight loss during the stay. Upon return to the facility, further weight loss was documented, but there was no timely documentation or intervention addressing the ongoing weight loss between May and July. The quarterly nutritional assessment did not reflect the hospital or recent facility weights, and incorrectly noted no significant weight loss, despite meal intake averaging only 50% and the resident refusing supplements. Interviews with staff revealed that standard procedures for monitoring significant weight loss, such as obtaining reweights and initiating weekly weights, were not followed in a timely manner. The dietitian and DON confirmed that the resident's weight loss was not addressed promptly, and the facility's policy requiring reweights within 48 hours of a five-pound deviation was not implemented. The lack of timely assessment and intervention contributed to the resident's continued decline, as evidenced by further weight loss and subsequent hospitalizations.
Failure to Follow Infection Control Procedures During Catheter and Incontinence Care
Penalty
Summary
The facility failed to ensure proper infection prevention and control procedures were followed during care for a resident with an indwelling urinary catheter. During observation, a certified nurse aide (CNA) performed catheter and incontinence care without adhering to established protocols. The CNA used wet washcloths placed directly on an unclean overbed table, did not use a barrier or basin, and failed to clean the catheter insertion site appropriately. The same gloves were used throughout the care process, including handling clean and soiled items, and the CNA did not change gloves or perform hand hygiene at appropriate intervals. Additionally, the CNA exited and re-entered the resident's room while still wearing the same gown and gloves used during care, and handled clean items after touching soiled materials without proper glove changes or hand hygiene. Further deficiencies were observed in the handling of soiled linens and personal protective equipment (PPE). The CNA placed soiled washcloths and briefs on the floor next to the resident's bed and in the bathroom doorway, rather than immediately disposing of them in appropriate bags. The CNA also failed to have trash bags ready prior to care, as required by facility policy. After completing care, the CNA walked through the hallway and accessed clean linen and medication carts while still wearing the soiled gown and gloves, further breaching infection control protocols. Only after these actions did the CNA perform hand hygiene and properly dispose of PPE and soiled items. Interviews with staff confirmed that the observed practices were inconsistent with facility policies and standard infection control procedures. Staff acknowledged that basins and clean washcloths should be used, soiled items should never be placed on the floor, and PPE must be removed before exiting a resident's room. Hand hygiene was also confirmed as a required step before and after glove changes. Review of facility policies corroborated these requirements, including proper cleaning of the catheter insertion site, appropriate disposal of soiled linens, and correct donning and doffing of PPE. The failure to follow these procedures was observed to affect one resident directly and had the potential to impact all residents on the unit.
Deficient Food Storage and Unsanitary Kitchen Conditions
Penalty
Summary
Surveyors observed multiple failures in the facility's kitchen related to food storage, labeling, and cleanliness. During an inspection, it was found that several food items in the walk-in cooler, including a spiral ham, chopped onion, diced turkey, butter, bacon bits, and beef fat, were either not labeled or not dated. In the walk-in freezer, beef slabs were left exposed on a cardboard box, showing significant freezer burn, and cookie dough bites were stored in an open plastic bag. These findings were confirmed by a dietary aide at the time of discovery. Further inspection of the kitchen revealed unsanitary conditions, including multiple light fixtures containing dust, debris, and dead bugs. The six-burner cooktop had a thick layer of black food buildup around and underneath the burners, and the microwave used for resident food was extremely dirty with brown residue. The facility's policy on food preparation and storage was reviewed and found to be undated, but it stated that food items should be kept free of harmful organisms and substances. The observed deficiencies had the potential to affect all 104 residents in the facility.
Improper Disposal and Sanitation of Dumpster Area
Penalty
Summary
The facility failed to maintain the dumpster area in a clean and sanitary condition, as observed during a survey with a dietary aide. Significant amounts of debris, including plastic gloves, used plastic silverware, paper plates with food residue, brown bags, and various plastic items were found scattered to the left of the dumpster. In front of the dumpster, a cardboard box was observed on the ground, appearing to have been run over multiple times by vehicles. To the right of the dumpster, the facility's grease barrel was found open to the air with a stock pot of water placed on top. These findings were confirmed by staff during the survey. This deficiency had the potential to affect all 104 residents residing in the facility, as noted in the facility census at the time of the survey.
Failure to Provide Correct Menu Items and Serving Sizes
Penalty
Summary
The facility failed to ensure that residents received correct serving sizes and all menu items as specified on the posted menu. Observations and interviews revealed that several residents received smaller portions than required, and some menu items were substituted or omitted entirely. For example, residents reported receiving small portions at mealtimes and not knowing what was on the menu prior to receiving their meals. Review of the menu indicated specific serving sizes and items for different diet types, but during meal service, staff used incorrect scoop sizes, resulting in smaller portions. Additionally, some menu items such as coleslaw and apple slices were replaced with chips, cottage cheese with fruit, and applesauce cups, which were also served in smaller portions than required. Further observations showed that some residents did not receive fruit cups or dessert with their meals, and staff confirmed these omissions. The dietary manager acknowledged that substitutions were made due to unavailable items and verified that the portions served were not consistent with the menu requirements. These deficiencies affected multiple residents and had the potential to impact all residents except those who were NPO (nothing by mouth). The findings were based on direct observation, record review, and staff and resident interviews.
Failure to Follow Sanitary Food Handling and Serving Procedures
Penalty
Summary
Dietary staff failed to follow proper food handling and sanitation procedures during meal service. One dietary aide was observed using a dish cloth to dry silverware, rather than allowing them to air dry as required by facility policy, and then placed the dried silverware into a holder. The aide confirmed she was unaware that this method was not permitted. Additionally, during lunch tray preparation, another staff member was seen assembling sandwiches by handling bread, deli meat, lettuce, and tomato with the same pair of gloved hands, without using serving utensils as expected. The dietary manager confirmed that serving utensils should have been used. The facility's policy specifies that all food service equipment should be cleaned, sanitized, air-dried, and that tongs or other utensils should be used to avoid direct hand contact with food. Two residents were identified as receiving nothing by mouth per physician orders, and thus were not affected by the meal service.
Sanitation Deficiencies in Food Storage and Preparation
Penalty
Summary
The facility failed to ensure that food was stored, prepared, and served under sanitary conditions, potentially affecting 111 residents who received meals from the kitchen. During an observation, several issues were noted in the facility's kitchen. In the main freezer, bread and French fries were stored in clear plastic bags without labels or dates. In the dry food storage area, an open bag of powdered sugar was wrapped in ripped plastic wrap, spilling out when handled, and other bread items lacked labels or dates. A bag of tortilla shells was found with an expired use-by date, and an unlabeled container with a brown substance was stored without a label or date. Live gnats were observed near the bread and dish machine, and wet oven trays were stored with clean pots and pans. Additionally, there was a heavy build-up of black grime on the floor under the dish machine and dried food particles and grime on the walls where they met the floor throughout the kitchen. Two tray carts used for transporting resident food had a large amount of dried white substance resembling dried milk, indicating they were not kept clean and sanitary. These observations were confirmed by the Dietary Manager during an interview, highlighting the facility's non-compliance with sanitary food storage and preparation standards.
Deficiency in Food Temperature and Palatability
Penalty
Summary
The facility failed to ensure that food served to residents was palatable, attractive, and at a safe and appetizing temperature. During an observation of the kitchen food production and lunch tray line meal service, it was noted that while all hot foods initially reached acceptable temperatures above 165 degrees Fahrenheit, a second set of temperatures was not taken to monitor the food throughout the service. A test tray was prepared and sent to the dining room, where the temperatures were taken by the Dietary Manager. The ham slice was found to be 106 degrees Fahrenheit, barely warm to taste, the cold potato salad was 75 degrees Fahrenheit, not cold, and the mixed vegetables were 136 degrees Fahrenheit, only warm. These temperatures were verified by the Dietary Manager. Interviews with six residents revealed dissatisfaction with the food service. Residents reported that hot foods were served cold, the food did not taste good, and some even resorted to ordering food from outside due to the poor quality. The facility's policy on food temperatures at the point of service requires that hot food items be cooked, held, and served at appropriate temperatures, with frequent monitoring to ensure safe food holding temperatures. This deficiency was investigated under Complaint Number OH00162967.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care to two residents, resulting in prolonged periods of discomfort and potential health risks. Resident #10, who was moderately cognitively impaired and required substantial assistance due to hemiplegia and hemiparesis, was left in a soiled state from before 10:00 A.M. until after 2:00 P.M. The resident had been in a chair since before 7:00 A.M. and was not checked or changed until CNA #335, with the help of LPN #312, transferred her to bed. The resident's brief was found to be completely saturated with urine and stool, indicating a significant delay in care. Similarly, Resident #74, who was cognitively intact but required supervision for toileting due to overflow incontinence and muscle weakness, was left sitting in a chair with saturated sheets from 8:45 A.M. until after 1:00 P.M. The room had a strong odor of urine, and the resident reported having asked for assistance hours earlier. Staff interviews revealed that residents were typically checked and changed only twice per shift, which was insufficient for the needs of these residents. The facility's policy required incontinence care to be provided as needed, but this was not adhered to, leading to the deficiency.
Failure to Use PPE During Wound Care Under EBP
Penalty
Summary
The facility failed to ensure that staff wore appropriate Personal Protective Equipment (PPE) when caring for a resident on the South unit who was under Enhanced Barrier Precautions (EBP). This deficiency was observed during wound care for Resident #51, who had a history of type two diabetes mellitus, anoxic brain damage, urinary tract infection, acute respiratory failure with hypoxia, and other infections. The resident was dependent on staff for all Activities of Daily Living (ADLs) and had orders for EBP due to a heel wound, a foley catheter, and tube feedings. Despite these orders, the Registered Nurse (RN) performing wound care did not wear a gown, which was required for high-contact resident care activities under EBP. The RN, who was also the facility's Wound Care Nurse and Infection Preventionist, acknowledged the oversight during an interview, stating that she forgot to put on her gown. The facility's policy on Enhanced Barrier Precautions, last reviewed in November 2023, clearly stated that gowns and gloves are to be used for high-contact resident care activities for residents with wounds or indwelling medical devices. This incident was identified as a deficiency during the investigation of a complaint, highlighting a lapse in adherence to infection control protocols.
Unsecured Firearm Incident in LTC Facility
Penalty
Summary
The facility failed to provide a safe environment free from potential accident hazards when a State tested Nursing Assistant (STNA) brought an unsecured loaded firearm into the facility. The firearm, along with additional rounds of ammunition, was left wrapped in a fleece vest and placed in a clear plastic bag on a cart in the 3 North Hallway. This area was accessible to residents, and one resident mistakenly took the bag to her room, found the firearm, and placed it under her mattress. The facility was unaware of the firearm's location until the resident informed another STNA, who then notified the local police department. The police took possession of the firearm and ammunition. The incident involved Resident #64, who had diagnoses including depression, anemia, and uncomplicated alcohol dependence. The resident had mild or no cognitive impairment but experienced daily occurrences of feeling down or depressed. A psychiatry note indicated that the resident was alert and oriented to person and place but had poor memory, insight, and judgment. The resident found the unattended bag on the cart, believed it was hers, and took it to her room, where she discovered the loaded firearm and hid it under her mattress. STNA #563 admitted to bringing the loaded firearm to work for personal protection due to working nights and taking the bus. The STNA stored the firearm with his personal belongings in a bag at his workstation on the third floor. The STNA noticed the bag was missing after returning from lunch and notified a nurse. The facility staff, including the Director of Nursing (DON) and Unit Manager (UM), conducted searches of the facility but were unable to locate the firearm until Resident #64 informed STNA #592 about it. The facility's policy prohibits firearms and other weapons on the premises, and STNA #563 was subsequently terminated for violating this policy.
Removal Plan
- STNA #563 informed Unit Manager (UM) #628 his coat and firearm were missing from the 3 North Hallway. UM #628 immediately notified the DON of the missing firearm.
- The DON notified the Administrator of the missing firearm.
- The Administrator notified the local police department (LPD) of the missing firearm.
- The DON assigned managers to search the first, second, and third floors of the facility for the missing firearm.
- The Local Police Department (LPD) arrived at the facility. The Administrator and UM #628, along with the responding officer, reviewed camera surveillance to determine if the missing firearm could be seen being removed from the last known location. The cameras did not assist in identifying who may have removed the bag carrying the missing firearm.
- The DON and Administrator assigned new areas for managers to search for the missing firearm, including dietary, the basement, and the exterior of the facility.
- The DON and Maintenance Supervisor (MS) #618 searched the garbage for the missing firearm.
- A second officer from the LPD arrived and obtained a statement from STNA #563 regarding the missing firearm.
- STNA #592 located the missing firearm in Resident #64's room. The LPD took immediate possession of the firearm.
- STNA #563 was suspended pending the investigation into the firearm he brought into the facility.
- An Ad Hoc QAPI was held with the Administrator, DON, Business Office Manager (BOM) #537, Cook #639, Receptionists #535 and #583, Corporate Admission (CA) #701, Dietary Tech (DT) #702, Assistant Business Office Manager (ABOM) #565 and Admissions Director (AD) #703 to review the facility policy on Firearms and Other Weapons. The facility prohibits employees, residents, visitors, vendors, or others from possessing firearms or other weapons while in/on facility premises.
- The DON notified Medical Director (MD) #704 of the incident involving the firearm.
- Chief Clinical Officer (CCO) #705 re-educated the DON on the facility's policy on firearms and other weapons.
- The DON and CCO #705 educated all staff, including five activities staff, two admissions staff, two business office staff, one central supply staff, 25 dietary staff, seven hospitality aides, 12 housekeepers, two laundry staff, 27 Licensed Practical Nurses (LPN), one maintenance staff, three medication technicians, three social workers, two therapists, three receptionists, 10 Registered Nurses (RN) and 37 STNAs related to the facility firearm policy. Education was provided in person for staff at the facility and over the phone for those off duty.
- UM #628 completed a skin assessment for Resident #64. No new areas of concern were identified.
- The DON or designee completed an assessment of all residents. Residents were safe and at baseline. No psychosocial concerns were identified.
- The Administrator placed new, more prominent signage at the entrances prohibiting firearms in the facility.
- Maintenance Staff (MS) #618 changed door codes due to the suspension of STNA #563.
- The DON or designee implemented a system to audit five random staff four times weekly for four weeks then three random staff weekly for eight weeks to ensure knowledge of the facility's firearms policy. Findings would be reviewed in weekly QAPI meetings to ensure compliance with the policy.
- Regional Director of Operations (RDO) #706 notified STNA #563 of termination of employment due to not following the facility policy on firearms.
Latest citations in Ohio
Surveyors found that multiple hazardous storage areas, including a closet near medical records, a beauty salon used to store chemical cases, a supply room in one nursing station, a room leading to a smoking area, a housekeeping room near therapy, and a lobby storage room, lacked required self-closing or automatic-closing doors. These conditions did not comply with NFPA 101 requirements for hazardous area enclosure and had the potential to affect all residents and staff in an emergency.
Surveyors found that the facility did not conduct fire drills on every shift each quarter and did not vary drill conditions as required by NFPA 101. Record review showed that one shift lacked a documented drill for an entire quarter, and the pattern of drill times and dates did not demonstrate varied conditions. The Maintenance Director confirmed the incomplete and noncompliant fire drill schedule, which affected all residents and staff emergency preparedness.
Surveyors found that the facility did not maintain clear egress corridors as required by NFPA 101, with a TV/video cart plugged into a corridor outlet and multiple unsecured chairs placed in the hallway near resident rooms and the secured unit dining room, including directly in front of a fire extinguisher. These items projected about 29 inches into an approximately eight-foot-wide corridor and were located in front of the handrail, potentially affecting 28 residents and staff’s ability to assist in an emergency. The Maintenance Director confirmed these corridor obstructions during the survey.
A resident with intact cognition receiving Medicare Part A skilled services for metabolic encephalopathy had services discontinued while benefit days remained, but the facility did not issue the required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN). The Social Services Director later confirmed that no SNF ABN was provided and reported she believed only a Notice of Medicare Non-Coverage (NOMNC) was needed when all skilled services were stopped. This practice conflicted with the facility’s written policy, which required SNF ABNs to be issued when extended care items or services were initiated, reduced, or terminated due to expected non-coverage by Medicare.
Surveyors identified that the facility exceeded the acceptable medication error rate when two residents with type 2 DM received insulin doses that were not administered according to orders or manufacturer instructions. In two separate observations, an LPN administered Novolog and another LPN administered insulin glargine and insulin lispro without priming the insulin pens, and the insulin lispro and Novolog were given after the residents had already consumed a significant portion of their breakfast meals, despite orders for administration before meals. Manufacturer information for both insulin products required priming before each injection to ensure accurate dosing, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and specified time frames.
A cognitively intact resident with behavioral issues, including physical aggression and noncompliance with care, was in a secured unit and was observed tapping on the window/door. A dietary aide, despite being told by a CNA and an RN not to enter the secured unit and that the resident’s assigned aide could assist, went onto the unit and interacted with the resident, including offering to buy a soda after seeing money in the resident’s hand. The resident struck the aide in the face, and the aide responded by punching the resident in the face; a CNA reported hearing the aide say, “I will hit you again,” and then observed the resident bleeding. The resident was later found at the hospital to have an open mandibular fracture and non-restorable teeth requiring extraction, and the facility’s investigation and policy definitions led to the incident being substantiated as staff-to-resident physical abuse.
A resident with severe cognitive impairment, osteoporosis, and total dependence for transfers was being moved from bed to wheelchair with a mechanical lift when CNAs reported that an undersized sling and a forceful pull on the lift caused the resident to fall feet‑first from the sling, with staff catching the upper body while both legs struck the floor and one leg bent behind. Witnesses heard a loud pop and observed immediate pain, bruising, swelling, and deformity of the leg, yet the responding LPN did not complete a thorough musculoskeletal assessment, did not document a fall, and the physician and resident representative were not promptly informed of a suspected injury. Through the night and into the next day, staff and the roommate reported the resident crying out in pain and an obviously abnormal leg, but nursing notes only reflected intermittent acetaminophen administration without clear pain documentation, and the physician was contacted primarily about yelling and behavior. Mobile X‑rays obtained later showed a displaced distal femur fracture, which was not reviewed until the following day, when hospital imaging confirmed a closed displaced comminuted femur fracture and a hand fracture. The facility’s internal investigation was incomplete and inaccurate, with leadership denying a fall, preparing a single typed statement minimizing the event, and having multiple staff sign it despite later testimony that the statement was false and that staff were told not to discuss the incident.
Surveyors found multiple instances of improper food storage and labeling, including undated and unlabeled opened dairy products, beverages, and prepared foods in the main walk-in cooler and freezer, as well as a serving scoop left resting directly on stored pasta. Additional issues included covered but undated pre-poured juices, milk, and thickened beverages in a reach-in cooler used for tray line, and a nurses' station refrigerator containing a dated bag of a resident’s food from over a week prior and three undated half-sandwiches. In a resident’s personal refrigerator, staff confirmed three undated bags of grapes with visible mold. These conditions did not comply with facility policies requiring cold foods to be stored off the floor, wrapped or covered, labeled, dated, and for resident refrigerators to be monitored daily with unsafe or moldy food discarded.
Surveyors found unsanitary kitchen conditions, including a dirty tray holding clean pitchers, soiled storage carts containing clean dishware and disposables, and multiple trays of open juice in a reach-in refrigerator that were unlabeled and undated. In a walk-in refrigerator, they observed a bag of bologna marked only with a freeze date, lacking a thaw or use-by date, and appearing slimy and discolored. Observation of the high-temp dishwasher showed rinse temperatures below the 180°F minimum required for hot water sanitizing, and review of several months of temperature logs revealed repeated sub-minimum wash and rinse temperatures and numerous missing entries. Facility policies required dishwashing to meet specified temperature standards and all refrigerated foods to be covered, labeled, and dated with a use-by date, but these requirements were not consistently followed.
Surveyors found that the facility did not maintain a safe, clean, and homelike environment as required by its policy. In one shared bedroom, wallpaper was peeling in several areas, including behind each bed, below a window, and near baseboards, and a black substance was present around the base of the toilet. A CNA confirmed these conditions. In addition, three cracked or broken light covers were observed in a hall restroom. These environmental issues affected two residents and had the potential to affect all residents.
Failure to Maintain Self-Closing Doors for Multiple Hazardous Storage Areas
Penalty
Summary
Surveyors identified a deficiency related to hazardous area protection and door requirements under NFPA 101, 2012 Edition. During facility tours, they observed that multiple hazardous storage areas did not have self-closing or automatic-closing doors as required for hazardous areas such as combustible storage and chemical storage. These areas included a closet next to medical records, a beauty salon being used to store cases of chemicals, a supply room in Station #2, and the room leading to the smoking area in Station #3. On a subsequent tour, surveyors observed additional hazardous areas without self-closing doors. The housekeeping room across from therapy and the lobby storage room were both noted to lack self-closing door mechanisms. The facility census at the time was 59 residents, and the surveyors stated that this deficient practice had the potential to affect all residents and staff's ability to assist in an emergency. The Maintenance Director verified these findings at the time they were observed.
Plan Of Correction
K 0321 This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be admissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as its allegation of substantial compliance as of 06/12/2026 K-0321 Doors with Self-Closing Devices Corrective action for resident/s: 1. The closet door next to medical records was lacking a self-closing door on 5/19/2026. Maintenance director to add self-closing device to closet door next to medical records on or before 06/12/2026 in accordance with applicable code. 2. The beauty salon had chemicals stored in it on 5/19/2026. Maintenance director moved chemicals from beauty salon on 05/20/2026 in accordance with applicable code. 3. The supply room on station 2 was lacking a self-closing door on 5/19/2026. Maintenance director to add self-closing door to supply room on station 2 on or before 06/12/2026 in accordance with applicable code. 4. The room to the smoking area on station 3 was lacking a self-closing door on 5/19/2026. Maintenance director to add a self-closing door to the smoking are on station 3 on or before 06/12/2026 in accordance with applicable code. 4. The housekeeping room across from therapy was lacking a self-closing door on 5/19/2026. Maintenance director to add a self-closing door to the housekeeping room across from therapy gym on or before 06/12/2026 in accordance with applicable code. 5. The lobby storage room was lacking a self-closing door on 5/19/2026. Maintenance director to add a self-closing door to the lobby storage room on or before 06/12/2026 in accordance with applicable code. Identification of other residents who may be affected: LNHA and Maintenance director/designee completed a full facility audit for doors with self-closing devices on 05/26/2026. Any corrective action, including, doors identified as needing self-closures will be added on or before 06/09/2026 in accordance with applicable code. Measures for systemic change: LNHA educated Maintenance Director on 05/26/2026 regarding NFPA 101-2012 sections 19.3.2.1 and 19.3.5.9 specifically regarding doors with self-closing devices. How Corrective Action will be monitored Ongoing "Doors with Self-Closing device audit" to be completed weekly x 2 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 06/12/2026
Failure to Conduct Required Quarterly Fire Drills on All Shifts
Penalty
Summary
The facility failed to conduct fire drills in accordance with NFPA 101, 2012 Edition, sections 19.7.1 through 19.7.1.8, specifically by not holding drills every shift each quarter and not varying drill conditions as required. Record review on 06/09/25 at approximately 10:32 A.M. showed there was no fire drill conducted for the first shift during the third quarter. The documented first-shift fire drills occurred on 01/30/26 at 2:42 P.M., 04/30/26 at 1:51 P.M., and 10/31/25 at 10:58 A.M., indicating a missed quarter. Second-shift fire drills were recorded on 02/26/26 at 5:20 P.M., 06/03/25 at 4:35 P.M., 08/29/25 at 3:46 P.M., and 11/25/25 at 5:09 P.M., and third-shift drills on 02/28/26 at 11:47 P.M., 05/30/25 at 12:18 A.M., 07/22/25 at 11:34 P.M., 09/26/25 at 11:40 P.M., and 12/15/25 at 5:17 A.M. The surveyor determined that drills were not conducted under varied conditions and that the required quarterly drill on each shift was not consistently performed. The Maintenance Director confirmed these findings at the time they were identified, and the deficiency had the potential to affect all 59 residents and staff response in an emergency. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency related to facility-wide emergency preparedness practices and documentation of fire drills.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 05/29/2026 K-0712 Fire Drills Corrective action for resident/s: There were no records of a fire drill for the first shift of the third quarter of 2025. First shift fire drill completed on 5/24/2026 by maintenance director/designee with no findings or corrective action necessary. Identification of other residents who may be affected: On 5/26/2026 Maintenance director/designee completed 100% audit of the scheduled fire drills to ensure a drill is scheduled quarterly each shift with no findings or corrective action necessary. Measures for systemic change: LNHA educated Maintenance Director on 05/26/2026 regarding NFPA 101-2012 section 19.7.1.4 through 19.7.1.7. specifically including fire drill frequency requirements. How Corrective Action will be monitored Ongoing "Fire Drill Audit" to be completed weekly x 2 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 05/29/2026
Obstructed Egress Corridors Due to Equipment and Chairs
Penalty
Summary
The facility failed to maintain required clear egress widths in corridors in accordance with NFPA 101, 2012 Edition, sections 19.2.3.4 through 19.2.3.5 and 7.3.2 through 7.3.2.3, creating projections into the egress corridor that exceeded allowable limits. Surveyors observed that on one day in Station #3, a cart with a television and video equipment was plugged into an outlet in the corridor by room 38, and five activity room chairs were placed in the corridor near the secured unit dining room directly in front of a fire extinguisher. On the following day, surveyors again observed chairs in the Station #3 corridor, with four by room 35 and four by the activities room, and the same television cart still in the corridor; the chairs were not secured. The corridor was approximately eight feet wide, and the projections extended approximately 29 inches into the corridor in front of the handrail. These conditions had the potential to affect 28 residents in the facility and the staff’s ability to assist in an emergency, and the Maintenance Director confirmed the observations at the time of discovery. No specific resident medical histories or conditions were described in the report, only that 28 residents were potentially affected and the facility census was 59.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be subsequent remedial measures and should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 05/29/2026 K-0232 Clear path of egress Corrective action for resident/s: 1. On 05/18/2026 station 3 had a cart with a television parked in the corridor by room 38 that exceeded allowable limits. Maintenance director/designee moved the TV cart into the activity room, out to the corridor on 05/18/2026 in accordance with applicable code. 2. On 5/18/2026 station 3 had 5 chairs in the corridor near the dining room directly in front of the fire extinguisher. Maintenance director/designee moved the chairs into the dining room, out of the corridor on 5/18/2026 in accordance with applicable code. 3. On 5/19/2026 station 3 had 4 chairs by the activity room and 4 by room 35. In addition, the TV cart was in the corridor. The maintenance director/designee moved the chairs and TV cart into the dining room, out of the corridor on 5/19/2026 in accordance with applicable code. Identification of other residents who may be affected: Maintenance director/designee completed a 100% facility audit for clear paths of egress on 5/26/26 with no findings or corrective action necessary. Measures for systemic change: Maintenance Director/designee educated staff on 5/26/2026 regarding NFPA 101-2012 section 19.2.3.4 and 19.2.3.5 specifically including maintaining a clear path of egress. How Corrective Action will be monitored Ongoing "Path of Egress Audit" to be completed weekly x 2 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 05/29/2026
Failure to Issue Required SNF ABN When Discontinuing Medicare Part A Services
Penalty
Summary
The deficiency involves the facility’s failure to issue a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) when Medicare Part A services were discontinued for a resident who still had available benefit days. The resident was admitted with a diagnosis of metabolic encephalopathy and had intact cognition per the Minimum Data Set assessment. The facility’s own SNF Beneficiary Notification Review documented that Medicare Part A skilled services began on 02/11/26 and the last covered day was 03/11/26, and that the facility initiated discharge from Medicare Part A services before the resident’s benefit days were exhausted. Despite this, no SNF ABN was provided to the resident or the resident’s representative. During interviews, the Social Services Director stated that the SNF ABN was issued hours prior to the last covered day but, upon reviewing her files, confirmed that no SNF ABN had actually been issued for this resident. She further explained that she believed an SNF ABN was only required if one skilled service remained and that if all skilled services were being discontinued, only the Notice of Medicare Non-Coverage (NOMNC) needed to be issued. The Administrator, however, stated that a resident should always receive both a SNF ABN and a NOMNC when Medicare Part A services are discontinued and benefit days remain. Review of the facility’s written policy dated 03/28/23 showed that the facility was required to issue SNF ABNs for initiation, reduction, or termination of extended care items or services when Medicare payment was not expected, which did not occur in this case.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as its allegation of substantial compliance as of 05/29/2026 F-0582 Corrective action for resident/s: On 5/14/26 Resident #34 was informed of rights and responsibilities related to Advanced Beneficiary Notice and voiced understanding of information for future reference by administrator. Identification of other residents who may be affected: Any resident receiving skilled services from nursing or therapy services. The Administrator audited all residents who were discharged from skilled services in the past 30 days to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary Notice on 5/29/26. No non-compliance was noted. Measures for systemic change: On 5/14/2026 Business Office Manager, Director of Rehab, Minimum Data Set nurse, Director of Nursing and Social Services Director were educated on proper procedure of issuing of Notice Of Medicare Non Coverage and Advanced Beneficiary Notice by administrator. All upcoming discharges from skilled services will be reviewed weekly at Utilization Review meeting to ensure notices will be delivered timely. How Corrective Action will be monitored: Administrator or designee to complete audits of all residents being discharged from skilled services to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 5/29/26
Insulin Administration Errors and Failure to Prime Insulin Pens
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5%, with surveyors identifying 3 errors out of 28 medication administration opportunities, resulting in a 10.71% error rate. For one resident with type 2 diabetes mellitus and moderate cognitive impairment, the physician’s order directed Novolog insulin 10 units via subcutaneous pen-injector to be given before meals. During an observed medication pass, the LPN administered 10 units of Novolog insulin without priming the pen and did so after the resident had already consumed approximately 50% of the breakfast meal. The LPN later confirmed she did not prime the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer instructions for the Novolog FlexPen specified that an air shot (priming) must be performed before each injection to ensure proper dosing. Another resident, also diagnosed with type 2 diabetes mellitus and with intact cognition, had orders for insulin glargine 35 units subcutaneously twice daily and insulin lispro 20 units subcutaneously before meals, plus 12 units subcutaneously if blood glucose was between 251 mg/dL and 300 mg/dL. During an observed medication administration, an LPN administered 35 units of insulin glargine and 32 units of insulin lispro without priming the insulin pens and after the resident had consumed approximately 90% of the breakfast meal, despite orders for insulin lispro to be given before meals. The LPN later stated she could not remember if she had primed the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer information for insulin lispro stated that the pen must be primed before each injection to confirm insulin delivery and remove air, and that failure to prime could result in too much or too little insulin. The DON confirmed the expectation that insulin be administered as ordered, including priming each pen with two units before dialing the prescribed dose, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and required time frames.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 5/29/2026. F-0759 Corrective action for resident/s: Residents #21 and #22 were assessed and evaluated by nurse and Director of Nursing 5/14/26. Resident #21 and #22 both denied any adverse effects and none were noted upon assessment by the Director of Nursing on 5/14/2026. Notification made to physician on 5/14/2026. LPN # 2 competency Eval on insulin administration with the Director of Nursing completed 5/14/2026. Identification of other residents who may be affected: Diabetic residents on assignment of LPN #2/station 2 have the potential to be affected and were assessed by the DON/Designee on 5/14/26 and found to be within normal limits. Measures for systemic change: All Nurses were educated by the Director of Nursing on the steps for Insulin administration per competency, diabetes clinical protocol policy, Medication and treatment orders policy, administering medications policy, and Obtaining fingerstick Glucose Level policy On 5/14/2026. How Corrective Action will be monitored: Director of Nursing and Assistant Director of Nursing will complete insulin administration audits on 5 nurses. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance: 5/29/2026
Staff-to-resident physical abuse resulting in jaw fracture and tooth loss
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from staff-to-resident physical abuse, resulting in serious injury. A dietary aide entered a secured unit where a cognitively intact resident with a history of behavioral issues, including physical aggression and noncompliance with care and medications, was located. The resident had been tapping or knocking on the window/door of the secured unit, drawing the attention of the dietary aide. Multiple staff, including a CNA and an RN, told the dietary aide not to go onto the secured unit, noting that the resident’s assigned aide could assist and that the resident had been agitated the previous day. Despite these instructions, the dietary aide went onto the secured unit. Witness statements and interviews indicate that upon entering the unit, the aide interacted with the resident, including offering to buy the resident a soda after seeing the resident holding money. According to staff statements and the aide’s own account, the resident then struck the aide in the face. The aide responded by punching the resident in the face. A CNA on the unit reported stepping between the two to attempt to deescalate the situation and then calling for the nurse due to the resident’s aggression. The CNA also reported hearing the aide tell the resident, “I will hit you again,” and then observed that the resident was bleeding. Following the punch, the resident was noted by staff to be bleeding from the nose and mouth. The resident was assessed by nursing and subsequently transported to the hospital. Hospital records documented that the resident sustained an open fracture of the right jaw, with a loose right lateral mandibular incisor and bleeding from the socket at the fracture site. The resident’s remaining 11 teeth were extracted because they could not be restored. A police report documented that staff reported the incident as an assault in which a staff member punched a resident after the resident had punched the staff member. The facility’s policy defined abuse as the willful infliction of injury resulting in physical harm, including physical abuse such as hitting and punching, and the facility substantiated that the dietary aide had physically abused the resident.
Failure to Ensure Safe Mechanical Lift Transfer, Timely Assessment, and Pain Management After Traumatic Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure safe mechanical lift transfers, adequate assessment, timely physician and representative notification, and appropriate pain management for a severely cognitively impaired, non‑ambulatory resident who required a mechanical lift with two‑person assistance for all transfers. The resident had multiple relevant diagnoses, including vascular dementia, osteoarthritis, a right hip prosthesis, chronic kidney disease, and a history of fractures and osteoporosis/osteopenia. On the morning of 04/22/26, during a mechanical lift transfer from bed to wheelchair, multiple CNAs reported that the sling appeared too small, the lift was pulled forcefully from under the bed, and the resident fell feet‑first out of the sling, with staff catching her upper body while both legs hit the floor and one leg bent behind her. A loud popping sound was heard, the resident screamed and cried out in pain, and witnesses observed immediate bruising, swelling, and apparent misalignment of the left knee/leg. Despite this, the nurse who responded did not perform a complete head‑to‑toe or range‑of‑motion assessment focused on the leg, and the incident was not documented as a fall from the lift. Following the incident, nursing staff actions and documentation were incomplete and inconsistent with the resident’s presentation. Progress notes on 04/22/26 documented only a skin tear to the left forearm and a head‑to‑toe assessment with no new areas, and there were no notes describing a fall, leg injury, or significant pain. Multiple CNAs and the resident’s roommate reported that the resident cried out in pain throughout the night and that her left leg appeared swollen, bruised, and deformed, yet nursing notes from the night shift only recorded administrations of acetaminophen without documenting the reason for administration, pain assessment findings, or any musculoskeletal concerns. One RN reported being asked to look at the resident on 04/22/26, noting swelling of the left leg but performing no further assessment. The physician was not notified within one hour of a suspected musculoskeletal injury as required by facility policy, and the resident’s representative was not informed that the resident had fallen from the mechanical lift. On 04/23/26, staff continued to report the resident’s ongoing pain and abnormal leg appearance, but the physician was contacted only about increased yelling and behavior, with a focus on agitation and prior hip/groin pain history rather than a new traumatic event. The DON later documented that a loud popping noise occurred during a Hoyer lift transfer with three staff present and that no abnormalities or signs of pain were noted, and the physician was asked to order bilateral hip and knee X‑rays as a precaution, without documenting a fall. Mobile X‑rays were obtained on 04/23/26, but the results, which showed a displaced distal femur fracture on a limited lateral view, were not reviewed until 04/24/26. Only then was the fracture acknowledged and discussed with the physician and resident representative. Subsequent hospital evaluation identified a closed displaced comminuted supracondylar fracture of the left femur and a distal fifth metacarpal fracture of the left hand. The facility’s internal investigation was incomplete and inaccurate: the DON denied a fall on 04/22/26, prepared a single typed statement describing only a popping sound while the resident was suspended over the bed, and had multiple staff sign it, even though at least two CNAs and an agency DON later reported that the statement was false and that staff felt intimidated and were told not to talk about the incident. The facility also failed to adequately manage the resident’s pain following the injury. Although the MAR shows acetaminophen administrations on 04/22/26 and early 04/23/26, there was no associated documentation of pain scores or clinical rationale in the progress notes for some doses, and staff interviews and the roommate’s account described the resident crying out in pain whenever touched and throughout the night. The physician later stated he was under the impression the fracture was non‑displaced and that, because the resident was bedbound, he did not feel she needed pain medication, and he was unaware of the severity of the femur fracture or the additional hand fracture. Overall, the facility did not follow its own physician communication policy for falls with musculoskeletal deformity or leg pain, did not perform and document thorough assessments at the time of the incident and during the subsequent night, did not promptly review diagnostic imaging, and did not conduct a complete, accurate investigation into the circumstances of the mechanical lift transfer and resulting injuries.
Improper Food Storage and Labeling in Facility and Resident Refrigerators
Penalty
Summary
Surveyors identified a failure to store food in accordance with professional standards and facility policy, creating the potential for foodborne illness for nearly all residents who received food from the kitchen. In the walk-in cooler, they observed multiple items that were opened and partially used without any open dates, including two cartons of heavy whipping cream, bins of individually poured and covered beverages, and a tray of covered fruit cocktail bowls. A large pan of pasta with ground meat was stored with the serving scoop resting directly on the food, covered with plastic wrap and not dated. A cart in the cooler held a 22-quart container of dark liquid with no label or date, and a pink plastic pitcher resting directly on the cart surface, which was coated with a dark unidentified material. A box of bacon was stored directly on the floor. The Director of Dietary Services confirmed the presence of undated, unlabeled, and improperly stored food items in the walk-in cooler. In the walk-in freezer, surveyors found an unsealed and undated bag of frozen chicken breasts and an unsealed and undated bag of pork pizza topping, which the Director of Dietary Services also confirmed. The reach-in cooler used for tray line contained a variety of pre-poured juices, milk, thickened beverages, and tea that were covered but not dated. At a nurses' station refrigerator, surveyors observed a plastic bag of food labeled with a resident’s name and dated more than a week earlier, along with three half-sandwiches wrapped in plastic without dates; the LPN present verified these findings. In a resident’s personal refrigerator, three undated bags of grapes with visible mold were found, and a CNA confirmed the grapes were moldy and undated. Facility policies required cold foods to be stored at least six inches above the floor, wrapped or in covered containers, labeled, and dated, and required resident refrigerators to be monitored daily, with food appropriately labeled and unsafe or moldy food discarded. These practices were not followed, resulting in the cited deficiency under the complaint investigation.
Unsanitary Kitchen Practices and Improper Dishwashing Temperatures
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service operations related to unsanitary kitchen conditions, improper food labeling and dating, and failure to operate the dishwasher according to manufacturer and policy requirements. During an initial kitchen tour, they observed a plastic tray holding clean pitchers with a brown-like substance on it, and three open, three-shelf carts with crumbs and debris on the shelves where clean insulated plate lids and sleeves of disposable bowls, cups, and lids were stored. Multiple trays of juice in a reach-in refrigerator were open, unlabeled, and undated. In the walk-in refrigerator, surveyors found a plastic bag of bologna with only a freeze date and no thaw or use-by date; the bologna appeared slimy and lighter in color. The facility census was 67, with one resident identified as not receiving meals from the kitchen, and the deficiency was noted as having the potential to affect all residents receiving food from the kitchen. Surveyors also observed the high-temperature dishwasher in use and recorded a wash temperature of 168°F and rinse temperatures of 160°F, 176°F, 178°F, 178°F, and 178°F over five cycles, despite the machine label and facility policy requiring a minimum wash temperature of 150°F and a minimum rinse temperature of 180°F for hot water sanitizing. A staff member confirmed the dishwasher had not been running earlier that morning, verified it was a high-temperature machine that should rinse at a minimum of 180°F, and acknowledged the observations regarding the dirty tray, soiled carts, unlabeled juice, and improperly dated bologna. The staff member stated that items in the reach-in refrigerator were normally prepped the night before and asserted that the bologna always had that color before discarding it. Review of the dishwasher temperature logs for January through April 2026 showed repeated failures to meet required wash and rinse temperatures and numerous instances of missing documentation. In January, multiple wash temperatures were below the 150°F minimum, and several meals lacked recorded wash and rinse temperatures. February logs showed at least one sub-minimum wash temperature and many missing wash and rinse entries for various meals. March logs included at least one meal with no documented wash or rinse temperatures. April logs documented several wash temperatures below 150°F and rinse temperatures below 180°F, along with multiple days and meals where wash and/or rinse temperatures were not recorded at all. Facility policies on sanitation, kitchen infection control, and food receiving and storage required dishwashing to meet temperature and sanitation standards and refrigerated foods to be covered, labeled, dated, and used, frozen, or discarded by their use-by date, which was not consistently followed according to the survey findings.
Environmental Maintenance and Cleanliness Deficiencies in Resident Room and Common Restroom
Penalty
Summary
Surveyors identified that the facility failed to maintain a safe, clean, comfortable, and homelike environment as required by its “Homelike Environment” policy. Observation of a shared bedroom for Residents #46 and #56 showed wallpaper peeling from the wall in multiple locations, including behind each resident’s headboard, below the window, and near the baseboards. In the same room’s bathroom, a black substance was observed around the base of the toilet. During an interview conducted concurrently with these observations, CNA #175 confirmed the presence of the peeling wallpaper and the black substance around the toilet base. Further observation with CNA #175 in the C hall restroom revealed that three light covers in that restroom were cracked or broken. The facility’s written policy, revised in February 2021, states that residents are to be provided with a safe, clean, comfortable, and homelike environment. The conditions observed in the residents’ bedroom, bathroom, and the C hall restroom were inconsistent with this policy and affected two identified residents, with the potential to affect all residents in the facility.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
