Clovernook Health Care And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Cincinnati, Ohio.
- Location
- 7025 Clovernook Avenue, Cincinnati, Ohio 45231
- CMS Provider Number
- 365551
- Inspections on file
- 47
- Latest survey
- April 14, 2026
- Citations (last 12 mo.)
- 16
Citation history
Health deficiencies cited at Clovernook Health Care And Rehabilitation Center during CMS and state inspections, most recent first.
Surveyors identified multiple failures in food storage, labeling, and sanitation, including uncovered and undated prepared foods, expired dairy products, and opened, undated dry goods, along with missing paper towels at a handwashing sink. Food temperature logs showed multiple days and meals without recorded temperatures, despite policy requiring documentation at every meal. During pureed food preparation, a staff member reassembled a blender using gloves that had contacted contaminated surfaces without sanitizing hands. Ceiling vents over food prep areas were visibly soiled, one vent lacked a cover, there were no test strips to verify sanitizer concentration, no sanitizer testing logs for several months, and dish machine temperature gauges were unreadable due to condensation, preventing required temperature checks.
Surveyors found that the facility, licensed for more than 120 Medicare/Medicaid beds, did not employ a full-time qualified LSW as required. Personnel records showed that the person functioning in the social services role had been hired as a CNA and later promoted to social services but did not hold a social work license. In an interview, the Administrator confirmed both the regulatory requirement for a full-time LSW and that no LSW was employed at the facility.
Surveyors identified that nursing staff did not follow the facility’s hand hygiene policy when a unit manager and an LPN with direct resident care responsibilities wore long, painted artificial fingernails, contrary to the requirement for short, natural nails and discouragement of artificial nails. In addition, a resident with chronic kidney disease, DM, vascular dementia, dialysis treatments, and wounds had physician orders and a care plan for EBP, including use of gowns and gloves and directing staff and visitors to follow EBP, but the room lacked EBP signage and PPE availability. A RN and the infection prevention nurse confirmed that EBP had not been properly implemented for this resident, despite the facility’s EBP policy requiring such precautions for residents with wounds and indwelling devices.
Two residents experienced substandard environmental conditions when one cognitively intact resident with spinal stenosis fell from a shower chair as CNAs pushed the chair forward over a known raised, buckled area of the shower floor with chipped and missing tiles, despite staff awareness that residents should be pulled backward over the hump, and another cognitively intact resident with multiple chronic conditions, including hemiplegia, DM, and cardiovascular disease, was found with heavily soiled bed linens and a room floor littered with dirt, debris, and food crumbs, conditions verified by the DON.
The facility failed to conduct and document required initial and quarterly care conferences with residents and/or their representatives, as confirmed through record review and staff interviews. Several residents with complex conditions, including ESRD, dependence on dialysis, Alzheimer’s disease, heart disease, schizoaffective disorder, alcohol abuse, and anoxic brain damage, either had no initial care conference documented or missed multiple quarterly conferences. The Administrator acknowledged that quarterly care conferences were required and that there was no physical or electronic documentation to verify that these conferences occurred, despite a facility policy stating that residents and their representatives would be invited to care conferences with advance notice.
The facility failed to provide required nail care and personal hygiene assistance to multiple dependent residents. Several residents with conditions such as diabetes, cerebral infarction with hemiplegia, traumatic brain injury, peripheral vascular disease, and bilateral amputations were observed with long, jagged fingernails containing an unknown brown substance, despite care plans calling for regular nail trimming and cleaning. These residents reported wanting their nails cut and cleaned but needing staff help, and staff acknowledged the need for nail care. Another resident, cognitively intact and dependent on staff for bathing, dressing, and hygiene, remained in bed in a soiled hospital gown from breakfast through lunchtime and was not assisted to get up and dressed until well after a requested time. On a subsequent day, this resident was again observed in bed in a hospital gown, reported that her incontinence brief had not been changed for over five hours, and stated she had repeatedly requested assistance; staff confirmed that expected two-hour incontinence care and directed hygiene assistance had not been provided.
Staff did not follow the RD-planned renal diet menu when preparing meals for multiple residents on renal diets. During a lunch meal service, a staff member served pasta salad in a self-selected portion size and prepared grilled cheese sandwiches using American cheese instead of the Swiss cheese required for renal diets. The menu for the renal diet included pasta salad but did not specify a portion size, and facility policy stated that renal diet residents were allowed Swiss cheese and should avoid American cheese. The Diet Manager confirmed that the pasta portion size should have been clarified by the RD and that the incorrect cheese type was used.
A resident with an indwelling Foley catheter and multiple comorbidities, including CHF, CKD stage III, and major depressive disorder, was observed with a catheter bag attached to the bed frame facing the corridor without a dignity cover, leaving urine visible to anyone passing by. An LPN confirmed the absence of a dignity bag and acknowledged that one should have been in place. Facility policy on quality of life and dignity requires staff to promote dignity and assist residents in keeping urinary catheter bags covered, and prohibits demeaning practices that compromise dignity.
A resident with severe cognitive impairment and multiple comorbidities had genetic testing performed and was started on mirtazapine without documented notification or consent from the resident’s representative, despite facility policy and staff statements that new orders and changes in status should be communicated to the primary contact and documented. The representative later reported only learning of these medications and the genetic testing after the resident was transferred, while an LPN confirmed there was no documentation of notification and indicated that a genetic testing company handled consent without facility staff involvement.
The facility failed to provide and accurately complete the Notice of Medicare Non-Coverage (NOMNC) for three Medicare Part A beneficiaries with intact cognition who were receiving skilled services for conditions including asthma with acute exacerbation, type II DM, morbid obesity, left femur fracture, acute embolism, and cerebral infarction with hemiplegia. For each resident, the medical record and Skilled Nursing Beneficiary Protection Notification Review documented Medicare Part A episode start dates and last covered days, but there was no documentation that a NOMNC was issued, and in one case the Medicare Part A start date was recorded incorrectly. The President of Clinical Operations confirmed that NOMNCs were not provided, despite a facility policy requiring issuance of the notice at least two days before Medicare benefits end.
Surveyors found that the facility failed to develop comprehensive care plans for two residents, one with severe, ongoing pain and another with a history of frequent medication refusal. One resident, with multiple renal and diabetic conditions and physician orders for pain medications, had documented severe pain interfering with sleep and was observed in obvious distress, yet the care plan contained no pain management focus or interventions. Another resident with end stage renal disease and type 1 DM had repeated documented refusals of several ordered medications, but the care plan did not address or reflect this ongoing pattern of refusal, as confirmed by an LPN and a unit manager.
A resident with multiple comorbidities experienced escalating pain and repeatedly refused to get out of bed, with documentation of high pain scores and ineffective analgesia. A STAT x-ray later showed a femur fracture, but although an LPN received the results and stated she called the on-call provider, the call was not documented and the provider group was not notified until many hours later, delaying hospital transfer despite facility policy requiring prompt notification for changes in condition. In a separate case, another resident with severe cognitive impairment and dysphagia underwent an MBS that was inconclusive, and the hospital recommended obtaining an order for a more extensive MBSS; however, no order was obtained, no MBSS was scheduled, and neither the DON nor the LPN unit manager ensured follow-up on the written recommendation.
The facility failed to ensure safe smoking practices and safe shower chair maneuvering for two residents. One resident with oral cancer, a tracheostomy, impaired cognition, and a need for supervision with ADLs was initially assessed as a non-smoker, but the care plan later identified the resident as a smoker. Despite documentation of an apparent cigarette burn on the resident’s feeding tube and staff finding the resident smoking on a patio and keeping cigarettes at the bedside, no updated smoking assessment or specific safety interventions were implemented, contrary to facility policy. In a separate incident, another resident who required maximum assistance with bathing fell forward out of a shower chair when staff pushed the chair forward over a known hump in the shower room floor, despite the resident’s request to be pulled backward and staff knowledge that pulling the chair backward over the elevation was the safer method, in conflict with the facility’s fall prevention policy.
Staff failed to implement and monitor ordered fluid restrictions for three residents with cardiac and renal conditions, including those on renal diets and dialysis. One resident with heart failure received more fluid than the ordered daily limit, and the fluid restriction was not timely incorporated into the care plan, CNA tasks, or meal tickets. Another resident with CHF and CKD had an ordered fluid restriction but no corresponding care plan, CNA tasking, or dietary notation, and was observed with a full water pitcher and multiple cups of fluid at meals, which the resident reported occurred routinely. A third resident with ESRD on dialysis had no care plan or dietary documentation of a fluid restriction, was observed with large volumes of fluid at bedside and on the meal tray, and reported frequent refills of a personal water cup, with dialysis records showing excess fluid removal. Leadership and policy documents confirmed that water pitchers should be removed and fluid restrictions clearly communicated and followed by nursing and dietary, which did not occur.
A resident with chronic pain and multiple comorbidities was ordered scheduled Lyrica and Robaxin for pain, but staff failed to assess and document pain levels before and after medication administration over several months. MARs for multiple months lacked any pain scores or effectiveness documentation, and the resident reported ongoing pain rated 6–7/10 and stated no one had asked about pain since admission. The DON acknowledged unawareness of the resident’s kidney stone and unrelieved pain and confirmed that nurses did not document pain levels as expected, while the CNP confirmed staff did not communicate the resident’s pain levels or the ineffectiveness of the current pain regimen, contrary to the facility’s pain assessment policy.
A resident with severe cognitive impairment and hemiplegia, dependent on staff for all transfers, sustained bruising and swelling to the face when the Hoyer lift sling bar struck them during a transfer. Two CNAs were present, and staff interviews confirmed the incident occurred due to failure to prevent the bar from hitting the resident, contrary to facility policy.
The facility failed to ensure the activities program was directed by a qualified professional, affecting all 116 residents. The Admissions Director, hired as the Activity Director, lacked a resume and an Activity Director certificate. The HR Manager confirmed the absence of verification of past work experience, and the Administrator verified the individual was not qualified.
The facility did not employ a full-time, qualified social worker, affecting all 116 residents. The last social worker was hired and terminated within a few months, and the Administrator incorrectly believed the facility was licensed for fewer beds than required for this position.
The facility failed to coordinate transportation for a resident requiring dialysis, resulting in missed treatments and subsequent hospitalization. Additionally, there was a lack of communication with the dialysis center for another resident, violating facility policy. Interviews revealed issues with responsibility and staffing, contributing to these deficiencies.
The facility failed to ensure food safety and storage practices, with dented cans found in the kitchen and improper labeling and dating of food items in unit refrigerators. Observations revealed unlabeled and undated food items, and inconsistencies in monitoring refrigerator temperatures. Staff interviews indicated a lack of clear responsibility for these tasks, contributing to the deficiency.
A resident with severe cognitive impairment was pulled backwards in a geriatric chair by a CNA, contrary to facility policy which requires pushing chairs forward to maintain resident dignity. Staff interviews confirmed the expectation to push chairs forward, aligning with the facility's dignity policy.
The facility failed to ensure that the authorization to establish a Resident Funds Trust Account was witnessed by someone who was not an employee, affecting two residents. The authorization forms for these residents were signed by the residents and the BOM, but lacked a witness signature. An interview confirmed the absence of a non-employee witness.
A facility failed to notify a resident when their funds were within $200 of the Medicaid resource limit. A review of the resident's account showed a balance close to the $2,000 limit, but no notification was given. The Business Office Manager mistakenly thought the limit was $2,500.
A resident with chronic pain syndrome had a discrepancy between the physician's order and the medication label for oxycodone, leading to potential confusion in administration. The facility lacked a process to update medication labels immediately upon order changes, as confirmed by staff interviews.
A resident with type two diabetes had incomplete documentation in their medical records regarding the administration of Trulicity. The MAR indicated scheduled doses, but two entries were marked with a code requiring further details, which were missing from the progress notes. Interviews with nursing staff confirmed the lack of documentation, contrary to facility policy.
A resident with type two diabetes mellitus received the wrong insulin due to a medication error at an LTC facility. The resident was supposed to receive Novolog insulin according to a sliding scale but was mistakenly given Lantus insulin in the morning by an RN in training. The error was confirmed through observations and interviews with the involved staff, highlighting a failure to adhere to the facility's medication administration policies.
The facility employed an unqualified Dietary Manager, affecting all 115 residents receiving food from the kitchen. The Dietary Manager lacked necessary certifications or an associate degree in food service management, as confirmed by the RDO. The job description required registration as a Food Services Director in the state, which was not met.
A resident with a stage III pressure ulcer did not receive treatment as per the physician's order. The ulcer was supposed to be cleansed with derma cleanse, triad paste applied, and left open to air. Instead, staff used soap and water and applied triad paste to a dressing. Interviews confirmed the deviation from the prescribed treatment, and the facility's wound care policy was not followed.
A resident sustained a right distal femoral fracture after an STNA attempted to transfer them using a Hoyer lift without the required assistance of a second staff member. The incident was not immediately reported, and the resident's complaints of pain were initially overlooked. The STNA was terminated for failing to follow proper procedures.
Failure to Maintain Safe Food Storage, Temperature Monitoring, and Sanitation Practices
Penalty
Summary
The deficiency involves failure to store, label, date, and monitor food in accordance with facility policy and sanitary standards. Surveyors observed multiple issues in the kitchen, including uncovered prepared foods in the walk-in refrigerator with no dates or labels, undated wrapped sandwiches, a bag of boiled eggs without an open date, and an opened container of cottage cheese past its use-by date. Additional items such as opened and undated cheese and lettuce were also found. In the reach-in refrigerator, there were two containers of unidentifiable foods with no labels or dates. The dry storage area contained opened and undated bags of pasta, cake mix, potato chips, cheesecake mix, and frosting mix, as well as multiple cans of food with no received dates. The handwashing sink in the kitchen had no paper towels available. The Diet Manager confirmed that these foods should have been discarded, that paper towels should have been present at the handwashing sink, and that canned foods should be dated upon receipt, in contrast to the facility’s written policy requiring foods to be covered, labeled, dated, and rotated. The deficiency also includes failures in food temperature monitoring and dishwashing/sanitization practices. Review of food temperature logs for March and April showed missing temperature entries for entire days and for multiple supper meals, despite the Diet Manager stating that kitchen staff are supposed to log food temperatures at every meal. During observation of food preparation, a staff member reassembled a clean puree blender bowl and blade while wearing gloves that had already contacted the food counter and multiple items in the dish machine area, without sanitizing hands beforehand. Surveyors also observed six ceiling vents over the food preparation area with visible blackened fuzzy debris and one vent without a cover. There were no test strips available to check the chemical concentration of the sanitizing solution in the dishwashing area, and there were no logs of sanitizer bucket testing for several months. The dishwasher temperature gauges had internal condensation that made the temperatures unreadable. The Diet Manager verified that the staff member should have sanitized her hands before reassembling the food processor, that the vents should be clean and covered, that the sanitizer solution had not been tested due to lack of appropriate test strips, and that the dish machine temperature could not be monitored as required by facility policy.
Failure to Employ Required Full-Time Licensed Social Worker
Penalty
Summary
The facility failed to employ a full-time qualified Licensed Social Worker (LSW) despite being licensed for 126 Medicare/Medicaid beds and having a census of 119 residents, which required a full-time LSW. Review of personnel records showed that the individual serving in the social services role, identified as Social Service Worker (SSW) #175, was originally hired as a Certified Nursing Assistant (CNA) on 02/26/25 and later promoted to the SSW position on 10/27/25. Further review of this employee’s file confirmed that she did not hold a social work license. During an interview on 04/08/2026 at 3:23 P.M., the Administrator acknowledged that the facility was required to have a full-time qualified LSW and confirmed that SSW #175 was not licensed as a social worker and that the facility did not have any LSW employed at the time of the survey.
Failure to Enforce Hand Hygiene Standards and Implement Enhanced Barrier Precautions
Penalty
Summary
The deficiency involves failures in the facility’s infection prevention and control program related to hand hygiene and implementation of enhanced barrier precautions (EBP). Surveyors observed a unit manager and an LPN, both with direct resident care responsibilities, wearing long, opaque artificial fingernails that extended beyond the tips of their fingers. The unit manager’s nails were multicolored with raised decorations, and the LPN’s nails were opaque yellow. Both staff members confirmed in interviews that they had painted artificial fingernails extending beyond their fingertips. These practices were inconsistent with the facility’s Handwashing/Hand Hygiene policy dated October 2023, which required personnel with direct resident care responsibilities to maintain short, natural fingernails that do not extend past the fingertips and strongly discouraged artificial fingernails, prohibiting them for staff caring for severely ill or immunocompromised residents. The deficiency also includes failure to implement EBP for a resident with significant medical needs. The resident, admitted with chronic kidney disease, diabetes mellitus, and vascular dementia, had an order for outpatient dialysis twice weekly and was documented as having severely impaired cognition and dependence on staff for ADLs. The care plan, updated in early April, included an order for EBP with interventions directing staff and visitors to follow EBP, use gowns and gloves for all personal care, and educate staff and visitors on EBP. A physician’s order specified EBP related to dialysis access and wounds. However, observation revealed that the resident’s room lacked an EBP sign and there was no PPE available outside the room. A RN confirmed the resident required EBP due to dialysis and open wounds and acknowledged the absence of required signage and PPE. The infection prevention nurse also confirmed that EBP had not been properly implemented for this resident and that the order for EBP had not been obtained until the same day as the observation, despite the facility’s EBP policy stating that EBP should be used for residents with wounds and/or indwelling medical devices and remain in place for the duration of the stay or until resolution of the risk factors.
Failure to Maintain Safe Shower Environment and Clean Resident Room
Penalty
Summary
The deficiency involves the facility’s failure to provide a safe and clean environment for two cognitively intact residents. One resident, admitted with diagnoses including constipation, insomnia, vitamin D deficiency, and spinal stenosis, fell in the shower room when being transported in a shower chair over an uneven, buckled area of the shower floor. According to the post-fall investigation and staff and resident interviews, the shower room floor on the 300 hallway had a raised “hump” near the shower stall entrance and chipped and missing tiles. Staff reported that residents had to be pulled backwards in the shower chair over this hump to avoid them falling forward, but on the day of the incident the CNA pushed the resident forward over the hump despite the resident’s attempt to instruct the CNA to pull him backwards, resulting in the resident leaning forward and falling out of the chair and reporting severe pain. Multiple staff, including CNAs and an LPN, confirmed the presence of the buckled, uneven flooring and the need to move residents backward over the hump. The second resident, admitted with multiple diagnoses including hemiplegia/hemiparesis, cerebral infarction, DM, peripheral vascular disease, major depressive disorder, atherosclerotic heart disease, mood disorder, hypertensive heart disease, and insomnia, was found to be living in an unclean environment. During an observation of this resident’s room with the DON, the resident’s bed sheet was heavily soiled with dried red and brown substances all over, and the room floor was heavily soiled with dirt, debris, and food crumbs scattered throughout. The DON verified these conditions at the time of observation. These findings occurred despite a facility policy stating that residents are to be provided with a safe, clean, comfortable, and homelike environment.
Failure to Conduct and Document Required Resident Care Conferences
Penalty
Summary
The deficiency involves the facility’s failure to conduct and document timely initial and regular care conferences with residents and/or their representatives as required by regulation and facility policy. For one resident admitted with cerebral infarction, ESRD, and chronic congestive heart failure, the record showed only a single care conference held to discuss missing items, with no other documented care conferences. Another resident with acute respiratory failure, Alzheimer’s disease, and heart disease had no documentation of an initial care conference in the medical record. In each of these cases, the Administrator confirmed there was no physical or electronic documentation to verify that required care conferences had been conducted. Additional residents were affected by missed quarterly care conferences. One resident with ESRD and dependence on dialysis had only two care conferences documented in one year and none in the following year, leaving entire quarters without care conferences despite the Administrator’s acknowledgment that quarterly conferences were required. Another resident with schizoaffective disorder, alcohol abuse, and anoxic brain damage had no documented quarterly care conferences for the third and fourth quarters of a given year. Review of the facility’s policy on Resident Participation-Assessment/Care Plans showed that residents and/or their representatives were to be invited to care conferences with seven days’ advance notice, but the records and interviews demonstrated that this process was not followed for the affected residents.
Failure to Provide Nail Care and Personal Hygiene Assistance to Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate nail care and personal hygiene assistance to dependent residents, despite care plans and policies requiring such care. One resident with cirrhosis of the liver and type 2 diabetes, cognitively intact and requiring maximal assistance with personal hygiene, had a care plan intervention to keep fingernails short and avoid excessive moisture. Observation showed this resident’s fingernails were long, jagged, and had an unknown brown substance underneath. The resident stated he wanted his nails cut and cleaned but needed staff assistance, and a CNA confirmed the nails needed cutting and cleaning. Another resident with cerebral infarction, right-sided hemiplegia/hemiparesis, and chronic kidney disease, cognitively intact and dependent on staff for personal hygiene, also had a care plan indicating a self-care deficit and need for maximal assistance. Observation revealed long, jagged fingernails with an unknown brown substance, and the resident reported wanting his nails cut and cleaned but requiring staff help; a CNA verified the need for nail care. A third resident with traumatic brain injury and chronic kidney disease, with severe cognitive impairment and requiring moderate assistance with personal hygiene, was observed with similarly long, jagged fingernails and an unknown brown substance under the nails; an LPN confirmed the nails needed to be cut and cleaned. A fourth resident with cerebrovascular accident, peripheral vascular disease, and bilateral below-knee amputations, with moderate cognitive impairment and dependent for personal hygiene, had a care plan intervention to check nail length and trim and clean on bath day and as necessary. This resident was also observed with long, jagged fingernails and an unknown brown substance, stated he wanted his nails cut and cleaned but needed staff assistance, and a CNA confirmed the need for nail care. A fifth resident with hemiplegia/hemiparesis, cerebral infarction, and diabetes mellitus, cognitively intact and requiring staff assistance with bathing, dressing, and personal hygiene, reported not having had a shower and remaining in bed since breakfast, despite asking a CNA several times to get up and get dressed by a specific time to access her resident account. Observation showed the DON removing pieces of egg from the resident’s hospital gown and confirmed the resident was still in bed at lunchtime wearing a gown with food remnants from breakfast. The resident later confirmed she was not gotten out of bed and dressed until after the requested time, and the CNA acknowledged it was after that time before she had a chance to clean and dress the resident. On the following day, observations in the morning and afternoon again found the resident lying in bed wearing a hospital gown; the resident stated she had asked another CNA several times for help to clean up and get dressed and that her incontinence brief had not been changed since before breakfast. That CNA confirmed she had not assisted the resident with personal care since before breakfast and acknowledged she was expected to change incontinence briefs every two hours, but more than five hours had passed. An LPN confirmed she had directed the CNA to assist the resident to get up and dressed after breakfast, but the aide failed to do so. The facility’s policy on supporting activities of daily living stated that residents unable to carry out ADLs independently would receive services necessary to maintain grooming and personal hygiene.
Failure to Follow RD-Planned Renal Diet Menu and Portion Specifications
Penalty
Summary
The facility failed to implement the renal diet menu as planned by the Registered Dietitian (RD) for 15 residents on renal diets. During a lunch meal service, a staff member plated pasta salad for residents on renal diets using a #16 scoop and prepared grilled cheese sandwiches for these residents using American cheese. The Diet Manager confirmed that residents on renal diets should have received Swiss cheese instead of American cheese, in accordance with facility policy stating that residents on renal diets were allowed Swiss cheese and should avoid American cheese. The lunch menu for the renal diet included pasta salad but did not specify a portion size, and described a grilled cheese sandwich made with two slices of bread and three slices of Swiss cheese. Because the menu did not indicate a portion size for the pasta salad for the renal diet, the staff member chose a portion size based on personal judgment, and the Diet Manager acknowledged that the appropriate renal pasta portion should have been clarified by the RD. This deficiency affected 15 facility-identified residents receiving renal diets out of a total facility census of 119 residents. The observations, staff interviews, and review of the facility menu and policy showed that the menu lacked specific renal diet portion guidance and that staff did not follow the renal cheese type specified by policy and the RD-planned menu.
Uncovered Foley Catheter Bag Compromised Resident Dignity
Penalty
Summary
The facility failed to provide dignified care to Resident #58, who had an indwelling Foley catheter, by not keeping the urinary catheter bag covered as required by facility policy. Resident #58 was admitted on 03/07/26 with diagnoses including congestive heart failure, acute cystitis with hematuria, chronic kidney disease stage III, and major depressive disorder, and the admission MDS documented moderate cognitive impairment, bowel incontinence, and use of a bladder catheter. On 04/06/26 at 11:00 A.M., surveyors observed that the resident’s catheter bag was attached to the right side of the bed frame facing the corridor without a dignity bag, making the urine in the bag visible to anyone in the hallway. At 11:03 A.M., LPN #414 confirmed that the catheter bag did not have a dignity bag and acknowledged that it should have had one. Review of the facility’s “Quality of Life-Dignity” policy, revised August 2009, showed that staff are required to promote dignity and assist residents by helping them keep urinary catheter bags covered, and that demeaning practices and standards of care that compromise dignity are prohibited. This deficiency was cited as non-compliance under Complaint Numbers 2806245 and affected one of four residents reviewed for dignity, in a facility with a census of 119.
Failure to Notify Resident Representative of New Medication and Genetic Testing
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s representative of significant changes in the resident’s care, specifically new medication orders and genetic testing. Closed record review for Resident #138 showed the resident was admitted with multiple complex diagnoses, including cerebellar ataxia, dysphasia, vascular dementia, polyneuropathy, chronic pain syndrome, a left above-knee amputation, and schizoaffective disorder. An MDS assessment documented that the resident was severely cognitively impaired, dependent for all ADLs, and receiving antipsychotic, antianxiety, and antidepressant medications. On 04/03/25, informed consent for genetic testing was documented as having been obtained verbally from the resident, despite the documented severe cognitive impairment, and there was no documentation that the resident’s representative had been notified or had provided consent for the testing. Further record review showed that on 07/17/25, the physician ordered mirtazapine (Remeron) for the resident, but there was no documentation that the resident’s representative was notified of this new medication order. During interviews, the resident’s representative reported discovering multiple medications, including mirtazapine, only after the resident was transferred to another facility and stated she had not been informed of the initiation of mirtazapine or the reason for its use, nor of the genetic testing or its results. An LPN stated that facility practice required notifying the resident and primary contact of new orders and documenting this in the record, and confirmed there was no documentation of notification to the representative regarding the mirtazapine order or the genetic testing. The LPN also stated that the genetic testing company’s representative handled consent for testing and that facility staff were not involved. Facility policy on change in condition or status required prompt notification of the resident, attending physician, and resident representative of changes in medical or mental condition or status.
Failure to Provide and Accurately Complete NOMNC for Medicare Part A Discharges
Penalty
Summary
The deficiency involves the facility’s failure to accurately complete and provide the Notice of Medicare Non-Coverage (NOMNC) to residents whose Medicare Part A skilled services were ending. For one resident with asthma with acute exacerbation, type II diabetes mellitus, and morbid obesity, records showed admission, transition to Medicare Part A, and discharge dates, as well as an MDS Discharge-Return Not Anticipated assessment indicating intact cognition. The facility’s Skilled Nursing Beneficiary Protection Notification Review documented a Medicare Part A skilled service episode start date and last covered day, but there was no documented evidence that a NOMNC was given to this resident. A second resident with a left femur fracture and type II diabetes mellitus had intact cognition per the MDS Discharge-Return Not Anticipated assessment and a documented Medicare Part A skilled service episode start date and last covered day, yet again there was no evidence a NOMNC was provided. A third resident with acute embolism and thrombosis of the right lower extremity and cerebral infarction with left hemiplegia/hemiparesis was admitted, transitioned to Medicare Part A, and later discharged, with intact cognition noted on the MDS Discharge-Return Not Anticipated assessment. The facility’s review listed an incorrect Medicare Part A skilled service episode start date and a last covered day, but there was no documented NOMNC for this resident. During interview, the President of Clinical Operations confirmed the facility failed to provide NOMNCs to these three residents, despite a policy stating that a NOMNC must be issued at least two calendar days before Medicare benefits end.
Failure to Develop Comprehensive Care Plans for Pain and Medication Refusal
Penalty
Summary
The deficiency involves the facility’s failure to develop comprehensive care plans addressing pain management and medication refusal for two residents. One resident was admitted with diagnoses including acute pyelonephritis, bladder and kidney calculi, chronic kidney disease, and diabetes mellitus, had intact cognition, and required staff assistance with ADLs. Physician orders included Lyrica twice daily for chronic pain syndrome and Robaxin four times daily for pain, but the care plan dated shortly after admission did not include any focus or interventions for pain management. A pain assessment documented that this resident experienced severe pain frequently over the previous five days that interfered with sleep. Observation showed the resident in bed, constantly moving with a pained expression, and the resident reported urinary frequency, flank pain from a kidney stone, and rated the pain as 10 out of 10. The DON confirmed that the resident’s care plan did not address the need for pain management. The second resident was admitted with end stage renal disease and type 1 diabetes mellitus. The care plan developed after admission did not include a focus on the resident’s frequent refusal of medications, despite active physician orders for Lyrica, Renvela, calcium carbonate, trazodone, and Prostat. Multiple progress notes over several days documented repeated refusals of Renvela, calcium carbonate, trazodone, and Prostat at various times, indicating an ongoing pattern of medication refusal. An LPN confirmed that this resident had a history of frequently refusing medications throughout the stay, and the Unit Manager verified that the care plan did not reflect this frequent refusal. These findings show that the facility did not develop and implement complete, measurable care plans that addressed identified needs related to pain management and medication refusal for the affected residents.
Failure to Act on Change in Condition and Arrange Recommended Follow-Up Testing
Penalty
Summary
The deficiency involves the facility’s failure to provide timely care and treatment in response to a resident’s change in condition and to promptly act on diagnostic results. One resident with hypertensive heart disease, prior cerebral infarction, right-sided hemiplegia/hemiparesis, and diabetes was admitted in early January and was care planned as a substantial one-person assist for ADLs. Throughout late January and early February, the Medication Administration Record documented repeated administration of Tramadol for high pain scores ranging from 7 to 10, along with multiple nursing notes describing the resident’s refusal to get out of bed and non-verbal signs of pain. On one occasion, Tramadol was documented as ineffective. A nurse practitioner assessed the resident for left knee and shoulder pain and ordered a STAT x-ray of the left shoulder and hip. The STAT x-ray, completed the evening of the same day, showed a left femur fracture, and the radiology company faxed the results multiple times and left a voicemail for the facility. An LPN acknowledged receiving the x-ray results that night, recognized the fracture, and stated she called the on-call physician and left a message, but she did not document this call. She also confirmed the resident had significant pain overnight and did not want to get out of bed. The x-ray results were not reported to the provider group until the following morning, approximately 12 hours after the results were available, at which time the NP ordered the resident sent to the hospital. The medical director characterized the 12-hour delay between the x-ray being reported to the facility and the physician group being notified as unusually long and a breakdown in the reporting system. The DON confirmed staff did not notify her of the fracture on the evening the results were received, and the facility’s policy required prompt notification of the physician and others when there is a change in condition or discovery of an injury. A second deficiency involved the facility’s failure to arrange follow-up medical testing after an external diagnostic study. Another resident with cerebellar ataxia, dysphagia, vascular dementia, severe cognitive impairment, and total dependence for ADLs underwent a modified barium swallow (MBS). The hospital report indicated that meaningful results could not be obtained due to the resident’s inability to follow instructions and recommended that the facility obtain a physician’s order for a more extensive modified barium swallow study (MBSS). The medical record contained no orders for an MBSS. The DON stated she was not aware of the hospital’s recommendation and explained that unit managers were responsible for reviewing documents and orders when residents returned from appointments to ensure follow-up was completed. The LPN unit manager confirmed that no one had obtained an order or scheduled the recommended MBSS, and the resident’s representative reported she had returned from the appointment with paperwork indicating the need for an MBSS but had not heard back from the facility about any follow-up study.
Failure to Ensure Smoking Safety and Safe Shower Chair Maneuvering
Penalty
Summary
The deficiency involves the facility’s failure to assess and manage smoking safety for a resident and to implement safe maneuvering of a shower chair for another resident, resulting in accident hazards. One resident was admitted with malignant neoplasm of the lip, status post skin graft, had a tracheostomy, and was documented on the MDS as having impaired cognition and needing supervision with ADLs. An initial smoking safety evaluation at admission indicated the resident was not a smoker, and no further smoking assessments were completed. However, the care plan updated shortly after admission identified the resident as a smoker and included interventions such as instructing on smoking cessation and observing for burns, creating a discrepancy between the assessment and the care plan. Subsequent nursing notes documented that during a bolus tube feeding, the resident’s feeding tube was found leaking from what appeared to be a cigarette burn, and later staff found the resident sitting in a wheelchair on his patio smoking a cigarette. Staff confiscated the cigarette and searched the room for additional smoking materials. Later observation showed the resident retrieving a pack of cigarettes from his nightstand and leaving the room, and the resident confirmed he was going to smoke. The administrator acknowledged that no updated smoking assessment had been completed after the initial one that listed the resident as a non-smoker, and that no specific safety interventions were implemented following discovery of the apparent cigarette burn on the feeding tube or the resident smoking on the patio, despite a facility policy requiring evaluation of smoking status on admission and change in condition and prohibiting residents from keeping smoking items in their possession. The deficiency also includes an incident in which another resident fell from a shower chair due to unsafe maneuvering over uneven flooring. This resident, cognitively intact and requiring maximum assistance with bathing, fell forward out of a shower chair when CNAs maneuvered the chair over a hump in the shower room floor. The fall investigation identified uneven flooring and instability while crossing the elevation as contributing environmental factors, and the root cause was documented as failure to maintain resident stability and positioning during transport in the shower chair, particularly while maneuvering over the floor elevation. The resident reported that he had instructed the CNA to pull the chair backward over the hump, but the CNA continued to push the chair forward, resulting in the fall. Multiple staff, including CNAs, an LPN, and the maintenance supervisor, confirmed the presence of a large hump in the shower room floor and that for safety residents should be pulled backward over the hump rather than pushed forward, while the facility’s fall policy required identification and use of appropriate interventions to prevent falls.
Failure to Implement and Monitor Ordered Fluid Restrictions
Penalty
Summary
The facility failed to ensure staff followed ordered fluid restrictions for three residents with significant cardiac and renal conditions. One resident with pulmonary hypertension, bradycardia, and heart failure had an RD-ordered 1500 ml/day fluid restriction, with 840 ml to be provided by dietary and 660 ml by nursing. The MAR showed this resident received 1680 ml of fluid in a 24-hour period, exceeding the ordered restriction. The resident’s care plan was not updated to include the fluid restriction until several days later, and the CNA care plan did not include monitoring of the restriction as a task. During a lunch observation, the resident received no fluids, and the meal ticket did not contain any information about the fluid restriction. The CNA caring for the resident stated she did not know the resident was on a fluid restriction, and the DM confirmed there was no fluid restriction noted on the meal ticket, despite facility fluid restriction instructions specifying a set amount of fluid to be provided at lunch. A second resident with congestive heart disease, chronic kidney disease, and diabetes had a physician’s order for a renal diet and a 2000 ml/day fluid restriction, with 740 ml assigned to nursing and 1260 ml to dietary. There was no care plan addressing fluid restriction for this resident, and the CNA care plan did not include monitoring of the restriction. Meal tickets for breakfast, lunch, and supper contained no documentation of a fluid restriction. During observation, the resident had a full facility-provided water pitcher of approximately 960 ml on the overbed table and 480 ml of fluid on the meal tray. The resident reported that dietary and nursing did not follow the fluid restriction and routinely provided two to three cups of fluid at each meal and a full water pitcher daily. The DM verified there was no fluid restriction noted on the meal ticket, although the facility’s fluid restriction instruction sheet specified a lower fluid amount to be provided at lunch for this level of restriction. A third resident with end stage renal disease and dependence on dialysis had physician’s orders for a renal diet and a 1500 ml/day fluid restriction, with 840 ml assigned to nursing and 660 ml to dietary. There was no care plan for fluid restriction, and the CNA care plan did not include monitoring of the restriction. Meal tickets for all meals lacked any documentation of a fluid restriction. Dialysis records showed the resident was over dry weight with 1500 ml of fluid removed on one date and 3000 ml removed on another. During observation, the resident had a facility-provided water container of approximately 720 ml on the overbed table and 240 ml of fluid on the meal tray. The resident stated that dietary and nursing did not follow the fluid restriction and that CNAs filled a 20-ounce personal water cup one to two times per day, and also reported being verbally counseled by the dialysis nurse for being over dry weight due to excessive fluid intake. The UM and Administrator confirmed that residents on fluid restrictions should have water pitchers removed, and that fluid restrictions should be documented on CNA care plans and meal tickets and followed by both nursing and dietary, as required by the facility’s “Encouraging and Restricting Fluids” policy.
Failure to Assess and Document Pain and Effectiveness of Analgesics
Penalty
Summary
The deficiency involves the facility’s failure to routinely assess, document, and monitor pain and the effectiveness of pain medications for a resident on a pain management program. The resident was admitted with diagnoses including acute pyelonephritis, bladder and kidney calculi, chronic kidney disease, and type 2 diabetes mellitus, and had physician orders for Lyrica 50 mg twice daily for chronic pain syndrome and Robaxin 500 mg four times daily for pain. The MDS showed the resident had intact cognition and required staff assistance with ADLs. Review of the MARs for February, March, and April 2026 revealed no documentation of the resident’s pain level prior to administration of Lyrica and Robaxin and no documentation of the effectiveness of these medications in relieving the resident’s pain. During an interview, the resident reported a current pain level of six to seven on a 1–10 scale and stated that since admission no one had asked about her pain level. The DON confirmed she was unaware the resident had a kidney stone and had complained of unrelieved pain, and verified that nurses had not documented the resident’s pain level before and after administration of pain medications on the MARs for the reviewed months, despite the expectation that staff document pain level with each administration. The CNP confirmed that staff had not communicated the resident’s pain levels or that the current pain regimen was not effective. Review of the facility’s Pain Assessment and Management policy showed that staff were required to assess pain at least each shift for acute pain or significant changes in chronic pain, at least weekly for stable chronic pain, and to document the resident’s reported pain level with enough detail to gauge pain status and intervention effectiveness, which was not done in this case.
Failure to Prevent Injury During Hoyer Lift Transfer
Penalty
Summary
The facility failed to ensure that a resident was free from avoidable accidents during transfers with a mechanical (Hoyer) lift. The resident involved had multiple diagnoses, including sequelae of cerebral infarction, hemiplegia, congestive heart failure, and severely impaired cognition, and was dependent on staff for all activities of daily living, including transfers. The care plan and physician orders specified that transfers were to be performed using a Hoyer lift with two-person assistance. During a transfer, staff failed to prevent the Hoyer lift sling bar from hitting the resident's face, resulting in bruising and swelling to the lower left side of the mouth, lip, and chin. Staff interviews confirmed that two CNAs were present during the transfer and that the injury occurred when the sling bar swung back and struck the resident. The facility's policy on using a mechanical lifting machine required staff to ensure that the sling bar does not hit the resident during transfers. The incident report and staff interviews verified that this policy was not followed, leading to the resident's injury. The deficiency was identified during a complaint investigation and was based on medical record review, incident report, staff interviews, and policy review.
Unqualified Activity Director in Facility
Penalty
Summary
The facility failed to ensure that the activities program was directed by a qualified professional, which had the potential to affect all 116 residents. The Admissions Director, who was hired as the Activity Director, did not have a resume with work experience or an Activity Director certificate in their personnel file. An interview with the Human Resource Manager confirmed that the facility lacked verification of the Activity Director's past work experience and that the individual did not meet the qualifications required for the position. The Administrator also verified that the Activity Director was not qualified.
Failure to Employ a Qualified Full-Time Social Worker
Penalty
Summary
The facility failed to employ a full-time, qualified social worker, which is a requirement for facilities with more than 120 beds. This deficiency had the potential to affect all 116 residents residing at the facility. The employee file review revealed that the most recent social worker was hired on September 18, 2024, and terminated on December 19, 2024. An interview with the Administrator confirmed that the facility did not have a qualified social worker available for the residents. The Administrator mistakenly believed that the facility was only licensed for 119 beds.
Failure to Coordinate Dialysis Care and Communication
Penalty
Summary
The facility failed to provide safe and appropriate dialysis care for Resident #117 by not assisting and coordinating transportation to the dialysis center. Resident #117, who had diagnoses including end-stage renal disease (ESRD), heart failure, dysphagia, and dementia, missed dialysis treatments on three occasions due to transportation issues. The facility did not ensure that the necessary transportation forms were signed and submitted, resulting in the resident missing dialysis appointments on 12/26/24, 12/28/24, and 12/30/24. This led to the resident being sent to the hospital for evaluation and treatment after experiencing symptoms related to missed dialysis. Additionally, the facility failed to maintain active and ongoing communication with the dialysis center for Resident #05. Despite physician orders requiring the completion of a dialysis communication sheet with assessment and vital signs, there was no documented evidence of communication between the facility and the dialysis center for this resident. This lack of communication was verified by the Director of Nursing (DON) and was a breach of the facility's policy on care for residents with end-stage renal disease. Interviews with facility staff, including the Nurse Practitioner, Admissions Director, and Administrator, revealed a lack of clarity and responsibility regarding the arrangement of transportation and communication with the dialysis center. The facility had not had a social worker since 12/19/24, which contributed to the failure in arranging transportation for Resident #117. The Administrator acknowledged that the facility did not meet Resident #117's needs, and the resident's family expressed dissatisfaction with the care provided. The deficiency was investigated under Complaint Number OH00161189.
Deficiencies in Food Safety and Storage Practices
Penalty
Summary
The facility failed to ensure proper food safety and storage practices, as evidenced by the presence of dented cans in the kitchen and improper labeling and dating of food items in unit refrigerators. During an observation, four dented cans were found on the canned food rack, including two six-pound cans of pineapple, one six-pound can of mandarin oranges, and a six-pound can of stew vegetables. The Dietary Manager confirmed the findings and acknowledged that dented cans should be removed and returned for credit, as they pose a risk of bacterial growth and foodborne illness. Additionally, the facility did not maintain proper labeling and dating of residents' food items stored in unit refrigerators. Observations revealed unlabeled and undated food items, such as a foam container with barbecue chicken, a to-go cup from a local restaurant, and an open box of pizza snack rolls that were thawed despite instructions to keep them frozen. Interviews with dietary staff and nursing staff indicated a lack of clear responsibility and procedures for labeling, dating, and monitoring food items, leading to confusion and improper food storage practices. The facility also failed to consistently monitor and document the temperatures of unit refrigerators, which is crucial for ensuring food safety. Observations showed that temperature tracking logs were not present, and the thermometer in one refrigerator displayed a temperature of 30 degrees Fahrenheit without any recorded monitoring. Interviews with staff revealed inconsistencies in understanding who was responsible for checking and recording refrigerator temperatures, further contributing to the deficiency in maintaining safe food storage conditions.
Failure to Maintain Resident Dignity During Mobility Assistance
Penalty
Summary
The facility failed to maintain the dignity of Resident #54 during mobility assistance. Resident #54, who has severe cognitive impairment due to Huntington's disease, requires substantial assistance for mobility and uses a manual wheelchair. On the day of the observation, a Certified Nursing Assistant (CNA) was seen pulling the resident backwards in a mobile reclining geriatric chair from the resident's room to the nurse's station, which is approximately twenty-five feet away. This action was confirmed by the CNA, who acknowledged that pulling the chair was easier but recognized that pushing the chair forward would be more appropriate. Interviews with various staff members, including another CNA, a Licensed Practical Nurse/Unit Manager (LPN/UM), and the Director of Nursing (DON), confirmed that the facility's policy and expectation is to push chairs forward, allowing residents to see where they are going. The facility's policy on dignity, revised in February 2021, emphasizes that residents should be treated with dignity and respect at all times, promoting their well-being and self-esteem. The DON stated that staff had been educated on the importance of dignity and the proper method of transporting residents in chairs.
Failure to Ensure Proper Witnessing of Resident Fund Authorizations
Penalty
Summary
The facility failed to ensure that the authorization to establish a Resident Funds Trust Account was witnessed by someone who was not an employee of the facility. This deficiency affected two residents out of six reviewed for resident funds. In the case of Resident #9, the resident funds management authorization and agreement were signed by the resident and the Business Office Manager (BOM) #25, but lacked a witness signature. Similarly, for Resident #73, the authorization was signed by the resident and BOM #25, but again, there was no witness signature. An interview with BOM #25 confirmed that the authorization forms were not witnessed by someone who was not an employee of the facility.
Failure to Notify Resident of Medicaid Resource Limit
Penalty
Summary
The facility failed to notify a resident when their available funds were within the $200.00 Medicaid resource limit. This deficiency was identified during a review of resident fund documents and a staff interview. Specifically, the quarterly resident account statements for one resident showed a balance of $1,974.44, which is within $200.00 of the $2,000.00 Medicaid resource limit. However, there was no evidence that the resident was notified of this. During an interview, the Business Office Manager confirmed the finding and admitted to mistakenly believing the resource limit was $2,500.00 instead of $2,000.00.
Medication Labeling Discrepancy for Narcotic Administration
Penalty
Summary
The facility failed to ensure that a narcotic medication was accurately labeled to reflect current physician orders for a resident diagnosed with chronic pain syndrome. The resident had an order for oxycodone five milligrams, two tablets every eight hours as needed for pain. However, the label on the medication blister pack indicated an outdated order of one tablet every four hours as needed. This discrepancy was not updated on the Individual Control Drug Record (ICDR) or the medication label, leading to potential confusion in medication administration. Interviews with staff revealed that there was no process in place to match the Medication Administration Record (MAR) with the actual medication label or to update the label when an order changed. The Licensed Practical Nurse/Unit Manager acknowledged the lack of a process to change the medication label immediately upon order change. The Director of Nursing stated that the system required a change of order to be indicated in red ink or with a sticker on the label, but this was not done. The pharmacist confirmed that medication should not be administered if the label does not match the order, emphasizing the importance of updating both the blister pack card and the controlled medication sheet when an order changes.
Incomplete Medication Administration Documentation
Penalty
Summary
The facility failed to ensure that the medical records of a resident contained complete and accurate information regarding medication administration. The resident, who was admitted with a diagnosis of type two diabetes mellitus, had a prescription for Trulicity to be administered weekly. The Medication Administration Record (MAR) indicated that the medication was scheduled for administration on specific dates, but there was incomplete documentation for two of these dates. Specifically, the MAR showed a code '9', indicating 'Other/See Progress Notes', for the scheduled doses on two occasions, but the progress notes did not provide details on whether the medication was administered or any related circumstances. Interviews with the nursing staff revealed a lack of documentation regarding the administration of the medication. An LPN confirmed that she documented the code '9' but could not recall the details of the situation or whether the pharmacy or physician was contacted. The facility's policy requires detailed documentation when a medication is withheld, refused, or administered at a different time, including the reason and any actions taken. However, this policy was not followed, leading to incomplete records for the resident's medication administration.
Significant Medication Error in Insulin Administration
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors during insulin administration. This deficiency was identified through the case of a resident with type two diabetes mellitus, who had specific physician orders for Novolog (rapid-acting) insulin to be administered according to a sliding scale three times a day, and Lantus (long-acting) insulin to be administered at bedtime. On a particular day, the resident's glucose reading required six units of Novolog, but instead, six units of Lantus were administered in the morning by a registered nurse (RN) who was in training. This error was observed during a medication administration session and was confirmed through interviews with the involved RN, a licensed practical nurse (LPN), and the assistant director of nursing (ADON). The error occurred because the RN administered Lantus instead of Novolog, despite both insulin pens being available in the medication cart. The LPN, who prepared the medication, assumed the correct insulin was given, as Lantus was only supposed to be administered at night. The facility's policy on administering medications requires verification of the right medication, dosage, and method before administration, which was not adhered to in this instance. The pharmacist confirmed the error, noting the difference between the two types of insulin and the need for monitoring the resident for adverse effects. The facility's policies on medication and insulin administration were not followed, leading to this significant medication error.
Unqualified Dietary Manager Employed
Penalty
Summary
The facility failed to employ a qualified Dietary Manager, which had the potential to affect all 115 residents receiving food from the kitchen. During an interview, the Dietary Manager revealed she did not possess a certified dietary manager certificate, certified food service manager certificate, a national certification for food service management and safety from a national certifying body, or at least an associate degree in food service management. This was confirmed by the Regional Director of Operations, who verified that the Dietary Manager did not meet the minimum qualifications required for the position. The job description for the Director of Food Service indicated that the individual must be registered as a Food Services Director in the state and assist in planning, developing, organizing, implementing, evaluating, and directing the Food Services Department and its activities. This deficiency was investigated under Complaint Number OH00157178.
Failure to Follow Physician's Order for Pressure Ulcer Treatment
Penalty
Summary
The facility failed to follow the physician's order for the treatment of a pressure ulcer for a resident, which was identified during a survey. The resident, who was cognitively impaired and dependent on staff for various activities, had a stage III pressure ulcer on the sacrum. The physician's order specified that the ulcer should be cleansed with derma cleanse, triad paste applied, and left open to air every shift. However, during an observation, it was noted that the resident's coccyx had a dressing covered with feces, and the treatment was not performed as ordered. Instead, the area was cleansed with soap and water, and triad paste was applied to a dressing rather than directly to the skin, contrary to the physician's instructions. Interviews with the staff involved confirmed the deviation from the prescribed treatment. The STNA admitted to using only soap and water for cleansing, while the LPN acknowledged applying the treatment incorrectly. The supervising LPN also confirmed that she had provided incorrect instructions for the treatment. The facility's policy on wound care, which mandates adherence to physician orders, was not followed, leading to this deficiency. This incident was part of a complaint investigation, highlighting non-compliance with established wound care protocols.
Improper Hoyer Lift Transfer Results in Resident Injury
Penalty
Summary
The facility failed to ensure a resident was safely transferred by a Hoyer mechanical lift, resulting in actual harm. On the night of the incident, a State Tested Nursing Assistant (STNA) attempted to transfer Resident #15 from a wheelchair to a bed using a Hoyer lift without the required assistance of a second staff member. During the transfer, the resident's right leg was hit on the mechanical lift support bar, causing the resident to complain of pain. An X-ray later revealed that the resident had sustained a right distal femoral fracture, which required surgical repair and a subsequent hospital stay of five days. The resident, who had multiple medical conditions including cirrhosis, anxiety, chronic respiratory failure, morbid obesity, depression, diabetes, osteoarthritis, and chronic pain, was dependent on two staff members for all transfers using a Hoyer lift. Despite this, the STNA proceeded with the transfer alone, contrary to the facility's policy and the Hoyer Lift Manufacturer Guidelines. The incident was not immediately reported to the Nurse Practitioner (NP) or the Medical Director (MD), and the resident's complaints of pain were initially attributed to other causes. The facility's investigation revealed that the STNA had lied about receiving assistance from an LPN during the transfer. The STNA was subsequently terminated for failing to follow the proper procedures. The incident highlighted a significant lapse in adherence to safety protocols, resulting in severe injury to the resident. The facility's policy required at least two staff members to perform such transfers, and this protocol was not followed, leading to the resident's injury.
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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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