Continuing Healthcare Of Shadyside
Inspection history, citations, penalties and survey trends for this long-term care facility in Shadyside, Ohio.
- Location
- 60583 State Route 7, Shadyside, Ohio 43947
- CMS Provider Number
- 366285
- Inspections on file
- 36
- Latest survey
- March 27, 2026
- Citations (last 12 mo.)
- 6
Citation history
Health deficiencies cited at Continuing Healthcare Of Shadyside during CMS and state inspections, most recent first.
The facility failed to issue timely refunds to two residents or their estate after discharge and death, respectively. One resident with multiple sclerosis and osteoporosis was discharged to another setting, but a refund of private pay funds was not issued until more than 90 days later, exceeding both regulatory and facility policy timeframes. Another resident with dementia died in the facility, and a substantial refund owed to the estate was also delayed beyond 90 days, with the responsible party reporting repeated, unanswered contacts to corporate staff. The receptionist, who handled petty cash and communicated with the off‑site business office, and the administrator both confirmed that the refunds were not processed within the required time limits.
The facility’s written assessment of its staffing needs did not accurately reflect the number of staff required to meet resident care needs. The assessment, based on an average daily census of 83 residents including a locked memory care unit, listed estimated numbers of licensed nurses and nurse aides needed for direct care. However, the Regional Administrator later confirmed that administrative nurses (such as the DON, ADON, and MDS nurse) had been incorrectly counted as direct-care licensed staff, and administrative personnel (such as admissions and medical records staff) had been counted as nurse aides. This resulted in an inaccurate facility-wide assessment of the staffing resources necessary to meet residents’ assessed needs and care plans.
A severely cognitively impaired resident, fully dependent for ADLs and with multiple medical conditions, was observed seated alone in the dining room wearing only a hospital gown that left the back and legs exposed, with a full breakfast tray in front of him that he was not feeding himself. A CNA acknowledged bringing the resident to the dining room in the gown due to time and staffing constraints and recognized this was not appropriate but did not further cover the resident. An LPN stated it was acceptable for residents to be in the dining area in hospital gowns, despite the resident’s inability to choose his attire. This situation conflicted with the facility’s written policy requiring that residents be treated with dignity, respect, and privacy.
Staff failed to protect resident health information privacy by discussing medical conditions and treatment plans in public areas. A nurse practitioner and an RN discussed one resident’s medications in a hallway and assessed another resident’s ankle pain and new medication orders at a table in an activities room while other residents were present, without seeking the resident’s preference or moving to a private area. During a meal, a speech therapist questioned a resident with cognitive issues about a recent doctor’s appointment in a crowded dining room and then loudly asked an LPN across the room for details, prompting the LPN to describe the appointment within earshot of other residents and visitors, contrary to the facility’s privacy policy.
A resident with severe cognitive impairment, dysphagia, and total dependence for ADLs was brought to the dining room in an open-back hospital gown, leaving the resident exposed, and left sitting alone with a full breakfast tray and no staff assistance for an extended period. Breakfast had been delivered earlier, but no staff were present in the dining area, and the resident, who required full assistance with eating, was not fed until a CNA arrived from another unit and provided feeding without reheating the food. Staff interviews indicated there were not enough personnel or time to dress the resident appropriately before breakfast and that morning medication pass limited nurses’ ability to assist with feeding, despite a facility policy requiring care that maintains resident dignity and privacy.
Surveyors observed two residents in a memory care dining area eating lunch while a visitor held a small dog at the table, allowing the dog to lay its head on the table surface. The visitor, who had been holding the dog prior to the meal, did not perform hand hygiene and continued to hold the dog while feeding a resident. An LPN confirmed the sequence of events, and the DON acknowledged that having a dog at the table during meals and feeding a resident without hand hygiene violated the facility’s infection control policy, which is intended to reduce the risk of acquiring infections.
A resident with dementia and a history of falls experienced an unwitnessed fall and was found on the floor by a CNA, who notified an RN. The RN did not assess the resident or provide treatment, and the incident was not documented. The resident later complained of hip pain and showed decreased mobility, but was not transferred to the hospital until two days later, when an x-ray revealed a hip fracture.
A resident with multiple chronic conditions sustained a laceration to her foot requiring sutures after contacting a torn and rough footboard while attempting to sit up in bed. The unsafe condition of the footboard was not addressed prior to the incident, and there was no evidence of a system for ongoing maintenance and timely repair of resident equipment to prevent injuries.
A resident with multiple respiratory conditions experienced a decline in respiratory status, including labored breathing and low oxygen saturation. Staff administered oxygen above the ordered range for several days without additional interventions or updates to the care plan, and there was a lack of documented assessment or monitoring during a critical period. The resident was eventually transferred to the hospital and admitted for acute respiratory failure, COPD exacerbation, and pneumonia.
Four residents received antibiotics without meeting established infection criteria or proper documentation. In each case, antibiotics were administered for suspected infections such as pneumonia or UTI, but required surveillance checklists were incomplete or missing, and appropriate diagnostic tests were not always performed or communicated to the provider. Facility policy requiring infection prevention oversight and documentation was not consistently followed.
The facility did not follow dietary recommendations for two residents with complex medical needs, including not providing a prescribed nighttime protein snack for a resident on dialysis and failing to consistently document meal intake for another resident with malnutrition and dementia. Staff interviews and record reviews confirmed that dietary orders were not implemented and meal intake documentation was incomplete.
A resident with end stage renal disease and multiple comorbidities had all morning medications withheld on dialysis days over several months without a current physician order. Staff followed an outdated order from a previous admission, and the facility did not coordinate with the dialysis center or provider to clarify medication administration times, leading to improper medication management.
A resident admitted under hospice care with multiple diagnoses did not have medications properly reconciled on admission, resulting in an incorrect Lorazepam order and inconsistent documentation of Morphine administration. The MAR and narcotic count sheet contained discrepancies, and staff confirmed the errors in medication entry and record-keeping.
A resident with dementia and a history of falls experienced an unwitnessed fall that was not documented in the medical record, and neither the resident's representative nor the physician was notified until several days later, after the resident was hospitalized. This failure to follow notification protocols was confirmed by facility staff and was not in accordance with the facility's fall policy.
A resident with multiple comorbidities and a history of pressure ulcers was found to have a pressure relieving air mattress set incorrectly for their weight, contrary to the manufacturer's guidelines. Staff were unaware of the correct setting and did not address the service light, which indicated the mattress required maintenance. Documentation showed the mattress was checked regularly, but the improper setting and lack of response to the service alert persisted.
Failure to Timely Issue Resident Refunds After Discharge and Death
Penalty
Summary
The facility failed to ensure residents received refunds due within the regulatory timeframe of 30 days, and also failed to meet its own 90‑day refund policy. One resident with multiple sclerosis and osteoporosis was admitted and later discharged to an assisted living facility, with nursing documentation confirming the discharge. An invoice showed that this resident’s refund check for $1,565 was not issued until more than 90 days after discharge, exceeding both the facility’s policy and regulatory requirements. Another resident with dementia was admitted and later expired in the facility, with nursing notes documenting the death and notification of the physician, family, and hospice. An invoice indicated that a refund check for $6,440 to this resident’s estate was issued more than 90 days after the resident’s death. The responsible party reported not having received the refund despite multiple contacts with corporate staff. The receptionist, who managed petty cash and communicated with the corporate office, believed refunds should be issued within 90 days and acknowledged that the time elapsed for this refund exceeded that period. The administrator confirmed that refunds are processed by the corporate office, not on-site, and acknowledged that both residents’ refunds were issued later than 90 days after discharge or death and beyond the 30‑day regulatory requirement.
Inaccurate Facility Assessment of Staffing Needs
Penalty
Summary
The facility failed to accurately complete its facility-wide assessment regarding the number of staff needed to provide competent care to all residents during routine operations and emergencies. The written Facility Assessment Tool, updated 02/13/26, documented an average daily census of 83 residents, including a locked memory care unit with a 32-bed capacity and an average daily census of 28. The assessment identified a wide range of care needs for the memory care unit, including ADLs, mobility and fall risk, bowel and bladder care, skin integrity, mental health and behavioral needs, medications, pain management, infection prevention and control, management of medical conditions, therapy, nutrition, and person-centered psycho/social/spiritual support. The facility’s assessment stated it estimated needing 12–14 licensed nursing staff to provide direct care, 20–25 nurse aides, and three nursing personnel with administrative duties to care for the resident population. During an interview, the Regional Administrator confirmed that the staffing estimates documented on the Facility Assessment were incorrect. She explained that, when determining the number of licensed nurses providing direct care, she had inappropriately included administrative nurses such as the DON, ADON, and MDS nurse. Similarly, when calculating the number of nurse aides, she had included individuals in administrative roles, such as admissions and medical records staff. As a result, the facility assessment did not accurately reflect the overall number of facility staff actually needed to ensure a sufficient number of qualified staff were available to meet each resident’s needs as identified through resident assessments and care plans. This deficiency was identified as an incidental finding during the investigation of Master Complaint Number 2746972.
Resident Dignity Not Maintained When Brought to Dining Room in Exposing Hospital Gown
Penalty
Summary
Surveyors identified a failure to protect a resident’s dignity when a severely cognitively impaired memory care resident was observed seated alone in the dining room wearing only a hospital gown, with his back and legs exposed. The resident had multiple medical diagnoses including unspecified dementia, psychosis, delusional disorder, TIA, depression, anxiety, and significant physical limitations such as muscle weakness, difficulty walking, and unsteadiness. His most recent MDS showed a BIMS score of 0, highly impaired vision, unclear speech, and dependence on staff for all ADLs, including dressing, toileting, and eating. At the time of observation, he had a full breakfast tray in front of him but was not feeding himself. A CNA confirmed that the resident had been brought to the dining room in the hospital gown and stated there was not enough time or staff to get him dressed before breakfast, acknowledging that this was not appropriate attire for the dining room but leaving him uncovered. An LPN reported she believed it was appropriate for residents, particularly skilled residents, to be in the dining area in hospital gowns, while also acknowledging that this resident could not choose how he was dressed due to his cognitive impairment. The resident’s spouse stated she believed staff did everything they could given staffing ratios and that responses could be delayed because staff were busy. The facility’s Dignity, Respect, and Privacy Policy stated that residents were to be treated with respect and cared for in a manner that protected their privacy, but this was not followed in this incident.
Failure to Protect Resident Health Information Privacy in Public Areas
Penalty
Summary
The deficiency involves failures to maintain the privacy and confidentiality of residents’ personal health information during clinical interactions in public areas. A nurse practitioner and an RN discussed medications with Resident #7 in a hallway near a resident room after the resident approached the NP with questions about medications prescribed the prior day; there was no evidence the NP directed the resident to a private location for this discussion. The same NP and RN then went to the activities room, where six residents were seated at a table playing a dice game, and the NP discussed Resident #42’s ankle pain and the plan to prescribe new medication at the table without asking if the resident was comfortable being assessed there or making any accommodations to move her away from the other residents. Resident #42’s record contained a progress note documenting that she was seen by the NP and that new orders were received related to complaints of leg pain. A separate incident occurred in the dining area during lunch, where a speech therapist spoke with Resident #79 about a recent doctor’s appointment in the presence of two visitors, 11 residents, and two LPNs. When the resident, who had cognitive issues, could not provide the information, the therapist loudly called across the room to an LPN to ask about the appointment, and the LPN responded by describing the physician visit loudly enough to be heard from the other side of the room. The LPN later confirmed that private medical information had been requested and shared in the full dining area and acknowledged that this information should not have been disclosed in that public setting. These actions were inconsistent with the facility’s Dignity, Respect, and Privacy Policy, which requires that unnecessary individuals be asked to leave while care is provided and that residents’ privacy and dignity be maintained.
Insufficient Staffing Led to Delayed Feeding and Inappropriate Attire in Dining Area
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient nursing staff to maintain the highest practicable psychosocial well-being of a resident who was dependent for all ADLs and required full assistance with eating. The resident had severe cognitive impairment (BIMS score of 0), highly impaired vision, unclear speech, and multiple medical diagnoses including dementia, dysphagia, psychosis, delusional disorder, depression, anxiety, and significant physical limitations such as muscle weakness, difficulty walking, and unsteadiness. The MDS documented that the resident was dependent for eating and all ADLs, required a mechanically altered diet, and needed to be up in a chair for meals with assistance for intake per speech therapy. On the morning of the survey observation, breakfast trays arrived to the memory care unit shortly before 8:00 A.M. At 8:55 A.M., the resident was observed sitting alone in the dining room in a wheelchair, wearing a hospital gown that was open in the back, leaving his back and legs exposed, with a full breakfast tray in front of him. No staff were present in the dining area, and the resident was not feeding himself. A CNA confirmed that the resident had been brought to the dining room in the hospital gown because there was not enough time or enough staff to get him dressed before breakfast, despite knowing this attire was not appropriate for the dining room. The care plan included interventions for fall risk and having the resident eat meals in the all-purpose room for closer monitoring when awake. The resident remained without feeding assistance until 9:23 A.M., when another CNA arrived from a different unit and began feeding him, giving a few bites without reheating the food and then completing the meal. This CNA believed the resident sometimes fed himself and was unsure why he had not been fed earlier, estimating that breakfast trays arrived around 8:00 A.M. An LPN stated that nurses helped feed residents when they could but that mornings were very busy with medication pass, and she believed it was acceptable for a resident to be in the dining area in a hospital gown, even though the resident could not choose his clothing due to cognitive impairment. The resident’s spouse reported that he had required assistance with eating since a recent hospitalization for pneumonia and that she came daily to feed him lunch, noting that staff response could be delayed because they were very busy. The facility’s Dignity, Respect, and Privacy Policy required that residents be treated with respect and cared for in a manner that protected their privacy.
Dog at Dining Table and Lack of Hand Hygiene Breach Infection Control Policy
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program when a visitor’s dog was allowed at a dining table while residents were eating. During observation of the memory care unit dining area at lunchtime, two residents were seated together at a small table, each accompanied by a visitor. The visitor for Resident #77 was holding a small dog that repeatedly laid its head on the dining table. When Resident #77’s lunch tray arrived, the visitor continued to hold the dog and began feeding the resident without performing hand hygiene. An interview with LPN #384 confirmed that the visitor had been present prior to lunch, had continuously held the dog, and had not washed her hands or put the dog down at any point before feeding the resident. In a separate interview, the DON confirmed that having a dog at the table while residents were eating, and holding a dog while feeding a resident without hand hygiene, constituted an infection control issue and was against the facility’s infection control policy. Review of the facility’s Infection Control Prevention Policy, updated 01/11/25, showed that the facility’s policy was to provide care in a safe environment that promoted health and reduced the risk of acquiring infections. This incident was cited as an incidental finding of non-compliance during investigation of a master complaint.
Failure to Timely Assess and Treat Resident After Unwitnessed Fall
Penalty
Summary
A deficiency occurred when a resident experienced an unwitnessed fall with injury, and the facility failed to provide a timely assessment and necessary treatment. The incident began when a CNA observed the resident on the floor in front of her wheelchair and notified an RN. However, the RN did not assess the resident or provide needed treatment at that time. The CNA, after waiting for the nurse, assisted the resident back into her wheelchair without a nursing assessment, and there was no documentation of the fall or any assessment in the medical record for that date. Following the fall, the resident, who had a history of dementia, Alzheimer's disease, repeated falls, and was receiving hospice care, complained of hip pain and exhibited decreased mobility. Despite these symptoms, the resident was not transferred to the emergency room until two days later, after further assessment revealed significant pain and physical changes, including a leg length discrepancy. X-rays subsequently confirmed an acute right hip fracture, and the resident was then transferred to the hospital for treatment. Interviews and record reviews confirmed that the facility's fall policy, which required immediate assessment and notification of the physician and family, was not followed. The RN did not assess the resident after being notified of the fall, and the incident was not documented in the medical record. The lack of timely assessment and intervention resulted in a delay in necessary treatment for the resident's injury.
Failure to Maintain Safe Resident Equipment Resulting in Injury
Penalty
Summary
A deficiency occurred when the facility failed to maintain a resident's bedroom furniture in a safe condition, resulting in an injury. The resident, who had a history of respiratory failure, COPD, and type II diabetes, sustained a laceration to the top of her right foot after her foot came into contact with a torn and rough footboard while she was attempting to sit up in bed. The incident happened in the early morning hours, and the wound required hospital treatment, including the placement of seven sutures. Documentation and interviews confirmed that the footboard was in a state of disrepair at the time of the incident. Further review and staff interviews revealed that the rough patch on the footboard had not been addressed prior to the injury. There was no evidence provided to show that the facility had an effective system in place for the ongoing maintenance and timely repair of resident equipment to prevent such injuries. The resident's medical condition, including significant leg swelling and fragile skin, increased her vulnerability to injury, but the unsafe condition of the footboard was the direct cause of harm.
Failure to Provide Timely and Adequate Respiratory Care
Penalty
Summary
The facility failed to provide adequate and timely respiratory care and treatment for a resident with a complex medical history, including COPD, asthma, and recent pneumonia. The resident experienced a decline in respiratory status, exhibiting symptoms such as shortness of breath, abnormal lung sounds, and decreased oxygen saturation. Despite an order for oxygen at 1-5 liters per minute, staff increased the oxygen to seven liters without additional interventions or new orders, and there was no documented evidence of further assessment or monitoring of the resident's respiratory or neurological status for a two-day period. The resident's care plan included interventions for COPD, such as monitoring for signs of respiratory insufficiency and infection, but there was no documentation reflecting the use of oxygen or updates to the plan of care after the resident's respiratory decline. Progress notes indicated that the resident had labored breathing and low oxygen saturation, yet no new treatments or orders were implemented by the nurse practitioner after these findings. The medication administration record showed that oxygen was administered above the ordered range for five days, with no corresponding documentation of physician notification or adjustment of the care plan. Ultimately, the resident developed new onset shortness of breath and chest pain, with abnormal lung sounds and pitting edema, leading to a transfer to the hospital where the resident was admitted for acute respiratory failure with hypoxia, acute exacerbation of COPD, and pneumonia. Interviews with staff confirmed concerns about the resident's status and a lack of timely intervention or escalation of care prior to the hospital transfer.
Failure to Ensure Antibiotic Use Met Established Criteria
Penalty
Summary
The facility failed to ensure that antibiotic usage met established criteria, as evidenced by the administration of antibiotics to four residents without proper documentation or justification according to McGeer's criteria. In one case, a resident with chronic respiratory failure, heart failure, and liver disease was given Omnicef for pneumonia despite not meeting the criteria for antibiotic treatment, with no documented explanation from the physician. The infection preventionist confirmed that the x-ray did not show pneumonia and there was no evidence supporting the need for antibiotics. Another resident with heart failure, diabetes, and benign prostatic hyperplasia received Bactrim for a urinary tract infection after returning from the hospital, but was not listed on the infection control log and did not have McGeer criteria completed. The DON and RN confirmed that the resident did not meet the criteria for antibiotic treatment, and the infection preventionist was not notified until several days after the antibiotics were started. Similarly, a resident with dementia and diabetes was started on Keflex for a suspected urinary tract infection without a completed culture or McGeer criteria form, and there was no evidence that the physician was informed about the lack of culture results. A fourth resident with dementia, ileus, and dysphagia was treated with Keflex for a urinary tract infection after returning from the emergency room, despite a urinalysis showing no significant growth and not meeting McGeer's criteria. The DON documented that the resident was started on antibiotics in the emergency room, but the medical provider ordered the medication to be continued based on a change in condition, agitation, and increased confusion, rather than established infection criteria. Facility policy required the infection preventionist to ensure appropriate testing and documentation before antibiotics were ordered, but this was not consistently followed.
Failure to Implement Dietary Recommendations and Monitor Nutrition
Penalty
Summary
The facility failed to implement dietary recommendations and adequately monitor and document meal intake for two residents with significant nutritional needs. For one resident with end stage renal disease, protein-calorie malnutrition, heart failure, diabetes, and liver disease, the dialysis dietician had recommended high-protein snacks at night to address low albumin levels. Despite this recommendation being faxed to the facility, there was no evidence of a corresponding order, documentation, or provision of a nighttime protein snack. Interviews confirmed that the facility's dietician had misplaced the recommendation, and the resident did not routinely receive a protein snack at night unless specifically requested. For another resident with dementia, anemia, malnutrition, and other chronic conditions, the care plan included multiple interventions to address nutritional risk, such as monitoring meal intake and providing assistance as needed. However, review of documentation revealed several instances where meal intake was not recorded, and analysis of the available records showed variable and often low meal consumption. Staff interviews confirmed that meal intake was expected to be documented for every meal, but gaps in documentation were present. Observations and interviews further supported that the facility did not consistently follow through on dietary recommendations or maintain accurate records of residents' nutritional intake. The lack of implementation of specific dietary orders and incomplete documentation of meal consumption contributed to the deficiency in ensuring adequate food and fluid provision to maintain residents' health.
Failure to Clarify and Implement Dialysis Medication Orders
Penalty
Summary
The facility failed to ensure that dialysis orders regarding the holding of medications were clarified and properly implemented for a resident with end stage renal disease and multiple comorbidities, including heart failure, diabetes, and liver disease. Medical record review showed that after the resident's readmission, there was no evidence of physician orders to hold medications on dialysis days, yet staff continued to withhold all morning medications on those days. This practice occurred repeatedly over several months, as documented in the medication administration records, without any supporting physician order. Interviews with the DON confirmed that staff were following an outdated order from a previous admission and had not obtained clarification or new orders from the physician or dialysis center. The DON acknowledged that staff held all morning medications on dialysis days in February, March, and April without a current physician order. The facility's policy required coordination with the dialysis center and provider regarding medication administration times, but this was not followed, resulting in the deficiency.
Failure to Reconcile and Accurately Document Medications on Admission
Penalty
Summary
The facility failed to ensure proper reconciliation of medications upon admission for a resident who was admitted under hospice care and had multiple complex diagnoses, including dementia, Alzheimer's disease, COPD, and a malignant neoplasm. The hospice medication list specified Lorazepam 0.5 mg to be given every four hours for anxiety and/or restlessness, and Morphine Sulfate Oral Solution to be administered in varying doses based on pain level or shortness of breath. However, the physician order entered at admission incorrectly listed Lorazepam to be given four times a day instead of every four hours as per the hospice order. This discrepancy was confirmed by the Regional Clinical RN during an interview. Additionally, there were inconsistencies in the documentation and administration of Morphine Sulfate. The Medication Administration Record (MAR) and the narcotic count sheet did not match regarding the times and amounts of Morphine administered. For example, the MAR showed doses of 0.75 ml and 1.0 ml administered at specific times, while the narcotic count sheet recorded a 0.5 ml dose at different times, indicating inaccurate documentation. These failures in medication reconciliation and documentation were identified through medical record review and staff interviews.
Failure to Notify Resident Representative and Physician After Unwitnessed Fall
Penalty
Summary
A resident with multiple diagnoses, including dementia, Alzheimer's disease, chronic obstructive pulmonary disease, malignant neoplasm of the bronchus or lung, and a history of repeated falls, was admitted to the facility on hospice services. The resident's baseline care plan identified them as being at risk for elopement, wandering, and falls, with interventions in place such as keeping commonly used articles within reach, maintaining clear pathways, monitoring for side effects of psychotropic medications, and assigning a room close to the nurses' station. On a specified date, the resident experienced an unwitnessed fall, as documented in the facility's investigation. Despite the fall, there was no documentation in the resident's medical record indicating that the fall occurred, nor was there evidence that the resident's representative or physician was notified at the time of the incident. Notification to the responsible party and physician did not occur until several days later, after the resident was hospitalized. The facility's fall policy required prompt notification of the physician and resident representative following a fall, but this protocol was not followed in this instance.
Failure to Set and Maintain Pressure Relieving Mattress per Manufacturer Guidelines
Penalty
Summary
The facility failed to ensure that a pressure relieving air mattress was set according to the resident's weight and maintained per the manufacturer's guidelines for a resident with a history of pressure ulcers and multiple comorbidities, including suspected deep tissue injury, peripheral vascular disease, anemia, chronic kidney disease, vascular dementia, hemiplegia, protein-calorie malnutrition, and diabetes. The resident's care plan and medical records indicated the use of an air mattress as an intervention for impaired skin integrity, with the resident weighing 174.5 pounds. However, observations revealed that the mattress was set at a level intended for residents weighing 441-500 pounds, rather than the correct setting for the resident's weight range of 163-244 pounds as specified by the manufacturer's label and manual. Despite staff documenting that the mattress was checked every shift and no issues were noted, the incorrect setting persisted, and the service light on the mattress was illuminated, indicating the need for service after a certain number of hours of use. Interviews with staff, including the ADON and CNA, confirmed a lack of awareness regarding the correct weight-based setting and the significance of the service light. The facility was not tracking the service light or notifying the rental company when it was activated, as required by the manufacturer's guidelines. These actions and inactions resulted in the failure to provide appropriate pressure ulcer care and prevention for the resident.
Latest citations in Ohio
Surveyors found that multiple hazardous storage areas, including a closet near medical records, a beauty salon used to store chemical cases, a supply room in one nursing station, a room leading to a smoking area, a housekeeping room near therapy, and a lobby storage room, lacked required self-closing or automatic-closing doors. These conditions did not comply with NFPA 101 requirements for hazardous area enclosure and had the potential to affect all residents and staff in an emergency.
Surveyors found that the facility did not conduct fire drills on every shift each quarter and did not vary drill conditions as required by NFPA 101. Record review showed that one shift lacked a documented drill for an entire quarter, and the pattern of drill times and dates did not demonstrate varied conditions. The Maintenance Director confirmed the incomplete and noncompliant fire drill schedule, which affected all residents and staff emergency preparedness.
Surveyors found that the facility did not maintain clear egress corridors as required by NFPA 101, with a TV/video cart plugged into a corridor outlet and multiple unsecured chairs placed in the hallway near resident rooms and the secured unit dining room, including directly in front of a fire extinguisher. These items projected about 29 inches into an approximately eight-foot-wide corridor and were located in front of the handrail, potentially affecting 28 residents and staff’s ability to assist in an emergency. The Maintenance Director confirmed these corridor obstructions during the survey.
A resident with intact cognition receiving Medicare Part A skilled services for metabolic encephalopathy had services discontinued while benefit days remained, but the facility did not issue the required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN). The Social Services Director later confirmed that no SNF ABN was provided and reported she believed only a Notice of Medicare Non-Coverage (NOMNC) was needed when all skilled services were stopped. This practice conflicted with the facility’s written policy, which required SNF ABNs to be issued when extended care items or services were initiated, reduced, or terminated due to expected non-coverage by Medicare.
Surveyors identified that the facility exceeded the acceptable medication error rate when two residents with type 2 DM received insulin doses that were not administered according to orders or manufacturer instructions. In two separate observations, an LPN administered Novolog and another LPN administered insulin glargine and insulin lispro without priming the insulin pens, and the insulin lispro and Novolog were given after the residents had already consumed a significant portion of their breakfast meals, despite orders for administration before meals. Manufacturer information for both insulin products required priming before each injection to ensure accurate dosing, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and specified time frames.
A cognitively intact resident with behavioral issues, including physical aggression and noncompliance with care, was in a secured unit and was observed tapping on the window/door. A dietary aide, despite being told by a CNA and an RN not to enter the secured unit and that the resident’s assigned aide could assist, went onto the unit and interacted with the resident, including offering to buy a soda after seeing money in the resident’s hand. The resident struck the aide in the face, and the aide responded by punching the resident in the face; a CNA reported hearing the aide say, “I will hit you again,” and then observed the resident bleeding. The resident was later found at the hospital to have an open mandibular fracture and non-restorable teeth requiring extraction, and the facility’s investigation and policy definitions led to the incident being substantiated as staff-to-resident physical abuse.
A resident with severe cognitive impairment, osteoporosis, and total dependence for transfers was being moved from bed to wheelchair with a mechanical lift when CNAs reported that an undersized sling and a forceful pull on the lift caused the resident to fall feet‑first from the sling, with staff catching the upper body while both legs struck the floor and one leg bent behind. Witnesses heard a loud pop and observed immediate pain, bruising, swelling, and deformity of the leg, yet the responding LPN did not complete a thorough musculoskeletal assessment, did not document a fall, and the physician and resident representative were not promptly informed of a suspected injury. Through the night and into the next day, staff and the roommate reported the resident crying out in pain and an obviously abnormal leg, but nursing notes only reflected intermittent acetaminophen administration without clear pain documentation, and the physician was contacted primarily about yelling and behavior. Mobile X‑rays obtained later showed a displaced distal femur fracture, which was not reviewed until the following day, when hospital imaging confirmed a closed displaced comminuted femur fracture and a hand fracture. The facility’s internal investigation was incomplete and inaccurate, with leadership denying a fall, preparing a single typed statement minimizing the event, and having multiple staff sign it despite later testimony that the statement was false and that staff were told not to discuss the incident.
Surveyors found multiple instances of improper food storage and labeling, including undated and unlabeled opened dairy products, beverages, and prepared foods in the main walk-in cooler and freezer, as well as a serving scoop left resting directly on stored pasta. Additional issues included covered but undated pre-poured juices, milk, and thickened beverages in a reach-in cooler used for tray line, and a nurses' station refrigerator containing a dated bag of a resident’s food from over a week prior and three undated half-sandwiches. In a resident’s personal refrigerator, staff confirmed three undated bags of grapes with visible mold. These conditions did not comply with facility policies requiring cold foods to be stored off the floor, wrapped or covered, labeled, dated, and for resident refrigerators to be monitored daily with unsafe or moldy food discarded.
Surveyors found unsanitary kitchen conditions, including a dirty tray holding clean pitchers, soiled storage carts containing clean dishware and disposables, and multiple trays of open juice in a reach-in refrigerator that were unlabeled and undated. In a walk-in refrigerator, they observed a bag of bologna marked only with a freeze date, lacking a thaw or use-by date, and appearing slimy and discolored. Observation of the high-temp dishwasher showed rinse temperatures below the 180°F minimum required for hot water sanitizing, and review of several months of temperature logs revealed repeated sub-minimum wash and rinse temperatures and numerous missing entries. Facility policies required dishwashing to meet specified temperature standards and all refrigerated foods to be covered, labeled, and dated with a use-by date, but these requirements were not consistently followed.
Surveyors found that the facility did not maintain a safe, clean, and homelike environment as required by its policy. In one shared bedroom, wallpaper was peeling in several areas, including behind each bed, below a window, and near baseboards, and a black substance was present around the base of the toilet. A CNA confirmed these conditions. In addition, three cracked or broken light covers were observed in a hall restroom. These environmental issues affected two residents and had the potential to affect all residents.
Failure to Maintain Self-Closing Doors for Multiple Hazardous Storage Areas
Penalty
Summary
Surveyors identified a deficiency related to hazardous area protection and door requirements under NFPA 101, 2012 Edition. During facility tours, they observed that multiple hazardous storage areas did not have self-closing or automatic-closing doors as required for hazardous areas such as combustible storage and chemical storage. These areas included a closet next to medical records, a beauty salon being used to store cases of chemicals, a supply room in Station #2, and the room leading to the smoking area in Station #3. On a subsequent tour, surveyors observed additional hazardous areas without self-closing doors. The housekeeping room across from therapy and the lobby storage room were both noted to lack self-closing door mechanisms. The facility census at the time was 59 residents, and the surveyors stated that this deficient practice had the potential to affect all residents and staff's ability to assist in an emergency. The Maintenance Director verified these findings at the time they were observed.
Plan Of Correction
K 0321 This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be admissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as its allegation of substantial compliance as of 06/12/2026 K-0321 Doors with Self-Closing Devices Corrective action for resident/s: 1. The closet door next to medical records was lacking a self-closing door on 5/19/2026. Maintenance director to add self-closing device to closet door next to medical records on or before 06/12/2026 in accordance with applicable code. 2. The beauty salon had chemicals stored in it on 5/19/2026. Maintenance director moved chemicals from beauty salon on 05/20/2026 in accordance with applicable code. 3. The supply room on station 2 was lacking a self-closing door on 5/19/2026. Maintenance director to add self-closing door to supply room on station 2 on or before 06/12/2026 in accordance with applicable code. 4. The room to the smoking area on station 3 was lacking a self-closing door on 5/19/2026. Maintenance director to add a self-closing door to the smoking are on station 3 on or before 06/12/2026 in accordance with applicable code. 4. The housekeeping room across from therapy was lacking a self-closing door on 5/19/2026. Maintenance director to add a self-closing door to the housekeeping room across from therapy gym on or before 06/12/2026 in accordance with applicable code. 5. The lobby storage room was lacking a self-closing door on 5/19/2026. Maintenance director to add a self-closing door to the lobby storage room on or before 06/12/2026 in accordance with applicable code. Identification of other residents who may be affected: LNHA and Maintenance director/designee completed a full facility audit for doors with self-closing devices on 05/26/2026. Any corrective action, including, doors identified as needing self-closures will be added on or before 06/09/2026 in accordance with applicable code. Measures for systemic change: LNHA educated Maintenance Director on 05/26/2026 regarding NFPA 101-2012 sections 19.3.2.1 and 19.3.5.9 specifically regarding doors with self-closing devices. How Corrective Action will be monitored Ongoing "Doors with Self-Closing device audit" to be completed weekly x 2 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 06/12/2026
Failure to Conduct Required Quarterly Fire Drills on All Shifts
Penalty
Summary
The facility failed to conduct fire drills in accordance with NFPA 101, 2012 Edition, sections 19.7.1 through 19.7.1.8, specifically by not holding drills every shift each quarter and not varying drill conditions as required. Record review on 06/09/25 at approximately 10:32 A.M. showed there was no fire drill conducted for the first shift during the third quarter. The documented first-shift fire drills occurred on 01/30/26 at 2:42 P.M., 04/30/26 at 1:51 P.M., and 10/31/25 at 10:58 A.M., indicating a missed quarter. Second-shift fire drills were recorded on 02/26/26 at 5:20 P.M., 06/03/25 at 4:35 P.M., 08/29/25 at 3:46 P.M., and 11/25/25 at 5:09 P.M., and third-shift drills on 02/28/26 at 11:47 P.M., 05/30/25 at 12:18 A.M., 07/22/25 at 11:34 P.M., 09/26/25 at 11:40 P.M., and 12/15/25 at 5:17 A.M. The surveyor determined that drills were not conducted under varied conditions and that the required quarterly drill on each shift was not consistently performed. The Maintenance Director confirmed these findings at the time they were identified, and the deficiency had the potential to affect all 59 residents and staff response in an emergency. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency related to facility-wide emergency preparedness practices and documentation of fire drills.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 05/29/2026 K-0712 Fire Drills Corrective action for resident/s: There were no records of a fire drill for the first shift of the third quarter of 2025. First shift fire drill completed on 5/24/2026 by maintenance director/designee with no findings or corrective action necessary. Identification of other residents who may be affected: On 5/26/2026 Maintenance director/designee completed 100% audit of the scheduled fire drills to ensure a drill is scheduled quarterly each shift with no findings or corrective action necessary. Measures for systemic change: LNHA educated Maintenance Director on 05/26/2026 regarding NFPA 101-2012 section 19.7.1.4 through 19.7.1.7. specifically including fire drill frequency requirements. How Corrective Action will be monitored Ongoing "Fire Drill Audit" to be completed weekly x 2 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 05/29/2026
Obstructed Egress Corridors Due to Equipment and Chairs
Penalty
Summary
The facility failed to maintain required clear egress widths in corridors in accordance with NFPA 101, 2012 Edition, sections 19.2.3.4 through 19.2.3.5 and 7.3.2 through 7.3.2.3, creating projections into the egress corridor that exceeded allowable limits. Surveyors observed that on one day in Station #3, a cart with a television and video equipment was plugged into an outlet in the corridor by room 38, and five activity room chairs were placed in the corridor near the secured unit dining room directly in front of a fire extinguisher. On the following day, surveyors again observed chairs in the Station #3 corridor, with four by room 35 and four by the activities room, and the same television cart still in the corridor; the chairs were not secured. The corridor was approximately eight feet wide, and the projections extended approximately 29 inches into the corridor in front of the handrail. These conditions had the potential to affect 28 residents in the facility and the staff’s ability to assist in an emergency, and the Maintenance Director confirmed the observations at the time of discovery. No specific resident medical histories or conditions were described in the report, only that 28 residents were potentially affected and the facility census was 59.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be subsequent remedial measures and should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 05/29/2026 K-0232 Clear path of egress Corrective action for resident/s: 1. On 05/18/2026 station 3 had a cart with a television parked in the corridor by room 38 that exceeded allowable limits. Maintenance director/designee moved the TV cart into the activity room, out to the corridor on 05/18/2026 in accordance with applicable code. 2. On 5/18/2026 station 3 had 5 chairs in the corridor near the dining room directly in front of the fire extinguisher. Maintenance director/designee moved the chairs into the dining room, out of the corridor on 5/18/2026 in accordance with applicable code. 3. On 5/19/2026 station 3 had 4 chairs by the activity room and 4 by room 35. In addition, the TV cart was in the corridor. The maintenance director/designee moved the chairs and TV cart into the dining room, out of the corridor on 5/19/2026 in accordance with applicable code. Identification of other residents who may be affected: Maintenance director/designee completed a 100% facility audit for clear paths of egress on 5/26/26 with no findings or corrective action necessary. Measures for systemic change: Maintenance Director/designee educated staff on 5/26/2026 regarding NFPA 101-2012 section 19.2.3.4 and 19.2.3.5 specifically including maintaining a clear path of egress. How Corrective Action will be monitored Ongoing "Path of Egress Audit" to be completed weekly x 2 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 05/29/2026
Failure to Issue Required SNF ABN When Discontinuing Medicare Part A Services
Penalty
Summary
The deficiency involves the facility’s failure to issue a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) when Medicare Part A services were discontinued for a resident who still had available benefit days. The resident was admitted with a diagnosis of metabolic encephalopathy and had intact cognition per the Minimum Data Set assessment. The facility’s own SNF Beneficiary Notification Review documented that Medicare Part A skilled services began on 02/11/26 and the last covered day was 03/11/26, and that the facility initiated discharge from Medicare Part A services before the resident’s benefit days were exhausted. Despite this, no SNF ABN was provided to the resident or the resident’s representative. During interviews, the Social Services Director stated that the SNF ABN was issued hours prior to the last covered day but, upon reviewing her files, confirmed that no SNF ABN had actually been issued for this resident. She further explained that she believed an SNF ABN was only required if one skilled service remained and that if all skilled services were being discontinued, only the Notice of Medicare Non-Coverage (NOMNC) needed to be issued. The Administrator, however, stated that a resident should always receive both a SNF ABN and a NOMNC when Medicare Part A services are discontinued and benefit days remain. Review of the facility’s written policy dated 03/28/23 showed that the facility was required to issue SNF ABNs for initiation, reduction, or termination of extended care items or services when Medicare payment was not expected, which did not occur in this case.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as its allegation of substantial compliance as of 05/29/2026 F-0582 Corrective action for resident/s: On 5/14/26 Resident #34 was informed of rights and responsibilities related to Advanced Beneficiary Notice and voiced understanding of information for future reference by administrator. Identification of other residents who may be affected: Any resident receiving skilled services from nursing or therapy services. The Administrator audited all residents who were discharged from skilled services in the past 30 days to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary Notice on 5/29/26. No non-compliance was noted. Measures for systemic change: On 5/14/2026 Business Office Manager, Director of Rehab, Minimum Data Set nurse, Director of Nursing and Social Services Director were educated on proper procedure of issuing of Notice Of Medicare Non Coverage and Advanced Beneficiary Notice by administrator. All upcoming discharges from skilled services will be reviewed weekly at Utilization Review meeting to ensure notices will be delivered timely. How Corrective Action will be monitored: Administrator or designee to complete audits of all residents being discharged from skilled services to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 5/29/26
Insulin Administration Errors and Failure to Prime Insulin Pens
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5%, with surveyors identifying 3 errors out of 28 medication administration opportunities, resulting in a 10.71% error rate. For one resident with type 2 diabetes mellitus and moderate cognitive impairment, the physician’s order directed Novolog insulin 10 units via subcutaneous pen-injector to be given before meals. During an observed medication pass, the LPN administered 10 units of Novolog insulin without priming the pen and did so after the resident had already consumed approximately 50% of the breakfast meal. The LPN later confirmed she did not prime the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer instructions for the Novolog FlexPen specified that an air shot (priming) must be performed before each injection to ensure proper dosing. Another resident, also diagnosed with type 2 diabetes mellitus and with intact cognition, had orders for insulin glargine 35 units subcutaneously twice daily and insulin lispro 20 units subcutaneously before meals, plus 12 units subcutaneously if blood glucose was between 251 mg/dL and 300 mg/dL. During an observed medication administration, an LPN administered 35 units of insulin glargine and 32 units of insulin lispro without priming the insulin pens and after the resident had consumed approximately 90% of the breakfast meal, despite orders for insulin lispro to be given before meals. The LPN later stated she could not remember if she had primed the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer information for insulin lispro stated that the pen must be primed before each injection to confirm insulin delivery and remove air, and that failure to prime could result in too much or too little insulin. The DON confirmed the expectation that insulin be administered as ordered, including priming each pen with two units before dialing the prescribed dose, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and required time frames.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 5/29/2026. F-0759 Corrective action for resident/s: Residents #21 and #22 were assessed and evaluated by nurse and Director of Nursing 5/14/26. Resident #21 and #22 both denied any adverse effects and none were noted upon assessment by the Director of Nursing on 5/14/2026. Notification made to physician on 5/14/2026. LPN # 2 competency Eval on insulin administration with the Director of Nursing completed 5/14/2026. Identification of other residents who may be affected: Diabetic residents on assignment of LPN #2/station 2 have the potential to be affected and were assessed by the DON/Designee on 5/14/26 and found to be within normal limits. Measures for systemic change: All Nurses were educated by the Director of Nursing on the steps for Insulin administration per competency, diabetes clinical protocol policy, Medication and treatment orders policy, administering medications policy, and Obtaining fingerstick Glucose Level policy On 5/14/2026. How Corrective Action will be monitored: Director of Nursing and Assistant Director of Nursing will complete insulin administration audits on 5 nurses. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance: 5/29/2026
Staff-to-resident physical abuse resulting in jaw fracture and tooth loss
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from staff-to-resident physical abuse, resulting in serious injury. A dietary aide entered a secured unit where a cognitively intact resident with a history of behavioral issues, including physical aggression and noncompliance with care and medications, was located. The resident had been tapping or knocking on the window/door of the secured unit, drawing the attention of the dietary aide. Multiple staff, including a CNA and an RN, told the dietary aide not to go onto the secured unit, noting that the resident’s assigned aide could assist and that the resident had been agitated the previous day. Despite these instructions, the dietary aide went onto the secured unit. Witness statements and interviews indicate that upon entering the unit, the aide interacted with the resident, including offering to buy the resident a soda after seeing the resident holding money. According to staff statements and the aide’s own account, the resident then struck the aide in the face. The aide responded by punching the resident in the face. A CNA on the unit reported stepping between the two to attempt to deescalate the situation and then calling for the nurse due to the resident’s aggression. The CNA also reported hearing the aide tell the resident, “I will hit you again,” and then observed that the resident was bleeding. Following the punch, the resident was noted by staff to be bleeding from the nose and mouth. The resident was assessed by nursing and subsequently transported to the hospital. Hospital records documented that the resident sustained an open fracture of the right jaw, with a loose right lateral mandibular incisor and bleeding from the socket at the fracture site. The resident’s remaining 11 teeth were extracted because they could not be restored. A police report documented that staff reported the incident as an assault in which a staff member punched a resident after the resident had punched the staff member. The facility’s policy defined abuse as the willful infliction of injury resulting in physical harm, including physical abuse such as hitting and punching, and the facility substantiated that the dietary aide had physically abused the resident.
Failure to Ensure Safe Mechanical Lift Transfer, Timely Assessment, and Pain Management After Traumatic Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure safe mechanical lift transfers, adequate assessment, timely physician and representative notification, and appropriate pain management for a severely cognitively impaired, non‑ambulatory resident who required a mechanical lift with two‑person assistance for all transfers. The resident had multiple relevant diagnoses, including vascular dementia, osteoarthritis, a right hip prosthesis, chronic kidney disease, and a history of fractures and osteoporosis/osteopenia. On the morning of 04/22/26, during a mechanical lift transfer from bed to wheelchair, multiple CNAs reported that the sling appeared too small, the lift was pulled forcefully from under the bed, and the resident fell feet‑first out of the sling, with staff catching her upper body while both legs hit the floor and one leg bent behind her. A loud popping sound was heard, the resident screamed and cried out in pain, and witnesses observed immediate bruising, swelling, and apparent misalignment of the left knee/leg. Despite this, the nurse who responded did not perform a complete head‑to‑toe or range‑of‑motion assessment focused on the leg, and the incident was not documented as a fall from the lift. Following the incident, nursing staff actions and documentation were incomplete and inconsistent with the resident’s presentation. Progress notes on 04/22/26 documented only a skin tear to the left forearm and a head‑to‑toe assessment with no new areas, and there were no notes describing a fall, leg injury, or significant pain. Multiple CNAs and the resident’s roommate reported that the resident cried out in pain throughout the night and that her left leg appeared swollen, bruised, and deformed, yet nursing notes from the night shift only recorded administrations of acetaminophen without documenting the reason for administration, pain assessment findings, or any musculoskeletal concerns. One RN reported being asked to look at the resident on 04/22/26, noting swelling of the left leg but performing no further assessment. The physician was not notified within one hour of a suspected musculoskeletal injury as required by facility policy, and the resident’s representative was not informed that the resident had fallen from the mechanical lift. On 04/23/26, staff continued to report the resident’s ongoing pain and abnormal leg appearance, but the physician was contacted only about increased yelling and behavior, with a focus on agitation and prior hip/groin pain history rather than a new traumatic event. The DON later documented that a loud popping noise occurred during a Hoyer lift transfer with three staff present and that no abnormalities or signs of pain were noted, and the physician was asked to order bilateral hip and knee X‑rays as a precaution, without documenting a fall. Mobile X‑rays were obtained on 04/23/26, but the results, which showed a displaced distal femur fracture on a limited lateral view, were not reviewed until 04/24/26. Only then was the fracture acknowledged and discussed with the physician and resident representative. Subsequent hospital evaluation identified a closed displaced comminuted supracondylar fracture of the left femur and a distal fifth metacarpal fracture of the left hand. The facility’s internal investigation was incomplete and inaccurate: the DON denied a fall on 04/22/26, prepared a single typed statement describing only a popping sound while the resident was suspended over the bed, and had multiple staff sign it, even though at least two CNAs and an agency DON later reported that the statement was false and that staff felt intimidated and were told not to talk about the incident. The facility also failed to adequately manage the resident’s pain following the injury. Although the MAR shows acetaminophen administrations on 04/22/26 and early 04/23/26, there was no associated documentation of pain scores or clinical rationale in the progress notes for some doses, and staff interviews and the roommate’s account described the resident crying out in pain whenever touched and throughout the night. The physician later stated he was under the impression the fracture was non‑displaced and that, because the resident was bedbound, he did not feel she needed pain medication, and he was unaware of the severity of the femur fracture or the additional hand fracture. Overall, the facility did not follow its own physician communication policy for falls with musculoskeletal deformity or leg pain, did not perform and document thorough assessments at the time of the incident and during the subsequent night, did not promptly review diagnostic imaging, and did not conduct a complete, accurate investigation into the circumstances of the mechanical lift transfer and resulting injuries.
Improper Food Storage and Labeling in Facility and Resident Refrigerators
Penalty
Summary
Surveyors identified a failure to store food in accordance with professional standards and facility policy, creating the potential for foodborne illness for nearly all residents who received food from the kitchen. In the walk-in cooler, they observed multiple items that were opened and partially used without any open dates, including two cartons of heavy whipping cream, bins of individually poured and covered beverages, and a tray of covered fruit cocktail bowls. A large pan of pasta with ground meat was stored with the serving scoop resting directly on the food, covered with plastic wrap and not dated. A cart in the cooler held a 22-quart container of dark liquid with no label or date, and a pink plastic pitcher resting directly on the cart surface, which was coated with a dark unidentified material. A box of bacon was stored directly on the floor. The Director of Dietary Services confirmed the presence of undated, unlabeled, and improperly stored food items in the walk-in cooler. In the walk-in freezer, surveyors found an unsealed and undated bag of frozen chicken breasts and an unsealed and undated bag of pork pizza topping, which the Director of Dietary Services also confirmed. The reach-in cooler used for tray line contained a variety of pre-poured juices, milk, thickened beverages, and tea that were covered but not dated. At a nurses' station refrigerator, surveyors observed a plastic bag of food labeled with a resident’s name and dated more than a week earlier, along with three half-sandwiches wrapped in plastic without dates; the LPN present verified these findings. In a resident’s personal refrigerator, three undated bags of grapes with visible mold were found, and a CNA confirmed the grapes were moldy and undated. Facility policies required cold foods to be stored at least six inches above the floor, wrapped or in covered containers, labeled, and dated, and required resident refrigerators to be monitored daily, with food appropriately labeled and unsafe or moldy food discarded. These practices were not followed, resulting in the cited deficiency under the complaint investigation.
Unsanitary Kitchen Practices and Improper Dishwashing Temperatures
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service operations related to unsanitary kitchen conditions, improper food labeling and dating, and failure to operate the dishwasher according to manufacturer and policy requirements. During an initial kitchen tour, they observed a plastic tray holding clean pitchers with a brown-like substance on it, and three open, three-shelf carts with crumbs and debris on the shelves where clean insulated plate lids and sleeves of disposable bowls, cups, and lids were stored. Multiple trays of juice in a reach-in refrigerator were open, unlabeled, and undated. In the walk-in refrigerator, surveyors found a plastic bag of bologna with only a freeze date and no thaw or use-by date; the bologna appeared slimy and lighter in color. The facility census was 67, with one resident identified as not receiving meals from the kitchen, and the deficiency was noted as having the potential to affect all residents receiving food from the kitchen. Surveyors also observed the high-temperature dishwasher in use and recorded a wash temperature of 168°F and rinse temperatures of 160°F, 176°F, 178°F, 178°F, and 178°F over five cycles, despite the machine label and facility policy requiring a minimum wash temperature of 150°F and a minimum rinse temperature of 180°F for hot water sanitizing. A staff member confirmed the dishwasher had not been running earlier that morning, verified it was a high-temperature machine that should rinse at a minimum of 180°F, and acknowledged the observations regarding the dirty tray, soiled carts, unlabeled juice, and improperly dated bologna. The staff member stated that items in the reach-in refrigerator were normally prepped the night before and asserted that the bologna always had that color before discarding it. Review of the dishwasher temperature logs for January through April 2026 showed repeated failures to meet required wash and rinse temperatures and numerous instances of missing documentation. In January, multiple wash temperatures were below the 150°F minimum, and several meals lacked recorded wash and rinse temperatures. February logs showed at least one sub-minimum wash temperature and many missing wash and rinse entries for various meals. March logs included at least one meal with no documented wash or rinse temperatures. April logs documented several wash temperatures below 150°F and rinse temperatures below 180°F, along with multiple days and meals where wash and/or rinse temperatures were not recorded at all. Facility policies on sanitation, kitchen infection control, and food receiving and storage required dishwashing to meet temperature and sanitation standards and refrigerated foods to be covered, labeled, dated, and used, frozen, or discarded by their use-by date, which was not consistently followed according to the survey findings.
Environmental Maintenance and Cleanliness Deficiencies in Resident Room and Common Restroom
Penalty
Summary
Surveyors identified that the facility failed to maintain a safe, clean, comfortable, and homelike environment as required by its “Homelike Environment” policy. Observation of a shared bedroom for Residents #46 and #56 showed wallpaper peeling from the wall in multiple locations, including behind each resident’s headboard, below the window, and near the baseboards. In the same room’s bathroom, a black substance was observed around the base of the toilet. During an interview conducted concurrently with these observations, CNA #175 confirmed the presence of the peeling wallpaper and the black substance around the toilet base. Further observation with CNA #175 in the C hall restroom revealed that three light covers in that restroom were cracked or broken. The facility’s written policy, revised in February 2021, states that residents are to be provided with a safe, clean, comfortable, and homelike environment. The conditions observed in the residents’ bedroom, bathroom, and the C hall restroom were inconsistent with this policy and affected two identified residents, with the potential to affect all residents in the facility.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
