Continuing Healthcare Of Toledo
Inspection history, citations, penalties and survey trends for this long-term care facility in Toledo, Ohio.
- Location
- 4420 South Avenue, Toledo, Ohio 43615
- CMS Provider Number
- 365488
- Inspections on file
- 31
- Latest survey
- April 29, 2026
- Citations (last 12 mo.)
- 9
Citation history
Health deficiencies cited at Continuing Healthcare Of Toledo during CMS and state inspections, most recent first.
Surveyors found that the facility failed to notify two residents’ representatives when the residents experienced significant changes in condition, despite a policy requiring such notification. One resident with multiple chronic conditions, mild cognitive impairment, and dependence for transfers developed chest pain and was sent to the ER without the POA being informed. Another resident with depression, anxiety, rheumatoid arthritis, osteoarthritis, hyperlipidemia, and COPD developed abdominal pain, spasms, and audible wheezing, leading to imaging, labs, and medications being ordered, but again without POA notification. In both cases, the Administrator confirmed that the representatives were not notified.
Two residents who used oxygen, CPAP, and nebulizer treatments were found with respiratory equipment that was not maintained or stored in a sanitary manner. One resident’s room contained nasal cannulas on the floor next to an oxygen concentrator and a portable oxygen tank, none of which were dated, and a CPAP machine with undated tubing and an uncovered mask, contrary to facility policy requiring daily cleaning and bagging. Another resident’s nebulizer machine had tubing that was not dated. An LPN and a CNA confirmed these observations, and the DON acknowledged there was no policy for oxygen nasal cannulas or nebulizer tubing, despite stating that such tubing should be changed and dated weekly.
A resident with mild cognitive impairment and multiple chronic conditions was found with a medication cup containing several pills and an inhaler left on the bedside table without a nurse present. A CNA confirmed the medications were unattended, and an LPN acknowledged she was responsible for them and that residents are supposed to be observed when taking medications. Facility policies required that medications be either under the direct observation of the person administering them or locked in a medication cart, and that staff observe residents consuming medications, but these requirements were not followed.
A resident with severe cognitive impairment and total dependence for toileting did not receive timely incontinence care, resulting in saturated and soiled bed sheets, strong odors, and improper use of multiple incontinence products. Staff confirmed that care was not provided during the night, and facility policy requiring regular perineal care was not followed.
A resident with severe cognitive impairment and incontinence was found with a moldy water cup and soiled bed linens, while strong odors of urine and stool were present in the hallway. Staff confirmed lapses in cleaning and linen changes, and there was no documentation of water cup cleaning by dietary staff.
A resident with a suprapubic catheter did not receive consistent monitoring and care as required by physician orders and facility policy. Documentation was missing for daily cleansing and dressing changes at the catheter site, and urinary output was not consistently recorded. Observation confirmed the absence of a required dressing, and the DON acknowledged the lack of documentation for catheter site condition, treatment, and output.
The facility did not ensure that food and drink were served at safe and appetizing temperatures, resulting in multiple residents receiving cold and unpalatable meals. Staff and residents reported ongoing issues with food temperature and palatability, and direct observation confirmed that both hot and cold foods were served outside of safe temperature ranges. The Dietary Manager acknowledged these deficiencies, which affected several residents and had the potential to impact most individuals receiving meals from the kitchen.
Surveyors observed multiple areas of the facility that were not clean or well-maintained, including resident rooms with floor spots and wall scuffs, common areas with dirt and debris, hallways with cracked tiles and soiled walls, and a dining room with food spots, a cigarette butt, and debris. These conditions were confirmed by staff and did not meet the facility's policy for a safe, clean, and homelike environment.
A resident with epilepsy, who was cognitively intact, refused three consecutive doses of their prescribed anti-seizure medication. The facility did not notify the physician as required by policy, and this was confirmed through medical record review and staff interview.
The facility failed to prevent skin breakdown in three residents with severe cognitive impairment and dependency on staff for daily activities. Observations revealed residents with double incontinence briefs, inadequate incontinence checks, and repositioning, contrary to facility policy. Care plans lacked specific frequency for these interventions, leading to potential risks for pressure ulcers.
The facility failed to provide timely incontinence care for three residents, all with severe cognitive impairment and always incontinent. Observations revealed residents with double briefs, contrary to facility policy, and a lack of documentation and communication between shifts. The DON confirmed that double briefing increases the risk of skin breakdown and infections.
A resident at risk for pressure ulcers experienced deterioration of an existing stage four ulcer and developed additional stage three ulcers due to the facility's failure to replace a broken ROHO cushion and implement alternative pressure-relieving interventions. Despite recommendations from a wound specialist, the resident remained in a wheelchair without necessary pressure relief, and staff were unaware of required wound care treatments, leading to untreated wounds and further skin breakdown.
The facility failed to maintain an effective quality assurance program, resulting in repeated deficiencies in providing ADL care to residents. Observations during the survey revealed a resident with dirty fingernails and another with long, jagged nails and heavy facial hair, indicating inadequate personal hygiene care. These issues were confirmed by staff interviews, highlighting a systemic problem in the facility's quality assurance processes.
The facility failed to maintain a safe and sanitary environment for its residents. A resident's room had a strong urine odor and exposed drywall, while another's room had soiled incontinence briefs and a dirty bathroom. A resident was observed in a wheelchair without an armrest pad, and two residents reported dirty air conditioning units and dusty window blinds. These conditions were confirmed by staff and violated the facility's policy on providing a safe, clean, and homelike environment.
The facility failed to ensure proper hand hygiene during meal service, affecting six residents. An LPN and an STNA were observed not performing hand hygiene between resident contacts while delivering meal trays. The STNA misunderstood the facility's policy, which requires hand hygiene between resident interactions.
The facility failed to accurately complete MDS assessments for two residents. One resident had a documented intact range of motion despite having a limited range in the left shoulder, confirmed by therapy reports and staff. Another resident's MDS assessment inaccurately documented a pressure ulcer instead of a trauma injury to the forearm. The DON confirmed these inaccuracies.
The facility failed to provide adequate nail care for two residents dependent on staff for ADLs. One resident with diabetes and anxiety had long nails with debris, despite being scheduled for nail care on bath days. Another resident with multiple disorders was observed with long, jagged nails and heavy facial hair. Staff interviews confirmed the lack of consistent nail care, indicating a deficiency in meeting personal hygiene needs.
The facility failed to follow physician orders for wound care and did not implement the bowel protocol for three residents. A resident with a forearm wound did not receive the prescribed daily dressing change, while two residents on pain medication did not receive necessary interventions for constipation despite prolonged periods without bowel movements. Staff interviews confirmed the lack of adherence to protocols, indicating systemic issues in care delivery.
The facility failed to supervise two residents while smoking and did not maintain smoking materials safely. One resident, with impaired cognition, was observed smoking unsupervised, while another resident had a half-smoked cigarette in his room despite being out at a doctor's appointment. Staff confirmed the lack of supervision and improper handling of smoking materials.
A resident with a history of incontinence was found heavily soiled with urine during a night shift, and the responsible STNA failed to provide necessary perineal care. The DON confirmed the resident required assistance with incontinence needs, but the facility lacked a specific policy for assessing bowel and bladder needs, despite having a perineal care policy.
A facility failed to follow enhanced barrier precautions for a resident with MRSA and a stage four pressure ulcer. An STNA did not wear a gown while providing incontinence care and carried an unbagged soiled brief through the facility. The resident's care plan required gown and glove use during high-contact activities, which was not adhered to, violating the facility's infection control policy.
The facility did not offer COVID-19 booster vaccines to three residents, as indicated by their medical records, which showed no education or consent for booster vaccines since their last administration in 2022. The DON confirmed the oversight, despite facility policy requiring vaccine offers and education when supplies are available, aligning with CDC guidelines for those aged 65 and older.
A facility failed to maintain an effective pest control program, resulting in gnats and house flies in a resident's room. The resident, with multiple health issues and impaired cognition, was observed with pests on bed linen and in the restroom. Staff confirmed the infestation, and the Maintenance Director was unaware and lacked documentation of pest prevention treatments.
The facility failed to ensure STNAs completed required training on dementia care and 12 hours of continuing education annually, potentially affecting all 61 residents. Personnel files for several STNAs lacked documentation of dementia care training, and interviews confirmed the absence of such training due to the facility not having a designated dementia unit.
Failure to Notify Resident Representatives of Changes in Condition
Penalty
Summary
The deficiency involves the facility’s failure to notify residents’ representatives of significant changes in condition, as required by facility policy. For one resident with multiple complex diagnoses including acute kidney failure, heart failure, stage three chronic kidney disease, symptomatic epilepsy, and obstructive sleep apnea, the quarterly MDS showed mild cognitive impairment, use of a walker and manual wheelchair, and a need for maximal assistance with transfers and moderate assistance with ADLs, as well as use of dialysis services. A progress note documented that this resident experienced chest pain and was sent to a local emergency room for treatment, but there was no documentation that the resident’s power of attorney (POA) was notified of this change in condition. In an interview, the Administrator confirmed that the POA had not been notified of this event. A second resident, admitted with depression, anxiety, rheumatoid arthritis, osteoarthritis, hyperlipidemia, and COPD, had a quarterly MDS indicating mild cognitive impairment, no behaviors or refusals of care, use of a manual wheelchair, dependence for transfers, independent mobility, and a need for moderate assistance with ADLs. A progress note documented that this resident experienced abdominal pain, spasms, and audible wheezing, and that imaging, labs, and medications were ordered in response. However, there was no indication in the record that this resident’s POA was notified of the change in condition. In an interview, the Administrator confirmed that the POA had not been notified. Review of the facility’s policy titled “Change in a Resident’s Condition or Status” stated that the facility would notify a resident’s representative in the event of a significant change in condition, which did not occur for these two residents.
Failure to Maintain and Store Respiratory Equipment in a Sanitary Manner
Penalty
Summary
The deficiency involves the facility’s failure to maintain and store respiratory equipment in a sanitary manner for two residents who used oxygen, CPAP, and nebulizer treatments. For one resident with multiple diagnoses including asthma, heart failure, chronic kidney disease, obstructive sleep apnea, and use of dialysis services, surveyors observed a nasal cannula lying on the floor next to an oxygen concentrator in the resident’s private room, with no label indicating the date it was initiated. A CPAP machine was also observed on the nightstand with tubing that was not dated and a mask that was not covered to protect it from dust and germs. Additionally, a portable oxygen tank was present with another nasal cannula on the floor that was also not dated. An LPN confirmed these observations and stated that oxygen and CPAP tubing should be dated, nasal cannulas should not be on the floor, and CPAP masks should be cleaned and bagged daily after use. The facility’s CPAP/BiPAP Cleaning policy required CPAP masks to be cleaned and dried daily after use and then stored in a plastic bag. For a second resident with diagnoses including depression, anxiety, rheumatoid arthritis, osteoarthritis, hyperlipidemia, and COPD, surveyors observed a nebulizer machine on the nightstand with tubing that was not labeled with the date it was initiated. A CNA confirmed that the nebulizer tubing was not dated. During an interview, the DON stated that the facility did not have a policy or procedure regarding the maintenance of oxygen nasal cannulas and nebulizer tubing, and further confirmed that oxygen nasal cannulas and nebulizer tubing should be changed and labeled with the date of initiation once weekly. This lack of policy and failure to follow existing CPAP cleaning and storage requirements resulted in respiratory equipment for both residents not being maintained and stored in a sanitary manner.
Unsecured and Unsupervised Medications Left at Resident Bedside
Penalty
Summary
Surveyors identified a deficiency in medication administration and storage involving one resident. The resident had diagnoses including depression, anxiety, rheumatoid arthritis, osteoarthritis, hyperlipidemia, and COPD, and a recent MDS assessment documented mild cognitive impairment, no behaviors or refusals of care, use of a manual wheelchair, dependence for transfers, independent mobility, and a need for moderate assistance with activities of daily living. During observation of the resident’s room, surveyors found a medication cup on the bedside table containing one green oblong pill, one white oblong pill, and four white round pills, along with an inhaler next to the cup. At the time of this observation, no nurse was present in the room. A CNA confirmed the presence of the medications and inhaler on the bedside table, and an LPN later confirmed she was the nurse responsible for those medications. The LPN also confirmed that residents should be observed consuming their medications when they are administered. Review of the facility’s “Medication Administration” policy stated that nursing staff administering medications should observe the resident consuming their medications. Review of the facility’s “Medication Storage” policy stated that medications would be under the direct observation of the person administering medications or locked in a medication cart. The unattended medications at the bedside, not under direct observation or secured, were identified as an incidental finding during a complaint investigation.
Failure to Provide Timely Incontinence Care and Maintain Cleanliness
Penalty
Summary
A deficiency was identified when a resident with severe cognitive impairment and total dependence for toileting and showers did not receive timely incontinence care. The resident, who was always incontinent of bowel and bladder, was observed to have a strong odor of urine and stool coming from their room. Upon further observation, the resident's bed sheets were found to be saturated with urine and soiled with stool, and the resident was wearing an incontinence brief with an additional brief used as a pad inside. Staff interviews confirmed that the resident's incontinence care products were saturated from the overnight shift and that care had not been provided during the night. The certified nurse aide reported that the stool was stuck to the resident's skin and that the bed sheets had not been changed during the morning care. The facility's policy required perineal care to be provided as needed to promote cleanliness, comfort, and prevent infection and skin breakdown. However, the care plan for the resident specified peri-care with each incontinence episode, and the Director of Nursing stated that briefs should be checked and changed every two hours. Despite these requirements, the resident did not receive timely incontinence care, and multiple incontinence products were used in a manner not consistent with standard practice. This failure affected one resident directly and had the potential to impact other residents identified as incontinent.
Failure to Maintain Cleanliness and Sanitation in Resident Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment for residents, as evidenced by unclean water cups and persistent strong odors of urine and stool. One resident with severe cognitive impairment, functional bladder incontinence, and total dependence for toileting and showers was found to have a water cup on her dresser containing a black substance identified as mold, along with floating debris and film in the water. The resident was unaware of the location of her water cup, and staff confirmed the presence of mold. Dietary staff were responsible for cleaning water cups, but there was no documentation of cleaning practices. Additionally, a strong odor of urine and stool was observed in the hallway outside the same resident's room. The resident reported her incontinence brief had not been changed during the night, and staff confirmed that while her brief was changed in the morning, her bed sheets, which were saturated with urine and soiled with stool, had not been changed. Facility policy required a clean, sanitary, and comfortable environment, including clean bed linens and pleasant scents, but these standards were not met.
Failure to Maintain and Monitor Suprapubic Catheter Care and Documentation
Penalty
Summary
The facility failed to maintain and monitor a resident's urinary catheter system, specifically for a resident with a suprapubic catheter. The resident, who was admitted with multiple diagnoses including quadriplegia, neuromuscular dysfunction of the bladder, and a history of urinary tract infection, was dependent on staff for all activities of daily living and had a care plan that addressed some aspects of catheter care. However, the care plan did not include interventions to monitor the suprapubic stoma or to record the amount of urine collected in the catheter drainage bag. Physician orders required daily cleansing of the suprapubic catheter site and application of a dry dressing, but there was no documentation that this was performed on several specified dates. Additionally, there was a lack of assessment of the catheter stoma site in the medical record. Observation revealed that the resident did not have a dressing in place at the suprapubic insertion site as ordered. Electronic documentation also showed inconsistent recording of urinary output, with several shifts and days lacking any documentation of output. The facility's catheter care policy required catheter care every shift, regular changing of privacy bags, and emptying of drainage bags at specified intervals, but these practices were not consistently documented or observed. The Director of Nursing confirmed the lack of documentation regarding the catheter stoma condition, site treatment, and urinary output.
Failure to Serve Palatable Food at Safe Temperatures
Penalty
Summary
The facility failed to ensure that food and drink were served at safe, appetizing temperatures and were palatable, as required by both FDA guidelines and facility policy. Multiple residents who received meals in their rooms reported that their food was consistently cold and, in some cases, not palatable. Staff interviews confirmed that food delivered to resident rooms was typically at room temperature. During observation, a test tray revealed that hot foods, such as a fish sandwich, carrots, and green beans, were served below the recommended temperature of 140°F, with readings of 123°F, 110°F, and 108°F, respectively. The milk was also served above the safe cold temperature, at 53°F, and Jell-O was observed to be in a liquid state rather than properly set. The fish sandwich was described as cold, mushy, and overwhelmingly salty, making it unpalatable. Residents and staff consistently reported complaints regarding both the temperature and palatability of the food. The Dietary Manager acknowledged these concerns and verified the issues with the food's temperature and quality during the survey. The facility's own policy requires that residents receive nourishing, palatable, and well-balanced diets that meet their needs and preferences, but this standard was not met for several residents, with the potential to affect nearly all residents receiving meals from the kitchen.
Failure to Maintain Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean, well-maintained, and homelike environment, as evidenced by multiple observations throughout the building. In one resident's room, there were large spots on the floor by the bed, scuff marks on the walls, and two gouges on the floor, each approximately three inches in diameter. The administrator confirmed these findings. In the common area of the 200-hall, dirt and debris were observed coating the floor by the nurse's station, which was also verified by the administrator. Additional observations included a hallway with eight cracked tiles, a wall soiled with an unidentified black substance near a resident's room, and another wall splattered with an unidentified brown substance next to a different resident's room. An LPN confirmed the presence of these issues. In the dining room of the 200-hall, there were 14 spots of unidentified food on the floor, a cigarette butt by the scale, and the floor under the air filter was coated with an unidentified black substance and debris. These findings were verified by staff interviews and were not in accordance with the facility's policy to provide a safe, clean, comfortable, and homelike environment.
Failure to Notify Physician After Multiple Medication Refusals
Penalty
Summary
The facility failed to notify the physician when a resident, who was cognitively intact and had a diagnosis of epilepsy, refused their prescribed anti-seizure medication, Keppra, for three consecutive doses. Medical record review showed that the resident refused both morning and bedtime doses on one day and the morning dose the following day, with no documentation indicating that the physician was informed of these refusals. Staff interview with the DON confirmed the lack of physician notification, and review of facility policy revealed that the nurse is required to notify the physician after two or more consecutive refusals of medication or treatment. This deficiency was identified during a complaint investigation.
Failure to Prevent Skin Breakdown in Residents
Penalty
Summary
The facility failed to provide adequate interventions to prevent skin breakdown for three residents, as observed during a survey. Resident #1, who had severe cognitive impairment and was dependent on staff for daily activities, was found with two incontinence briefs applied, contrary to facility policy. The resident was also missing an offloading boot, which was part of the care plan to prevent pressure ulcers. Documentation showed a lack of consistent incontinence checks and repositioning, which are critical for preventing skin breakdown. Resident #2, also with severe cognitive impairment and dependent on staff, was similarly found with two incontinence briefs and was soiled with urine. The staff was unaware of the last incontinence care provided, and there was a lack of documentation for repositioning and incontinence checks. The care plan did not specify the frequency for these interventions, which are essential for maintaining skin integrity. Resident #3, with severe cognitive impairment and at high risk for pressure ulcers, was found in a similar situation with two incontinence briefs and inadequate documentation of incontinence checks and repositioning. The facility's policies on pressure injury prevention and management were not followed, as evidenced by the lack of systematic documentation and adherence to care plans designed to prevent skin breakdown.
Failure to Implement Timely Incontinence Care
Penalty
Summary
The facility failed to implement timely and appropriate incontinence care interventions for three residents, as observed during a survey. Resident #1, who has severe cognitive impairment and is always incontinent of bowel and bladder, was found in bed with two incontinence briefs applied. The resident was unable to indicate when they were last checked for incontinence, and there was no documentation of incontinence checks after 9:23 P.M. the previous day. The CNA responsible for the resident at the time of observation had not received a report from the previous shift, and the Director of Nursing (DON) confirmed that double briefing is against facility policy due to the risk of skin breakdown and infections. Resident #2, also with severe cognitive impairment and always incontinent, was similarly found with two briefs and soiled with urine. The CNA on duty was unaware of the last incontinence check, and there was no documentation of checks after 11:48 P.M. the previous night. Interviews with staff revealed a lack of communication between shifts, with CNAs not providing reports to incoming staff. The DON reiterated the policy against double briefing and the requirement for CNAs to document incontinence checks. Resident #3, who is dependent on staff for all activities of daily living and always incontinent, was found with two briefs and no documentation of incontinence checks after 8:22 A.M. the previous day. The CNA on duty had not received a report from the previous shift, and the DON confirmed the facility's policy against double briefing. The lack of documentation and communication between shifts contributed to the failure to provide timely and appropriate incontinence care for these residents.
Failure to Provide Adequate Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevention for a resident, resulting in the deterioration of an existing stage four pressure ulcer and the development of additional stage three pressure ulcers. The resident, who was at risk for pressure ulcers due to conditions such as paraplegia and diabetes, had a specialized ROHO cushion removed from their wheelchair for repair, and no alternative pressure-relieving intervention was implemented. This lack of intervention led to the resident developing two new stage three pressure ulcers and worsening of the existing stage four ulcer. The resident's medical record indicated a history of chronic stage four pressure ulcer on the right ischium, which was not healing as expected. Despite recommendations from a wound specialist to off-load the wound and use a specialized cushion, the facility did not replace the broken cushion or provide alternative pressure relief. Observations revealed that the resident remained in the wheelchair for extended periods without the necessary pressure relief, contributing to the skin breakdown. Interviews with staff, including a State Tested Nurse Aide and a Licensed Practical Nurse, revealed a lack of awareness and implementation of the required wound care treatments. The resident was found without dressings on their wounds, and there was a delay in applying the prescribed treatments. The Director of Nursing confirmed the absence of a pressure-relieving cushion and acknowledged the resident's inability to reposition themselves, which further exacerbated the situation.
Failure in Quality Assurance Program and ADL Care
Penalty
Summary
The facility failed to maintain an effective quality assurance program to address repeated quality concerns, as evidenced by deficiencies identified during three consecutive annual surveys. The CASPER Report dated August 2, 2024, highlighted deficiencies in providing activities of daily life (ADL) care to dependent residents during the annual surveys conducted in August 2019 and August 2022. This issue affected all 61 residents in the facility, indicating a systemic problem in the facility's quality assurance processes. Specific observations during the current annual survey revealed that Resident #24, who had intact cognition and was dependent on staff for personal hygiene, had dirty fingernails with dark debris under them on multiple occasions. Similarly, Resident #44, with moderately impaired cognition and dependent on staff for ADLs, was observed with long, jagged fingernails with black/brown debris and heavy facial hair growth. These observations were confirmed by staff interviews, indicating a failure to provide adequate personal hygiene care to these residents. The facility's policy on Quality Assurance and Performance Improvement (QAPI) stated that performance improvement activities should be monitored in QAA Committee meetings, but the repeated deficiencies suggest that these activities were not effectively implemented or sustained.
Facility Fails to Maintain Safe and Sanitary Environment
Penalty
Summary
The facility failed to maintain a safe and sanitary environment for its residents, as evidenced by several observations and interviews. Resident #36's room was found to have a strong urine odor, peeling paint, and exposed drywall, which was confirmed by both a Licensed Practical Nurse and the Maintenance Director. Resident #43's room was observed to have a foul odor, with soiled incontinence briefs, clothing, and linen on the floor, as well as a bathroom with soiled towels and toilet paper. A housekeeper verified the frequent soiled condition of the room. Resident #35 was observed multiple times seated in a wheelchair without an armrest pad on the left side, causing the resident's arm to rest on a thin pipe. A State-tested Nurse Aide confirmed the missing armrest and was unaware of its absence. Resident #46 reported dirt inside the air conditioning unit cover, which was confirmed by an observation that revealed dust rolling up from the filters. The Activities Director verified that maintenance was responsible for cleaning the air conditioning unit filters. Resident #47's air conditioning unit vents were coated with a brown substance, and the window blinds had a heavy buildup of dust. The resident stated that the facility had not cleaned the air conditioning unit in three years, although he had cleaned it himself once. An LPN confirmed the dirty condition of the air conditioning unit and window blinds. A housekeeper planned to deep-clean the room later in the day. The facility's policy on providing a safe, clean, comfortable, and homelike environment was not adhered to, as evidenced by these findings.
Failure in Hand Hygiene During Meal Service
Penalty
Summary
The facility failed to ensure proper hand hygiene was practiced during meal service, affecting six residents. Observations revealed that a Licensed Practical Nurse (LPN) did not perform hand hygiene after assisting a resident with a wheelchair and before handling another resident's meal tray. The LPN confirmed the lapse in hand hygiene during an interview. Additionally, a State tested Nurse Aide (STNA) was observed delivering meal trays to multiple residents without performing hand hygiene between contacts. The STNA handled personal items and picked up a salt packet from the floor without cleaning her hands. During an interview, the STNA acknowledged not performing hand hygiene and misunderstood the facility's hand hygiene policy, which requires hand hygiene between resident contacts. The facility's policy review confirmed the requirement for hand hygiene between resident interactions.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments were completed accurately for two residents. Resident #47, who was admitted with diagnoses of neoplasm of the brain and anxiety, had an annual MDS assessment indicating intact cognition and no functional limitations in the range of motion of the upper extremity. However, a physical therapy progress report and an updated therapy plan revealed that the resident had a limited range of motion in the left shoulder, from zero to 90 degrees, which was confirmed by the Rehabilitation Services Director. An interview and observation with the resident further confirmed the limited range of motion and associated pain. Resident #155, admitted with a diagnosis of a wound to the right forearm, had an MDS assessment indicating a pressure ulcer/injury, a scar over a bony prominence, or a non-removable dressing/device. However, a weekly wound evaluation and a skin observation tool indicated that the resident had a trauma injury to the right forearm. The Director of Nursing confirmed that the MDS assessments for both residents were documented incorrectly, highlighting inaccuracies in the facility's assessment process.
Inadequate Nail Care for Dependent Residents
Penalty
Summary
The facility failed to provide adequate nail care for residents who were dependent on staff for assistance with activities of daily living (ADLs). Resident #24, who had diagnoses of type II diabetes mellitus and anxiety, was observed with long nails and dark debris under them on multiple occasions. Despite being dependent on staff for personal hygiene, her nails were not trimmed or cleaned as per her care plan, which indicated that nail care should be performed on bath days and as necessary. Interviews with staff confirmed that nail care was the responsibility of State Tested Nurse Aides (STNAs), but it was not consistently performed. Similarly, Resident #44, who had multiple diagnoses including schizoaffective disorder and vascular dementia, was observed with long, jagged fingernails with black/brown debris and heavy facial hair growth. This resident was also dependent on staff for ADLs, including personal hygiene. Staff interviews verified the observations of inadequate nail care. The facility's failure to ensure proper nail care for these residents highlights a deficiency in meeting the personal hygiene needs of residents who rely on staff assistance.
Failure to Follow Wound Care and Bowel Protocols
Penalty
Summary
The facility failed to adhere to physician orders for wound care and did not implement the bowel protocol as required, affecting three residents. Resident #155, who had a wound on the right forearm, did not receive the prescribed daily dressing change on 08/11/24, as confirmed by both the resident and LPN #426. The bandage was observed to be unchanged since 08/10/24, and there was no documentation of wound care on 08/11/24. Despite the wound showing improvement, the lack of adherence to the dressing change schedule was noted. For Resident #24, who was on narcotic pain medication, the facility failed to administer as-needed stool softeners despite the absence of documented bowel movements from 05/29/24 to 06/06/24. The facility's protocol required intervention after 72 hours without a bowel movement, but this was not followed. The resident expressed concerns about constipation due to pain medication, and the Director of Nursing confirmed the protocol was not implemented as it should have been. Similarly, Resident #49, who had a history of irritable bowel syndrome, did not receive additional interventions for constipation despite no documented bowel movements from 06/01/24 to 06/07/24. Although the dose of Senna S was increased, no further actions were taken according to the bowel protocol, which included administering Milk of Magnesia, suppositories, or enemas if necessary. Interviews with staff confirmed the lack of adherence to the bowel protocol, highlighting a systemic issue in monitoring and addressing bowel movements in residents.
Inadequate Supervision and Unsafe Maintenance of Smoking Materials
Penalty
Summary
The facility failed to ensure adequate supervision and safe maintenance of smoking materials for residents who smoke, affecting two residents. Resident #21, diagnosed with bipolar disorder, dementia, and schizophrenia, was observed smoking unsupervised in the designated smoking area. Despite requiring supervision due to impaired cognition, Resident #21 was seen smoking two cigarettes simultaneously, with ashes on his shorts and cigarette butts scattered around the area. Interviews with facility staff, including the MDS Coordinator and LPN, confirmed the absence of supervision and the requirement for Resident #21 to be supervised while smoking. Resident #156, with diagnoses of chronic obstructive pulmonary disease and hypertension, was found to have a half-smoked cigarette on a cardboard pizza box in his room while he was out at a doctor's appointment. Although Resident #156 was assessed as safe to smoke without supervision, the presence of smoking materials in his room was not in line with the facility's policy, which states that smoking materials for residents requiring supervision should be maintained by nursing staff. The LPN confirmed the observation of the cigarette in Resident #156's room.
Failure in Timely Incontinence Care and Perineal Hygiene
Penalty
Summary
The facility failed to provide timely incontinence care and interventions for a resident, identified as Resident #36, who was frequently incontinent of bowel and bladder. The resident, who had a history of multiple medical conditions including epilepsy, diabetes, and acute kidney failure, was found heavily soiled with urine during a night shift. The State tested Nurse Aide (STNA) #405, who was responsible for the resident during this shift, did not check the resident for incontinence and was unaware of the resident's incontinence history. Upon discovering the resident's condition, the STNA assisted the resident to the restroom but failed to provide necessary perineal care to cleanse the resident of residual urine before dressing them in clean clothing. The Director of Nursing (DON) confirmed that the resident required assistance with incontinence needs and that residents should be thoroughly cleansed following an incontinence episode. However, the facility lacked a specific policy or procedure to assess resident bowel and bladder needs, although a perineal care policy was in place to promote cleanliness and prevent infection. This deficiency in care was identified through observation, medical record review, and staff interviews, highlighting a lapse in the facility's adherence to its own care policies.
Failure to Follow Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure that enhanced barrier precautions (EBP) were followed during personal care for a resident with a stage four pressure ulcer and methicillin-resistant Staphylococcus aureus (MRSA) bacteremia. The resident, who was dependent on staff for toileting and personal hygiene, had a physician order requiring staff to wear gowns and gloves during high-contact activities. Despite signage indicating the need for EBP, a State tested Nurse Aide (STNA) entered the resident's room and changed the resident's brief without wearing a gown, as required by the facility's policy. The STNA was observed carrying an unbagged soiled brief through the facility, past other resident rooms and the nurses' station, before disposing of it in the soiled utility room. The STNA admitted to not wearing a gown and carrying the brief unbagged because there was only one bag left in the resident's room. The Director of Nursing confirmed the resident's MRSA diagnosis and the requirement for EBP due to the infection in the resident's coccyx wound. The facility's policy mandates the use of gowns and gloves during high-contact care activities and requires soiled linens to be bagged at the bedside.
Failure to Offer COVID-19 Booster Vaccines
Penalty
Summary
The facility failed to offer COVID-19 booster vaccines to residents as indicated, affecting three residents out of five reviewed for COVID-19 vaccinations. The medical records for Residents #12, #15, and #34 showed that their last COVID-19 vaccination was administered on 08/19/22. There was no documentation of education or consent for acceptance or refusal of a COVID-19 booster vaccine following the administration in 2022 for these residents. An interview with the Director of Nursing confirmed that these residents were not offered COVID-19 vaccinations since 2022. The facility's policy, dated 05/23, stated that residents and staff would be offered the COVID-19 vaccine when supplies are available, and they would be screened for prior immunization, medical precautions, and contraindications. Education about the vaccine, including risks, benefits, and potential side effects, was to be provided before offering the vaccine. The CDC's updated guidelines recommend COVID-19 vaccination for everyone aged six months and older, with special considerations for those aged 65 and older to receive an additional dose of the updated vaccine.
Pest Control Deficiency in Resident's Room
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in an environment that was not free from pests. This deficiency was observed in the room of Resident #36, who was admitted with multiple diagnoses including epilepsy, type II diabetes mellitus, and acute kidney failure. The resident was assessed with moderately impaired cognition and required assistance with activities of daily living. Observations on two separate occasions noted the presence of gnats and house flies in the resident's room, including on the bed linen and in the restroom. During interviews, both a Licensed Practical Nurse and a State Tested Nurse Aide confirmed the presence of these pests in the resident's room. The Maintenance Director also verified the infestation but was unaware of the issue and could not provide documentation of any pest prevention treatments. This lack of awareness and documentation indicates a failure in the facility's pest control program, affecting the living conditions of Resident #36.
Deficiency in STNA Training on Dementia Care and Continuing Education
Penalty
Summary
The facility failed to ensure that state tested nurse aides (STNAs) completed necessary training on dementia care and the required 12 hours of continuing education annually. This deficiency had the potential to affect all 61 residents in the facility. Specifically, the personnel file for STNA #409, hired on 09/20/18, lacked evidence of the required continuing education and dementia care training. Similarly, STNAs #479, #419, and #449, hired in 2023, had no documentation of dementia care training in their files. Interviews with the Human Resources Director and an STNA confirmed the absence of dementia training, with the HR Director noting that the facility did not provide such training due to the lack of a designated dementia unit.
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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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