Country Club Center I
Inspection history, citations, penalties and survey trends for this long-term care facility in Dover, Ohio.
- Location
- 860 Iron Avenue, Dover, Ohio 44622
- CMS Provider Number
- 365417
- Inspections on file
- 37
- Latest survey
- April 17, 2026
- Citations (last 12 mo.)
- 20 (1 serious)
Citation history
Health deficiencies cited at Country Club Center I during CMS and state inspections, most recent first.
A resident with COPD, OSA, diabetes, and other chronic conditions experienced several days of urinary symptoms, not feeling well, poor intake, and refusal to get out of bed, which CNAs reported to nurses without evidence of a comprehensive assessment or timely provider notification specific to these complaints. The resident had prior NP orders for respiratory and antifungal treatments and later for a CXR, labs, Doxycycline, DuoNebs, and BID VS with parameters for notifying the provider, but there was no documentation explaining the rationale for these orders, no nursing or NP progress notes describing assessments, and no evidence the provider was notified of abnormal CXR findings. On the morning of the acute event, an RT and an RN documented fever of 102.1°F, HR 138, RR 24, SpO2 83% on RA, and bilateral rhonchi; oxygen, additional antibiotics, Tylenol, labs, and q4h VS were ordered, yet there was no subsequent documentation of the ordered VS monitoring or increased observation and interventions. Over ten hours later, an LPN starting the evening shift found the resident unresponsive-appearing, lethargic, hypotensive (55/31), febrile, with irregular respirations and on 3 L/min O2, prompting EMS transfer; hospital records showed severe septic shock, pneumonia, UTI, and acute hypoxic respiratory failure requiring ICU care. Surveyors found that nursing staff failed to follow ordered VS monitoring and that the facility did not ensure timely, comprehensive assessment and effective intervention for the resident’s change in condition, resulting in Immediate Jeopardy and actual harm.
The facility failed to protect a dependent, hemiplegic resident from a known aggressive roommate who had previously threatened to kill him over TV volume. Staff initially moved the aggressive resident to another room after he threatened to shoot his roommate, but, on direction from the DON and despite staff objections and the aggressor’s documented history of verbal and physical aggression, the two residents were placed back together without updating care plans or increasing monitoring. The aggressive resident later struck his roommate while he was in bed, causing bruising to the shoulder and arm and leading to fear, withdrawal, and self‑isolation. Documentation minimized the event as a verbal altercation, there was no timely evidence of physician or family notification, and the victim reported that no one followed up with him for a statement or investigation, contrary to the facility’s abuse policy requirements.
The facility failed to maintain sufficient nursing staff to meet residents’ care needs, resulting in prolonged call light response times and missed ADL care, including bathing and toileting. On survey entry, staffing levels were significantly below the facility’s own assessment and staffing plan. Several residents reported waiting from 30 minutes up to two hours for call lights to be answered, remaining on bedpans for extended periods, becoming incontinent while waiting for assistance to the bathroom, and rarely being transferred into wheelchairs due to lack of staff. Staff described chronic understaffing, difficulty completing expected showers, and being told not to shower residents requiring mechanical lifts due to time constraints. Record reviews showed multiple residents with complex medical conditions and documented needs for assistance with bathing and hygiene who received far fewer showers than scheduled, with refusals not followed by documented interventions. Call light audits confirmed numerous response times over 30 minutes, some exceeding two hours, consistent with resident and staff reports of inadequate staffing.
Surveyors found that multiple resident rooms had blue carpeting that was visibly stained, torn, snagged, and dirty, with damage and discoloration apparent from the hallway. A CNA reported that several carpeted rooms were not well kept and that prior attempts to clean the carpets with bleach had caused some of the staining, particularly in rooms that still had blue carpet rather than wood flooring. The Regional Maintenance Director confirmed that the carpets in these rooms needed replacement and noted that one apparent stain might actually be feces requiring prompt cleaning. Review of the facility’s room cleaning policy showed it addressed general room cleaning and disinfection but did not include any process for cleaning or maintaining resident room carpeting.
Multiple residents with significant medical conditions and documented dependence on staff for ADLs did not consistently receive scheduled showers or baths, and staff failed to document refusals or encouragement efforts as required by care plans and policy. Residents with osteomyelitis, diabetes, Parkinson’s disease, dementia, and other chronic conditions reported wanting showers but described staff saying they did not have time, or only washing limited body areas instead of providing full showers. Observations noted residents with disheveled, dirty hair, soiled clothing, and body odor, while records showed infrequent showers, unclear documentation of whether showers or bed baths occurred, and several missed scheduled bathing days. CNAs and an RN reported that residents were not getting showers per their preferences or care plans, cited inadequate staffing, and described being told not to shower residents requiring mechanical lifts, despite the presence of lift equipment, all contrary to the facility’s ADL policy requiring maintenance of grooming and personal hygiene.
The facility failed to prepare and provide food in the correct pureed consistency for several residents with physician-ordered pureed diets. During a lunch meal observation, pureed rice on the steam table was found to be gritty with large clumps instead of smooth, and the Dietary Supervisor confirmed it was not the correct puree texture. Review of the diet list showed multiple residents were ordered pureed diets, and facility policy defined therapeutic diets, including texture-modified diets, as physician- or practitioner-ordered as part of treatment for clinical conditions.
Two moderately cognitively impaired residents sharing a room, one with left-sided hemiparesis, anemia, and on aspirin therapy, were involved in a physical altercation after ongoing conflict over TV volume. One resident later reported that his roommate came through the privacy curtain and hit him while he was in bed, and staff interviews indicated the aggressor had a history of verbal/physical aggression and admitted to slapping the other resident on the head or shoulder. Initial documentation by the DON, who was not on-site, characterized the event as only a verbal dispute, and the Administrator was informed there was no physical contact, so the incident was not promptly reported to the state agency. There was no timely documentation of physician or family notification, no immediate staff statements were obtained, and no investigation was completed within the facility’s abuse policy timelines, despite later observation of bruising on the injured resident and subsequent grievance interviews confirming physical contact.
Two residents with a history of conflict over TV volume, one highly dependent with hemiplegia and bleeding risk and the other with documented aggressive behaviors, were placed together in a shared room despite prior threats by the more independent resident to shoot his roommate. The dependent resident later reported being punched or slapped while in bed, and the aggressive resident admitted to hitting him, with staff observing the dependent resident as scared and later noting bruising to his shoulder and arm. However, the DON’s late entry progress note minimized the event as a verbal dispute with no harm, no timely injury assessment or witness statements were obtained, CNAs were not asked for statements, and there was no documented, timely abuse investigation as required by the facility’s abuse policy, resulting in a failure to thoroughly investigate the abuse allegation.
Surveyors found that the facility failed to ensure a comprehensive discharge process for a resident with multiple complex conditions and an active plan to return to the community, as the care plan was not updated to reflect discharge planning, the discharge summary lacked a reconciled medication list, and there was no documented evidence that prescriptions were accurately provided or transmitted at discharge. In addition, another cognitively intact resident who was transferred to the hospital and later readmitted had no documentation that they or their representative received a required bed-hold notice or were offered the option to hold the bed, contrary to facility policy.
Surveyors found that the facility did not consistently review and revise care plans and discharge plans to reflect residents’ current needs and status. One resident with multiple chronic conditions had a care plan that still addressed infection risk from an indwelling catheter long after the catheter had been discontinued, and the care plan and active orders continued to require mechanical lift transfers even though the resident had been independently transferring for about two weeks per therapy direction. Another resident, cognitively intact and working toward discharge, had a discharge planning care plan that continued to list long-term placement due to needs exceeding community resources and was never updated to show that staff were actively assisting with discharge back to the community; the plan was only cancelled after the resident left the facility.
Surveyors found that the facility failed to provide adequate ADL support and honor bathing preferences for two residents who were cognitively intact and required staff assistance with bathing. One resident, who preferred morning baths and was care planned to be kept clean, dry, and odor free, received only a few baths during a month, with no documented refusals and an instance where she only received a sponge bath late in the evening after repeatedly asking for a bath. Another resident, who preferred bed baths and refused showers, had an ADL care plan that was not revised to reflect specific bathing preferences or frequency, and documentation showed inconsistent bathing intervals and at least one shower given despite the stated preference. Staff interviews confirmed that care plans did not accurately reflect these residents’ bathing preferences or needed frequency of care.
Surveyors found that the facility failed to provide an ongoing, individualized activity program consistent with residents’ assessed preferences and the facility’s own policy. Two residents with multiple comorbidities had detailed activity assessments and care plans listing interests such as one-on-one visits, bingo, music, religious practices, social events, and other pursuits, yet their records showed only a few brief one-on-one contacts and long gaps with no documented activities. Activity calendars lacked scheduled one-on-one sessions for certain months, offered limited variety, and posted calendars were not always within residents’ view, resulting in residents spending extended time in their rooms without engagement despite documented goals and interventions for activity participation.
The facility failed to ensure safe mechanical lift use and accessible call lights for residents at risk of falls. A resident with dementia, severe ADL dependence, and a history of falls was transferred with a mechanical lift when she slid out of the sling and ended up on the floor; staff selected sling sizes visually or by weight alone, without documented measurements or sling size in the record, despite manufacturer instructions requiring proper sizing and use of compatible slings. Another dependent resident was observed being transferred in a mechanical lift with the brakes unlocked, and the CNA operating the lift acknowledged both the failure to lock the brakes and the lack of Hoyer training. Multiple CNAs and the PT reported that mechanical lift training and return demonstrations had not been provided as described by leadership, and there was no documentation of annual lift training, contrary to facility policy. In a separate incident, a resident with a recent fall and hip fracture, care-planned for fall risk with an intervention to keep the call light within reach, was observed with the call light in a bag on the bedside table and unable to reach it, which was confirmed by the CNA at the bedside.
A resident admitted with multiple conditions, including lung cancer, COPD, paroxysmal A-fib, diabetes with polyneuropathy, and a UTI, had detailed hospital discharge orders for several medications such as Betapace, Carafate, Lotrisone cream, Macrobid, Lantus insulin, Nystatin, Gabapentin, and PRN albuterol-budesonide. Although an NP reviewed and approved these orders on admission, facility records showed they were never transcribed into the electronic system or administered, and the resident did not receive ordered insulin or antibiotics during the assessment period. An RN confirmed the orders were “missed” despite an expectation that the DON would perform a second check of new admission orders, contrary to the facility’s admission policy requiring review of all transfer information and orders.
Surveyors found that the facility failed to maintain accurate and complete medical records related to both abuse and accident events. In one case, a dependent resident with hemiparesis and moderate cognitive impairment reported being punched by a roommate who had a documented history of verbal and physical aggression, including threats to kill him; staff accounts described prior threats, room changes, and a later physical assault, while the DON, who was not on-site, entered a late note describing only a verbal dispute with no harm and initially characterized the event to the Administrator as non-physical. In another case, a cognitively impaired, fully dependent resident was reportedly lowered to the floor during a Hoyer transfer, but later complained of significant thigh pain and stated she had actually fallen; an anonymous staff member reported the resident fell out of the lift and that leadership directed staff to document that she was lowered, and there was no post-fall documentation or entry on the incident log despite an on-call provider treating the situation as a new fall.
A resident with diabetes, impaired cognition, decreased mobility, and incontinence, identified as at risk for skin breakdown, developed a new buttock pressure area that was documented as a small, painful open area but not followed by timely treatment orders or accurate documentation of wound location. For three days after the wound was first identified, no physician orders or specific interventions were implemented, and later NP wound care orders were delayed and in some cases incorrectly transcribed, while a wound culture result was never obtained or followed up. The wound progressed to an unstageable and then Stage III pressure ulcer with undermining, and the resident reported that dressings frequently fell off and were not consistently replaced. An RN was observed performing a dressing change without cleaning a visibly soiled overbed table, placing clean supplies and scissors on the dirty surface, and then using the contaminated scissors to cut and apply the dressing, contrary to facility wound care policy.
A resident with multiple complex conditions, including ESRD on dialysis, COPD, traumatic brain injury, and depression, requested help from CNAs to return to her room after dinner. One CNA stated she was busy passing trays, and another CNA used an expletive in connection with the request in front of the resident and others, which the resident reported as being directed at her and causing embarrassment and emotional distress. Witness accounts and the CNA’s own statement confirmed that the expletive was used within earshot of the resident. The resident reported crying herself to sleep afterward, yet nursing notes contained no documentation of the incident or of emotional support or counseling, despite a facility abuse policy that guarantees residents freedom from abuse, including verbal and emotional abuse.
A resident with intact cognition and multiple chronic conditions, including respiratory failure, COPD, PVD, DM, CKD, bipolar disorder, GAD, lymphedema, and gout, was observed to have their room door opened by maintenance staff without a prior knock while the staff member was performing fire watch rounds. The staff member acknowledged not knocking before entering. Facility policy on resident rights states that residents have the right, upon reasonable request, to have room doors closed and not opened without knocking, except in emergencies or when medically inadvisable as documented by the attending physician. No such exception was documented for this resident, resulting in a violation of the resident’s privacy rights.
Residents reported and records confirmed significant delays in call light response times, with some waiting over an hour for assistance. Despite staff education on timely response, there was no evidence of follow-up or monitoring, and grievances about the issue remained unresolved, affecting multiple residents.
Staff failed to follow infection control protocols during care for two residents, including not performing hand hygiene after glove removal and after contact with contaminated surfaces. These lapses occurred during wound care and incontinence care, despite facility policy requiring hand washing after glove removal and handling contaminated objects.
Multiple residents reported that their food was sometimes or always cold, and direct observation of meal service confirmed that hot foods dropped below required holding temperatures before being served. A test tray measured significantly below the facility's policy standard, and the food was confirmed to be cold by both thermometer and taste test, in violation of USDA guidelines and facility policy.
A resident with multiple chronic conditions and impaired cognition was not provided with a timely orthopedic referral as ordered, despite experiencing significant knee pain and awaiting further assessment. The facility administrator confirmed the appointment was not scheduled during the resident's stay.
A resident's room was found to be unclean and disorganized, with an empty medication cup on the floor, a basin containing a dried dark substance, clothes on the floor, brown discoloration and stool splatter on the toilet, and a suction machine container with a dried yellow substance. These conditions were confirmed by the Regional Maintenance Director during a facility tour.
A registered nurse failed to wear a gown, as required by Enhanced Barrier Precautions, while changing the dressing of a resident with a jejunostomy tube and recent tracheostomy removal. The resident's room had an EBP sign posted, and the facility's policy mandated both gown and glove use for high-contact care activities. The nurse acknowledged not following the policy during the observed dressing change.
The facility failed to serve meals at palatable temperatures, affecting all 55 residents. Multiple residents reported their meals were consistently cold. Observations confirmed that food temperatures dropped significantly by the time they were delivered. The Dietary Supervisor acknowledged the issue, and previous complaints about cold meals were noted in the facility's concern log.
The facility failed to maintain sanitary conditions in food storage and preparation, affecting all residents receiving meals. Observations revealed unlabeled and undated food items, inadequate sanitation practices, and a dish machine not meeting temperature requirements. Sanitation audits consistently scored below the desired goal, indicating ongoing issues with cleanliness and food storage practices.
The facility failed to maintain a clean and sanitary dumpster area, with debris including a Styrofoam plate, surgical gloves, and plastic utensils observed around the dumpsters. The Dietary Supervisor confirmed the debris, and a previous sanitation audit noted the area as unacceptable. The facility's policy prohibits trash on the ground.
The facility failed to provide appropriate diet consistency for residents on mechanically altered diets. A resident on a pureed diet received non-pureed potatoes, while another on a mechanical soft diet was served an intact hotdog. Two other residents received meals not consistent with their dietary needs. The dietary staff lacked guidance on diet consistencies, leading to these errors.
The facility failed to maintain proper infection control practices, including hand hygiene during meal distribution, handling of soiled linens, and storage of a nasal cannula. Additionally, Enhanced Barrier Precautions were not followed during IV medication administration, and proper disinfection and hand hygiene were not observed during wound care. These deficiencies affected multiple residents and were against the facility's policies.
The facility failed to maintain a safe environment, affecting three residents. A resident experienced water leakage from the bathroom into his room due to a short shower curtain and lack of a lip on the shower floor. The DON acknowledged this issue during an observation. Additionally, the DON verified gouges and missing pieces in the walls of two residents' rooms, with uncertainty about whether maintenance was informed.
The facility failed to ensure call lights were within reach for two residents, leading to a deficiency. One resident with severe cognitive impairment and multiple medical conditions had her call light out of reach on two occasions, confirmed by staff. Another resident with moderately impaired cognition and left side hemiparesis was unable to reach his call light while in a recliner, requiring him to yell for assistance. The facility's policy did not address the need for call lights to be within reach.
A facility failed to include a signed DNR form in a resident's medical record, despite the resident's documented wish to be a DNR-CCA. The resident's care plan and physician orders indicated their preference for no CPR, but both physical and electronic records lacked the necessary signed documentation. A nurse confirmed the absence of the form and could not explain why it was missing.
A resident's preference to wear undersized nightgowns, which exposed her abdomen and brief, was not documented in her care plan despite being known to the staff. The resident, who was cognitively intact and had multiple diagnoses, preferred her own nightgowns despite suggestions to cover herself. The facility's policy requires care plans to include all necessary instructions for person-centered care, which was not followed in this instance.
The facility failed to complete discharge summaries for two residents, one with schizoaffective disorder and another with metabolic encephalopathy, upon their discharge home. Despite the facility's policy requiring comprehensive discharge documentation, including a summary of stay and post-discharge plan of care, these were not completed. The absence of these documents was confirmed by the Social Service Designee and the Director of Nursing.
A resident at risk for falls due to Alzheimer's and other conditions did not have the ordered Dycem on their wheelchair, as observed by surveyors. The facility's policy requires fall interventions based on individual assessments, but this was not followed, leading to a deficiency.
The facility failed to ensure timely reweights and adequate monitoring of meal intakes for two residents, leading to deficiencies in nutritional care. One resident experienced a significant weight fluctuation that was not promptly reweighed, while another had inconsistent meal intake documentation and untimely reweights. The facility's policy required more frequent reviews based on changes in condition, but these were not adhered to, impacting the nutritional care provided.
A resident with chronic obstructive pulmonary disease and dementia was not receiving oxygen at the prescribed rate of 2 LPM, as it was set to 3.5 LPM. The nasal cannula tubing was undated and lying on the floor, and there was no signage indicating oxygen use. The DON and ADON confirmed these deficiencies.
A resident with chronic kidney disease and dependence on dialysis was not properly monitored for dialysis site complications, despite undergoing dialysis three times a week. The facility's policy required ongoing assessment, but no evidence of such monitoring was found in the medical records, a deficiency confirmed by the ADON.
A facility failed to address pharmacy recommendations for a resident with multiple diagnoses, including bipolar disorder and schizophrenia. The pharmacist suggested dose reductions for Restoril and Olanzapine and compliance with CMS regulations for Ativan. However, the physician's responses lacked the required rationale for not implementing these changes. An RN confirmed the recommendations were not fully addressed.
A facility failed to consistently monitor the blood glucose levels of a resident with diabetes mellitus, despite having orders to do so daily. The resident was on medications including Metformin, Trulicity, Tresiba insulin, and Humalog insulin. A review of records showed only one blood glucose level was recorded over a ten-day period, which was confirmed by an LPN.
A facility failed to manage psychotropic medications for a resident with psychiatric diagnoses, including bipolar disorder and schizophrenia. The resident was prescribed Restoril, Ativan, and Olanzapine without implementing gradual dose reductions (GDR) or providing documented rationale for contraindications. The pharmacist's recommendations for dosage adjustments were not addressed, and the physician's responses lacked necessary documentation, affecting the resident's medication management.
A facility failed to administer medications according to physician orders, resulting in a 10% error rate. A resident received an incorrect dosage of Mucinex, another was given unprimed Humalog Insulin, and a third received a lower dose of Mucus Relief due to stock issues. These errors were confirmed by the staff involved.
The facility failed to properly label, store, and dispose of medications for two residents. An insulin pen was stored at room temperature instead of refrigerated, and another insulin pen lacked a complete open date label. Additionally, a vial of flonase was found without an open date and no physician order. These issues indicate non-compliance with medication storage policies.
The facility's arbitration agreement failed to allow for a mutually agreeable arbitrator and venue, affecting all residents. The agreement specified the National Arbitration Forum as the arbitrator but did not provide a venue or allow residents a choice in the arbitration process. Interviews revealed that facility representatives were unaware of the need for mutual agreement and lacked a policy on arbitration agreements.
The facility failed to ensure pneumonia vaccinations were up-to-date for two residents. One resident received the PPSV23 vaccine but did not receive the recommended PCV15, PCV20, or PCV21 vaccines. Another resident also received the PPSV23 vaccine without the subsequent recommended doses. The facility's policy required assessment and administration of pneumococcal vaccines per CDC guidelines, but these were not followed.
The facility did not submit required Payroll Based Journal (PBJ) data for the administrator for the third quarter of fiscal year 2024, resulting in a 1 Star Rating. The Administrator confirmed that the corporate office handles PBJ submissions and acknowledged the oversight.
A facility failed to follow infection control standards during pericare for a resident. Two STNAs did not separate the labia while cleaning and improperly wiped from the rectal area toward the vagina. They also failed to remove soiled gloves and wash hands before touching the bedding and bed controls. The DON confirmed these actions were against facility policy.
A resident with a history of epilepsy, alcohol abuse, diabetes, chronic kidney disease, and muscle weakness reported an incident where an STNA used profanity and made inappropriate comments, instructing him not to use his call light. The resident, who was cognitively intact, felt safe despite the incident, which was corroborated by his roommate.
A resident with intact cognition did not receive prescribed hydrocodone-acetaminophen for pain management from April to June 2024. A nurse was the only staff member to sign out the medication, but it was not administered as recorded. The facility identified a discrepancy when six tablets were missing, leading to an investigation. The suspected nurse did not cooperate and refused a drug test, resulting in termination. The incident was reported to authorities.
The facility failed to perform routine respiratory assessments for two residents on continuous supplemental oxygen and nebulizer treatments. Despite physician orders for regular oxygen saturation monitoring, the residents' medical records showed infrequent assessments. Interviews with the DON, ADON, and an RT confirmed the lack of routine evaluations, highlighting a deficiency in the facility's respiratory care practices.
Failure to Monitor and Respond to Acute Change in Condition Leading to Septic Shock
Penalty
Summary
The deficiency involves the facility’s failure to timely and accurately assess a resident with multiple chronic conditions and to respond appropriately to an acute change in condition. The resident had diagnoses including GERD, hyperlipidemia, hypothyroidism, chronic gout, fatty liver, intellectual disabilities, OSA, COPD, fibromyalgia, insomnia, anxiety, diabetes mellitus, and panic disorder. Her care plan identified a potential for altered respiratory function related to COPD and OSA, with goals to prevent respiratory distress and infection, and interventions such as auscultating lung sounds, elevating the head of bed, encouraging fluids, coughing and deep breathing, and obtaining vital signs and pulse oximetry as ordered and as needed. Despite these identified risks and interventions, the facility did not ensure comprehensive assessment and monitoring when the resident’s condition changed. In the days leading up to the hospitalization, the resident and CNAs reported symptoms consistent with infection and decline. The resident stated she had a UTI for approximately two weeks and that she complained for four to five days of being unable to void and feeling unwell, but felt no one listened. CNAs reported the resident complained of itching, burning, frequent urge to urinate, not being cleaned or changed enough, not eating, and not getting out of bed, which was a change from her usual routine of getting up around the same time daily and walking to the bathroom. Staff reported these concerns to nurses and were told the resident would be given medications and monitored, but there was no evidence in the record that these complaints triggered a comprehensive nursing assessment or timely provider notification specific to these urinary and systemic symptoms. Provider orders were obtained on multiple occasions without corresponding documentation of assessment or rationale. On one date, the NP ordered Mucinex and percussive ventilation, and on another date ordered Diflucan and nystatin powder, both without any nursing or NP progress notes explaining why the orders were given or documenting a comprehensive assessment. Later, the NP ordered a chest x-ray, CBC, BMP, COVID test, Doxycycline, scheduled DuoNebs, and BID vital signs with specific parameters for notifying the provider if temperature, blood pressure, pulse, respiratory rate, or SpO2 were outside defined ranges. The chest x-ray subsequently showed diffuse bilateral lower lung opacities suggestive of pulmonary edema, atelectasis, and/or pneumonia, but there was no evidence the provider was notified of these abnormal results. The NP also documented the resident had respiratory congestion, increased temperature, and decreased oxygen saturation, and ordered monitoring of vital signs with instructions to alert the provider if changes were noted, but the facility did not document the required ongoing monitoring or follow-up. On the morning of the acute event, the respiratory therapist and an RN documented that the resident was febrile with a temperature of 102.1°F, tachycardic with a heart rate of 138, respiratory rate of 24, and SpO2 of 83% on room air, with bilateral rhonchi. The resident was placed on 3 L/min oxygen via nasal cannula, and the NP ordered Augmentin in addition to existing Doxycycline, Tylenol, laboratory tests, and vital signs every four hours for 24 hours. There was no documented rationale for adding a second antibiotic or a medical diagnosis to support the treatment, and no documentation that the abnormal vital signs were otherwise addressed beyond ordering Tylenol. After an 8:12 A.M. note showing post-nebulizer SpO2 of 91%, heart rate 121, respiratory rate 24, and persistent bilateral rhonchi, there was no documentation of the ordered q4h vital signs, no evidence of increased monitoring, and no documentation of interventions such as encouraging fluids, deep breathing, or upright positioning. More than ten hours later, an LPN starting the evening shift found the resident in a markedly worsened state. The LPN reported that the off-going nurse described the resident as sick but fine, yet upon walking rounds the LPN observed the resident with eyes rolled back, unresponsive, visibly lethargic, with irregular respirations and increased difficulty breathing. Vital signs at that time showed hypotension with a blood pressure of 55/31 mm Hg, temperature 102.3°F, heart rate 94, SpO2 90% on 3 L/min oxygen, and a mean arterial pressure of 39. EMS was called and the resident was transferred to the hospital. The facility’s own review concluded that nursing staff failed to follow the NP’s order for every four-hour vital sign monitoring, resulting in the resident’s decreasing blood pressure and declining condition not being recognized until the evening, and the surveyors determined that the facility failed to ensure the resident was comprehensively assessed and provided timely, necessary, and effective intervention in response to her change in condition. Hospital records documented that the resident was admitted with severe septic shock, acute cystitis, pneumonia, UTI, acute kidney injury, and acute hypoxic respiratory failure, requiring ICU-level care, vasopressor support, BiPAP, central venous catheter placement, and multiple IV antibiotics. The resident later reported that the emergency room physician told her it was almost too late and that she would have expired, and she described the experience as very traumatic. The facility census at the time was 52 residents, and this deficiency affected one resident reviewed for change in condition. The surveyors determined that the facility’s failure to timely and accurately assess the resident and respond to her acute change in condition resulted in Immediate Jeopardy and actual harm.
Failure to Protect Resident From Known Aggressive Roommate Resulting in Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from abuse by not implementing appropriate interventions after clear threats and known aggressive behavior, which led to a resident‑to‑resident physical assault. One resident with left‑sided hemiplegia, significant dependence on staff for ADLs, and a care plan goal to remain free from bruising and injury was verbally threatened by his roommate, who stated he would kill or shoot him over TV volume. Staff, including a CNA and the Social Services Designee (SSD), were aware of the threat, and the aggressive resident was initially moved to a private room. Despite this, the DON later directed that the aggressive resident be returned to the same room, without documented assessment of the threatened resident’s feelings of safety, without documented room‑change orders, and without updating either resident’s care plan or instituting increased monitoring or other protective interventions. Multiple staff interviews confirmed that the aggressive resident had a history of verbal and physical aggression, including prior physical assault of staff and specific threats to choke, shoot, or kill his roommate. Staff voiced concerns to management that returning the aggressive resident to the same room was unsafe, particularly because the threatened resident was physically dependent and unable to defend himself. Nonetheless, the residents were placed back together. On the night of the incident, staff reported that the aggressive resident punched or slapped his roommate while he was lying in bed, with his affected left side toward the aggressor. The victim later described being hit in the left shoulder while dozing, and the aggressor admitted to hitting him in the head or shoulder after becoming angry about language used by the roommate. Following the altercation, the victim reported pain and later exhibited a yellow‑green bruise on the left bicep and a quarter‑sized bruise on the left shoulder, which he attributed to the assault and which a CNA verified. Progress notes and interviews showed that the DON, who was not present at the time of the incident, authored a late entry describing only a verbal altercation and initially reported to the Administrator that there had been no physical contact. There was no timely documentation of family or physician notification regarding the victim being hit, and the victim stated that no one followed up with him for a statement and that he was unaware of any investigation. Staff also reported that they were not asked to provide statements at the time of the incident. The facility’s own abuse policy required immediate protection of residents, reporting to the Administrator and state agency, thorough investigation, documentation, and care plan review and revision, but the report shows that these steps were not carried out in connection with the threats and subsequent physical assault between these two residents. The aggressive resident’s record documented a care plan for inappropriate behaviors, including verbal and physical aggression and delusions, with goals of no injury to self or others and interventions such as documenting behaviors and redirecting him. A progress note documented that he had threatened to shoot his roommate over TV volume, and the on‑call physician ordered medication and increased checks. However, there is no evidence that this known risk was translated into sustained environmental or supervision interventions to prevent further conflict, nor that the threatened resident’s vulnerability and bleeding risk were incorporated into protective planning. Staff accounts consistently indicated that the decision to reunite the residents in the same room, despite prior threats and staff objections, directly preceded the physical assault that caused bruising and psychosocial harm, including fear, withdrawal, and self‑isolation in the victim.
Insufficient Nursing Staff Leading to Delayed Call Responses and Missed ADL Care
Penalty
Summary
The deficiency involves the facility’s failure to maintain sufficient nursing staff to meet residents’ total care needs, including timely response to call lights and provision of routine ADL care such as bathing and toileting. On the initial survey entrance, there were four licensed nurses and five CNAs on duty for 52 residents, despite the facility assessment indicating a need for 4 licensed nurses providing direct care, 13 nurse aides, and 3 other nursing personnel, with a general staffing plan based on 1:12 day/evening and 1:20 night ratios. The facility’s own assessment and staffing plan called for higher staffing levels than were present. The facility also had a policy on resident dignity and respect, including allowing residents flexibility and honoring preferences, which contrasted with reports of delayed care and unmet preferences. Multiple residents reported long delays in call light responses and inadequate assistance due to short staffing. One resident who required a mechanical lift for transfers stated he could only get into his electric wheelchair about once a week because there was not enough staff to help, causing him to miss resident council meetings despite being the council president. Another resident reported call light response times ranging from 45 minutes to two hours, and a resident admitted for therapy due to weakness stated it had taken up to two hours for staff to answer call lights. A resident reported waiting up to 30 minutes for call light response at night and having to pull a bedpan out from under herself after sitting on it so long that it became painful. Another resident, who required assistance with transferring and walking to the bathroom, reported waiting so long for help that she became incontinent, leading to raw and painful skin on her legs and vaginal area, and stated that staffing was short among both nurses and aides, especially at night. Staff interviews further described chronic understaffing and its impact on resident care. CNAs reported that it was nearly impossible to complete the expected number of showers per shift along with other responsibilities, and that there were usually only three aides on day shift. One CNA stated she had been told not to shower residents requiring a mechanical lift despite the presence of a lift chair in the shower room, and recounted a resident requesting a shower but only having her hair washed because the aide said she did not have time. Another CNA stated she never felt there were enough staff to meet resident needs and noted that extra staff were added to the schedule because surveyors were present. An RN stated that call light responses should be within five minutes and that responses over 10 minutes required follow-up, and confirmed there were 16 residents requiring mechanical lifts, which need at least two staff. Other staff reported residents not getting showers, the DON coming in on a short-staffed night and sleeping in her office, and that staffing expectations and workload, including care for residents on ventilators and with many wounds, were excessive and could affect resident care. Record review and resident interviews showed that residents were not consistently receiving scheduled showers or adequate ADL assistance, and that refusals were not always addressed with appropriate interventions. One resident with osteomyelitis, diabetes with foot ulcers, repeated falls, and impaired cognition required partial/moderate assistance with bathing and toileting and needed leg wounds covered before showering. Documentation showed only two showers over a period of more than two months, with multiple recorded refusals but no documentation of interventions to encourage or explain the need for ADL assistance. The resident reported wanting showers but being told staff did not have time to cover both legs, leading him to decline and instead wipe off. Another resident with diabetes, lung cancer, COPD, weakness, and urinary incontinence was care planned for maximum assistance with bathing and scheduled for showers three times weekly, but records showed multiple missed showers/bed baths on scheduled days. This resident reported not always receiving scheduled showers and having only one shower in the prior week; observation noted greasy, uncombed hair and body odor, and an RN verified missed bathing in March. A further resident with multiple serious diagnoses, including sepsis, dysphagia, pneumonitis, respiratory failure, obesity, malnutrition, and repeated falls, was cognitively intact and required partial to moderate assistance with bathing and dressing. Her care plan aimed to keep her clean, dry, and odor free, with staff assistance for hair care, oral care, dressing, and bathing. Electronic records showed she received showers on only three dates over approximately one month, and her spouse reported that he was present all the time and assisted with all of her care because he did not feel staff did enough to help with ADLs. The administrator confirmed the available shower documentation for this resident. Additionally, facility call light audit reports for a one-week period showed 19 instances where call light response times exceeded 30 minutes, with the shortest of these being 37 minutes and the longest 144 minutes, corroborating resident and staff reports of delayed responses and insufficient staffing.
Failure to Maintain Clean and Well-Kept Carpeting in Resident Rooms
Penalty
Summary
Surveyors identified a failure to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior environment for multiple residents. Observations of several resident rooms showed blue carpeting with multiple white stains, a brownish-red stain, and tears/snags at the entryway and throughout the rooms, with these conditions visible from the hallway. In one room shared by two residents, the carpet was described as stained and torn/snagged, and a CNA reported that several rooms with blue carpet were stained, torn, and dirty, and that attempts to clean them with bleach had caused some of the visible staining. The CNA also noted that these issues were primarily in rooms that still had blue carpeting, as most other rooms had wooden floors. Further observations of additional resident rooms confirmed that the blue carpeting was stained, torn/snagged, and not well kept, and these conditions were again visible from the hallway. The Regional Maintenance Director confirmed during the observations that the carpeting in these rooms needed to be replaced and acknowledged that one apparent stain might actually be feces on the carpet that required cleaning as soon as possible. Review of the facility’s “5 Step Resident Room Cleaning Procedure” policy, dated 10/2019, showed it addressed cleaning and disinfecting resident rooms but did not include any process for cleaning and maintaining carpeting in resident rooms. This combination of observed conditions, staff interviews, and policy review supported the finding that the facility failed to maintain a safe, clean, comfortable, and homelike environment for the affected residents.
Failure to Provide and Document Required ADL Bathing and Hygiene Assistance
Penalty
Summary
The deficiency involves the facility’s failure to provide and document assistance with activities of daily living (ADLs), particularly bathing and hygiene, for multiple residents who required staff support. Several residents had care plans and MDS assessments indicating needs for partial to total assistance with bathing, dressing, toileting, and personal hygiene, yet records and observations showed infrequent showers, missed scheduled baths, and inadequate documentation of refusals or encouragement efforts. For one resident with osteomyelitis, diabetes with foot ulcers, and impaired cognition, the care plan required staff assistance with ADLs and support for non‑compliant behaviors, but electronic records showed only two showers over a period of more than two months, and paper shower sheets documented multiple refusals without any notation of interventions to encourage or explain the need for care. This resident reported wanting showers but stated staff told him they did not have time to apply necessary wound‑protective devices, leading him to forego showers and instead wipe off. Another resident with Parkinson’s disease, dementia, and total dependence for ADLs had a documented preference for daytime showers three times weekly. In March, this resident was only bathed or showered on a few of the preferred days, and an observation found him in a wheelchair with disheveled, dirty‑appearing hair and soiled clothing, which a CNA confirmed. A resident with severe cognitive impairment and total dependence for ADLs had a care plan calling for assistance with bathing per preference and a documented preference for early morning showers three times weekly; however, March shower sheets showed only a few bed baths and multiple entries where it was unclear whether a bed bath or shower was provided. Another resident with moderate cognitive impairment and multiple medical conditions required partial to moderate assistance with showering and had a care plan goal to remain clean, dry, and odor free, yet he reported he did not always get to shower when he would like, could not safely shower in his room due to a slippery floor, and was observed disheveled with a dirty shirt. Additional residents with significant medical histories and documented ADL needs also did not receive showers or baths as planned. One cognitively intact resident who required partial to moderate assistance with bathing and dressing had electronic records showing only three showers over a one‑month period, and her spouse reported he was present all the time and provided all of her care, stating staff did not do enough to assist with her ADLs. Another resident requiring partial to moderate assistance with bathing and using a wheelchair had a care plan to remain clean, dry, and odor free and a preference for showers on specific days; records showed only one shower and two bed baths in March, and he reported it had been four weeks since he had been in the actual shower, stating staff only washed his groin area and that he did not feel clean. A newly admitted resident, cognitively intact and needing maximum assistance with bathing and moderate assistance with personal hygiene, was scheduled for showers three times weekly, but documentation showed multiple missed showers or bed baths, and she reported not always receiving showers as scheduled, stating she had only one shower in the prior week; she was observed with greasy, uncombed hair and body odor. Multiple CNAs and an RN reported that residents were not getting showers or baths per their preferences or care plans, cited insufficient staffing, and described expectations for a high number of showers per shift and instructions not to shower residents requiring mechanical lifts, despite available equipment. The facility’s ADL policy required provision of necessary services to maintain grooming and personal hygiene and adherence to care plan objectives, which was not met in these cases.
Failure to Provide Proper Pureed Diet Consistency
Penalty
Summary
The facility failed to ensure food was prepared in accordance with physician-ordered pureed diet consistencies for residents requiring texture-modified diets. During observation of the lunch meal service, pureed rice intended for residents on pureed diets was found in the warming table and, upon taste testing by the surveyor and the Dietary Supervisor, was noted to be gritty in texture with large clumps rather than smooth as required for puree consistency. The Dietary Supervisor confirmed that the rice did not meet the expected smooth, lump-free puree standard. Review of the facility diet list showed that six residents had physician orders for pureed diet consistency, and review of the facility’s therapeutic diet policy indicated that such diets are ordered by a physician, practitioner, or dietitian to alter the texture of the diet as part of treatment for a disease or clinical condition. This deficiency was cited under Complaint Number 2961570. The deficiency involved the facility’s failure to properly prepare and provide pureed food in the correct consistency for residents with physician-ordered pureed diets, as evidenced by the improperly prepared pureed rice and confirmation by the Dietary Supervisor that it did not meet puree standards.
Failure to Timely Report and Investigate Resident-to-Resident Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to timely report and investigate an allegation of resident-to-resident physical abuse to the Administrator and the State Survey Agency as required by policy and regulation. A cognitively impaired resident with left-sided hemiparesis, a history of stroke, anemia, and aspirin therapy, who required extensive assistance with ADLs and used a wheelchair, reported that his roommate came through the closed privacy curtain and punched him in the left shoulder while he was lying in bed dozing. The resident stated he did not know why he was hit and later reported being scared after the incident, fearing his roommate would find him again. He reported the incident to nursing staff but could not recall which nurse, and he stated that no one followed up with him or asked him for a statement, and he was not aware of any investigation. Multiple staff accounts and documentation showed that the incident was initially treated as a verbal altercation and not reported as physical abuse. A late entry progress note authored by the DON, who was not in the building at the time of the event, documented that the roommate was upset about TV volume and that no harm came to the resident. The Administrator reported that the DON informed her there had only been a verbal altercation and that the residents would be separated due to ongoing bickering about the TV, and based on this information the Administrator did not report the incident to the State Agency. The ADON, who was also not in the building at the time, confirmed there was no documentation of family or physician notification regarding the resident being hit, and acknowledged that the roommate was the aggressor. A CNA reported hearing a nurse yell for help and being told that the roommate was punching the resident; when the CNA asked the resident if he was okay, the resident said he could not talk about it because he did not want the roommate to "get" him again, and the CNA described the resident as scared and terrified. The CNA stated they were not asked to make a statement on the day of the incident or in the days following. Further interviews and grievance documentation later confirmed that the roommate admitted to physically striking the resident. The social services designee, who was not present when the incident occurred, learned of the altercation days later from CNAs and interviewed both residents. The injured resident described being hit in the shoulder and mentioned having a knot on his shoulder, which the designee did not verify. The roommate stated that he had heard the other resident use an expletive and that he went over and slapped him with an open hand on the head, later reiterating that he hit him in either the head or shoulder. The social services designee reported this information to corporate staff and completed grievance forms, which were eventually sent to the Administrator. Despite a text from the DON to the corporate VPO indicating there might be a self-reported incident and then stating "never mind" later that same day, there was no documented investigation by the DON. Subsequent observation revealed yellow-green bruising on the resident’s left bicep and a quarter-sized bruise on the left shoulder in various stages of healing, which the resident attributed to the altercation, and this was verified by a CNA. The facility’s abuse policy required timely reporting of all allegations of abuse to the Administrator and the state agency, protection of residents, notification of the physician and representative, and completion of an investigation within five working days, but these steps were not carried out as required for this incident. The second resident involved, the roommate, had a history of anxiety, heart failure, pulmonary embolism, and documented inappropriate behaviors including verbal and physical aggression toward staff and delusions. His care plan included goals for no injury to self or others and interventions such as documenting behaviors and redirecting him. His MDS showed moderate cognitive impairment and independence or supervision for mobility and transfers. A late entry progress note by the DON documented that he was yelling and verbally aggressive about TV volume and told his roommate to turn the volume down, but did not document the physical contact he later admitted. The combination of delayed recognition and documentation of the physical nature of the altercation, lack of timely reporting to the Administrator and State Survey Agency, absence of required notifications, and lack of a documented investigation within the facility’s specified timeframe led to the cited deficiency. The facility’s written abuse policy required that all incidents and allegations of abuse, neglect, exploitation, mistreatment, misappropriation, and injuries of unknown source be reported to the Administrator and to the state health department within specified timeframes, including within two hours for allegations of abuse or serious bodily injury and no later than 24 hours for other allegations. The policy also required immediate protective measures, psychosocial support via social services, documentation of assessments, notifications, and treatments in the nurse’s notes, and completion of an investigation within five working days. In this case, the allegation of resident-to-resident physical abuse was not promptly recognized, reported, or investigated in accordance with these requirements, resulting in noncompliance under the cited complaint numbers.
Failure to Thoroughly Investigate Resident-to-Resident Abuse Allegations
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate allegations of resident-to-resident abuse involving two residents. One resident with left-sided hemiplegia, chronic pain, anemia with aspirin therapy, and significant dependence on staff for ADLs reported that his roommate came through the closed curtain and punched him in the left shoulder while he was lying in bed dozing. His care plan included interventions to assist with transfers and mobility and to observe for bruising due to bleeding risk, and his MDS documented moderate cognitive impairment and extensive physical assistance needs. Despite this, the initial documentation by the DON, entered as a late entry, characterized the incident only as a disagreement over TV volume with no harm to the resident, and there was no contemporaneous documentation of a physical assault, assessment for injury, or immediate investigation. Multiple interviews and records later confirmed that a physical altercation had occurred and that the facility did not conduct a timely, thorough investigation as required by its abuse policy. The resident who reported being hit stated that he told a nurse about the incident but could not recall which nurse, and he reported that no one followed up with him or obtained a statement. The SSD learned of the incident days later, interviewed both residents, and documented that the dependent resident described being struck in the shoulder and having a “knot” on his shoulder, which the SSD did not verify. The alleged aggressor resident, who had a care plan for inappropriate behaviors including verbal/physical aggression and delusions, admitted in interviews and on a grievance form that he slapped or hit his roommate in the head or shoulder after being angered by the use of profanity. Staff interviews revealed that CNAs were aware of the physical assault, observed the dependent resident as scared and terrified, and were never asked to provide statements. Additional documentation showed that prior to the physical assault, the aggressive resident had threatened to shoot his roommate over TV volume, resulting in a temporary room change, and that staff questioned why the two residents were later placed back in the same room given ongoing issues. On observation weeks after the incident, the dependent resident had yellow-green bruising on the left bicep and a quarter-sized bruise on the left shoulder in various stages of healing, which he attributed to the altercation; this was verified by a CNA. The facility’s abuse policy required that all alleged violations of abuse, including resident-to-resident incidents, be investigated within five working days, with interviews of the resident, the accused, and all witnesses, collection of written statements, review of medical records, documentation of the investigation, and revision of care plans as needed. The Administrator and VPO confirmed there were no witness statements and no documented investigation by the DON, and the Administrator acknowledged that the investigation was not thorough, demonstrating noncompliance with the facility’s own abuse investigation policy. The second resident involved, who was more independent and had diagnoses including anxiety, hypertension, heart failure, and pulmonary embolism, had a care plan for inappropriate and aggressive behaviors with goals to prevent injury to self or others. Progress notes documented that he had previously threatened to shoot his roommate over TV volume, leading to physician notification and temporary relocation. Despite this history and staff concerns, the residents were returned to the same room, and when the subsequent physical assault occurred, the facility failed to promptly recognize, document, and investigate it as abuse. The lack of timely assessment, failure to obtain and document statements from involved staff and residents, and absence of a complete investigative record as required by policy formed the basis of the cited deficiency.
Failure to Ensure Comprehensive Discharge Planning and Bed-Hold Notification
Penalty
Summary
The deficiency involves the facility’s failure to ensure a comprehensive and accurately documented discharge process for one resident. A cognitively intact resident with multiple complex diagnoses, including hypertension, anxiety, cerebral infarction, peripheral vascular disease, gangrene, cardiomyopathy, diabetes, and other conditions, was discharged home after their health had improved sufficiently for a less skilled level of care. The resident’s care plan identified them as a long-term placement due to needs exceeding community resources and was not revised to reflect the facility’s active discharge planning back to the community, despite the MDS indicating an active discharge plan. The discharge planning care plan was only cancelled after the resident had already been discharged, with no documented updates showing the planned transition to home. At discharge, nursing documentation stated that discharge instructions were reviewed and that medications and prescriptions were provided as ordered. However, the discharge summary contained no evidence of the specific medications or prescriptions reviewed at discharge and no documented medication reconciliation for accuracy. The section of the discharge summary designated for post-discharge medications contained only a handwritten note stating “See List,” but no medication list was attached. The closed medical record did not contain copies of prescriptions or evidence of the medication orders being faxed to the pharmacy or provided to the resident on the day of discharge. Subsequent documentation showed that the resident’s power of attorney later reported that the prescriptions had not been received by the pharmacy, and the facility confirmed that the pharmacy had not received them, leading to a refax several days after discharge. The administrator confirmed that the discharge planning care plan lacked revisions reflecting the planned discharge back to the community and that the prescriptions had initially been faxed to a different number. Additionally, for another cognitively intact resident who was transferred to the hospital and later readmitted after a seven-day ICU stay, the record contained no documentation that the resident or their representative was given a bed-hold notice or the option to hold the bed or not at the time of transfer, despite facility policy requiring a bed-hold notice to be completed, delivered, and documented at the time of transfer.
Failure to Update Care and Discharge Plans to Reflect Current Resident Status
Penalty
Summary
The deficiency involves the facility’s failure to review and revise care plans after each assessment and in response to changes in residents’ needs, as well as failure to appropriately revise discharge plans of care. For one resident with diagnoses including acute systolic congestive heart failure, COPD, type 2 diabetes with polyneuropathy, muscle weakness, and a history of falls, the care plan revised on 03/04/26 still included a focus on risk of infection related to an indwelling medical device and an intervention to wear gown and gloves for high-contact care, despite the urinary catheter having been discontinued on 07/09/25 and no further catheter orders present. The same resident’s care plan and active orders required all transfers to be completed with a mechanical lift, with the mechanical lift intervention initiated on 01/18/26, yet on 03/30/26 the resident was observed independently transferring to a motorized scooter and into the restroom. A CNA confirmed the resident had been independently transferring for about two weeks based on therapy direction, but the order and care plan had not been updated. For another resident admitted with hypertension, anxiety, cerebral infarction, peripheral vascular disease, gangrene, and cardiomyopathy, the quarterly MDS assessment documented that the resident was cognitively intact for daily decision-making and had an active plan to discharge back to the community. However, the existing discharge planning care plan, dated 03/16/25, identified the resident as a long-term placement because his needs exceeded community resources and was not updated to reflect that the facility was assisting him with discharge back to the community. The discharge planning care plan remained unchanged and was only cancelled on 03/16/26 after the resident had already been discharged on 03/11/26, as confirmed by a nurse who verified that the discharge planning care plan was not revised when the facility assisted and ultimately discharged the resident back to the community.
Failure to Provide ADL Support and Honor Resident Bathing Preferences
Penalty
Summary
The deficiency involves the facility’s failure to provide care and services to support residents’ activities of daily living (ADLs), specifically bathing, in accordance with assessed needs and stated preferences. One resident with a BIMS score of 15, indicating no cognitive impairment, required assistance with multiple ADLs including bathing and toileting and was care planned to be kept clean, dry, and odor free, with staff assistance for hair care, toileting, and bathing as needed per preference. Shower/bed bath records for this resident in February 2026 showed only three baths provided during the month, with one missed due to lack of hot water and no documentation of refusals for the remainder of the month. The resident reported preferring morning baths and stated that on one day she repeatedly asked staff when she would be bathed, did not receive a bath during the day, and ultimately received only a sponge bath while on the toilet in the evening, leaving her feeling that her preferences and opinions did not matter. The Corporate Clinical Director confirmed the resident was not being bathed or showered per her preference or needed frequency. A second resident, who was cognitively intact and required moderate assistance with bathing, had an ADL care plan indicating a need for staff assistance with bathing per preference, but this care plan was not revised to reflect the resident’s specific bathing preferences or frequency. Another care plan addressing inappropriate behavior documented that this resident preferred bed baths and refused showers. Electronic ADL records for February and March 2026 showed that baths/showers were provided on several specific dates, with one documented refusal and at least one shower given despite the resident’s stated preference for bed baths. Interview with an RN confirmed that the ADL care plan was not updated to include the resident’s bathing preferences, including frequency, and that there were often five days between documented bathing. These findings, based on record review, staff and resident interviews, and documentation audits, demonstrate that the facility did not consistently provide ADL care, particularly bathing, in alignment with residents’ assessed needs and expressed preferences.
Failure to Provide Ongoing, Individualized Activity Program for Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide an ongoing, comprehensive activity program that met residents’ individual preferences and needs, as required by facility policy. Surveyors found that activity assessments and care plans identified specific interests and the importance of various activities for residents, but the facility did not implement or document activities consistent with those plans. Activity calendars lacked scheduled one-on-one activities for certain months, and there was little variety in daily activities from week to week. The facility’s own policy required admission activity assessments, ongoing updates, and individualized activity plans, including one-on-one activities to be completed per the activity calendar, but these were not carried out as written. One resident, identified as Resident #28, had multiple medical diagnoses including encephalopathy, heart failure, anemia, diabetes, and a fractured hip, and was cognitively intact per the MDS. The activity assessment for this resident documented numerous current interests and their importance, including one-on-one activities with animals/pets, beauty/barber services, exercise, family/friend visits, gardening, movies/TV, cooking, and current events, as well as small group interests such as bingo, cards, resident council, volunteering, walking, arts/crafts, community outings, and social parties. The care plan stated the resident was involved with activities little of the time and included interventions such as assisting the resident to activities, encouraging participation, inviting to resident council, breaking activities into manageable tasks, and providing an activity calendar. However, review of the medical record showed no evidence that the resident was offered or participated in the identified one-on-one or group activities during the review period. For Resident #28, the activity calendars for a specific month showed scheduled one-on-one visits on several dates and listed group activities such as weekly bingo, multiple weekly card/game sessions, weekly pet therapy, weekly outings, and a monthly spa day. Yet, the record of one-on-one activities contained only a few brief contacts, such as staff visiting while the resident’s husband was present, offering popsicles or snacks, and one instance of offering a word search that was declined by the husband when the resident was sleeping. The Activity Supervisor confirmed that these few documented contacts were all that had been provided since the resident’s admission. There was no documentation that the resident’s stated preferences for activities like bingo, pool, happy hour music, or other listed interests were implemented. Another resident, identified as Resident #2, had extensive medical conditions including CVA with hemiplegia, encephalopathy, chronic systolic CHF, respiratory failure, altered cognitive function, insomnia, sleep apnea, hypertension, atrial fibrillation, abdominal aortic aneurysm, and a prosthetic heart valve, and was severely impaired for daily decision-making per the MDS. The activity assessment documented current interests in individual activities such as animals/pets, current events, exercise, movies, music, and family/friend visits, as well as interests in religious studies, shopping, sing-alongs, social parties, volunteering, walking, and arts/crafts. Past interests included bingo, cards, cooking, creative writing, dominoes, educational programs, and reading. The care plan indicated the resident was involved with activities some of the time, with goals to participate in activities of choice and remain active with individual activities, and interventions similar to those for Resident #28, including assistance to activities, encouragement, and provision of an activity calendar. Despite these documented interests and care plan interventions, the record for Resident #2 showed only a few one-on-one activities, such as two visits where staff sat and talked with the resident for 10–15 minutes and one in-room manicure. There were documented gaps with no evidence of any activities provided over extended periods between specified dates. Observations showed the resident frequently lying in bed with no activities present in the room, and the resident stated she did not go out of her room much and did not know what she was going to do that day. The Activity Supervisor acknowledged that only a few one-on-one activities were documented since admission and stated the resident had cognitive impairment, did not want to join other activities, and only came out of her room for meals. The Administrator confirmed there were no documented activities in the electronic medical record for these residents beyond the few noted, that the calendars for several months did not include scheduled one-on-one activities, and that there was little variety in daily activities. Additional information from Social Services indicated that a separate Medicaid "Quality Moments" program provided emotional/behavioral support to certain qualifying residents, but this service was not provided by facility staff, was not available to all residents, and was not part of the residents’ activity care plans. Observations also showed that an activity calendar for Resident #2 was posted on the wall but not within the resident’s view. Overall, surveyors determined that, based on observation, record review, policy review, and interviews, the facility did not ensure that residents were provided with an ongoing, individualized activity program consistent with their assessed preferences and the facility’s own Resident Activities policy.
Unsafe Mechanical Lift Use and Inaccessible Call Light for Residents at Risk of Falls
Penalty
Summary
The deficiency involves the facility’s failure to ensure safe use of mechanical lifts and proper access to call lights, resulting in unsafe transfers and fall risk for multiple residents. One resident with severe cognitive impairment, extensive ADL dependence, a history of falls, and limited lower extremity mobility was transferred using a mechanical lift when she began sliding out of the sling. Two CNAs reported that during the lift, the resident slid out of the pad, came out the side of the sling, and ended up on the floor after they unclipped the lift pad. The resident’s medical record did not contain documentation of the required sling size, and staff reported that sling size was chosen visually or based only on weight, without formal measurement or documentation. Manufacturer guidelines for the specific lift in use required selection of a sling that met the patient’s needs and maximum safety, use of only the manufacturer’s slings, and adherence to a sizing chart based on both height and weight, but the facility did not have documentation that these requirements were followed for this resident. Another resident, dependent for ADLs and using a wheelchair for ambulation, was observed being transferred via mechanical lift by two CNAs. During this transfer, the CNA operating the lift did not lock the lift’s brakes before lifting the resident from a recliner or before lowering him into his wheelchair, contrary to the manufacturer’s instructions and the facility’s own mechanical lift policy, which required the lift to be stable and locked prior to lifting. The CNA confirmed at the time of observation that the brakes had not been locked and also stated she had never received Hoyer lift training at the facility. Facility policies required that residents be measured for proper sling size per manufacturer instructions, that lifts be locked prior to lifting, and that staff be trained and demonstrate competency on the specific lift devices used. Interviews with facility leadership and staff revealed discrepancies and gaps in mechanical lift training and competency validation. The DON and ADON stated that all CNAs were trained on mechanical lifts at hire and that staff had been trained and checked off on the new bariatric lift, but there was no sign-in sheet or documentation of this education. The physical therapist responsible for orientation reported that she did not provide mechanical lift training and only discussed communication with therapy and issued gait belts. Multiple CNAs reported they had never received mechanical lift training at the facility, had only watched the DON use the new bariatric lift, or that orientation checklists were simply checked off when new staff were shown where the lifts were stored, without return demonstration. The Administrator later confirmed that Hoyer lift training was part of the orientation checklist and that CNAs were trained by another CNA, and also confirmed there was no annual Hoyer lift training documented in CNA education or employee files, despite facility policy requiring initial and annual education and competency. A separate deficiency involved a resident at risk for falls whose care plan required that the call light be kept within reach. This resident, who had a history of a recent fall resulting in a left hip fracture while returning from the bathroom to bed, reported that fall and injury during interview. On observation, the resident’s call light was not within reach; it was in a bag on the bedside table, and the resident confirmed she could not reach it. A sign indicating the call light for assistance was hanging on the wall, but the device itself remained inaccessible. A CNA present at the bedside confirmed that the call light was out of reach, sitting on the nightstand in a bag, contrary to the care-planned intervention to keep the call light within reach for this resident at risk for falls.
Failure to Transcribe and Administer Hospital Discharge Medication Orders
Penalty
Summary
The facility failed to ensure that medications were administered without significant error for one resident. A resident was admitted with multiple diagnoses including malignant right lower lung cancer, obstructive sleep apnea treated with BiPAP, paroxysmal atrial fibrillation, asthma, chronic pain, GERD, COPD, diabetes mellitus with diabetic polyneuropathy, and a urinary tract infection. The hospital discharge summary included specific orders to start Betapace 40 mg twice daily, Carafate 1 g four times daily, Lotrisone cream to the vaginal area twice daily for eight doses, Macrobid twice daily for five days for a UTI, discontinue Metformin 500 mg and start Lantus 4 units at bedtime, complete a course of oral Nystatin liquid, administer Gabapentin 600 mg three times daily, and provide albuterol-budesonide aerosol PRN. The nurse practitioner reviewed and approved these medications upon admission. Despite this approval, review of the electronic order summary showed that none of these discharge medication orders were transcribed or started as ordered. The admission MDS indicated the resident was cognitively intact and did not receive insulin or an antibiotic during the assessment period, and a later NP note documented that the resident was not on any diabetes treatment upon arrival and that diabetes was being managed with diet. During interview, an RN confirmed that the discharge summary had been approved but the medications were not transcribed or administered from admission through the time of survey, stating they were “missed” and acknowledging that the DON was supposed to be the second check for new admission orders. The facility’s admission policy required review of all transfer information and orders, but this process did not occur as required for this resident’s medications.
Inaccurate Documentation of Resident Altercations and Fall Events
Penalty
Summary
The deficiency involves the facility’s failure to maintain comprehensive and accurate medical records and safeguard resident-identifiable information, particularly in relation to abuse/altercation events and an accident. For one resident with left-sided hemiparesis, chronic pain, depression, and moderate cognitive impairment, the DON entered a late progress note documenting only a verbal disagreement about TV volume and stating that no harm occurred, even though the DON was not in the facility at the time of the incident. Punch records confirmed the DON was not present when the event allegedly occurred. In contrast, a grievance completed later documented that the resident reported being punched in the left shoulder by his roommate while lying in bed, and the resident later stated no one followed up with him or obtained a statement, and he was unaware of any investigation. Multiple CNAs and the SSD reported that the roommate had previously threatened to shoot and kill this resident over TV volume, that the residents were separated and then moved back into the same room on the DON’s direction, and that staff concerns about the move were disregarded. The SSD reported being told by CNA staff that the roommate threatened to shoot the resident and that the DON instructed that staff not document the incident in the progress notes, although the SSD stated she did not pass on that instruction and an agency nurse did document the threat in the aggressor’s record. The SSD and several CNAs described a subsequent physical altercation in which the more independent roommate struck the dependent resident, who could not use his left arm and was largely bed- or wheelchair-bound. Staff accounts indicated the aggressor had a history of verbal and physical aggression, including threats to choke, shoot, or kill his roommate, and that he was moved out of and then back into the shared room before the physical assault. The Administrator stated she was initially told by the DON that the altercation was only verbal and therefore did not believe it needed to be reported as abuse. Later, grievance information indicated the resident reported being hit, and interviews with both residents confirmed that the aggressor admitted to slapping or hitting his roommate in the head or shoulder. An observation days later showed bruising on the dependent resident’s left bicep and shoulder, which the resident attributed to the altercation, and this was verified by a CNA. A second component of the deficiency concerns another resident with dementia, severe cognitive impairment, a history of falls, weakness, and total dependence for ADLs, who was reportedly lowered to the floor during a Hoyer lift transfer from wheelchair to bed. The progress notes contained only a brief statement that the resident was lowered to the floor, with no post-fall documentation completed at the time of the incident. An eCare triage note later documented that an unnamed facility staff member told the on-call provider that the resident had been lowered to the floor earlier in the shift, but by the end of the shift the resident cried out in pain in the right inner thigh, requested not to be moved, and was then saying she had actually fallen rather than been lowered. The call was categorized as a new fall, and the NP ordered pain medication, cold compresses, and a STAT X-ray. The NP’s subsequent note did not reference the fall or pain complaint, and the facility’s incident log for several months showed no recorded fall or incident for this resident. An anonymous staff member stated the resident fell out of the mechanical lift and was not lowered, and that the DON and ADON told staff to report that the resident was lowered rather than that she fell. The medical director confirmed that the pain complaint was consistent with an injury from falling out of a Hoyer or incorrect transfer and that he considered the event a fall due to the drastic change in planes, yet there was no corresponding fall entry on the incident log.
Failure to Timely Assess and Treat New Pressure Ulcer and Maintain Aseptic Wound Care Technique
Penalty
Summary
The deficiency involves the facility’s failure to comprehensively assess and promptly obtain treatment orders for a newly developed, in-house acquired pressure ulcer, resulting in further decline of the wound. The resident involved had multiple diagnoses including diabetes, diabetic neuropathy, hypertension, atherosclerotic heart disease, repeated falls, altered mental status, and a history of a left buttock Stage III pressure ulcer. The care plan identified the resident as needing assistance with ADLs due to decreased mobility and as being at risk for skin breakdown related to decreased mobility, diabetes, and incontinence, with interventions such as turning and repositioning, staff skin checks, toileting assistance, and appropriate diet. A Braden Scale assessment documented the resident as at risk for pressure injuries, and a quarterly MDS showed moderately impaired cognition and the need for assistance with mobility, but no pressure injuries at that time. On 12/12/25, a Weekly Skin Observation note documented a new reddened, hard area on the buttock measuring 0.5 cm, and a progress note the same day described a small open area on the buttock that was hard and painful to touch. The area was cleaned and covered with a bordered foam dressing, and it was reported to the NP and wound team, but no treatment order was written at that time. There was no further documentation of a buttock pressure ulcer or any ordered or completed treatments until 12/15/25, when a physician order was finally obtained for cleansing, topical antibiotic, dressing changes, and systemic antibiotics, and the location was documented as the left gluteal fold rather than the right buttock. The DON and the former wound nurse later acknowledged that the original documentation of the wound as being on the right buttock was incorrect and that the wound had always been on the left buttock, and the DON verified that no treatment orders or interventions were put in place for three days after the wound was first identified. Subsequent wound care NP notes documented that the buttock wound progressed to an unstageable ulcer and then a Stage III pressure ulcer, with measurements showing a significantly larger wound than initially described, the presence of slough, and later undermining. Orders for specific wound treatments, including Anasept gel, calcium alginate, silicone bordered foam dressings, Mesalt, and antibiotics, were written over time, but there were transcription errors and delays in initiating some NP orders. The DON confirmed that the NP’s 12/18/25 order for Anasept gel and moist gauze was not initiated until 12/23/25 and that the order for a silicone bordered foam dressing was incorrectly transcribed as a dry sterile dressing. A wound culture was obtained, but the facility never received or followed up on the results. During a later observation, the resident’s buttock wound was found without a dressing in place after the resident reported that dressings frequently fell off and were not always replaced when she requested. During the observed dressing change, the RN failed to prepare a clean, dry work area as required by policy, placed clean supplies and scissors on a visibly soiled overbed table, and used scissors that had been placed directly on the dirty surface to cut the dressing before applying it to the wound, contrary to the facility’s wound and skin care procedures.
Failure to Protect Resident From Verbal Abuse by CNA
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from verbal abuse by a CNA. The resident had multiple complex medical conditions, including traumatic subdural hemorrhage, COPD, asthma, respiratory failure, diabetes, blindness, heart failure, end-stage renal disease on dialysis, major depressive disorder, generalized anxiety disorder, cannabis use, hypertension, hypothyroidism, and traumatic brain injury. A recent MDS assessment documented intact cognition and no behaviors. On an evening in the dining room, the resident requested assistance from staff to return to her room. One CNA stated she would help when finished passing trays, while another CNA was reported to have responded with an expletive directed at or in front of the resident, in the presence of others, causing the resident to feel embarrassed and humiliated and to be tearful throughout the night. Multiple accounts described the same core event: the resident asked to be taken back to her room after dinner, one CNA indicated she was busy, and the other CNA used the word “[expletive]” in connection with the request. The resident reported that the CNA yelled “[expletive] you” at the dinner table and that she did not like this CNA because she was not nice and seemed to hate her. A social services designee documented that the resident said the CNA said “[expletive] you,” threw her arms down, and that another aide eventually pushed the resident back to her room, where the resident cried herself to sleep in her wheelchair. A witness CNA reported that the CNA in question said, “[expletive] I do not wanna do this,” in a manner that the resident heard, and the resident stated she would report the CNA to the DON. The CNA involved acknowledged in a written statement that she used the expletive in front of the resident after the resident requested to be put to bed, stating she was talking to another CNA and did not realize the resident heard her, and that she later went to the resident’s room to apologize. The facility’s abuse policy states that residents have the right to be free from abuse, including emotional or verbal abuse. Despite the resident’s report of crying herself to sleep and feeling embarrassed and humiliated, review of nursing progress notes for the period around the incident showed no documentation of the incident, emotional distress, or provision of emotional support or counseling. The social services designee stated she followed up with the resident the next day but confirmed there was no documentation in the chart of this follow-up for emotional support.
Failure to Knock Before Entering Resident Room Violates Privacy Policy
Penalty
Summary
The deficiency involves a failure to maintain resident privacy and confidentiality when staff did not knock before entering a resident’s room, contrary to facility policy and resident rights. Resident #16, who had intact cognition and multiple medical diagnoses including respiratory failure, COPD, peripheral vascular disease, diabetes, chronic kidney disease, bipolar disorder, generalized anxiety disorder, lymphedema, and gout, had been admitted to the facility prior to the survey. During an observation and interview on 01/17/26 at 10:12 A.M., Maintenance #106 opened Resident #16’s room door without knocking while conducting fire watch rounds and confirmed at that time that she had not knocked before entering. Review of the facility’s “Ohio Resident Rights and Facility Responsibilities” policy showed that residents have the right, upon reasonable request, to have room doors closed and not opened without knocking, except in emergencies or when not medically advisable as documented by the attending physician, conditions which were not documented for this resident. This failure to knock prior to entering the resident’s room constituted a breach of the facility’s own policy and the resident’s right to privacy, affecting one resident reviewed for privacy out of three sampled.
Failure to Resolve Resident Grievances Regarding Call Light Response
Penalty
Summary
The facility failed to ensure that resident grievances regarding the timely answering of call lights were resolved appropriately and within a reasonable timeframe. Multiple records, including in-service documentation, grievance logs, and resident council minutes, indicated ongoing concerns about delayed call light responses. Specific incidents were documented where residents waited extended periods, ranging from over 26 minutes to more than two hours, for their call lights to be answered. Residents consistently reported long wait times during interviews, and the issue was also raised during resident council meetings. Despite staff being in-serviced on the importance of timely call light response, there was no evidence of follow-up audits or monitoring to ensure compliance. The facility's grievance policy required immediate action to prevent further violations of resident rights, but the lack of timely resolution and monitoring led to repeated and unresolved complaints from residents. This deficiency affected nine residents and was substantiated through multiple sources, including direct resident interviews and review of facility records.
Failure to Follow Infection Control Protocols During Resident Care
Penalty
Summary
The facility failed to implement infection control standards during resident care, as evidenced by observations involving two residents. For one resident with chronic kidney disease, necrotizing fasciitis, and Fournier gangrene, a wound nurse was observed touching a trash can with gloved hands and then proceeding to perform wound care without changing gloves or sanitizing hands. Additionally, after handling a soiled colostomy bag, the nurse changed from soiled to clean gloves without performing hand hygiene in between, contrary to the facility's hand washing policy which requires hand washing after handling contaminated objects and after removing gloves. In a separate incident, a certified nurse assistant provided incontinence care to another resident with metabolic encephalopathy, COPD, diabetes, and vascular dementia. During care, the CNA changed contaminated gloves but did not perform hand hygiene before immediately donning new gloves to continue care. This action was also inconsistent with the facility's hand washing policy, which specifies that hands should be washed after removing gloves. Both staff members confirmed these practices during interviews.
Failure to Maintain Safe and Palatable Food Temperatures
Penalty
Summary
The facility failed to maintain palatable and appetizing food temperatures for residents, as evidenced by multiple complaints and direct observations. Resident council minutes documented a complaint about cold biscuits and gravy, and several residents reported that their food was sometimes or always cold. During a meal service observation, food items were initially prepared at appropriate temperatures, but a test tray placed on a food cart and distributed last was found to have significantly dropped in temperature. The BBQ chicken measured 122°F, the vegetable blend 107.5°F, and the mashed potatoes and gravy 112°F, all below the facility's policy requirement of holding hot foods at 135°F or above. The facility's policy, consistent with USDA guidelines, requires hot foods to be held at or above 135°F to prevent bacterial growth. However, the observed meal service process allowed food temperatures to fall into the 'danger zone' as defined by the USDA, with the test tray food confirmed to be cold by both thermometer and taste test. The deficiency was identified through resident interviews, review of council minutes, direct observation of meal service, and review of facility policy and USDA guidelines.
Failure to Arrange Ordered Orthopedic Consultation
Penalty
Summary
A deficiency occurred when the facility failed to arrange an orthopedic consultation as ordered for a resident who was admitted with multiple diagnoses, including congestive heart failure, hypertension, atherosclerotic heart disease, atrial fibrillation, venous insufficiency, diabetes, spinal stenosis, hypothyroidism, and anemia. The resident was transferred from assisted living to the skilled nursing facility due to increased difficulty with ambulation, and a new order was received for an orthopedic referral and pain management with Tramadol. Documentation in the medical record and occupational therapy evaluation indicated the resident was experiencing significant right knee pain and was awaiting an orthopedic appointment. Despite the physician's order for an orthopedic referral due to worsening knee pain, there was no evidence in the medical record that the referral was set up during the resident's stay. The resident, who had moderately impaired cognition, continued to report pain and was awaiting further assessment. The facility administrator confirmed that the orthopedic appointment was never scheduled, citing the short duration of the resident's stay as the reason.
Resident Room Not Maintained in Clean and Sanitary Condition
Penalty
Summary
The facility failed to maintain a resident's room in a clean, organized, and sanitary condition. During a facility tour with the Regional Maintenance Director, it was observed that the resident's room contained an empty medication cup on the floor, a basin on the sofa with a dried dark brownish red substance, clothes scattered on the floor, brown discoloration in the toilet with a splattered spot of stool on the toilet tank, and a dried yellow substance in the bottom of the suction machine container at the bedside. The Regional Maintenance Director confirmed these observations, verifying that the room was not clean, organized, or sanitary at the time of inspection. This deficiency was identified during an investigation under a specific complaint number and affected one resident in a facility with a census of 62.
Failure to Use Required PPE During Dressing Change Under Enhanced Barrier Precautions
Penalty
Summary
A deficiency occurred when a registered nurse failed to use appropriate personal protective equipment (PPE) during a dressing change for a resident with multiple medical conditions, including a malignant neoplasm of the esophagus, dysphagia, tracheostomy status, and a jejunostomy feeding tube. The resident had an order for the J-tube site to be cleaned and dressed three times daily, and a recent tracheostomy removal required daily bandage changes. During observation, the nurse donned gloves but did not wear a gown while changing the dressing, despite the presence of green drainage on the dressing and the resident's clothing. The resident's room had an Enhanced Barrier Precaution (EBP) sign posted, and the facility's EBP policy required both gown and glove use during high-contact care activities, such as device and wound care, for residents at risk of multi drug-resistant organism (MDRO) acquisition. The nurse acknowledged not wearing a gown during the procedure, which was inconsistent with facility policy and the posted precautions. This event was identified during a survey and affected one resident out of a facility census of 62.
Facility Fails to Serve Meals at Palatable Temperatures
Penalty
Summary
The facility failed to ensure that meals were served at a palatable temperature, affecting all 55 residents who received meals from the kitchen. Multiple residents, including those with various medical conditions such as atrial fibrillation, diabetes, and chronic kidney disease, reported that their meals were consistently served cold. Observations and interviews confirmed that residents found the food to be cold and unappetizing, with specific complaints about the temperature of the meals. During a tray line observation, it was noted that while food items were initially at a safe serving temperature, by the time they were delivered to residents, the temperatures had dropped significantly. For instance, the brussel sprouts were at 115 degrees Fahrenheit, and the ham was at 120 degrees Fahrenheit, both of which were not considered warm. The Dietary Supervisor confirmed these findings, noting that the food items were not warm enough. Additionally, the facility's concern log indicated previous complaints about cold room trays, and the facility's policy did not address the palatability of meals.
Sanitation and Food Storage Deficiencies in Kitchen
Penalty
Summary
The facility failed to ensure that food was stored, prepared, and served under sanitary conditions, potentially affecting all 55 residents who received meals from the kitchen. During an observation of the kitchen, several issues were noted, including unlabeled and undated food items in the walk-in cooler and freezer, such as hamburger patties, mashed potatoes, spaghetti sauce, taco meat, and carrots. The dry stock area had an opened bag of gravy mix not dated when opened, and the sandwich cooler had a buildup of shredded cheese. Additionally, the refrigerator/freezer combination unit contained several undated and open-to-air food items, including pickles, parmesan cheese, fish patties, potato wedges, tater tots, and breakfast sausage patties. The Dietary Supervisor confirmed that items should be dated when opened, not open to air, and discarded after seven days. The facility's sanitation audits consistently scored below the desired goal of 90%, indicating ongoing issues with kitchen cleanliness and food storage practices. Multiple audits revealed that a significant number of pieces of equipment in the cook's work area were not acceptable in terms of cleanliness. Additionally, there were repeated findings of undated, uncovered, or unlabeled food items, including moldy hotdogs and pasta. Despite the facility's policy requiring an action plan and follow-up review for scores below 90%, the sanitation scores remained low, with the most recent audit scoring 80%. The dish machine in the facility was also found to be non-compliant with temperature requirements for sanitization. The machine's rinse temperature did not meet the minimum requirement of 180 degrees Fahrenheit, as observed during a facility tour. Despite attempts to rerun the machine, the temperature did not exceed 150 degrees Fahrenheit for the rinse cycle. The facility's policy required manual washing or the use of disposable products if the dishwasher did not meet the proper temperatures. Additionally, the puree process was observed to be inadequate, as the dietary staff did not properly sanitize equipment by submerging it in a sanitizer solution, as required by the facility's procedure.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to maintain the dumpster area in a clean and sanitary manner, which had the potential to affect all residents residing in the facility. During an observation of the dumpster area, a buildup of debris was noted around the base of two dumpsters. The debris included a Styrofoam plate, an empty box of oatmeal cream pies, multiple blue surgical gloves, two large clear fast food plastic cups, a white carafe lid, a plastic shopping bag, several plastic drinking straws, numerous plastic utensils, two small plastic drinking cups, and a medicine cup. The Dietary Supervisor confirmed the presence of the debris during the observation. A review of the facility's Nutrition Services Quality Validation-Kitchen Sanitation document, dated two months prior, indicated that the area was previously noted as unacceptable due to trash around and behind the dumpster. An interview with the Dietitian confirmed that she conducted monthly sanitation audits in the facility kitchen and identified numerous cleanliness concerns. The facility's policy, dated five years prior, stated that trash should not be deposited on the ground for any reason.
Inadequate Diet Consistency for Mechanically Altered Diets
Penalty
Summary
The facility failed to ensure that residents requiring mechanically altered diets were served the appropriate diet consistency, affecting four residents. Resident #12, who had severe cognitive impairment and was on a pureed diet, was served non-pureed au gratin potatoes. The dietary staff did not have a spreadsheet to indicate what each diet was allowed, leading to the error. Similarly, Resident #42, with moderately impaired cognition and on a mechanical soft diet, was served an intact hotdog instead of a ground one, which was corrected after the surveyor's intervention. Resident #153, on a mechanical soft diet, was served tacos with lettuce cut into small square pieces instead of shredded, which was not appropriate for their diet. The dietary staff again lacked a spreadsheet to guide them on diet consistencies, resulting in the improper meal preparation. Resident #202, on a mechanical soft diet, was served ham that was cut up with a knife instead of being ground, which was corrected after the surveyor's intervention. The dietary staff were unsure of the requirements for a mechanical soft diet, contributing to the error. Additionally, the puree process for ham was observed to be inadequate, as the final product was not smooth and had bits sticking to the tongue. The dietary staff did not routinely test the puree consistency, leading to the initial improper preparation. The facility's policy on therapeutic diets, which should match resident orders, was not effectively implemented, resulting in these deficiencies.
Infection Control Deficiencies in Hand Hygiene and Barrier Precautions
Penalty
Summary
The facility failed to maintain proper hand hygiene during meal tray distribution, as observed with a State tested Nursing Assistant (STNA) who did not wash her hands between handling meal trays and interacting with residents. This was noted during a dining observation where the STNA moved personal items and assisted residents without performing hand hygiene, contrary to the facility's handwashing policy. This affected multiple residents who received meals in their rooms. In the laundry room, the facility did not ensure proper handling of soiled linens, as observed with a pile of bed pads and linens lying directly on the floor. The Housekeeping Supervisor confirmed the lack of a protective barrier and the absence of a policy for handling linens. Additionally, a resident's nasal cannula was not stored in a protective barrier when not in use, as confirmed by a Registered Nurse, which was against the facility's oxygen therapy policy. The facility also failed to utilize Enhanced Barrier Precautions (EBP) during intravenous medication administration for a resident with a peripherally inserted central catheter. The Licensed Practical Nurse did not wear a gown as required by EBP protocol. Furthermore, during wound care for another resident, the staff did not disinfect the over-the-bed table before placing supplies and failed to perform hand hygiene after cleansing the wound, which was against the facility's handwashing policy.
Facility Fails to Maintain Safe Environment
Penalty
Summary
The facility failed to maintain a safe environment in good repair, affecting three residents. Resident #160 experienced water leakage from the bathroom into his room due to a shower curtain that was too short, lacking a lip on the shower floor to contain the water. This issue was acknowledged by the Director of Nursing (DON) during an environmental observation. Additionally, the DON verified the presence of gouges and missing pieces in the walls of Residents #7 and #48's rooms, although it was unclear if maintenance had been informed about these issues.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that call lights were within reach for two residents, leading to a deficiency in accommodating the needs and preferences of these residents. Resident #7, who had severe cognitive impairment and multiple medical conditions including chronic obstructive pulmonary disease and vascular dementia, was observed on two occasions with her call light out of reach. On November 25, 2024, she was in her wheelchair with the call light attached to her bed's grab bar, and on November 27, 2024, the call light was hanging on her ventilator machine, both times confirmed by staff to be out of reach. Similarly, Resident #8, who had moderately impaired cognition and left side hemiparesis, was observed with his call light out of reach while sitting in a recliner. The call light was placed on the right grab bar, which was inaccessible due to his left side paralysis. Resident #8 reported that he had to yell for assistance as he could not reach the call light. This was confirmed by RN #320, who acknowledged that the call light was too short to reach the recliner. The facility's policy on call lights did not address the requirement for them to be within reach of residents.
Missing DNR Form in Resident's Medical Record
Penalty
Summary
The facility failed to ensure that a signed Do Not Resuscitate (DNR) form was present in the medical record of a resident, affecting their right to have their end-of-life wishes respected. The resident, who had diagnoses including intellectual disability, fatty liver, chronic obstructive pulmonary disease, and essential hypertension, had an order for DNR-CCA (do not resuscitate comfort care arrest) documented in their electronic medical record. Additionally, the resident's care plan indicated their wish to be a DNR-CCA, with interventions stating that no CPR should be performed and that advance directives would be reviewed quarterly and as needed. However, upon review, both the physical and electronic medical records lacked a signed DNR form to support the resident's expressed wishes. This deficiency was confirmed during an interview with a registered nurse, who acknowledged the absence of the signed code status form and was unable to provide an explanation for its omission.
Resident's Clothing Preference Not Documented in Care Plan
Penalty
Summary
The facility failed to ensure that a resident's preference to wear undersized clothing was documented in her care plan. The resident, who was cognitively intact and had diagnoses including panic disorder, bipolar disorder, anxiety disorder, intellectual disability, and morbid obesity, preferred to wear an undersized nightgown that exposed her abdomen and brief. Despite this preference being known to the staff, it was not included in her care plan, which is a requirement for providing effective and person-centered care. Observations and interviews with staff confirmed that the resident's preference for wearing undersized nightgowns was known but not documented in her care plan. The Director of Nursing and other staff members acknowledged the oversight, noting that the resident was finicky and preferred her own nightgowns despite suggestions to cover herself for modesty. The facility's policy mandates that care plans include all necessary instructions for care, including respecting residents' rights and preferences, which was not adhered to in this case.
Failure to Complete Discharge Summaries for Residents
Penalty
Summary
The facility failed to ensure that discharge summaries were completed for two residents, Resident #47 and Resident #51, as required by their policy. Resident #51 was admitted with multiple diagnoses including schizoaffective disorder and anxiety disorder, and was discharged home with her husband after completing rehabilitation services. However, there was no evidence of a discharge summary, post-discharge plan of care, or discharge instructions in her medical record. The Social Service Designee confirmed the absence of these documents, attributing it to her inexperience in the position. Similarly, Resident #47, who had diagnoses such as metabolic encephalopathy and type two diabetes, was discharged home after short-term rehabilitation. Despite the care plan indicating a need for a discharge summary, none was found in the resident's medical record. The Director of Nursing confirmed the lack of a discharge summary after reviewing the records. The facility's policy required a comprehensive discharge summary, including a summary of stay, medication reconciliation, and a post-discharge plan of care, none of which were completed for these residents.
Failure to Implement Fall Interventions for Resident
Penalty
Summary
The facility failed to implement fall interventions as ordered for a resident, identified as Resident #31, who was at risk for falls due to conditions such as Alzheimer's disease, dementia, and muscle weakness. The resident's care plan included specific interventions to mitigate fall risks, such as the use of Dycem on the wheelchair, medication reviews, and maintaining a clutter-free environment. However, during an observation, it was noted that the Dycem was not present on the resident's wheelchair, contrary to the physician's order dated 09/30/24. The deficiency was confirmed during an interview with a Certified Nursing Assistant (CNA) who acknowledged the absence of Dycem on the wheelchair. The facility's policy on falls, dated 01/27/20, mandates that residents at risk for falls be monitored and assessed, with interventions developed and implemented based on individual needs. Despite these guidelines, the necessary intervention for Resident #31 was not in place, contributing to the deficiency identified by the surveyors.
Deficiencies in Nutritional Monitoring and Documentation
Penalty
Summary
The facility failed to ensure timely reweights and adequate monitoring of meal intakes for two residents, leading to deficiencies in nutritional care. Resident #15, who had multiple diagnoses including anemia and osteoporosis, experienced a significant weight fluctuation that was not promptly reweighed to verify accuracy. Despite a dietary note indicating gradual weight loss and a recommendation for weekly weights, a 28.1-pound weight increase was recorded without immediate reweighting, which was later found to be inaccurate. The Registered Dietitian and Registered Nurse acknowledged the oversight in not obtaining a timely reweight. Resident #31, diagnosed with Alzheimer's disease and other conditions, also experienced issues with weight monitoring. The resident had a significant weight gain followed by a weight loss without timely reweights. Meal intakes were inconsistently documented, with numerous instances of missing intake records over two months. The Registered Dietitian confirmed the lack of documentation and acknowledged the ongoing problem with meal intake records at the facility. The facility's policy on nutrition and hydration required quarterly reviews by the dietitian and more frequent reviews based on changes in condition or weight concerns. However, the facility did not adhere to this policy, as evidenced by the delayed reweights and incomplete meal intake documentation for the residents. These deficiencies highlight lapses in the facility's monitoring and documentation processes, impacting the nutritional care provided to the residents.
Failure to Administer Prescribed Oxygen and Maintain Safety Protocols
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident by not administering oxygen at the prescribed dose, not ensuring oxygen in use signage was posted, and not dating the oxygen tubing or keeping it off the floor. This deficiency affected one resident who was admitted with diagnoses including chronic obstructive pulmonary disease, anxiety disorder, and unspecified dementia. A physician's order required continuous oxygen at two liters per minute via nasal cannula. However, an observation revealed that the resident's portable oxygen concentrator was set to deliver oxygen at 3.5 liters per minute, and the nasal cannula tubing was undated and lying on the floor. Additionally, there was no sign outside the resident's room indicating that oxygen was in use. Interviews with the Director of Nursing and Assistant Director of Nursing confirmed these findings.
Failure to Monitor Dialysis Site in Resident
Penalty
Summary
The facility failed to ensure proper assessment and monitoring of a resident undergoing dialysis, which was identified during a review of medical records, facility policy, and staff interviews. The resident, who had been admitted with conditions including diabetes mellitus, acute kidney failure, stage four chronic kidney disease, and dependence on renal dialysis, was not monitored for dialysis site complications as required. Despite having a dialysis port and undergoing dialysis three times a week, there was no evidence in the medical records of ongoing assessment or monitoring of the dialysis site. This lack of monitoring was confirmed by the Assistant Director of Nursing during an interview. The facility's policy stated that orders for central line care and other dialysis needs should be implemented and maintained, but this was not adhered to in the case of the resident.
Failure to Address Pharmacy Recommendations
Penalty
Summary
The facility failed to ensure that pharmacy recommendations were fully addressed for a resident with multiple diagnoses, including bipolar disorder, dementia with behavioral disturbance, manic episodes, and schizophrenia. The resident was prescribed Restoril for insomnia, Ativan for anxiety, and Olanzapine for psychotic symptoms. The pharmacist recommended a gradual dose reduction (GDR) for Restoril and Olanzapine, and compliance with CMS regulations for the Ativan prescription. However, the physician's responses to these recommendations lacked the required rationale for not implementing the suggested changes or dose reductions. Specifically, the pharmacist suggested reducing the Restoril dosage to achieve the minimum effective dose, but the physician's response only noted a pending psychiatric evaluation without providing a rationale for maintaining the current dose. Similarly, the Ativan prescription did not comply with CMS regulations, as it lacked a documented rationale and specific time frame for continuation. The Olanzapine prescription also did not include a rationale for not reducing the dose. An interview with a registered nurse confirmed that the pharmacy recommendations were not fully addressed, as there was no documented rationale for contraindicating the GDRs for Restoril and Olanzapine, nor was the Ativan recommendation fully addressed.
Failure to Monitor Blood Glucose Levels for Diabetic Resident
Penalty
Summary
The facility failed to ensure proper monitoring of blood glucose levels for a resident with diabetes mellitus, morbid obesity, and intellectual disabilities. The resident was prescribed Metformin, Trulicity, Tresiba insulin, and Humalog insulin, with orders to check blood glucose levels every morning. However, a review of the November 2024 Medication Administration Record (MAR) and blood glucose recordings revealed that between November 14 and November 23, only one blood glucose level was recorded on November 20. This lack of consistent monitoring was confirmed during an interview with an LPN, who acknowledged the order to check the resident's blood glucose level daily but noted the failure to do so consistently during the specified period.
Failure to Implement GDR and Document Rationale for Psychotropic Medications
Penalty
Summary
The facility failed to ensure proper management of psychotropic medications for a resident with multiple psychiatric diagnoses, including bipolar disorder, dementia with behavioral disturbance, manic episodes, and schizophrenia. The resident was prescribed Restoril for insomnia, Ativan for anxiety, and Olanzapine for psychotic symptoms. The facility did not implement gradual dose reductions (GDR) for these medications, nor did they provide documented rationale for why GDRs were contraindicated, as required by regulations. Specifically, the pharmacist recommended a reduction in Restoril dosage, but the physician's response lacked a rationale for maintaining the current dose. Similarly, the Ativan order did not include a time limit or rationale for its continued as-needed use, and the Olanzapine dosage was not reduced or justified. Interviews with facility staff confirmed the absence of documented rationale for not implementing GDRs and the lack of compliance with regulations regarding the as-needed use of anti-anxiety medications. The pharmacist's recommendations were not fully addressed, and the physician's responses did not provide the necessary documentation to justify the continued use of the prescribed dosages. This oversight affected the resident's medication management and demonstrated a failure to adhere to regulatory requirements for psychotropic medication use in the facility.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to ensure medications were administered in accordance with physician orders, resulting in a 10% medication error rate. Three errors were identified out of 30 opportunities for error, affecting three residents. Resident #10 was administered an incorrect dosage of Mucinex, receiving 400 mg instead of the prescribed 600 mg. This error was confirmed by the LPN responsible for the administration. Resident #152 received Humalog Insulin without the pen being primed, as required by the manufacturer's instructions. The RN administering the insulin confirmed the oversight. Additionally, Resident #20 was given 400 mg of Mucus Relief instead of the ordered 600 mg due to a lack of stock, as verified by the RN involved. These errors highlight a failure in adhering to prescribed medication dosages and administration protocols.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure proper labeling, storage, and disposal of multi-dose medication vials and pens, as observed during a survey. Specifically, one of the two medication carts observed had issues affecting two residents. For Resident #33, an insulin glargine pen was improperly stored at room temperature instead of being refrigerated as per manufacturer instructions. Additionally, an admelog insulin pen was found with an incomplete open date label, and it was discovered that there was no physician order for this medication, leading to its disposal. The manufacturer's guidelines for admelog require disposal after 28 days, but the lack of a complete date made it impossible to verify compliance. For Resident #252, a vial of flonase was found in the medication cart without an open date on the label, and there was no current physician order for flonase. The facility's policy mandates that expired medications be removed and destroyed, and that containers or vials be dated when initially opened. These observations indicate a failure to adhere to the facility's medication storage policy and manufacturer guidelines, potentially affecting the safety and efficacy of the medications administered to residents.
Arbitration Agreement Lacks Mutual Agreement on Arbitrator and Venue
Penalty
Summary
The facility failed to ensure that its arbitration agreement allowed for a mutually agreeable arbitrator and venue, affecting all 55 residents residing in the facility. The arbitration agreement specified that disputes would be resolved by binding arbitration administered by the National Arbitration Forum (NAF) under their rules and procedures. However, the agreement did not specify a venue for the arbitration, and if the NAF was no longer available, the parties were to mutually agree on an alternative organization. Interviews with the Vice President of Operations and Corporate Marketing revealed that during the admission process, residents were presented with the arbitration agreement by trained staff, but the agreement did not provide residents or their representatives with a choice in selecting the arbitrator or venue. Further interviews confirmed that the facility's arbitration agreement clearly stated the facility's choice of arbitrator without ensuring the venue would be convenient for both parties. The facility's representatives were unaware that the venue and arbitrators must be mutually agreed upon by both the resident or resident representative and the facility. Additionally, it was revealed that the facility did not have a policy on arbitration agreements, indicating a lack of awareness and compliance with the requirement for mutual agreement on arbitration terms.
Failure to Ensure Up-to-Date Pneumonia Vaccinations
Penalty
Summary
The facility failed to ensure that pneumonia vaccinations were up-to-date for two residents, Resident #7 and Resident #30, out of five reviewed for vaccination status. Resident #7 had received the PPSV23 vaccine on 12/17/21, but there was no documentation of receiving the PCV15, PCV20, or PCV21 vaccines as recommended by the Pneumonia Recommendations Vaccinations Advisor application. The application advised that Resident #7 should have received one dose of PCV15, PCV20, or PCV21 at least one year after the last dose of PPSV23, which was not administered. Infection Preventionist #356 confirmed that Resident #7 was not up-to-date on her vaccine and was unaware of the need for another dose. Similarly, Resident #30 had received the PPSV23 vaccine on 06/03/19, but there was no documentation of receiving the PCV15, PCV20, or PCV21 vaccines. The Pneumonia Recommendations Vaccinations Advisor application recommended that Resident #30 should have received one dose of PCV15, PCV20, or PCV21 at least one year after the last dose of PPSV23, which was not given. Infection Preventionist #356 also verified that Resident #30 was not up-to-date on her vaccine. The facility's policy, dated 01/20/20, stated that all newly admitted residents should be assessed for their pneumococcal vaccine status and receive the vaccine per CDC guidelines if consent and physician orders are obtained.
Failure to Submit Required PBJ Data
Penalty
Summary
The facility failed to ensure the submission of Payroll Based Journal (PBJ) data as required, which had the potential to affect all 53 residents residing in the facility. A review of the facility's PBJ submission data report revealed no evidence of administrator data submitted for the fiscal year 2024 for the third quarter, covering April 1 to June 30. This resulted in the facility receiving a 1 Star Rating for the same period. During an interview, the facility Administrator confirmed that the corporate office is responsible for submitting the PBJ data and acknowledged the absence of administrator data, which was not identified during their review.
Infection Control Deficiency in Pericare Technique
Penalty
Summary
The facility failed to adhere to infection control standards during pericare for a resident, as observed by surveyors. Two State Tested Nurse Aides (STNAs) were involved in the incident. After washing their hands and donning gloves, one STNA used a moist washcloth to clean the resident's groin area but did not separate the labia, which is against the facility's policy. The STNA then improperly cleaned a bowel movement by wiping from the rectal area toward the vagina, which is contrary to the recommended front-to-back cleaning method. This improper technique resulted in the resident not being adequately cleaned before a clean brief was applied. Additionally, the STNAs failed to follow proper glove removal and hand hygiene protocols. After cleaning the resident, they adjusted the resident's bedding and used the bed control without removing their soiled gloves. They also left the room with soiled linen before washing their hands. The Director of Nursing confirmed that the facility's policy requires gloves to be removed and hands washed before touching bedding or other surfaces. This deficiency was identified during a complaint investigation.
Failure to Ensure Resident Dignity and Respect
Penalty
Summary
The facility failed to ensure that residents were treated with dignity and respect, specifically affecting one resident. The incident involved a State-tested Nursing Assistant (STNA) who used profanity and made inappropriate comments to a resident, instructing him not to use his call light. The resident, who was cognitively intact and required assistance with activities of daily living, reported the incident, which was corroborated by his roommate. The resident involved had a medical history that included epilepsy, alcohol abuse, diabetes mellitus, chronic kidney disease, and muscle weakness. Despite the inappropriate behavior from the STNA, the resident reported feeling safe and denied any negative effects from the incident. The facility's census at the time was 55, and the deficiency was investigated under a specific complaint number.
Medication Misappropriation by Staff Member
Penalty
Summary
The facility failed to prevent the misappropriation of medication for a resident by a staff member. The resident, who had intact cognition, was admitted with multiple diagnoses including chronic respiratory failure, morbid obesity, and diabetes. The resident had a physician's order for hydrocodone-acetaminophen (Norco) for pain management, but the medication was not administered as prescribed from April to June 2024. A review of the narcotic sign-out sheet revealed that a registered nurse was the only staff member to sign out the medication during this period, yet the medication was not recorded as administered in the resident's Medication Administration Records (MAR) for May and June 2024. The facility identified a discrepancy when a supply of six tablets was found missing, and the suspected staff member was suspended pending investigation. The resident reported not receiving the medication for several months and was unaware of its availability. The facility's investigation included interviews with the resident, the suspected staff member, and other residents and staff. The suspected staff member did not cooperate with the investigation and refused a drug test. The facility concluded that misappropriation had occurred, leading to the termination of the staff member's employment. The incident was reported to local law enforcement, the Board of Pharmacy, and the Board of Nursing.
Failure to Conduct Routine Respiratory Assessments
Penalty
Summary
The facility failed to conduct routine respiratory assessments for residents requiring continuous supplemental oxygen and aerosolized respiratory medications. This deficiency affected two residents, one with chronic obstructive pulmonary disease and diabetes mellitus, and another with pulmonary fibrosis and hypertension. Both residents were prescribed supplemental oxygen and bronchodilator medications via nebulizer. However, their medical records showed a lack of routine monitoring of oxygen saturation levels, which is crucial for assessing the effectiveness of the oxygen therapy and ensuring the residents' respiratory needs are met. The medical records of the affected residents revealed sporadic monitoring of oxygen saturation levels, with significant gaps between assessments. The facility's policies for oxygen therapy and respiratory assessments did not address the need for routine evaluations. Interviews with the Director of Nursing, Assistant Director of Nursing, and a Respiratory Therapist confirmed the absence of regular respiratory assessments, including oxygen saturation monitoring, during continuous supplemental oxygen use and before and after nebulizer treatments. This deficiency was identified during an investigation under Complaint Number OH00153845.
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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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