Cridersville Nursing And Rehab
Inspection history, citations, penalties and survey trends for this long-term care facility in Cridersville, Ohio.
- Location
- 603 East Main Street, Cridersville, Ohio 45806
- CMS Provider Number
- 366171
- Inspections on file
- 21
- Latest survey
- April 29, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Cridersville Nursing And Rehab during CMS and state inspections, most recent first.
The facility failed to maintain accurate and complete crash cart audits for multiple full-code residents. Surveyors, accompanied by the DON, found that daily crash cart checks did not include verification of supply expiration dates, and that an extension cord documented as present on several audit dates was not actually in the cart. Audit logs also conflicted with the cart’s contents by indicating that required items such as eye protection, saline, and clear plastic were present when they were not. These findings were inconsistent with the facility’s policy requiring the crash cart to be checked every 24 hours and after each use, with prompt replacement of equipment and supplies.
A resident with mobility and cognitive impairments sustained a laceration requiring hospitalization after a wall-mounted bathroom sink, previously reported as unstable, detached from the wall and caused a fall. The sink lacked support legs and had not been subject to routine maintenance checks, despite concerns raised by residents to staff and maintenance. The incident resulted in actual harm and highlighted the absence of preventive measures for accident hazards.
Several residents with physical and cognitive impairments were unable to access a working bathroom sink in their shared room for an extended period, requiring them to use distant facilities for daily hygiene. Staff and residents repeatedly reported the issue, but the repair was delayed despite the facility receiving a replacement sink, resulting in ongoing inconvenience and, in one case, a resident fall.
A resident with multiple complex medical conditions, including end stage renal disease and heart failure, was prescribed warfarin but did not have a care plan addressing anticoagulant use. Review of records and staff interview confirmed the absence of a care plan for this medication, resulting in a deficiency identified during a complaint investigation.
A resident with severe cognitive impairment was found in her room with her pants down while another resident, who was cognitively intact, was observed touching her in the peri-area. Staff immediately intervened and separated the residents. Interviews confirmed the incident, and it was determined that the resident who was touched lacked the cognitive capacity to consent. The facility had not provided abuse education to all staff or conducted follow-up monitoring, contributing to the failure to protect the resident from sexual abuse.
A resident with Full Code status was found unresponsive and pulseless, but staff delayed the initiation of CPR while confirming code status and failed to continue resuscitation until EMS arrived. The RN in charge stopped CPR after one cycle, despite objections from other staff and the absence of a physician's order to discontinue. Essential equipment was missing from the crash cart, and EMS found no CPR in progress upon arrival, resulting in serious harm.
A resident with a history of respiratory failure and COPD returned from the hospital with orders for BiPAP therapy, but staff failed to ensure a current physician's order was in place or to document consistent use of the BiPAP device. The resident experienced episodes of respiratory distress, including a hospitalization for acute hypercapnic respiratory failure, with records showing several nights without BiPAP use and no documentation of refusals or reasons for missed therapy.
A resident with multiple chronic conditions experienced a significantly elevated blood pressure, but staff did not notify the physician or document any follow-up, contrary to facility policy and care plan interventions. This deficiency was confirmed through record review and DON interview.
A resident with surgical incisions and a wound vac did not have goals or interventions for wound care documented in their care plan. This was confirmed by the DON during a review of medical records and staff interviews.
The facility failed to complete required weekly wound assessments for a resident with a diabetic ulcer, did not perform wound treatments as ordered for another resident with multiple wounds, and did not ensure a resident attended a scheduled outside physician appointment. Documentation was missing for some missed treatments, and staff confirmed these deficiencies during interviews.
A resident with hypertension and other medical conditions received Metoprolol Tartrate on several occasions when their systolic blood pressure was below the physician-ordered threshold. Despite clear instructions to hold the medication under certain conditions, staff administered it outside the prescribed parameters, as confirmed by the DON and ADON. No adverse effects were noted.
The facility failed to timely cohort COVID-19 positive residents, affecting four individuals. A resident tested positive and was placed in a room with two negative residents, leading to another resident testing positive. Similarly, another resident tested positive and was not isolated, resulting in their roommate also testing positive. The facility did not adhere to CDC guidance for isolating COVID-19 positive residents.
A facility failed to report an allegation of abuse involving a cognitively impaired resident to the Ohio Department of Health as required by policy. The incident involved a CNA reporting that an RN bumped shoulders with the resident. An internal investigation found no negative findings, but the Administrator did not report the incident, believing the facility was not out of compliance.
A resident in a LTC facility did not receive assistance to maintain regular bowel movements, despite not having a bowel movement for several days and requesting a laxative. The facility's bowel elimination policy was not followed, and there was no documentation of the required interventions being implemented.
A facility failed to document and assess pressure ulcers for a resident, leading to a deficiency. The resident, admitted with multiple diagnoses, had a lesion on the upper back and a bed sore, but the medical record lacked a minimum data assessment and wound documentation until eight days later. The facility's policy required a complete skin check upon admission, which was not documented, resulting in the deficiency.
A resident with chronic pain and other health issues did not receive timely pain management due to a lack of Oxycodone in the medication cart. Despite having an active order, the resident was left in pain because the LPN did not contact the pharmacy or provider to resolve an issue with an expired prescription. The ADON confirmed the availability of Oxycodone in the emergency supply, but the LPN failed to act, delaying pain relief.
A resident with multiple health conditions was prescribed antibiotics for cellulitis without an end date, despite not having an active infection. The facility's infection control log did not list the resident as needing antibiotics, and the resident reported receiving them for unknown reasons. The RN confirmed the antibiotics were given preventatively for a resolved abscess.
A facility failed to document the administration of Oxycodone for a resident with multiple health issues, despite the medication being signed out on narcotic sheets. The ADON confirmed the documentation errors, although narcotic counts showed no discrepancies.
A facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with a surgical lesion site on the upper back. The resident's medical record lacked documentation about the wound, and the ADON was unaware of the need for EBP until information from a previous facility revealed the site was growing Staphylococcus. This oversight led to a deficiency in infection prevention and control.
A resident with a history of respiratory issues was not provided timely and appropriate care after refusing a non-invasive ventilator (NIV) and experiencing low blood pressure and oxygen saturation. The facility staff failed to notify the physician of these changes, and the resident was later found unresponsive and died after being sent to the hospital. Interviews revealed that staff were aware of the resident's non-compliance with the NIV but did not inform the physician.
The facility failed to notify physicians when residents were non-compliant with using non-invasive ventilators (NIVs) and when abnormal vital signs were recorded. Three residents with respiratory conditions were affected, as their refusals to use NIVs at night were not communicated to their physicians, despite facility policy requiring such notifications. Interviews confirmed the lack of documentation and communication regarding these issues.
Inaccurate Crash Cart Audits and Missing Emergency Equipment
Penalty
Summary
The facility failed to ensure accurate and complete crash cart audits for residents requiring basic life support, affecting eighteen of thirty-five residents who were designated as full code. During an observation of the crash cart with the DON, surveyors found that the daily audit documentation for the month did not include verification of expiration dates for crash cart supplies. Review of the crash cart audit logs showed that an extension cord was documented as being in the cart on multiple dates, but the extension cord was not present in the cart at the time of inspection. Additionally, the audit documentation indicated that required items, including eye protection, saline, and clear plastic, were not present in the crash cart, yet they were documented as being in the cart. The facility’s undated “Emergency Crash Cart” policy stated that the crash cart is to be checked every 24 hours and after every use, and that equipment and supplies are to be noted and replaced promptly, but the observed documentation and contents of the cart did not match these requirements. This deficiency was verified with the DON at the time of the survey and was cited under the requirement that personnel provide basic life support, including CPR, to residents requiring emergency care, subject to physician orders and advance directives, and was investigated under Complaint Number 2687380.
Plan Of Correction
Cridersville Care Center Provider Number:366171 Survey Type: Complaint Survey Survey Date: 04/29/26 This Plan of Correction (PoC) outlines the actions completed by the facility with regards to the deficiency citation. This Plan of correction does not constitute any admission of guilt or liability by the facility and is submitted only in response to the regulatory requirements. Please accept the following as the facility's credible allegation of compliance as of 4/30/26. F678 CPR All Full Code residents #18 have the potential to be affected by the alleged deficiency. On 4/27/26 the DON/ADON re-stocked the crash cart per the inventory sheet for all missing items. Crash cart inventory sheet updated and new one will go into effect on 5/1/26. All licensed nursing staff provided with training related to crash cart inventory being a daily audit review using inventory sheet on 4/27/26 per DON/designee. The DON/designee will conduct clinical rounds and conduct a random audit of crash cart three times per week for 4 (four) weeks to ensure compliance. The results of the audit will be documented. The facility conducted an Ad-Hoc QAPI meeting on 4/27/26 and discussed the alleged deficiency and corrective actions. Date when corrective action will be completed: 4/30/26
Failure to Prevent Avoidable Fall Due to Unsafe Bathroom Sink
Penalty
Summary
A deficiency occurred when a resident with a history of hemiplegia, malnutrition, difficulty walking, and cerebral infarction sustained an avoidable fall resulting in actual harm. The resident, who required set-up only for daily hygiene and weighed 115 pounds, was in a shared shower room bathroom when she leaned on the wall-mounted sink. The sink detached from the wall, fell to the floor, and broke into pieces. The resident fell onto a sharp piece of the broken sink, sustaining a five millimeter laceration to her lower back that hemorrhaged and required hospitalization for sutures. Prior to the incident, the resident and other residents had reported concerns about the sink being in disrepair to staff, including the maintenance department. The maintenance director confirmed that no routine maintenance checks were performed on sinks in the facility before the incident. The sink involved was old, wall-mounted, and lacked support legs, being attached only to the wall studs. After the incident, an audit revealed three other similar sinks in the facility. The maintenance director and administrator both confirmed that there were no prior routine checks or reports of disrepair for the other sinks before the audit. The incident was unwitnessed, but other residents responded quickly to the resident's call for help, and staff provided prompt assistance and arranged for emergency medical services. The administrator and maintenance director both acknowledged the sink's failure and the lack of routine maintenance checks. The resident expressed frustration about the ongoing lack of access to a functional bathroom sink following the incident.
Failure to Maintain Functional Bathroom Facilities for Residents
Penalty
Summary
The facility failed to maintain a homelike environment for several residents due to a non-functional bathroom sink in a shared room. Multiple residents, including those with impaired cognition, physical disabilities, and chronic illnesses, were affected by the lack of access to a working sink for daily hygiene needs. Residents reported having to walk to distant shower rooms or visitor bathrooms to wash their hands or perform personal care, which was described as inconvenient and bothersome, especially during evenings or when other residents were using those facilities. Observations confirmed that the shared bathroom adjacent to the residents' room was missing a porcelain sink basin, with only water lines and a faucet present. Staff interviews revealed that the sink had been in disrepair since it fell off the wall, causing a break in the water lines. The maintenance department and administration were aware of the issue, and residents and staff had reported the problem multiple times. Despite the facility receiving a replacement sink, the repair had not been completed by the time of the survey, and the project was not listed on the facility's work order or repair list. Documentation review showed that the sink had been non-functional for over a month, and the lack of timely repair resulted in ongoing inconvenience and disruption to residents' daily routines. One resident reported a fall in the bathroom due to the sink's disrepair, and others expressed frustration with the prolonged wait for repairs. The deficiency was substantiated through observations, interviews, and review of facility records and invoices.
Failure to Initiate Care Plan for Anticoagulant Use
Penalty
Summary
The facility failed to initiate a care plan addressing anticoagulation medication use for a resident admitted with multiple complex diagnoses, including end stage renal disease, diabetes mellitus, hyperkalemia, dependence on renal dialysis, heart failure, and intellectual disabilities. Medical record review showed that the resident had physician orders for warfarin sodium, an anticoagulant, but the care plan dated after the medication order did not include any interventions or monitoring related to anticoagulant therapy. This omission was confirmed during an interview with the Director of Nursing, who acknowledged the absence of a care plan for anticoagulant use. The deficiency was identified during a complaint investigation and affected one of three residents reviewed for care plans.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a resident from sexual abuse, as evidenced by an incident involving two residents on a secured unit. One resident with severely impaired cognition and a history of dementia, cerebral infarction, and psychotic disorder was found in her room with her pants down, while another resident, who was cognitively intact, was observed touching her in the peri-area. Staff immediately separated the residents and notified the nurse, who performed a head-to-toe assessment and found no injuries. The family and physician were notified, and the resident declined medical attention. Interviews with staff confirmed the incident, with a CNA stating she witnessed the inappropriate contact and immediately intervened. The DON acknowledged that the facility had not provided abuse education to all staff or conducted follow-up audits or monitoring related to abuse concerns. The Social Service Director stated that the resident who was touched did not have the cognitive capacity to consent to a sexual encounter, and the resident herself could not recall if she had consented to the contact. The facility's policy defines sexual abuse as non-consensual sexual contact of any type with a resident and requires investigation of all alleged violations. Despite this, the Administrator concluded that the encounter was mutual and did not substantiate the allegation of abuse after completing the investigation. The police were notified but did not investigate further. The facility's actions and lack of comprehensive staff education and monitoring contributed to the failure to ensure the resident was free from sexual abuse.
Failure to Provide Immediate and Continuous CPR to Full Code Resident
Penalty
Summary
A deficiency occurred when staff failed to immediately initiate and continuously perform cardiopulmonary resuscitation (CPR) on a resident who was identified as Full Code status and was found unresponsive without vital signs. Upon discovery, staff delayed the start of CPR while attempting to confirm the resident's code status, and once CPR was initiated, it was not maintained until emergency medical services (EMS) arrived. Instead, the registered nurse in charge stopped CPR after only one cycle, despite the resident's Full Code status and the absence of a physician's order to discontinue resuscitative efforts. The resident involved had a history of chronic obstructive pulmonary disease, atrial fibrillation, bipolar disorder, and acute respiratory failure, and was noted to have intact cognition and independent ambulation prior to the incident. On the day of the event, the resident was found unresponsive, cyanotic, and pulseless by staff. Multiple staff interviews and statements revealed confusion and lack of coordination regarding the resident's code status, delays in retrieving and using the crash cart, and the absence of essential equipment such as a backboard, oxygen, and a face mask for the Ambu bag. Staff resorted to improvising with a paper towel for rescue breaths due to missing equipment. EMS arrived to find that CPR had been stopped for approximately five minutes prior to their arrival, and immediately resumed life-saving measures. Staff interviews consistently indicated that the registered nurse in charge directed staff to stop CPR, asserting authority to call the code, despite objections from other staff members who recognized that CPR should have continued until EMS arrival. The failure to provide immediate and continuous CPR as required by the resident's Full Code status and facility policy resulted in serious life-threatening harm and/or death.
Failure to Ensure BiPAP Orders and Implementation After Hospitalization
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a BiPAP order was in place and implemented for a resident with a history of acute and chronic respiratory failure, COPD, and hypercapnia after returning from the hospital. The resident's care plan and hospital discharge orders specified the need for BiPAP therapy with specific settings, but upon review, there was no current physician's order for BiPAP, and the Medication Administration Record (MAR) did not reflect any BiPAP orders or documentation of its use for the relevant months. Staff interviews confirmed the absence of orders and documentation, and there was no record of resident refusals or consistent application of the BiPAP therapy as prescribed. The resident experienced episodes of respiratory distress, including an incident where she was found with an oxygen saturation of 38% and required emergency transfer to the hospital, where she was intubated for acute hypercapnic respiratory failure. Documentation from the BiPAP machine indicated several nights when the resident did not use the device, but there was no documentation explaining these gaps or indicating whether the resident refused therapy. Staff, including the DON and Respiratory Supervisor, were unable to provide evidence that the BiPAP was consistently applied or that refusals were documented. The lack of a current physician's order, absence of documentation in the MAR and progress notes, and failure to clarify or implement the recommended BiPAP settings after hospital discharge directly contributed to the resident's respiratory compromise and subsequent hospitalization. The deficiency affected one resident out of three reviewed for oxygen therapy in a facility with a census of 40.
Failure to Notify Physician of Elevated Blood Pressure
Penalty
Summary
The facility failed to notify a physician of a significant change in a resident's condition, specifically an elevated blood pressure reading. Medical record review showed that a resident with a history of chronic obstructive pulmonary disease, atrial fibrillation, bipolar disorder, and acute respiratory failure had a documented blood pressure of 167/124. Despite care plan interventions requiring monitoring and reporting of cardiovascular symptoms, there was no documentation of physician notification or follow-up blood pressure readings in the medical record, Medication Administration Record, or progress notes for the relevant dates. Interviews with the Director of Nursing confirmed that staff did not notify the physician about the elevated blood pressure, as required by facility policy. The policy mandates that the nurse supervisor or charge nurse must notify the resident's medical practitioner of changes in condition and document these actions in the medical record. The deficiency was identified during a complaint investigation and affected one resident out of three reviewed for change in condition.
Failure to Develop and Implement Wound Care Plan
Penalty
Summary
The facility failed to ensure that a complete care plan was developed and implemented for a resident with multiple medical conditions, including surgical incisions and a wound vac in use. Medical record review showed that the resident had surgical incisions on both hips and a wound vac applied to the left hip, but the care plan did not include any goals or interventions related to wound care or the use of the wound vac. This omission was confirmed during an interview with the DON, who acknowledged that the care plan lacked the necessary components for wound management for this resident. The deficiency was identified during a review of the resident's medical records and staff interviews, affecting one of three residents reviewed for wound care in a facility with a census of 40.
Failure to Complete Wound Assessments, Treatments, and Ensure Attendance at Medical Appointments
Penalty
Summary
The facility failed to complete weekly wound assessments for a resident with a diabetic ulcer. Medical record review showed that no weekly wound assessments with measurements were completed for the resident during a specific month, despite the presence of an active wound and a care plan that included wound management interventions. The Director of Nursing confirmed the absence of these required assessments during staff interview. Additionally, the facility did not complete wound treatments as ordered for another resident with multiple wounds resulting from frostbite and amputations. Review of the Treatment Administration Records (TAR) and physician orders revealed that wound care was not performed on several occasions for various wounds, including the right hand, left foot, left hand, left hip, and right foot. Documentation was also missing for some of the missed treatments, and the resident reported that wound care was not completed timely, particularly on the night shift. The Assistant Director of Nursing verified that wound care was not completed as ordered by the physician. The facility also failed to ensure that a resident attended a scheduled outside physician appointment. The resident was scheduled for a follow-up with an orthopedic physician but did not attend the appointment. The administrator initially stated that the resident had canceled the appointment, but the resident denied this, and the physician's office confirmed that the resident did not call to cancel. Staff interviews revealed that the facility did not have a policy regarding resident appointments.
Failure to Follow Physician Orders for Medication Administration
Penalty
Summary
Staff failed to follow physician orders during medication administration for a resident with a history of hypertension, superficial frostbite, tissue necrosis, homelessness, and cerebral vascular accident. The resident's care plan required evaluation of blood pressure and heart rate, and a physician's order specified that Metoprolol Tartrate should be held if the systolic blood pressure was under 110 or the heart rate was below 60. Despite these instructions, the medication was administered multiple times when the resident's systolic blood pressure was below the specified threshold. Review of the Medication Administration Record showed that on several occasions, the resident received Metoprolol Tartrate even though their systolic blood pressure readings were below 110, contrary to the physician's order. The Director of Nursing and Assistant Director of Nursing confirmed that the medication was given outside the prescribed parameters. Facility policy required medications to be administered according to orders, including any specified time frames. No negative effects were documented as a result of the medication administration.
Failure to Cohort COVID-19 Positive Residents
Penalty
Summary
The facility failed to timely cohort COVID-19 positive residents, affecting four residents. Resident #39, who was admitted with multiple diagnoses including cerebral palsy and chronic obstructive pulmonary disease, tested positive for COVID-19 on April 11, 2025, and was sent to the emergency room. Upon returning the same day, Resident #39 was placed in a room with two COVID-19 negative residents, #11 and #19, and was not moved until April 14, 2025. Resident #11 subsequently tested positive for COVID-19 on April 13, 2025. The Director of Nursing confirmed these events during an interview. Similarly, Resident #29, who had diagnoses including heart disease and diabetes, tested positive for COVID-19 on April 11, 2025, and was not cooperative with isolation measures. Resident #29 shared a room with Resident #34, who was not moved until April 14, 2025, and tested positive for COVID-19 on April 15, 2025. The facility's policy and CDC guidance recommend that residents confirmed to have SARS-CoV-2 infection should be placed in a single room or housed with other COVID-19 positive residents, which was not adhered to in these cases.
Failure to Report Alleged Abuse to ODH
Penalty
Summary
The facility failed to report an allegation of resident abuse to the Ohio Department of Health (ODH) as required by their policy. The incident involved a resident with dementia, depression, anxiety disorder, and psychotic disorder with delusions, who was cognitively impaired and required maximal staff assistance with activities of daily living. On a specific date, a Certified Nursing Assistant (CNA) reported an allegation of abuse against the resident by a Registered Nurse (RN). The CNA did not witness the incident but was informed by another CNA. The alleged incident involved the RN rushing past the resident and bumping shoulders, without causing the resident to stumble or fall. The facility conducted an internal investigation on the same day, interviewing involved staff members, and found no negative findings. Despite this, the facility's policy required that all allegations of abuse be reported to ODH immediately, but no later than two hours after the allegation was made. The Administrator decided not to report the incident to ODH, believing the investigation showed the facility was not out of compliance. This decision was contrary to the facility's policy, which mandates reporting all allegations of abuse to the appropriate authorities.
Plan Of Correction
F-0609 On 3/21/2025, Administrator completed a review of the ODH gateway and all SRI's have been reported timely/appropriately since 3/21/2025. SRI for Resident #3 will be submitted to the ODH Gateway EIDC system on or before 3/21/2025 for POC compliance. The facility Administrator was educated by the Regional Director of Operations on company Abuse, Neglect, Exploitation, Mistreatment and Misappropriation prevention and reporting policy on 3/21/2025. The facility Administrator or facility designee will audit 2x's a week for a period of 2 weeks then 1x a week for a period of 2 weeks to ensure all submitted State Reportable Incidents were reported timely/appropriately per reporting policy. The DON or designee will educate all staff on abuse and abuse reporting by 3/28/2025. Education included Abuse Policy and Timeliness of Abuse Reporting for Cridersville Healthcare. The DON or designee will review resident records for the last 2 weeks to ensure that there were no other allegations of abuse that were not reported by 3/24/2028. There was a total of 52 residents that were reviewed because they were in the building during this timeframe. Administrator reviewed all abuse allegations for last 30 days to make sure there was nothing else that wasn't reported. All results will be submitted to QAPI for review and determined if any further action is needed.
Failure to Assist Resident with Bowel Movements
Penalty
Summary
The facility failed to ensure that a resident received assistance to maintain regular bowel movements, affecting one resident. The resident, who was cognitively intact, reported not having a bowel movement for several days and had requested a laxative, which he had not received. The medical record review confirmed that the resident had not had a bowel movement for four consecutive days, and there was no as-needed laxative order in place. The resident's diagnoses included back pain, hypertension, coronary artery disease, sick sinus syndrome, and hyperlipidemia. The facility's bowel elimination policy outlined specific steps to be taken if a resident had no bowel movement within certain time frames, including administering prune juice or a bran mixture, assessing the abdomen, and considering osmotic and stimulant laxatives. However, there was no documentation indicating that these steps were followed for the resident in question. The Assistant Director of Nursing confirmed the lack of documentation of a bowel movement and the absence of initiation of the bowel protocol for the resident.
Failure to Document and Assess Pressure Ulcers
Penalty
Summary
The facility failed to complete skin assessments and document skin alterations for a resident, leading to a deficiency in pressure ulcer care. Resident #81, who was admitted with diagnoses including back pain, hypertension, coronary artery disease, sick sinus syndrome, and hyperlipidemia, was found to have a lesion on the upper back and a bed sore upon arrival. However, the medical record lacked a minimum data assessment and did not document the presence of a bed sore in the initial admission assessment. Physician orders were in place for wound care, but there was no evidence of a detailed description of the wounds until eight days after admission when the wound nurse assessed them. The wound nurse's assessment revealed a surgical biopsy site on the upper back and a stage three pressure ulcer on the coccyx. The facility's policy required a complete head-to-toe skin check upon admission, which was not documented for Resident #81. An interview with a registered nurse confirmed the absence of wound documentation until prompted by the surveyor. This oversight in documentation and assessment led to the deficiency noted by the surveyors.
Failure to Provide Timely Pain Management
Penalty
Summary
The facility failed to provide appropriate pain management for a resident experiencing significant pain. The resident, who had a history of paraplegia, chronic pain, and other serious health conditions, was admitted with an order for Oxycodone 5 mg every 6 hours as needed for pain. Despite this, the resident reported experiencing pain levels of 6 to 8 out of 10 and stated that she had requested her pain medication the previous night but was informed by the night nurse that there was no supply of Oxycodone available. The nurse had contacted the pharmacy, but the medication had not yet been delivered, leaving the resident in pain since the previous evening. Further investigation revealed that the Licensed Practical Nurse (LPN) was aware of the resident's pain medication order but confirmed the absence of Oxycodone in the medication cart. The LPN mentioned the possibility of obtaining an emergency dose from the emergency supply, but this was not pursued due to an expired handwritten prescription. The Assistant Director of Nursing (ADON) later verified that the Oxycodone order was not expired and was available for refill, and that there was Oxycodone in the emergency supply. However, the LPN admitted to not having contacted the pharmacy or the provider to resolve the issue, resulting in a delay in administering the necessary pain relief to the resident.
Resident Received Unnecessary Antibiotics
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medications. Resident #11, who has a medical history including paraplegia, chronic pain, obesity, pneumonia, bladder disorder, sepsis, heart failure, and neuromuscular dysfunction of the bladder, was prescribed Amoxicillin-Pot Clavulanate for cellulitis of the abdominal wall on 05/23/24. However, there was no end date specified for this medication in the orders. A review of the facility's infection control log from June 2024 to August 2024 did not list Resident #11 as having an active infection requiring antibiotics for cellulitis. An interview with Resident #11 revealed that they had been receiving antibiotics for an unknown reason and duration. Further, an interview with RN #158, the Infection Control Preventionist, confirmed that Resident #11 had been receiving the antibiotic since 05/23/24 without an end date until 08/20/24, despite not having an active infection. The antibiotics were being administered as a preventative measure for a resolved abscess.
Failure to Document Narcotic Administration
Penalty
Summary
The facility failed to ensure proper documentation of narcotic medication administration in the medical records for a resident. This deficiency was identified during a review of records and staff interviews, affecting one of the five residents reviewed for medication administration documentation. The resident involved had multiple diagnoses, including paraplegia, chronic pain, and heart failure, and was prescribed Oxycodone for pain management. However, there were several instances where the administration of Oxycodone was not documented in the Medication Administration Records (MARs), despite being signed out on the narcotic sign-out sheets. The discrepancies were noted on specific dates in July and August, where the narcotic sign-out sheets indicated that Oxycodone was administered, but the MARs lacked corresponding documentation. An interview with the Assistant Director of Nursing (ADON) confirmed these documentation errors, although there were no discrepancies in the narcotic counts. The ADON verified that nurses are required to document the administration of narcotics in the electronic records when they sign them out from the locked box.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for a resident, leading to a deficiency in infection prevention and control. The resident, who was admitted with diagnoses including back pain, hypertension, coronary artery disease, sick sinus syndrome, and hyperlipidemia, had a surgical lesion site on the upper back. The medical record lacked documentation regarding the reason for the antibiotic ointment prescribed or a description of the wound. The Assistant Director of Nursing (ADON) was unaware of the nature of the surgical biopsy site until information was obtained from the previous facility, revealing that the site was growing Staphylococcus. Consequently, the resident was not placed in EBP as required by the facility's policy for residents with wounds.
Failure to Provide Timely Care Leads to Resident's Death
Penalty
Summary
The facility failed to provide appropriate and timely treatment, care, and services to a resident who was assessed with changes in condition. The resident, who had a history of respiratory failure, COPD, and other medical conditions, was ordered to use supplemental oxygen and a non-invasive ventilator (NIV) to aid her respiratory status. However, the resident refused the NIV, and the staff did not notify the physician of this refusal. Subsequently, the resident was assessed with low blood pressure and low oxygen saturation levels, but these were not timely or appropriately reassessed, reported to the physician, or rechecked before administering medications. On the day of the incident, the resident was hypotensive in the morning and had low oxygen saturation in the afternoon, yet no follow-up assessments or notifications to the physician were made. Despite these critical changes in condition, the resident was administered antianxiety and narcotic pain medications. Later, the resident was found in distress, with blue lips, removing her shirt and oxygen, and was unresponsive with no vital signs. CPR was initiated, and the resident was sent to the hospital, where she was placed on a ventilator in the ICU and subsequently died. Interviews with staff revealed that the facility's staff were aware of the resident's non-compliance with the NIV but did not notify the physician. The Medical Director confirmed he was not informed of the resident's low blood pressure or oxygen levels until after the resident was sent to the hospital. The facility's policy required notification of changes in a resident's condition, but this was not followed, contributing to the resident's untimely death.
Removal Plan
- An interdisciplinary team (IDT) Quality Assessment and Assurance (QAA) meeting was held to discuss and develop a plan with Medical Director #800.
- MD #800 was notified of the Immediate Jeopardy and review of the facility change in condition policy and plan for corrective action was reviewed with no changes made.
- The change in condition policy was reviewed by the Administrator and IDON #600 with no changes made.
- IDON #600 and Assistant Director of Nursing (ADON) #500 provided education to all Licensed Practical Nurses (LPNs) and Registered Nurses (RNs), including managers, on the facility change in condition policy and staff response to a change in condition.
- All resident medical records were reviewed by IDON #600 and ADON #500 to review vital signs, oxygen saturation, and the resident's physical condition.
- All resident medical records were reviewed by IDON #600 and ADON #500 to review for change in condition.
- An audit tool was implemented to monitor resident charts relating to any change in condition, adverse effects, and specifically, assessments for changes in condition as it related to change in condition notification.
- Two (#20 and #25) additional resident medical records were reviewed for appropriate care and services with a change in condition with no concerns identified.
- LPN #203, LPN #206, ADON #500, and IDON #600, verified they were educated on the facility's policies related to treatment of a change in condition, physician notification of a change in condition, and to document all assessments, including follow up assessments, of all abnormal vital signs.
Failure to Notify Physicians of NIV Non-Compliance and Abnormal Vital Signs
Penalty
Summary
The facility failed to notify physicians when residents were not using non-invasive ventilators (NIVs) as ordered and when there were abnormal vital signs. This deficiency affected three residents who were dependent on NIVs due to conditions such as chronic obstructive pulmonary disease (COPD), respiratory failure, and paraplegia. The medical records and interviews revealed that the facility did not adhere to the policy of notifying the physician of significant changes in the residents' conditions. Resident #30, who had diagnoses including bipolar disorder, respiratory failure, and COPD, was not compliant with wearing her NIV as ordered. Despite multiple entries in the nursing progress notes indicating non-compliance and education provided to the resident, there was no documentation of the physician being notified. On one occasion, the resident's oxygen saturation dropped to 80%, yet the physician was not informed. The medical director confirmed that he was not notified of the resident's low oxygen level or her refusals to wear the NIV. Similarly, Resident #20 and Resident #25, both of whom required NIVs due to respiratory conditions, were non-compliant with using the devices at night. The progress notes for these residents also lacked documentation of physician notification regarding their refusals. Interviews with the assistant director of nursing and the interim director of nursing confirmed the absence of notifications to the physicians about the residents' non-compliance with NIV use, despite the facility's policy requiring such notifications.
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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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