Divine Rehabilitation And Nursing At Toledo
Inspection history, citations, penalties and survey trends for this long-term care facility in Toledo, Ohio.
- Location
- 1011 North Byrne Road, Toledo, Ohio 43607
- CMS Provider Number
- 366328
- Inspections on file
- 59
- Latest survey
- March 16, 2026
- Citations (last 12 mo.)
- 32
Citation history
Health deficiencies cited at Divine Rehabilitation And Nursing At Toledo during CMS and state inspections, most recent first.
A dependent hospice resident with Alzheimer’s disease, severe cognitive impairment, underweight status, and documented need for full assistance with eating did not receive required mealtime support. At breakfast, a CNA set up the tray, cut the food, and opened milk but left the room and did not return to feed the resident, who made no attempts to eat and only intermittently tried to drink from the milk carton; the tray was later removed with the food untouched. At lunch, the CNA provided limited hand-feeding, after which the resident consumed only a small amount of ice cream and a bite of beans, and no alternative food choices were offered despite the resident’s dependence on staff for eating, as confirmed by staff interviews and the care plan.
Improper glucometer disinfection and uncovered bedpans: An RN used the same glucometer for two residents with severe cognitive impairment and cleaned it with an alcohol swab instead of the facility’s EPA-registered disinfectant wipes required by policy and manufacturer instructions. The facility also left three soiled bedpans uncovered in a resident’s bathroom while the resident had a UTI and was receiving antibiotics; the resident said staff had been using the bedpans for urine samples, and an LPN verified they should have been discarded.
A resident with severe cognitive impairment and an indwelling Foley catheter had the drainage bag left hanging from the bed frame and visible from the common corridor while in bed. Although the care plan and MD order addressed catheter positioning and use of a dignity bag, staff confirmed the bag was exposed and no privacy bag was in place while the resident was in bed; the Administrator also stated the facility had no policy or procedure for placement of collection bags to ensure dignity.
Failure to monitor residents on psychotropic medications. Three residents receiving psychotropic meds were not monitored for behaviors or medication side effects. One resident with bipolar disorder and anxiety received clonazepam, another resident with depression received sertraline, and a third resident with dementia and depression received aripiprazole and Lexapro. The RNCC confirmed no behavior monitoring was in place to assess efficacy and/or side effects.
Failure to Provide Ordered Oral Care: A dependent resident with severe cognitive impairment, dysphagia, and a feeding tube did not consistently receive ordered oral care and lip balm. Observations found the resident's mouth open with dry, peeling lips on separate occasions, and staff interviews confirmed the resident's lips were often not well cared for and that the peeling condition reflected more than one shift without adequate oral/lip care.
A resident with impaired cognition, hemiplegia, and dependence on staff for lower body dressing was found in bed without ordered compression stockings on both lower extremities. An LPN confirmed the stockings were not being worn, and another LPN stated the resident could likely push them down but would not be able to remove them.
Incomplete wound assessment, treatment order errors, and missing offloading device use. A resident with a right heel PU had gaps in weekly wound documentation, incomplete wound descriptions, conflicting treatment orders, and an ordered x-ray that was not completed. Another resident ordered to wear offloading boots to both feet while in bed was observed without the boots or wearing only one boot, with staff needing to locate the missing device.
A resident with cognitive impairment was found with a cigarette box in his sweatshirt pocket containing two lighters, even though the smoking assessment and facility policy indicated smoking materials were to be stored by staff. Staff and the DON confirmed he should not have had lighters on him. In a separate issue, a resident with dementia and a long history of falls had a care plan for a bedside mat, but observations showed the mat was not consistently placed at the bedside and was sometimes under the bed or only on one side, with exposed floor space on the other side.
A resident with CHF, bipolar disorder, parkinsonism, type II DM, and anxiety was ordered double portions, but staff did not provide them. The resident said he was not receiving the ordered portions, and observation showed dietary staff plated his meal without double portions. The DM confirmed the kitchen ticket and computer system did not indicate double portions, even though the physician order required them.
Tube Feeding Not Provided as Ordered: A resident with a feeding tube, impaired cognition, dysphagia, and multiple chronic conditions did not receive the full ordered tube feeding. An LPN hung a 1-liter bottle of Jevity 1.2, and the next morning the bottle was empty and the pump was off; the LPN confirmed the resident received only one liter instead of the ordered 1260 ml and stated a second bottle should have been hung.
Unsecured medications were found in a resident’s dresser during an assessment when an LPN responded to the room after the resident had nasal bleeding. The resident had four medications stored in the drawer, including nasal sprays and inhalers, and several had no patient name listed. The resident had no current orders for bedside medication storage or self-administration, while the facility policy required drugs and biologicals to be stored in locked compartments.
Failure to complete ordered lab tests for a resident with epilepsy, dysphagia, DM2, bipolar disorder, dementia, and gastrostomy status. The resident had significantly impaired cognition and depended on tube feeding for most nutrition and fluid needs. A physician ordered CBC with diff, BMP, and Hgb A1C every 6 months, but the chart showed the last labs were completed months earlier, and the Administrator confirmed no labs were done before the order was discontinued.
Inaccurate weekly skin assessments were completed for a resident with an unstageable pressure ulcer to the right heel. An LPN who was new to wound care used measurements from an outside wound clinic to complete multiple facility skin grid assessments and confirmed she did not visually assess the heel on those dates, despite the resident’s diagnoses including DM2, heart failure, heart disease, and PVD.
A resident with T1DM was prescribed and administered Trulicity, a medication only approved for T2DM, despite being on both long-acting and short-acting insulin. Multiple staff, including a pharmacist and physician, confirmed Trulicity was not appropriate for T1DM, and interviews revealed a lack of awareness among staff regarding its use. The facility failed to ensure the resident's medication regimen was free from unnecessary drugs.
A resident with a history of abuse and PTSD was administered a second dose of the influenza vaccine by an RN, despite having previously received the vaccine and verbally refusing it. The nurse dismissed the resident's objections and those of her husband, then administered the vaccine in error instead of the ordered pneumococcal vaccine. The incident left the resident fearful and concerned for her health, and the facility administrator confirmed the medication error and violation of the resident's rights.
A resident with a history of alcohol dependence and mental health issues was subjected to excessive physical force by an LPN during an attempt to confiscate alcohol in the smoking area. The LPN physically restrained and struck the resident's arm multiple times, resulting in the resident experiencing fear, mental anguish, and a sense of being unsafe. The incident was confirmed by video surveillance and staff interviews, and the resident required increased observation due to reported depression and thoughts of self-harm.
The facility did not maintain effective pest control, resulting in persistent flies, gnats, and mice in resident rooms and common areas. Staff and residents reported frequent pest sightings, and staff used fly swatters during care. Despite recommendations from the pest control vendor for more aggressive treatment and environmental repairs, the facility relied on in-house remedies, leaving several issues unresolved.
A resident with multiple comorbidities was scheduled for a bone marrow biopsy, but the facility failed to follow pre-procedure physician orders, including NPO status and holding anticoagulant and aspirin therapy. Due to these omissions, the resident was served breakfast and received medications that should have been held, resulting in the cancellation and repeated rescheduling of the procedure. Staff interviews confirmed lapses in order entry, documentation, and communication.
A resident with multiple wounds, including a right heel pressure ulcer, did not receive timely assessment, measurement, or documentation of the wound. Physician-ordered treatments and interventions for the right heel were not consistently initiated or documented, and required skin checks were missed. The wound was not properly monitored, leading to a severe decline in condition that was only discovered upon hospital transfer.
A resident did not receive food prepared in a form that met their individual needs, as the facility did not consistently modify meals to accommodate specific dietary requirements or physical abilities.
The facility did not maintain proper food storage temperatures, as the walk-in refrigerator consistently operated above safe levels and staff resorted to opening the freezer door to cool it, causing ice buildup. Maintenance requests for repairs were pending, and some perishable items were moved to the freezer, but other foods remained at risk of spoilage. All residents except two were potentially affected, though no foodborne illnesses were reported.
A resident with complex medical needs returned from the hospital with a new order for Augmentin oral suspension to treat aspiration pneumonia. Due to the receiving nurse not including the hospital discharge order for the antibiotic, the resident did not receive any oral antibiotic for four days, resulting in eight missed doses until a new order for Amoxicillin was started. The DON confirmed the omission was due to the hospital order not being transcribed.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
A resident with cognitive impairment and physical care needs was left unsupervised outside overnight without staff supervision or personal care. The incident was not reported to the State Survey Agency within the required timeframe, as the facility delayed submitting the Self-Reported Incident for two days, contrary to its own policy.
A resident with multiple medical conditions and moderate cognitive impairment was not assessed for smoking safety upon admission or during required assessments, despite facility policy mandating such evaluations for all smokers. The oversight was discovered only after the Administrator observed the resident smoking on facility camera footage.
Two residents did not receive required care as documented in their medical records, including medication administration, g-tube flushes, and weekly skin assessments. The MARs were falsified to indicate that care was provided when it was not, as confirmed by interviews with the Administrator and DON.
Two residents experienced deficiencies in accident prevention and supervision: one suffered a lumbar fracture after falling from a mechanical lift due to a worn and improperly laundered sling pad, while another was left unattended during a bed bath and fell from an unlocked bed. Additionally, the facility failed to thoroughly investigate multiple falls for one resident, with incident reports lacking key details and follow-up.
The facility did not have an RN on duty for eight consecutive hours as required, with staffing records and postings confirming the absence of RN coverage for all shifts during a period when 77 residents were present. The Administrator verified the lack of RN presence during this time.
A resident with multiple chronic conditions did not receive timely incontinence checks or proper perineal care as required by care plans and facility policy. Staff failed to check and change the resident for several hours and did not cleanse the perineal area after an episode of incontinence, resulting in non-compliance with established protocols.
A resident with Full Code status was found unresponsive and without vital signs. Two LPNs assessed the resident but did not initiate CPR or call 911, instead pronouncing death without physician direction. The resident's care plan and physician orders required CPR and EMS notification, and family members confirmed they did not refuse life-saving measures. This failure to follow protocol resulted in the resident's death without attempted resuscitation.
A resident with a history of elopement and schizoaffective disorder was able to leave the facility unsupervised after a visitor opened the front door, as required 15-minute checks were not performed or documented and the WanderGuard was left on the wheelchair. Staff were unaware of the resident's absence until a CNA found her offsite. Additionally, two residents who smoked were not assessed for smoking safety upon admission or quarterly, contrary to facility policy.
A resident experienced a 24-hour delay in treatment for a hip fracture after the facility failed to receive and follow up on stat X-ray results, resulting in unmanaged severe pain and delayed hospital transfer. Additionally, another resident did not receive required weekly wound assessments, with no documentation of monitoring for over a month, placing the resident at risk for harm.
Multiple failures occurred in the facility, including an LPN not initiating CPR or contacting a physician for a resident with Full Code status, a resident with a history of elopement leaving undetected due to missed supervision checks, staff refusing to provide care resulting in delays, and ongoing substance use by residents with minimal intervention. These actions and inactions led to deficiencies in supervision, adherence to policy, and reporting, impacting the well-being and safety of all residents.
Surveyors found that staff did not keep call lights within reach for two residents who required assistance, including one with impaired mobility and another who was legally blind, despite care plans specifying this need. Additionally, there was a shortage of clean linens, leading to delayed care for a resident and the potential to affect others, with staff and management unaware of the issue.
Surveyors identified multiple environmental maintenance issues, including water-stained ceiling tiles, peeling wallpaper, and dirty, worn flooring throughout the facility. The Director of Maintenance confirmed these findings and noted that repairs had not been completed, with no scheduled date for service.
A resident who was dependent on TPN due to an intestinal blockage did not receive a scheduled dose, and the physician was not notified of the missed administration. Staff interviews revealed confusion over responsibility for clarifying and administering the TPN, and documentation confirmed that the required physician notification did not occur, contrary to facility policy.
Two residents with significant visual impairments did not have working overbed lights in their rooms for approximately three weeks, despite facility policy requiring adequate lighting. Staff and maintenance were aware of the issue, which was attributed to broken underground electrical wires, but repairs had not been completed, leaving the residents without proper lighting.
The facility did not report two critical incidents to the SSA: one involving a resident with Full Code status who did not receive CPR when found unresponsive, and another involving a cognitively intact resident who eloped from the facility and required emergency services. In both cases, required self-reported incidents were not submitted, and the Administrator confirmed the lack of reporting.
A resident with a history of mental health conditions and identified as an elopement risk exited the facility unsupervised after a visitor entered, later exhibiting delusional behavior at a nearby store. The facility did not initiate an immediate investigation of the elopement, and the DON was unaware of the incident until days later, resulting in a deficiency for failure to respond appropriately to an alleged violation.
Several dependent residents did not receive scheduled showers or timely assistance with ADLs, as required by facility policy. Documentation and interviews revealed that staff sometimes refused to provide care, leading to extended periods without bathing for residents with significant medical and cognitive needs. Management was aware of staff refusals, and residents reported delays and confusion regarding who was responsible for their care.
A resident who was dependent on staff for toileting and incontinent of bowel and bladder did not receive timely incontinence care as required by her care plan and facility policy. Staff interviews and observation confirmed that the resident had not been checked or changed for several hours, resulting in a heavily saturated incontinence brief. Multiple CNAs acknowledged not providing care during their shifts, and a staffing shortage was noted.
A resident with complex medical needs, including an intestinal blockage and chronic kidney disease, did not receive a scheduled dose of TPN as ordered by the physician. Although the TPN solution was available and RNs were present in the facility, confusion among nursing staff regarding order clarification and administration responsibilities led to the missed dose. Facility policy required verification and administration of TPN by nursing staff, but this was not followed.
Nursing staff failed to demonstrate competency in following advanced directives and acted outside their scope of practice by not initiating CPR and pronouncing death for a Full Code resident. Additionally, staff lacked knowledge of procedures for obtaining and acting on stat radiology results, resulting in delayed care for another resident. These deficiencies were identified through record review and staff interviews.
Three residents with histories of substance use were repeatedly found using or possessing illicit drugs and alcohol within the facility. Staff and resident interviews confirmed ongoing substance use, and documentation showed that interventions were limited to education and removal of substances or paraphernalia, without the provision of specialized behavioral health or substance use disorder services.
A resident with diabetes did not receive multiple scheduled doses of both long-acting and fast-acting insulin as ordered by the physician, with no documentation of refusal or reason for omission. Nursing staff confirmed that missing initials on the MAR indicated the medications were not given, contrary to facility policy requiring administration as ordered.
A resident with intact cognition and dependent on staff for personal care reported being sexually abused by a CNA during showers. The abuse involved inappropriate contact, occurring multiple times over a month, leading to the resident's anxiety and anger. The incident was reported by another CNA who noticed the resident's discomfort, prompting an investigation and police involvement.
A resident with intact cognition reported repeated sexual abuse by a CNA during personal care, which was not reported in a timely manner by the facility staff. The abuse involved inappropriate actions during care, and the resident expressed distress and anxiety. The accused CNA was terminated for unrelated reasons before the allegations were known.
A resident with conditions such as morbid obesity and diabetes, dependent on staff for personal care, was left in a soiled brief overnight due to staff's refusal to provide care, fearing accusations of sexual abuse. Despite using the call light, the resident was not attended to until the morning, violating the facility's ADL policy.
A facility employed an STNA without proper Ohio certification, affecting 77 residents. The STNA worked multiple shifts with an expired out-of-state certificate, contrary to facility policy requiring state-approved training and certification within four months of hire.
The facility failed to conduct timely fall reviews for four residents identified as high fall risks. A resident with dementia experienced a fall resulting in a laceration, but the post-fall evaluation was delayed. Another resident fell without injury, yet the evaluation was also delayed. A third resident experienced two falls, with evaluations not completed within the required timeframe. Additionally, a resident was overdue for a quarterly fall risk assessment. The facility's policy requires timely assessments to minimize fall risks.
Failure to Assist Dependent Hospice Resident With Meals and Offer Alternatives
Penalty
Summary
The deficiency involves the facility’s failure to provide required assistance with eating to a dependent resident. The resident had diagnoses including Alzheimer’s disease, dementia, moderate protein calorie malnutrition, mixed incontinence, osteoarthritis, and cerebral ischemia, and was admitted to hospice with cerebral atherosclerosis. The nursing and nutritional plans of care, MDS, and functional abilities assessment all documented that the resident had severe cognitive impairment, was rarely/never understood, was dependent on staff for all ADLs including eating, received a mechanically altered therapeutic diet, and was on physician-ordered supplements and a weight gain regimen due to being underweight with a BMI of 11.8. Care plan interventions included assisting with feeding, providing and serving supplements and diet as ordered, and monitoring and recording intake at every meal. On the morning of the observed deficiency, a CNA delivered the resident’s breakfast tray, elevated the head of the bed, uncovered the plate and hot cereal, cut up the food, added sugar to the cereal, placed a spoon in the bowl, opened the milk carton, and then left the room. Over the next several minutes, the resident was observed looking toward the television, then with eyes closed, and made no attempts to feed herself. The food remained uncovered and untouched. The resident later attempted only to drink from the milk carton, with no attempts to eat the food. During this time, the CNA was observed seated at a computer in the lounge and did not return to assist with feeding until nearly an hour later, at which point the CNA removed the tray with the food still untouched. The CNA confirmed in interview that the resident had not eaten any of the breakfast meal and that no assistance with breakfast had been provided. At lunchtime the same day, the CNA again delivered the meal tray, repositioned the resident in bed, uncovered and set up the meal, and this time sat next to the resident and provided spoon-fed bites, instructing the resident to take a bite of each item before refusing the meal. The CNA later reported to an RN that the resident consumed only half a portion of ice cream and a bite of beans, and then removed the tray, leaving the remaining ice cream on the overbed table. No alternative food choices were offered after the resident’s limited intake at lunch. In interviews, both the CNA and the RN verified that the resident was dependent on staff for eating, had not been assisted with breakfast, and had not been offered alternative food choices when refusing most of the lunch meal. The deficiency was cited as continued non-compliance from prior surveys.
Improper glucometer disinfection and uncovered bedpans
Penalty
Summary
The facility failed to ensure glucometers were properly disinfected after use. Resident #49, who had Alzheimer's disease, COPD, type 2 diabetes mellitus, and severe cognitive impairment, had blood glucose checked by RN #500 using a glucometer. After the check, RN #500 cleaned the glucometer with an alcohol swab. RN #500 later verified she used an alcohol swab and stated she was an agency nurse and was not aware of the facility policy for glucometer cleaning. Resident #35, who had vascular dementia and metabolic encephalopathy with severe cognitive impairment, also had blood glucose checked by RN #500 using the same glucometer that had just been used for Resident #49. RN #500 again returned to the medication cart and cleansed the glucometer with an alcohol swab. RN #500 verified disinfectant wipes were available in the medication cart. The DON verified staff should not be using alcohol swabs to clean and disinfect glucometers, and that the four residents using the glucometer had no known blood borne pathogens. The facility policy required glucometers to be cleaned and disinfected after each use with an EPA-registered healthcare disinfectant, and the manufacturer instructions stated the meter should be cleaned and disinfected between patient use. The facility also failed to properly store bedpans for Resident #54, who had schizophrenia, osteoarthritis, hypertension, chronic pain, impaired cognition, was always incontinent of bowel and bladder, and was dependent on staff for toileting hygiene. The resident had a multidrug resistant UTI and was receiving antibiotic therapy. Two soiled bedpans were observed on the bathroom sink and one soiled bedpan was on the floor under the sink, and none were placed inside a plastic barrier. The resident stated staff had been using the bedpans to collect urine samples. The uncovered bedpans remained in the same locations on a later observation, and an LPN verified they were uncovered and should have been discarded. The Administrator stated urinary bedpans should be stored in a plastic bag, and the facility policy required bedpans and urinals to be handled in a manner to prevent spread of infection and placed in a plastic bag.
Catheter Drainage Bag Left Visible From Common Corridor
Penalty
Summary
The facility failed to ensure a resident's urinary catheter drainage bag was covered and positioned to maintain dignity. Resident #5 was admitted with diagnoses including obstructive and reflux uropathy, obstructive hydrocephalus, vascular dementia, edema, chronic kidney disease, and abscess of prostate. The most current MDS showed severe cognitive impairment, dependence on staff for activities of daily living, and an indwelling urinary catheter in place. A nursing plan of care addressed the Foley catheter and included positioning the catheter bag and tubing below the bladder and away from the entrance room door, and a physician order directed that the indwelling urinary catheter be covered with a dignity bag and/or cover every shift. Observations on multiple occasions showed Resident #5 in bed with the indwelling catheter drainage bag hanging from the bed frame and draining yellow urine, with no privacy bag in place and the drainage bag visible from the common corridor. RN #500 confirmed the catheter drainage bags were to be kept in a privacy bag or out of common sight to maintain dignity. CNA #454 verified the drainage bag was exposed to the common corridor while the resident was in bed and stated a privacy bag was installed on the resident's high back chair, but not while the resident was in bed. The Administrator verified the facility did not have a policy or procedure instructing placement of collection bags or associated personal drainage devices to ensure dignity.
Failure to Monitor Residents on Psychotropic Medications
Penalty
Summary
The facility failed to ensure residents prescribed psychotropic medications were monitored for behaviors and medication side effects. This affected three residents reviewed for psychotropic medication use out of a census of 60. Resident #1 was admitted with diagnoses including congestive heart failure, bipolar disorder, parkinsonism, type II diabetes mellitus, and anxiety, had intact cognition on the annual MDS, and was ordered clonazepam 1 mg twice daily for anxiety. Resident #1’s care plan identified a mood problem related to anxiety, depression, and bipolar disorder and included monitoring and documenting side effects and effectiveness of medications. Resident #48 was admitted with diagnoses including depression, type II diabetes mellitus, heart disease, and peripheral vascular disease, had intact cognition on the quarterly MDS, and was ordered sertraline Hcl 25 mg daily for depression. Resident #66 was admitted with diagnoses including pelvic fractures, cerebral infarction, dementia, bariatric surgery, and Raynaud’s syndrome, was alert and oriented on admission, and had a baseline care plan stating medications and side effects should be monitored. Resident #66 was ordered aripiprazole 10 mg daily for depression and Lexapro 20 mg daily for antidepressant use. During interview and concurrent record review, the RNCC confirmed there was no behavior monitoring in place to monitor for efficacy and/or side effects of the psychotropic medications for Residents #1, #48, and #66.
Failure to Provide Ordered Oral Care
Penalty
Summary
The facility failed to ensure a dependent resident received adequate oral care as ordered. Resident #23 was admitted with diagnoses including epilepsy, dysphagia, type II diabetes mellitus, bipolar disorder, dementia, and gastrostomy status. The quarterly MDS showed the resident had severely impaired cognition, had a feeding tube, and was dependent on staff for oral hygiene and personal hygiene. Physician orders required Chapstick to the lips every shift and oral care twice daily because the resident received no food or drink by mouth. Observations showed the resident lying in bed with the mouth open and the lips appearing dry and peeling on two separate occasions. On a later observation, the lips appeared moist and hydrated with no peeling. During interviews, an LPN stated she provided oral care and applied lip balm, and noted the resident's lips were often not well cared for when she returned after a day off. A CNA stated she provided oral and lip care and confirmed the lips were peeling, with excess skin wiping off easily, and said the condition would have taken more than one shift without lip or oral care to become that dry and peeled. The facility policy stated residents unable to carry out ADLs would receive necessary services to maintain good nutrition, grooming, and personal and oral hygiene.
Failure to Apply Ordered Compression Stockings
Penalty
Summary
The facility failed to ensure that compression stockings were applied as ordered for one resident. The resident had an admission history including viral hepatitis B, chronic viral hepatitis C, nontraumatic intracranial hemorrhage, and hemiplegia, and the quarterly MDS indicated impaired cognition and dependence on staff for lower body dressing. A physician order required compression stockings to both lower extremities every morning, but observation found the resident lying in bed without the stockings on. An LPN confirmed the stockings were not being worn and stated they were not in the resident’s bed or on the floor. Another LPN who routinely worked with the resident stated the resident was dependent on staff for lower body dressing and could probably push the stockings down but would not be able to remove them.
Incomplete wound assessment, treatment order errors, and missing offloading device use
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was not met for two residents. Resident #48 was admitted with diagnoses including heart failure, left above-knee amputation, type II diabetes mellitus, heart disease, and peripheral vascular disease, and had an unstageable pressure ulcer to the right heel. Although the resident went to an offsite wound clinic multiple times for treatment and assessment of the heel wound, facility weekly wound documentation was missing for several intervals, and the facility’s skin observation tools and later skin grid pressure assessments did not include wound measurements, wound bed description, surrounding tissue description, odor, drainage, or wound stage. The facility’s RNCC confirmed the wound should have been assessed weekly, and the RNCDR stated there was not adequate evidence in the facility documentation to support that the resident had a pressure ulcer, leading to the quarterly MDS being modified to indicate no pressure ulcer. Resident #48 also had wound treatment order issues. Offsite wound clinic orders and facility physician orders differed in frequency, and the record showed overlapping wound treatment orders were documented as being provided concurrently. The RNCC confirmed the resident’s treatment orders were not aligned and that a night shift wound treatment order remained active after new offsite wound clinic orders were implemented. In addition, an offsite wound clinic order dated 02/25/26 included a follow-up item for a right foot x-ray to be completed as soon as possible, but the facility did not complete the x-ray after receiving the order. Resident #6 had an order to wear offloading boots to both lower extremities while in bed as tolerated, with refusals to be documented. On one observation, the resident was lying in bed with one boot on the floor near the bed and was not wearing the ordered boot. On another observation, the resident was wearing only one offloading boot, and the LPN had to search for the missing boot and apply it with the resident’s consent. The resident’s MDS indicated impaired cognition and dependence on staff for lower body dressing, and no pressure ulcers were documented.
Unsafe smoking material storage and missing fall intervention placement
Penalty
Summary
The facility failed to ensure smoking materials were stored safely for a resident with cognitive impairment and failed to ensure the resident’s smoking assessment accurately reflected his condition. Resident #58 had diagnoses including type II diabetes mellitus with chronic kidney disease, hypertension, intellectual disabilities, schizophrenia, anxiety disorder, bipolar disease, and COPD. His MDS showed moderate cognitive deficits and care plan interventions included instruction on smoking risks and facility smoking policy, with staff to observe for cigarette burns. However, the smoking safety screen assessment documented no cognitive loss, no dexterity problems, and that the resident needed the facility to store his lighter and cigarettes, while also stating he was safe to smoke without supervision. During observation, the resident was upset about missing cigarettes, and a CNA found a cigarette box in his sweatshirt pocket containing two lighters. The CNA removed the box, opened it, and showed the lighters, then returned the box with the lighters back into the resident’s pocket. The Administrator later verified the resident should not have lighters on his person and removed the box and lighters from the sweatshirt pocket. The Administrator and DON both confirmed the resident had cognitive impairment and should not have had cigarette lighters on him. The facility’s smoking policy stated smoking materials were to be maintained by staff and returned to staff after smoking. The facility also failed to ensure fall interventions were in place as care planned for Resident #11, who had dementia, repeated falls, injury of the left lower leg, hypertension, and anxiety disorder. The resident’s MDS showed severely impaired cognition, rejection of care, wheelchair use with staff propulsion, incontinence, and a history of falls. The care plan identified high fall risk and included a mat to the bedside, but did not specify which side. Multiple observations showed the mat placed only on the right side of the bed, with no mat on the left side and exposed floor space between the bed and wall measuring about 24 inches. On one observation, the mat was under the bed rather than at the bedside, and an LPN verified the mat was not placed as indicated. The facility fall prevention policy required interventions to be initiated based on the resident’s fall risk and care plan.
Diet Order Not Reflected in Kitchen System
Penalty
Summary
The facility failed to ensure a resident received the diet ordered by the physician. Resident #1 was admitted with diagnoses including CHF, bipolar disorder, parkinsonism, type II DM, and anxiety, and the annual MDS indicated intact cognition and that he required setup for eating. His weight was stable from 11/02/25 through 03/05/26, and a physician order dated 12/24/25 directed that he receive double portions. A nutrition assessment later noted weight loss after a recent hospitalization and stated he would benefit from re-implementing double portions. During interview, Resident #1 stated he was not receiving double portions and felt he should be. On observation, dietary staff plated his noon meal without providing double portions, and the staff member confirmed the meal ticket did not indicate double portions. The Dietary Manager stated the kitchen used a separate computer system from the clinical EMR, that diet orders were imported into the kitchen system, and that the resident should have been receiving double portions. Review of the kitchen system showed double portions were not indicated, and the DM stated the system had been implemented in early January 2026 and some diet orders entered before then may not have merged correctly.
Tube Feeding Not Provided as Ordered
Penalty
Summary
The facility failed to ensure that Resident #23 received tube feeding nutrition as ordered by the physician. Resident #23 was admitted on 07/14/20 with diagnoses including epilepsy, dysphagia, type II diabetes mellitus, bipolar disorder, dementia, and gastrostomy status. The quarterly MDS dated 01/02/26 showed significantly impaired cognition, a feeding tube, and reliance on tube feeding for 51% or more of nutrition and fluid needs. The physician ordered Jevity 1.2 at 60 ml/hr for 21 hours per day, starting at 10:00 A.M. and stopping at 6:00 A.M. On 03/04/26 at 9:47 A.M., an LPN hung a one-liter bottle of Jevity 1.2 and it was running at 60 ml/hour. On 03/05/26 at 7:00 A.M., the resident's tube feeding bottle was observed empty and the pump was off, and the bottle was dated 03/04/26. The LPN confirmed it was the same bottle hung the previous morning and acknowledged the resident received only one liter instead of the ordered 1260 ml, stating a second bottle should have been hung to provide the full ordered amount.
Unsecured Medications Found in Resident Dresser
Penalty
Summary
The facility failed to safely store medications for one resident, Resident #43, who was admitted with diagnoses including chronic obstructive pulmonary disease, arteriovenous malformation of the digestive system, paranoid schizophrenia, and disorganized schizophrenia. The annual MDS showed a BIMS score of 13, indicating intact cognition, and the care plan last revised 02/27/26 allowed the resident to keep medications at bedside, although the current monthly physician orders included no order to keep medications at the bedside and no order to self-administer medications. During an observation on 03/02/26 at 9:08 A.M., Resident #43 had blood coming from his nose, and an LPN entered the room to assess him. The resident stated he had medications in his dresser, and the LPN opened the top drawer and found four unsecured medications: two nasal sprays and two respiratory inhalers. The LPN later identified the medications as one bottle of over-the-counter saline nasal spray, one bottle of oxymetazoline hydrochloride 0.05% 12-hour nasal spray, Asmanex inhaler, and Combivent inhaler 20 mcg per 100 mcg. The LPN confirmed that the oxymetazoline nasal spray, Asmanex inhaler, and Combivent inhaler had no patient name listed, and that Resident #43 had no order for saline nasal spray, oxymetazoline hydrochloride 0.05% 12-hour nasal spray, or Asmanex nasal spray. The facility policy titled Medication Storage, dated 2025, stated all drugs and biologicals will be stored in locked compartments.
Failure to Complete Ordered Laboratory Tests
Penalty
Summary
The facility failed to ensure laboratory tests were completed per physician orders for one resident (#23) out of five reviewed for laboratory tests. Resident #23 was admitted with diagnoses including epilepsy, dysphagia, type II diabetes mellitus, bipolar disorder, dementia, and gastrostomy status, and the quarterly MDS indicated significantly impaired cognition, a feeding tube, and reliance on tube feeding for 51% or more of nutrition and fluid needs. A physician order dated 10/03/24 and discontinued 02/26/26 required CBC with differential, BMP, and hemoglobin A1C every six months, but the resident's record showed the most recent laboratory tests were completed on 06/02/25. The Administrator confirmed on 03/05/26 that no laboratory tests had been completed for Resident #23 since 06/02/25 and before the order was discontinued.
Inaccurate Weekly Skin Assessments for Resident With Heel Pressure Ulcer
Penalty
Summary
The facility failed to ensure skin assessments were completed accurately for one resident with an unstageable pressure ulcer to the right heel. The resident was admitted with diagnoses including heart failure, acquired absence of the left leg above knee, type II diabetes mellitus, heart disease, and peripheral vascular disease. The quarterly MDS assessment documented intact cognition and one unstageable pressure ulcer. Review of the resident’s skin grid pressure assessments showed weekly assessments dated 12/29/25, 01/05/26, 01/12/26, 01/19/26, 01/26/26, 02/02/26, 02/09/26, and 02/16/26, all completed and signed by the wound care LPN on 02/16/26. During interview, the wound care LPN stated she was new to the wound care role on 12/29/25 and was aware the resident was being seen by an outside wound clinic for the right heel ulcer. She stated she was not aware the ulcer needed to be assessed weekly at the facility and later confirmed she created the skin grid assessments for the listed dates on 02/16/26 using measurements from the offsite clinic’s documentation. She confirmed she did not complete a visual assessment of the resident’s right heel on those dates and stated she measured the heel wound on 02/16/26, with measurements consistent with the size documented on the previous assessments.
Unnecessary Medication Administered to Resident with Type I Diabetes
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medications. A resident with a diagnosis of Type I diabetes mellitus (T1DM) was prescribed and administered Trulicity, a medication only approved for use in Type II diabetes mellitus (T2DM). Medical record review showed the resident was cognitively intact, required insulin injections, and had multiple diagnoses related to T1DM. Despite this, physician orders and the Medication Administration Record confirmed that Trulicity was administered on several occasions during the resident's stay. Interviews with facility staff, including a pharmacist, nurse practitioner, physician, LPN, and RN, revealed a lack of awareness regarding the appropriateness of Trulicity for T1DM. Both pharmacists and the physician confirmed that Trulicity is not approved or effective for T1DM due to its mechanism of action, which requires endogenous insulin production. The nurse practitioner who prescribed the medication admitted to treating T1DM and T2DM similarly and was unaware of the resident's specific needs. The facility's policy required that residents' medication regimens be managed to avoid unnecessary drugs, but this was not followed in this case.
Resident Rights Violated When Nurse Administers Unwanted Second Influenza Vaccine
Penalty
Summary
A facility failed to honor a resident's right to self-determination and a dignified existence when a nurse administered a second dose of the influenza vaccine to a resident against her will. The resident, who had a history of abuse and PTSD, had previously declined the influenza and pneumococcal vaccinations upon admission, with her declination witnessed and documented. Despite this, the resident later consented to and received the influenza vaccine in October. In November, a physician order was placed for a pneumococcal vaccine, but the vaccine was not yet available in the facility. On the day of the incident, a registered nurse approached the resident to administer what was supposed to be the pneumococcal vaccine. The resident verbally refused the vaccination, stating she had already received the influenza vaccine, and her husband, present via video call, also expressed concern. The nurse dismissed their objections, insisted they did not know what they were talking about, and proceeded to inject the resident with the influenza vaccine a second time, despite her clear refusal and previous administration. This action was documented as a medication error, as the nurse administered the wrong vaccine and did so without the resident's consent. The resident reported feeling afraid of the nurse following the incident and expressed concerns about her health due to receiving two influenza vaccinations within a short period. The facility's policies confirmed residents' rights to refuse immunizations and required medications to be administered as ordered and in accordance with professional standards. The administrator verified that the nurse administered the influenza vaccine against the resident's will and that a medication error had occurred.
Resident Subjected to Excessive Physical Force During Alcohol Confiscation
Penalty
Summary
A deficiency occurred when a resident with a history of alcohol dependence, anxiety, depression, and other medical conditions was subjected to excessive physical force by a staff member. The resident, who was moderately cognitively impaired and independently mobile in a wheelchair, was found drinking alcohol in the designated smoking area without a physician's order. When approached by staff, the resident became agitated and was accused of threatening staff, but video surveillance later showed that a Licensed Practical Nurse (LPN) used physical force to search the resident and confiscate alcohol, including pulling on the resident's coat and arms multiple times. The incident escalated when the LPN, after being instructed by another nurse to confiscate the alcohol, repeatedly reached into the resident's coat and physically restrained the resident's arm. The situation further deteriorated when the LPN struck the resident's arm multiple times after the resident pointed a finger at her. Other staff present intervened by removing a cigarette from the resident's hand, citing safety concerns. The resident subsequently reported feeling unsafe, fearful, and experiencing mental anguish as a result of the altercation. The facility's investigation confirmed the events as seen on video and through staff and resident interviews. The LPN involved had received prior training on abuse prevention but nonetheless engaged in actions that resulted in mental harm and a sense of insecurity for the resident. The incident was reported to the facility administration and state agency, and the resident was placed on one-to-one observation due to expressed feelings of depression and thoughts of self-harm following the event.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to ensure effective pest control, resulting in the presence of flies, gnats, and mice in multiple areas, including resident rooms and common spaces. Staff interviews revealed that excessive numbers of flies were present in the halls, and both staff and residents reported frequent sightings of mice, particularly in two residents' rooms. Staff resorted to using fly swatters during medication passes and in resident rooms, and residents who were able kept fly swatters at hand. Reports of mice in resident rooms were made to administration, and staff noted that the pest control measures in place were not effective. Observations confirmed the presence of multiple flies and gnats in at least one resident's bedroom, with flies seen on drinking cups and bedside tables. Residents reported direct encounters with mice, including a mouse on a bed and daily sightings in their rooms. Maintenance staff acknowledged ongoing issues with mice and flies, and stated that organic peppermint oil spray was used in an attempt to address the problem, but mice continued to be seen. The pest control vendor had provided recommendations for more aggressive treatment, but the facility opted to try in-house remedies instead. Review of pest control records showed that while monthly standard services were performed, several recommendations from the pest control vendor remained unaddressed by the facility. These included repairing door gaps, fixing water leaks, cleaning debris, and cutting overgrown vegetation, all of which were identified as the facility's responsibility. The facility's pest control policy stated that appropriate chemicals and methods would be used to control pests, but the ongoing presence of pests and unaddressed recommendations indicated a failure to maintain an effective pest control program.
Failure to Follow Pre-Procedure Orders Results in Canceled Biopsies
Penalty
Summary
The facility failed to follow pre-procedure physician orders for a resident scheduled for a bone marrow biopsy, resulting in the procedure being canceled and rescheduled multiple times. The resident, who had diagnoses including heart failure, peripheral vascular disease, and acute respiratory failure, was on anticoagulant therapy and required significant assistance with activities of daily living. After returning from an oncology appointment, the resident had new orders for a bone marrow biopsy, including instructions to be NPO (nothing by mouth) starting at midnight before the procedure and to hold certain medications, such as apixaban and aspirin, prior to the procedure. Despite these orders, the facility did not properly enter the NPO status or medication holds into the Medication Administration Record (MAR), and the resident was served breakfast on the morning of the scheduled procedure. As a result, the bone marrow biopsy was canceled. When the procedure was rescheduled, the facility again failed to hold the resident's anticoagulant and aspirin as instructed, leading to a second cancellation. Documentation confirmed that the resident received the medications on the days they were supposed to be held. Interviews with facility staff revealed that there were delays in uploading important documents into the electronic medical record (EMR), and communication of new orders was primarily verbal. The Director of Nursing confirmed that pre-procedure instructions were not entered into the EMR, and the dietary staff were only verbally informed of NPO orders. The unit manager acknowledged that the process for reviewing and entering new orders after appointments was not completed as required, directly contributing to the failure to follow pre-procedure instructions.
Failure to Assess, Document, and Treat Pressure Ulcer on Right Heel
Penalty
Summary
A resident with a history of anemia, Type II diabetes mellitus, and chronic kidney disease was admitted to the facility with multiple wounds, including a left below-the-knee amputation, a stage IV pressure ulcer, a stage III pressure ulcer, and a venous ulcer. Upon admission, the resident was noted to have black eschar on the right heel and second toe, but there was no evidence that these wounds were assessed, described, or measured. Physician orders for offloading pressure boots and daily skin prep to the right heel were in place, but documentation showed inconsistent application and monitoring of these interventions, with several days lacking evidence of treatment or documentation of refusals. Throughout the resident's stay, required skin assessments and wound documentation were not completed as ordered. Skin observation tools and progress notes repeatedly failed to assess or mention the right heel pressure ulcer, and weekly skin checks were not consistently performed or documented. When a new open wound was discovered on the right heel, there was no immediate documentation of the wound's characteristics, and the new treatment order was not initiated until two days later. Wound care notes and treatment administration records did not reflect timely or complete implementation of physician-ordered treatments for the right heel wound. The resident was eventually transferred to the hospital, where the right heel wound was found to be gangrenous and infested with maggots. Interviews with facility staff confirmed that the right heel wound was not monitored or assessed from admission until it was seen by the wound care physician, and that required treatments and interventions were not consistently documented or performed. Facility policy required ongoing assessment and documentation of wound care, but these procedures were not followed for the resident's right heel pressure ulcer.
Failure to Provide Food in Appropriate Form for Individual Needs
Penalty
Summary
The facility failed to ensure that each resident received food prepared in a form designed to meet their individual needs. This deficiency indicates that meals were not consistently modified or adapted to accommodate the specific dietary requirements or physical abilities of residents, such as those needing pureed, chopped, or otherwise altered food textures.
Failure to Maintain Safe Food Storage Temperatures
Penalty
Summary
The facility failed to ensure that all food was stored at appropriate temperatures, as required by professional standards. Review of temperature logs for the walk-in refrigerator in August 2025 showed recorded temperatures ranging from 50 to 65 degrees, which is above the recommended maximum of 42 degrees for safe food storage. During a kitchen tour, the walk-in refrigerator was observed to be at 50 degrees, and there was no internal thermometer present. Staff interviews confirmed that the refrigerator had not been functioning properly since July 2025, and maintenance requests for repairs had been submitted but not yet approved or completed. To compensate, staff had been opening the freezer door to cool the refrigerator, resulting in ice accumulation in the freezer due to condensation. The Director of Dietary confirmed that eggs, raw meat, and dairy were being stored in the freezer instead of the refrigerator to reduce spoilage risk, but acknowledged that other items in the refrigerator could potentially spoil due to inconsistent temperatures. The Director of Maintenance verified that the refrigerator did not maintain safe temperatures, especially during times when staff were not present to monitor and adjust conditions. The Regional Administrator confirmed that the refrigerator was not maintaining appropriate temperatures according to facility logs and observations. The deficiency had the potential to affect all residents except two who did not receive food from the kitchen, but there were no reports of residents exhibiting symptoms of foodborne illness at the time of the investigation.
Failure to Administer Physician-Ordered Antibiotic Following Hospital Discharge
Penalty
Summary
A resident with multiple complex medical conditions, including sepsis, heart failure, dysphagia, and a gastric ulcer, was admitted to the facility and later experienced a choking episode that required hospital transfer. Upon discharge from the hospital, the resident was prescribed Augmentin oral suspension to be administered every 12 hours for nine days to treat aspiration pneumonia. However, upon the resident's return to the facility, the receiving nurse did not include the hospital discharge orders for the Augmentin antibiotic in the resident's medication orders. As a result, the resident did not receive any oral antibiotic from the time of readmission until four days later, when a new order for a different antibiotic, Amoxicillin, was entered and started. The Medication Administration Record confirmed that no oral antibiotics were administered during this period, resulting in eight missed doses. The Director of Nursing verified that the omission occurred due to the failure to transcribe the hospital discharge order for the Augmentin antibiotic upon the resident's return.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Timely Report Alleged Neglect to State Survey Agency
Penalty
Summary
A deficiency occurred when the facility failed to report an allegation of neglect in a timely manner to the State Survey Agency (SSA). A resident with multiple diagnoses, including stroke, parkinsonism, cognitive impairment, and incontinence, was found to have been left unsupervised outside on the smoking patio overnight without staff supervision or personal care. The incident was discovered by a registered nurse during morning medication rounds, after another resident indicated the individual was outside. The resident, who experienced periods of confusion, stated he was cleaning, but required assistance for toileting and transfers and was always incontinent. The facility's Self-Reported Incident (SRI) was created two days after the event was discovered, and the summary investigation confirmed the report to the SSA was not made until two days after the incident. According to facility policy, all alleged violations should be reported immediately, but not later than two hours if abuse or bodily injury is involved, or within 24 hours if not. The administrator confirmed the delay in reporting the incident to the SSA, which was not in accordance with the facility's policy.
Failure to Complete Smoking Assessment for Resident
Penalty
Summary
The facility failed to ensure that a smoking assessment was completed for a resident who smoked, as required by facility policy. The resident, who had a history of cerebral infarction, traumatic brain injury, difficulty walking, anxiety disorder, urinary incontinence, parkinsonism, cognitive communication deficit, and nicotine dependence, was moderately cognitively impaired and dependent on staff for toileting and transfers. Despite these conditions, there was no evidence that a Smoking Safety Screen was completed upon admission or during subsequent assessments until several months later. The deficiency was identified when the Administrator, while reviewing camera footage for an unrelated investigation, observed the resident smoking outside. This led to the discovery that the resident's smoking status had not been identified or assessed during the admission process or quarterly assessments, contrary to facility policy. The policy required all residents to be asked about tobacco use at admission and during each MDS assessment, with further assessment for those who smoked to determine supervision needs. This lapse was noted as a continued non-compliance from previous surveys.
Failure to Maintain Accurate Medical Records and Documentation
Penalty
Summary
The facility failed to ensure the accuracy of medical records for two residents. For one resident with multiple diagnoses including stroke, parkinsonism, and cognitive impairment, the Medication Administration Record (MAR) documented that various medications, enteral feedings, and g-tube flushes were administered as ordered. However, interviews with the Administrator and DON confirmed that no medications or treatments were actually provided during a specified time period, and the MAR had been falsified by a nurse. The facility's investigation into a neglect allegation revealed that the resident's physician-ordered treatments were not carried out as documented. For another resident with diagnoses including diabetes, COPD, dementia, and hypertension, the MAR indicated that weekly skin assessments were completed on several dates. However, review of the medical record and interviews with the DON and Administrator confirmed that no skin assessments had been performed since a prior date, despite documentation to the contrary. These findings demonstrate that the facility did not maintain accurate medical records in accordance with accepted professional standards.
Failure to Prevent Accidents and Inadequate Fall Investigation
Penalty
Summary
A deficiency occurred when a resident who required transfers with a mechanical lift was not transferred safely, resulting in actual harm. The resident, with a history of morbid obesity, heart disease, and osteoporosis, was dependent on staff and a mechanical lift for transfers. During a transfer from a shower bed to her regular bed, the sling pad used with the mechanical lift broke, causing the resident to fall and sustain a lumbar vertebral compression fracture. Staff interviews and documentation revealed that the sling pad had visible signs of wear, including frayed and distressed straps, and had been improperly laundered in a commercial dryer, which contributed to the deterioration of the material. Despite warnings on the sling pad label and in the instruction manual to inspect for wear and avoid drying in a dryer, the facility had not replaced sling pads regularly or ensured proper inspection before use. Another deficiency was identified regarding the supervision and assistance provided to a second resident during bathing and in the investigation of multiple falls. This resident, with diagnoses including bipolar disorder, spinal stenosis, and Parkinsonism, was at risk for falls and required substantial assistance for bed mobility and bathing. On one occasion, the resident fell from bed while being left unattended by a CNA who had failed to lock the bed wheels. The incident report and staff interviews confirmed that the bed was left unlocked and the resident was left alone, leading to the fall. The facility's documentation did not show that a thorough investigation or formal education for the CNA was completed beyond immediate verbal instruction. Additionally, the facility failed to conduct thorough investigations into several other falls experienced by the same resident. Incident reports for multiple unwitnessed falls lacked critical information, such as the resident's location prior to the fall, whether safety interventions like a perimeter mattress or call light were in place or used, and whether the fall mat was present. The facility's fall prevention policy required post-fall assessments and documentation but did not provide specific guidance for comprehensive investigations. The lack of detailed investigation and documentation placed the resident at risk for further harm.
Lack of Required RN Coverage
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was present and working for eight consecutive hours daily, as required. Review of staffing schedules and timekeeping records for the period of 06/02/25 through 06/08/25 showed that there was no RN coverage for eight consecutive hours on 06/03/25, with a gap in RN staffing from the beginning of the third shift on 06/02/25 until the second shift on 06/04/25. The nursing staff information posting for 06/03/25, when the facility census was 77 residents, also indicated no RN coverage on any shift. The Administrator confirmed in an interview that no RN worked eight consecutive hours in the facility on 06/03/25. This deficiency affected all residents in the facility on that date.
Failure to Provide Timely and Appropriate Incontinence and Perineal Care
Penalty
Summary
A deficiency occurred when a resident, admitted with multiple diagnoses including coronary artery disease, congestive heart failure, peripheral vascular disease, morbid obesity, and chronic kidney disease, did not receive timely incontinence care and appropriate perineal hygiene. The resident was care planned for incontinence of bowel and bladder, requiring checks and changes every two hours and as needed, with specific instructions for perineal cleansing and use of moisture barrier. Documentation showed the last incontinence check was at 4:55 A.M., and by 8:14 A.M., the resident reported being soiled and not having been checked since approximately 5:00 A.M. The CNA who assumed care at 6:30 A.M. was unaware of the last incontinence check and had not checked the resident since starting her shift, despite knowing the resident required frequent checks. During observation, two CNAs provided a bed bath and incontinence care but failed to cleanse the resident's perineum after an episode of bowel and urinary incontinence. The resident's brief was found to be heavily soiled, and while the buttocks were cleansed and barrier cream applied, the perineal area was not cleaned according to facility policy. The CNA later confirmed that perineal cleansing was not performed. Facility policies required thorough perineal care to prevent infection, but these were not followed, resulting in non-compliance.
Failure to Initiate CPR and Contact EMS for Full Code Resident
Penalty
Summary
The facility failed to initiate Cardiopulmonary Resuscitation (CPR) or call 911 for Emergency Medical Services (EMS) for a resident who was found unresponsive, not breathing, and without a pulse, despite having advance directives and a physician order indicating Full Code status. Two LPNs responded to the resident's room after being alerted by a CNA, assessed the resident, and confirmed the absence of vital signs. Neither nurse initiated CPR nor contacted EMS, and instead, they called the time of death without physician direction or the involvement of a qualified health professional. The resident involved had multiple diagnoses, including chronic obstructive pulmonary disease (COPD), dementia, prostate cancer, hypertension, congestive heart failure, and orthostatic hypotension. The resident's care plan and physician orders clearly indicated Full Code status, with interventions specifying to call 911 and initiate CPR in the absence of a pulse. At the time of the incident, a family member was present at the bedside, but there was no documentation or confirmation that the family member or the resident's Power of Attorney (POA) had authorized withholding CPR. Interviews with the resident's daughter and granddaughter confirmed that neither directed staff to withhold life-saving measures. Staff statements revealed that the LPNs did not initiate CPR because they believed the family at bedside refused it, but this was not corroborated by the family members involved. The LPNs also called the time of death, which was outside their scope of practice, and did not seek direction from a physician. The facility's policy required staff to provide basic life support, including CPR, for residents with Full Code status prior to EMS arrival, in accordance with the resident's advanced directives. This failure to follow established protocols and physician orders resulted in the resident passing away without life-saving measures being attempted.
Failure to Prevent Elopement and Complete Smoking Safety Assessments
Penalty
Summary
A deficiency occurred when a resident with schizoaffective disorder, a history of numerous elopement attempts, and an identified risk for elopement was able to leave the facility without staff knowledge. The resident had a WanderGuard device attached to her wheelchair, as she had previously removed the device from her person multiple times. Despite being on 15-minute supervision checks, there was no evidence that these checks were completed on the day of the incident. The resident was able to exit the facility when a visitor used a code to open the locked front door, and she left her wheelchair and the attached WanderGuard in the lobby before walking out unaccompanied. The resident walked approximately 0.2 miles to a local carryout, traversing a sidewalk with broken concrete and rocks along a busy five-lane road. Staff were unaware of her absence until a CNA, who was on a lunch break, happened to find her sitting on the floor of the carryout about 35 minutes after she had left the facility. At the time, the resident was actively hallucinating and expressing delusional thoughts. Documentation and interviews confirmed that staff did not perform or document the required 15-minute supervision checks on the day of the elopement, and staff were not aware the resident had left until notified by the CNA who found her. Additionally, the facility failed to complete required admission and quarterly smoking safety assessments for two residents who smoked, as mandated by facility policy. These assessments are necessary to determine if residents can smoke unsupervised or require safety measures. The lack of timely assessments placed these residents at risk for potential harm, as their ability to safely smoke was not evaluated upon admission or at required intervals.
Delayed X-ray Result Follow-up and Incomplete Wound Monitoring
Penalty
Summary
The facility failed to ensure timely receipt and follow-up of stat X-ray results, resulting in a delay in treatment for a resident who suffered a right hip fracture. After a fall, the resident initially complained of knee pain, prompting a stat X-ray order for the knee. The following morning, the resident reported severe hip pain, and a stat X-ray of the hip was ordered and completed. The radiology vendor faxed the results, which confirmed a right femoral neck fracture, to the facility within the hour. However, the facility did not receive or act upon these results until approximately 24 hours later, despite the expectation that staff should follow up with the vendor if results were not received within four to six hours. During this period, the resident experienced severe pain and was not transferred to the hospital for evaluation and treatment until the results were finally reviewed the next day. Additionally, the facility failed to ensure weekly wound monitoring and assessments for another resident with a venous ulcer. Although there was an order for regular wound care and the facility policy required weekly documentation of wound assessments, there was no evidence in the medical record that such assessments or monitoring were completed for over a month. The responsible LPN stated that wound measurements were not uploaded into the electronic medical record and that, during her absence, no documentation was available to confirm ongoing monitoring or assessment of the wound, including from outside wound care providers. These deficiencies were identified through medical record review, staff and vendor interviews, and policy review. The failures resulted in actual harm to one resident due to delayed treatment of a hip fracture and placed another resident at risk for more than minimal harm due to lack of wound monitoring.
Failure to Administer Facility to Ensure Resident Well-Being and Safety
Penalty
Summary
The facility failed to administer its operations in a manner that enabled effective and efficient use of resources to maintain the highest practicable well-being of its residents. In one instance, a resident with Full Code status was found without vital signs, and two LPNs did not initiate CPR, failed to call EMS, and called the time of death without contacting a physician, which was outside their scope of practice. The LPNs reported that the resident's family refused life-saving measures, but investigation revealed the Power of Attorney was not present at the time, contrary to what was initially reported to the Administrator. Another resident with a history of elopement was able to leave the facility undetected by leaving her wheelchair, which had a WanderGuard, in the lobby and ambulating out the front door. Staff failed to perform required 15-minute supervision checks and were unaware these checks were still required. The incident was not reported to the State Survey Agency as potential neglect, and the DON was unaware of the elopement until the complaint investigation began. No investigation or additional interventions were implemented at the time to ensure the resident's safety. Additional deficiencies included staff refusing to provide care for a resident, resulting in delayed care, and ongoing substance use issues within the facility. One resident was reported to use crack cocaine in the building daily, with administration aware but only providing education and removing paraphernalia when found. Other residents were observed with open containers of alcohol on facility premises, despite facility policies prohibiting routine alcohol consumption. These events demonstrate failures in supervision, adherence to policy, and reporting requirements, affecting the care and safety of all residents.
Failure to Ensure Call Light Accessibility and Adequate Linen Supply
Penalty
Summary
Surveyors identified that staff failed to ensure call lights were within reach for two residents who required assistance, despite care plans specifying this intervention. One resident, with a history of stroke, impaired mobility, and dependence for toileting and personal hygiene, was observed with her call light on the floor, out of reach. Another resident, who was legally blind and at risk for falls, was found with her call light draped over a chair or pinned above her head, both times inaccessible. Both residents confirmed they could not reach their call lights, and staff interviews verified the call lights were not within reach as required by facility policy and care plans. Additionally, the facility failed to maintain a sufficient supply of clean linens for resident use. Observations revealed a lack of clean towels and washcloths in multiple shower rooms, and a resident reported delayed morning care due to the unavailability of clean towels. Staff interviews confirmed the shortage and indicated a lack of awareness among management and laundry staff regarding the insufficient linen supply, resulting in delayed care for at least one resident and the potential to affect others.
Environmental Maintenance Deficiencies Identified
Penalty
Summary
The facility failed to maintain the environment in good repair, as evidenced by observations of water-stained ceiling tiles surrounding a sprinkler head, peeling wallpaper throughout the hallways, dirty and stained flooring, and patches of flooring that were worn and discolored from use. These deficiencies were confirmed during an interview with the Director of Maintenance, who stated that the sprinkler was no longer leaking but the stained ceiling tile could not be replaced until the sprinkler company completed their work, with no known date of service for the repair. The Director of Maintenance also indicated that the ceiling tile had been in this condition since he began working at the facility approximately one and a half months prior. Review of the facility's policy confirmed that the facility was required to provide a safe, clean, and comfortable environment, including necessary housekeeping and maintenance services.
Failure to Notify Physician of Missed TPN Dose
Penalty
Summary
The facility failed to notify a resident's physician of a missed dose of total parenteral nutrition (TPN) for a resident who was dependent on intravenous nutrition due to an intestinal blockage and was on a NPO (nothing by mouth) diet. The resident was admitted for TPN therapy and had multiple diagnoses, including intestinal blockage, intestinal fistula, colon cancer, hypertension, and chronic kidney disease. On the date in question, the Medication Administration Record indicated that the TPN was not administered, and nursing progress notes confirmed the missed dose, citing the need for an RN to administer the medication and that the on-call nurse was aware. Interviews with staff revealed that there was confusion regarding responsibility for clarifying TPN orders and administration, with LPNs directed to consult with RNs, and RNs expected to clarify orders with the physician or pharmacy. Despite these communications, there was no documentation that the resident's physician was notified of the missed TPN dose, as required by facility policy. The Director of Nursing confirmed that the physician was not informed of the missed dose, and the facility's policy mandates prompt notification of the physician in such situations.
Failure to Provide Functional Lighting for Visually Impaired Residents
Penalty
Summary
The facility failed to ensure that residents had working lights in their rooms, affecting two residents who were both cognitively intact and had significant visual impairments. One resident, admitted with a history of stroke, glaucoma, peripheral vascular disease, and heart disease, was dependent on staff for toileting and personal hygiene and required glasses for full-time use. Observations revealed that this resident's overbed light was not functioning, and the resident reported that the light had been out for approximately three weeks, even after being temporarily relocated due to a non-working bed. Another resident, diagnosed as legally blind, also did not have a functioning overbed light, with only the bathroom light operational in the room. This resident similarly reported that the room lights had not worked for three weeks. Staff interviews confirmed the non-functioning lights, and the Director of Maintenance acknowledged awareness of the issue, attributing it to broken underground electrical wires and indicating that repairs were pending. Facility policy required the maintenance of adequate and comfortable lighting levels, but periodic rounds to ensure functioning lights did not prevent this prolonged outage.
Failure to Report Elopement and Failure to Initiate CPR for Full Code Resident
Penalty
Summary
The facility failed to report two significant incidents to the State Survey Agency (SSA) as required by policy and regulation. In the first incident, a resident with a Full Code status was found not breathing and without a pulse, but staff did not initiate CPR as ordered. Both the LPN and the Administrator confirmed that CPR was not started, and review of the facility's reporting system showed no evidence that a self-reported incident (SRI) was submitted regarding this failure to implement life-saving measures. The resident's medical history included COPD, dementia, prostate cancer, and congestive heart failure, and the care plan specifically directed staff to initiate CPR and call 911 in such situations. In the second incident, another resident, who was cognitively intact and had multiple diagnoses including angina, depression, and schizoaffective disorder, exited the facility without staff knowledge and went to a nearby store. The resident exhibited delusional behavior and required emergency services, though ultimately returned to the facility with staff assistance. Video surveillance confirmed the resident left the building unaccompanied. Despite management being made aware and the incident being documented, there was no evidence that an SRI was submitted to the SSA regarding this elopement. The Administrator confirmed she was not notified of the elopement and that no report was made.
Failure to Investigate Resident Elopement Incident
Penalty
Summary
The facility failed to investigate an incident of elopement involving a resident who was identified as an elopement risk and had a care plan in place with specific interventions, including the use of a WanderGuard device and regular monitoring. The resident, who had diagnoses including schizoaffective disorder, depression, and anxiety, was cognitively intact according to the most recent MDS assessment. On the date of the incident, the resident exited the building without staff knowledge after a visitor entered the facility, and went to a nearby store. The resident exhibited delusional behavior, refused to return, and emergency services were contacted but later canceled. The resident eventually returned to the facility with staff assistance. Despite the incident, the facility did not initiate an immediate investigation as required by its own policy on abuse, neglect, and exploitation. The DON was not aware of the unsupervised elopement until several days after the event, and an investigation was not started until that time. This lapse in timely response and investigation of the elopement constituted the deficiency cited by surveyors.
Failure to Provide Scheduled Showers and Timely ADL Assistance
Penalty
Summary
The facility failed to ensure that dependent residents received scheduled showers and timely assistance with activities of daily living (ADLs), as evidenced by medical record reviews, resident and staff interviews, and policy review. Three residents were affected, each with varying degrees of cognitive and physical impairment, and all were dependent on staff for bathing and other ADLs. Documentation showed significant gaps between scheduled showers and actual bathing events, with some residents going up to 11 days without a shower or bed bath, and no evidence that care was offered or refused during these periods. For one resident with chronic respiratory and cardiac conditions, staff were documented as refusing to provide care due to frustration with the resident's behavior, resulting in the resident waiting extended periods for assistance and sometimes not being offered showers as scheduled. Interviews with CNAs, a unit manager, and the DON confirmed that staff frequently refused to care for this resident, and that the issue was ongoing and known to management. The resident also reported delays in receiving nighttime care, with staff claiming uncertainty about who was assigned to assist her. Another resident with severe cognitive impairment and a third resident requiring moderate staff assistance for bathing also experienced missed or delayed showers, with documentation showing long intervals without care and no record of refusals. The DON confirmed that these residents were not offered or provided showers as required. Facility policy required staff to provide care and services for all ADLs, including bathing, but this was not consistently followed for the residents reviewed.
Failure to Provide Timely Incontinence Care
Penalty
Summary
A deficiency occurred when a resident, who was cognitively intact and dependent on staff for toileting due to incontinence of bowel and bladder, did not receive timely incontinence care as required by her care plan and facility policy. The resident, with a history of congestive heart failure, diabetes mellitus, and chronic kidney disease, reported that her last incontinence care was provided at approximately 5:00 A.M. and that she had not been checked or changed since then. Staff interviews confirmed that the resident had not received incontinence care during the morning shift, despite the facility's policy to check and change incontinent residents every two hours and as needed. Observation later in the morning revealed the resident was wearing a heavily saturated incontinence brief, and staff present at the time verified the resident's report and the condition of the brief. Multiple CNAs interviewed acknowledged that they had not provided incontinence care to the resident during their shifts, with one CNA noting a staffing shortage due to a call-off. Review of the facility's Activities of Daily Living policy confirmed the expectation for necessary services to maintain personal hygiene for residents unable to perform ADLs.
Failure to Administer TPN per Physician Orders
Penalty
Summary
The facility failed to ensure that total parenteral nutrition (TPN) was administered according to physician orders for one resident who required this therapy. The resident, who had diagnoses including intestinal blockage, intestinal fistula, colon cancer, hypertension, and chronic kidney disease, was admitted specifically for TPN therapy. Physician orders specified the administration of a TPN Electrolytes Solution intravenously over a 14-hour period with detailed infusion rates. On one occasion, documentation on the Medication Administration Record indicated that the TPN was not administered, and nursing progress notes confirmed the missed dose, citing the need for an RN to administer the medication and a lack of clarification regarding the order. Interviews with staff revealed that there was confusion among the nursing staff regarding responsibility for clarifying and administering the TPN. The on-call LPN directed the in-house LPN to consult with the RNs present, as RNs were responsible for TPN administration. The Director of Nursing confirmed that two RNs were present and responsible for the administration, and that the TPN solution was available in the facility at the time. Facility policy required verification of practitioner orders for TPN, but the missed administration occurred despite the medication being on site and staff being present.
Failure to Ensure Staff Competency in Advanced Directives and Radiology Procedures
Penalty
Summary
The facility failed to ensure that nursing staff demonstrated appropriate competencies in the implementation of advanced directives and acted within their scope of practice. In one instance, a resident with diagnoses including COPD, dementia, prostate cancer, hypotension, and hypertension with congestive heart failure was documented as Full Code, meaning all life-saving measures should be implemented if cardiac arrest occurs. When this resident was found without vital signs, two LPNs did not initiate CPR and instead pronounced the resident dead, which is outside their scope of practice and contrary to facility policy and state regulations. Both LPNs had current CPR certifications, and one acknowledged in an interview that she should have performed CPR regardless of family wishes due to the Full Code status. The facility policy required staff to provide basic life support in accordance with the resident's advanced directives, and state law specifies that LPNs are not authorized to pronounce death. In another case, the facility failed to ensure staff were knowledgeable about procedures for obtaining and acting on radiology results. A resident with multiple diagnoses, including heart failure and a history of cancer, reported severe hip pain and received a stat X-ray order. Although the X-ray was completed and the results were available within an hour, the facility did not receive or act on the results until the following day. The DON confirmed that the results should have been followed up within four to six hours, and the nurse on duty reported not knowing where else to check for the results beyond the medical record system. The delay in receiving and acting on the X-ray results was attributed to a lack of staff knowledge regarding the facility's procedures for obtaining radiology reports. These deficiencies were identified through medical record review, staff interviews, review of job descriptions, educational consultation forms, and facility policy. The incidents affected two of four residents reviewed for staff competencies, with a facility census of 79 at the time of the survey.
Failure to Provide Adequate Behavioral Health Services for Substance Use Disorders
Penalty
Summary
The facility failed to provide necessary behavioral health care and services to residents with substance use disorders, as evidenced by multiple documented incidents involving three residents. One resident with a history of cocaine use and moderate cognitive impairment was repeatedly found smoking unknown substances, suspected to be crack cocaine, both in his room and in designated smoking areas. Staff interviews confirmed that the resident regularly smoked crack inside the facility, and paraphernalia consistent with crack cocaine use was found in his possession. Despite these findings, the only interventions implemented were education and removal of paraphernalia, with no additional behavioral health services or substance use interventions provided. Another resident, also moderately cognitively impaired, was repeatedly found in possession of and consuming alcohol within the facility. Nursing notes and staff interviews documented several occasions where alcohol was confiscated from the resident, and the resident was re-educated about facility policy and the dangers of drinking while on medication. However, the care plan interventions were limited to education and general support, with no evidence of specialized substance use disorder treatment or behavioral health services being provided. A third resident with a history of alcohol and illegal substance use, as well as multiple medical and psychiatric diagnoses, was observed drinking beer in the facility's smoking area. Staff verified the presence of alcohol, and the resident's care plan included only encouragement to express feelings and maintain contact with supportive family and friends. There was no documentation of targeted behavioral health interventions or substance use disorder treatment. The facility's policy acknowledged the risks of alcohol use but did not outline or implement comprehensive behavioral health services for residents with substance use disorders.
Failure to Administer Insulin as Ordered
Penalty
Summary
A deficiency was identified when a resident with a diagnosis of diabetes mellitus did not receive insulin medications as ordered by the physician. Medical record review showed that the resident was cognitively intact and had physician orders for both long-acting and fast-acting insulin, including scheduled doses and sliding scale coverage. The Medication Administration Record (MAR) for March 2025 revealed multiple instances where the resident did not receive the prescribed insulin glargine and insulin lispro at scheduled times. There was no documentation in the nursing progress notes indicating that the resident refused these medications. During an interview, a registered nurse confirmed that missing initials on the MAR indicated the medications were not administered. The facility's policy required medications to be administered as ordered by the physician and in accordance with professional standards. The failure to administer insulin as ordered and the lack of documentation for missed doses or refusals led to the identified deficiency.
Resident Sexual Abuse by CNA
Penalty
Summary
The facility failed to protect a resident from sexual abuse by a staff member, resulting in actual harm. The resident, who had intact cognition and was dependent on staff for personal care, reported being sexually abused by a Certified Nursing Assistant (CNA) during showers. The abuse involved inappropriate and non-consensual contact, which occurred multiple times over a month. The resident expressed feelings of anxiety and anger following the incidents. The abuse was discovered when another CNA noticed the resident's discomfort during care and inquired about it. The resident disclosed the inappropriate actions of the first CNA, who had been rough and had inserted a gloved finger into the resident's anus multiple times. This disclosure led to an immediate report to the facility's administration and the initiation of an investigation. The facility's investigation revealed that the abusive CNA had previously made inappropriate comments about the resident to other staff members, which were initially dismissed as rumors. The abusive CNA was terminated for unrelated insubordination before the abuse allegations came to light. The police were contacted, and an investigation was initiated. The facility's policy on abuse defines such actions as willful infliction of injury and non-consensual sexual contact, which aligns with the reported incidents.
Failure to Timely Report Suspected Sexual Abuse
Penalty
Summary
The facility staff failed to report suspected sexual abuse in a timely manner, affecting one resident. The resident, who had intact cognition and was dependent on staff for personal care, reported that a Certified Nursing Assistant (CNA) had been sexually inappropriate during care. The resident expressed distress and anxiety during interviews, indicating that the inappropriate behavior occurred multiple times in December. The incident came to light when another CNA, who had overheard the accused CNA making inappropriate comments about the resident, was informed by the resident about the abuse. The resident described the inappropriate actions during personal care, which included the insertion of a gloved finger into the resident's rectum. Despite the resident's initial belief that the actions were accidental, the repeated nature of the incidents led to the realization of abuse. The facility's investigation revealed that the accused CNA had been assigned to care for the resident on specific dates and had made inappropriate comments to other staff members. The accused CNA was terminated for unrelated insubordination before the abuse allegations were known. The facility's failure to report the abuse promptly was identified as a deficiency, highlighting a lapse in the timely reporting of suspected abuse.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care to a dependent resident, identified as Resident #46, who was unable to perform activities of daily living independently. Resident #46, who had intact cognition, was dependent on staff for personal care due to conditions such as morbid obesity, congestive heart failure, asthma, and diabetes mellitus. On the night of 01/07/25, Resident #46 experienced a bowel movement at 12:15 A.M. but was not changed until 8:00 A.M. the following morning. Despite using the call light throughout the night, the resident reported that staff opened the door but refused to provide care, citing fear of being accused of sexual abuse. Interviews with staff confirmed that third shift CNAs refused to care for Resident #46 due to concerns about potential accusations of sexual assault, following a self-reported incident of sexual abuse by a staff member that was under investigation. The resident's room was observed to have a strong odor of feces, and the sheets were soiled, indicating neglect in providing necessary incontinence care. The facility's policy on Activities of Daily Living (ADLs) mandates that residents unable to perform these activities should receive necessary services to maintain hygiene, which was not adhered to in this case.
Unlicensed STNA Employed Without Ohio Certification
Penalty
Summary
The facility failed to ensure that a State Tested Nursing Aide (STNA) was properly licensed with the State of Ohio, which had the potential to affect all 77 residents. A review of the personnel file for STNA #200 revealed that the aide was hired with an expired nursing assistant registration from another state and had no current or expired licensure in Ohio. Despite this, STNA #200 worked multiple shifts, as evidenced by the clock in/out report, without the necessary certification. An interview with the Administrator confirmed that STNA #200 was employed and providing care to residents without being certified with the State of Ohio Nurse Aide Registry. The facility's policy requires that nurse aides must have completed a State-approved nurse aide training or competency evaluation program and provide documentation of certification within four months of hire. However, STNA #200 did not meet these requirements, as they were not certified in Ohio and had an expired out-of-state certificate.
Failure to Conduct Timely Fall Reviews and Assessments
Penalty
Summary
The facility failed to conduct timely fall reviews for four residents, all of whom were identified as high fall risks. Resident #70, who had dementia and required extensive assistance for mobility, experienced a fall resulting in a laceration. However, the post-fall evaluation was not completed until eight days later. Similarly, Resident #71, also with dementia, fell without injury, but the post-fall evaluation was delayed by 13 days. Resident #5, with multiple diagnoses including dementia and chronic obstructive pulmonary disease, experienced two falls on the same day, yet the post-fall evaluations were not completed within the required 72-hour timeframe. Additionally, Resident #62, who had chronic kidney disease and dementia, was overdue for a quarterly fall risk assessment, with the last assessment completed several months prior. The facility's policy mandates that fall risk assessments be conducted every 90 days and post-fall evaluations be completed within 72 hours. The Director of Nursing confirmed these lapses in compliance with the facility's fall prevention program, which aims to minimize fall risks through timely assessments and interventions.
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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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