Embassy Of Lebanon
Inspection history, citations, penalties and survey trends for this long-term care facility in Lebanon, Ohio.
- Location
- 700 Monroe Road, Lebanon, Ohio 45036
- CMS Provider Number
- 365920
- Inspections on file
- 28
- Latest survey
- April 14, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Embassy Of Lebanon during CMS and state inspections, most recent first.
The facility failed to maintain the required continuous 8-hour daily RN coverage when the DON left the building to accompany a resident to outpatient surgical procedures, leaving only LPNs on duty for resident care. Staffing records showed no RN worked in the facility on one of the days in question, despite schedules indicating the DON was present, and the DON later confirmed she was away from the facility for much of the day and not present for eight consecutive hours. Interviews with the resident, the transportation coordinator, the DON, the administrator, and a regional RN corroborated that the DON twice accompanied the resident to a surgical center in another city, that her time in the facility that day was brief, and that the staffing documentation inaccurately reflected her hours, resulting in a day without the required RN coverage for all residents.
A facility failed to timely report an allegation of verbal abuse to the state survey agency after a severely cognitively impaired hospice resident with dementia and behavioral disturbances was subjected to raised voice and hand-clapping in the face by a CNA during care, which another CNA viewed as verbal abuse and reported to the DON by text. The accused CNA later wrote a statement describing the hand-clapping as an attempt to calm the resident, and an LPN stated she did not witness aggression, but the facility’s file contained only limited documentation and no complete investigation or body assessment. Staff interviews revealed that multiple residents had requested not to receive care from this CNA, and that the CNA had previously been escorted out and suspended for unacceptable behavior toward staff, with residents describing the CNA as loud and confrontational. The DON acknowledged not obtaining the requested witness statement and determining the incident was not abuse, and the Administrator acknowledged that an SRI was not initiated as required by the facility’s abuse, neglect, and exploitation reporting policy.
A resident with severe cognitive impairment, multiple psychiatric and medical diagnoses, and total dependence for ADLs was the subject of an alleged verbal abuse incident when a CNA reportedly raised her voice and clapped her hands in front of the resident’s face during care, which another CNA reported to the DON by text. The facility’s investigation file contained only the alleged CNA’s written account, an LPN’s statement that no aggression was witnessed, and evidence of a group text titled “Abuse and Neglect,” but lacked further investigation documentation such as additional witness statements, resident assessments, or interviews, despite facility policy requiring immediate and comprehensive investigation of suspected abuse.
Two dependent residents who required staff assistance with eating did not receive timely meal assistance; their trays were delivered and left covered and untouched in their rooms without staff present, despite one resident having quadriplegia and the other having ALS with dysphagia and high aspiration risk. Another dependent resident with impaired cognition and multiple comorbidities, who relied on staff for personal hygiene and bathing, was observed with long facial hair on the chin, jawline, and upper lip, with records showing a missed scheduled shower and no documentation that shaving was performed during multiple showers.
A resident with end stage renal disease, recent sepsis from pneumonia, and multiple chronic conditions was prescribed numerous medications, including antibiotics for pneumonia. During a med pass, an LPN, interrupted by another resident’s behaviors and faced with two residents sharing the same last name and adjacent rooms, failed to follow the five rights of medication administration and gave this resident another resident’s full medication regimen, which included metformin despite a documented metformin allergy. After receiving the wrong medications, the resident developed abnormal VS, increased confusion, altered level of consciousness, and abnormal speech, and was later hospitalized with altered mental status, acute hypoxic and hypercapnic respiratory failure requiring mechanical ventilation, and septic shock secondary to pneumonia.
Surveyors found multiple instances where medications and biologicals were left unsecured and unsupervised in resident rooms, contrary to facility policy requiring safe, locked storage. One resident with significant neurologic and mobility impairments had diclofenac gel and an antiseptic solution left in the room, both labeled to contact poison control if ingested. Another resident with respiratory failure, a Foley catheter, and a G-tube had a prescription nystatin powder bottle sitting on the dresser, labeled for external use only and to contact poison control if ingested. A third resident with Parkinson’s disease and dementia had an Inbrija inhalation device left on the dresser without an order for bedside self-administration, which an LPN acknowledged should not have been in the room.
Surveyors found that the facility’s water management plan for Legionella control was incomplete and lacked key CDC-recommended elements, including specific water temperature monitoring locations, defined validation measurements, and detailed processes to ensure effectiveness. The plan did not include clear procedures for frequent monitoring of temperature, disinfectant residuals, and pH, nor did it ensure a detectable disinfectant residual throughout the potable water system. During interviews, the Administrator could not produce chlorine monitoring logs and confirmed that no chlorine testing logs existed, acknowledging that the current water management plan was not comprehensive. This deficiency had the potential to affect all 59 residents in the facility.
Two medication errors occurred when an LPN administered and crushed enteric coated Aspirin and extended release Guaifenesin for a resident with multiple diagnoses, despite facility policy and physician orders prohibiting this practice. This resulted in a medication error rate of eight percent, exceeding the allowable threshold.
A resident did not receive his morning medications on a day he was on a leave of absence from the facility. The medications were left in the cart and not sent with him, leading to the resident experiencing vomiting and diarrhea. The incident was confirmed by an LPN after the resident reported the issue.
A facility failed to maintain a resident's privacy during catheter care, as a CNA did not pull the curtain or close the door, potentially exposing the resident to others. The resident, who required substantial assistance and had a suprapubic catheter, was left without privacy during the procedure, contrary to the facility's dignity policy.
A facility failed to document catheter care for a resident with a suprapubic catheter, despite a physician's order for care every shift. The resident had multiple health issues, including neuromuscular dysfunction of the bladder and quadriplegia, and was dependent on staff for care. The Treatment Administration Record showed several instances of undocumented catheter care, which was confirmed by the DON.
The facility failed to follow physician orders for medication administration, affecting two residents. One resident received conflicting doses of melatonin due to duplicate orders, while another was given midodrine without proper blood pressure checks, contrary to physician instructions. The DON confirmed these errors, which violated the facility's medication administration policy.
A resident with type one diabetes mellitus received insulin injections without the required safety test being performed by an LPN, resulting in a significant medication error. The LPN did not prime the insulin pen-injectors as per manufacturer instructions and facility policy, leading to non-compliance identified during a complaint investigation.
A facility failed to accurately document the dietary intake of a resident dependent on staff for meals, resulting in incomplete records over a two-week period. Despite the resident's stable weight and no reported issues with meal support, the facility did not adhere to its policy on supporting activities of daily living, leading to a deficiency.
Two residents experienced medication administration errors, resulting in an 8% error rate. An LPN failed to withhold blood pressure medication for a resident with low systolic pressure and administered the wrong laxative to another resident. These actions were contrary to the facility's medication administration policy.
The facility failed to follow infection control procedures for two residents requiring Enhanced Barrier Precautions (EBP). A nurse administered medication to a resident with a g-tube without wearing a gown, and a respiratory therapist performed tracheostomy suctioning on another resident without a gown. Both residents had EBP signs and isolation carts with PPE outside their rooms, and the facility's policy mandates gown use during high-contact care activities.
Failure to Maintain Required RN Coverage Due to DON Escorting Resident to Surgery
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a registered nurse (RN) was present in the facility for eight consecutive hours a day as required, affecting all 59 residents. Review of staffing schedules for 04/01/26 to 04/07/26 showed that the RN/Director of Nursing (DON) was scheduled for eight hours daily Monday through Friday. However, review of employment time punches for 04/06/26 revealed that no RN worked in the facility that day and that three LPNs each worked 12-hour shifts to care for residents. The facility’s policy on Sufficient Staffing, dated 01/2026, stated that a RN would serve as the DON and provide administrative oversight of nursing services consistent with regulatory requirements. Resident and staff interviews further clarified the circumstances leading to the deficiency. One resident reported that the DON had to accompany him to an outpatient surgical appointment on a Monday because there was a mix-up with times and the respiratory therapist could not go, and that the same situation occurred for another appointment on 04/02/26. The transportation coordinator stated that on 04/06/26 the DON left the facility with this resident at 10:00 A.M. for outpatient surgery in a bordering city about 40 minutes away, returned briefly to the facility for about 20 minutes after the surgical center confirmed a respiratory therapist did not need to stay, and then had to return to pick up the resident, with another staff member ultimately going to the surgical center after the coordinator’s shift ended. The DON confirmed she accompanied the resident to the surgical center on 04/02/26 and 04/06/26, verified that the staffing tool reflected incorrect hours for her on 04/06/26, and acknowledged she was not in the facility continuously for eight hours and that there was no RN in the facility that day. The administrator and a regional RN also verified that the employment punches for 04/06/26 did not show the required eight RN hours for facility coverage.
Failure to Timely Report Allegation of Verbal Abuse
Penalty
Summary
The deficiency involves the facility’s failure to timely report an allegation of verbal abuse to the state survey agency as required by its abuse, neglect, and exploitation policy. A resident with severe cognitive impairment, dementia with behavioral disturbances, intermittent explosive disorder, psychosis, anxiety, and multiple psychoactive and other medications was dependent for all ADLs and receiving hospice services. The resident’s care plan noted cognitive loss with memory problems, impaired decision-making, and altered mental status, with interventions focused on monitoring understanding and honoring preferences. Progress notes around the time of the incident documented increased anxiety and an increase in Ativan dosage, but subsequent notes were silent regarding behaviors. During care, a CNA was observed by another CNA to raise her voice and clap her hands in front of the resident’s face while providing care, which the witnessing CNA considered verbal abuse. This witnessing CNA reported the incident to the DON via text and stated she was never contacted for additional information. A written statement later obtained from the accused CNA described clapping her hands and calling the resident’s name in an attempt to calm the resident, who was reportedly screaming uncontrollably, and asserted she was not aggressive. Another LPN provided a statement indicating she did not witness the CNA being aggressive toward the resident. The file contained a text message titled “Abuse and Neglect” sent to current employees, but lacked further documentation such as a complete investigation, additional witness statements, or body assessments related to the incident. Interviews with staff revealed broader concerns about the CNA’s behavior and the facility’s response. An LPN reported that several residents had requested that this CNA not provide their care and that the CNA had been previously suspended for alleged verbally abusive behavior toward staff, then returned to work and reportedly boasted about having a paid vacation. Another CNA reported knowledge of the CNA being escorted out of the facility for unacceptable behavior toward staff, and that residents had described the CNA as loud and confrontational. The DON acknowledged speaking with the reporting staff member the morning after the incident and requesting a witness statement that was never received, and stated she concluded the incident was not abuse based on the resident’s behavioral history and staff statements. The Administrator confirmed that the facility did not initiate a self-reported incident (SRI) for this event and acknowledged that one should have been initiated, despite facility policy requiring reporting of all alleged violations to the administrator, state agency, adult protective services, and other required agencies within specified time frames.
Failure to Thoroughly Investigate Allegation of Abuse
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate and document an allegation of abuse involving Resident #53. Resident #53 had multiple diagnoses including COPD, intermittent explosive disorder, psychosis, dementia with behavioral disturbances, and anxiety, with severely impaired cognition and dependence for all ADLs, and was receiving hospice services and several psychotropic and other medications. The care plan noted cognitive loss with memory problems, impaired decision-making, and altered mental status, with interventions to monitor understanding, repeat information as needed, and honor resident choices. During care, CNA #32 reported witnessing CNA #31 raise her voice and clap her hands in front of Resident #53’s face while providing care, which CNA #32 considered verbal abuse. CNA #32 stated she reported the incident to the DON via text and was never contacted for additional information. The facility’s investigation file for this incident contained a witness statement from CNA #31, who documented that Resident #53 was screaming uncontrollably after being gotten up into a chair, and that she gently clapped her hands and called the resident’s name to get her attention and calm her, after which the resident calmed but later began screaming again related to a shower. The file also contained a statement from an LPN who reported not witnessing CNA #31 being aggressive, and a document showing that a text message titled “Abuse and Neglect” was sent to current employees. The file did not include any further documentation such as additional investigation notes, other witness statements, body assessments, or resident interviews. The Administrator confirmed that a self-reported incident and thorough investigation should have been completed but were not, contrary to the facility’s Abuse, Neglect and Exploitation policy requiring immediate investigation and identification and interviewing of all involved persons when abuse is suspected.
Failure to Provide Timely Meal Assistance and Grooming for Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide timely assistance with activities of daily living (ADLs), specifically meal assistance, for two dependent residents and grooming care for one dependent resident. One resident with chronic respiratory failure, cervical vertebra fracture, and quadriplegia was care planned as totally dependent for all ADLs, including eating, and had an active order for a regular pureed diet with thin liquids. Surveyors observed that this resident’s meal tray was delivered to the room and left covered on the bedside table, with the resident lying in bed with eyes closed and no staff present to assist with eating. Another resident with ALS, intact cognition, and high aspiration risk due to dysphagia and respirator dependence was also care planned to receive assistance with feeding in an upright position. This resident’s meal tray was delivered and left covered and untouched on a table to the resident’s right, with no staff present to assist, and the resident reported that staff had not come to feed him and that he was unable to feed himself and had not seen the tray delivered due to limited vision. The deficiency also includes failure to provide grooming care related to facial hair for a dependent resident. This resident had COPD, moderate persistent asthma, and schizoaffective disorder bipolar type, with impaired cognition and documented dependence on staff for toileting, personal hygiene, and bathing, and a care plan indicating total dependence and the need for two staff for showering and bathing. Review of the shower schedule and CNA documentation showed a missed scheduled shower and lack of documentation that shaving occurred during multiple showers. During observation, the resident was noted to have long white facial hair on the chin, jawline, and upper lip, and shower sheets provided for several dates were silent regarding shaving, with some shower documentation unavailable. The Regional Director of Operations confirmed the presence of long facial hair on this resident.
Significant Medication Error Due to Wrong-Resident Administration
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications were administered to the correct resident, resulting in significant medication errors. A resident with end stage renal disease, recent hospitalization for sepsis secondary to pneumonia and hypothermia, and multiple chronic conditions was admitted with numerous prescribed medications, including antibiotics for pneumonia and other routine therapies. The resident’s care plan included administering medications as ordered, monitoring for adverse reactions to antibiotics, and reporting pertinent lab results to the physician. On the evening in question, the resident was mistakenly given another resident’s full set of medications, which included aspirin, Entresto, Lasix, Lexapro, metformin, metoprolol tartrate, quetiapine fumarate, Rexulti, Seroquel, and Xanax. The resident had a documented allergy to metformin. The error occurred during a medication pass when the LPN was interrupted by the potentially dangerous behaviors of another resident. The LPN later stated that the two residents involved had the same last name, lived on the same unit in adjacent rooms, and that she failed to follow the five rights of medication administration, leading to the wrong medications being given. Following administration of the incorrect medications, the resident exhibited changes in condition, including abnormal vital signs and a mental status change characterized by increased confusion, altered level of consciousness, and abnormal speech. Initial vital signs documented after the error included low blood pressure and decreased respiratory rate, and an e-interact change in condition evaluation noted the resident was tired, weak, confused or drowsy, with low blood pressure and reduced oxygen saturation on room air. The resident was subsequently sent to the hospital, where records documented admission for altered mental status and diagnoses including acute hypoxic and hypercapnic respiratory failure requiring mechanical ventilation and septic shock secondary to pneumonia. The facility’s own policy defined a medication error as preparation or administration of drugs not in accordance with physician orders or accepted professional standards and stated that significant errors are those resulting in cognitive deterioration or impairment.
Unsecured Medications and Biologicals Left in Resident Rooms
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications and biologicals were securely stored and not left unsecured in resident rooms. For one resident with cerebrovascular disease, right-sided hemiplegia, contractures, diabetes mellitus, decreased mobility, and a chronic skin condition, surveyors found two tubes of diclofenac sodium 1% gel and a bottle of Dyna-Hex 4 antiseptic solution left in the room, unsecured and unsupervised, despite orders for diclofenac gel to be applied topically for pain. Both products were labeled with instructions to contact poison control if ingested. The DON confirmed these items should not have been left in the room and should have been stored locked in the treatment cart. Another resident with acute on chronic respiratory failure with hypoxia, non-traumatic subarachnoid hemorrhage, hypothyroidism, decreased mobility, a Foley catheter, and a gastrostomy tube had a prescription bottle of nystatin powder 100,000 units/gram found sitting unsecured on the dresser, with a pharmacy label stating it was for external use only and to contact poison control if ingested; the resident’s physician orders were silent for any topical medications. A third resident with neurocognitive disorder with Lewy bodies, dementia with psychotic disturbances, delusions, and Parkinson’s disease had an Inbrija (Parkinson treatment) inhalation device found on the dresser, unsecured and unsupervised, despite an order for PRN inhalation and no order for bedside self-administration. An LPN confirmed the inhaler should not have been left in the room, and the facility’s “Storage of Medication” policy required all drugs and biologicals to be stored in a safe, secure, and orderly manner.
Non-comprehensive Water Management Plan and Lack of Chlorine Monitoring Logs
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a comprehensive water management plan (WMP) for infection prevention and control, specifically related to Legionella control, as outlined by CDC guidance. The existing undated WMP included a team list, building water system descriptions, diagrams of water flow and potential Legionella growth areas, control measures and monitoring, general interventions when control limits were not met, and a broad validation statement. However, the plan did not specify the exact areas or sources from which water temperatures would be obtained. The validation section lacked defined measurements or processes and only stated that control measures should be followed and records of findings and testing should be kept, without detailing how effectiveness would be evaluated. Further review against the CDC Legionella Control Toolkit showed that the facility’s WMP did not meet key elements recommended for a comprehensive program, such as frequent monitoring of temperatures, disinfectant residuals, and pH, and ensuring a detectable disinfectant residual throughout the potable water system. During interviews, the Administrator was unable to locate WMP chlorine logs and confirmed there were no logs of chlorine testing. The Administrator also acknowledged that the facility’s WMP was not a comprehensive plan that included the key elements according to CDC guidelines. This deficiency had the potential to affect all 59 residents in the facility, as the census at the time was 59.
Medication Error Rate Exceeds Five Percent Due to Improper Administration
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as two medication errors were identified out of 25 opportunities, resulting in an eight percent error rate. The errors involved a resident with a history of kidney disease, metabolic encephalopathy, and seizures, who had mild cognitive impairment. The resident had active physician orders for Aspirin 81 mg chewable daily for DVT prevention and Mucinex (Guaifenesin) 12-hour 600 mg extended release twice daily for pneumonia. During medication administration, an LPN prepared and administered Aspirin 81 mg enteric coated and Guaifenesin 400 mg extended release, instead of the prescribed forms. The medications were also crushed, despite facility policy and documentation stating that enteric coated and extended release medications should not be crushed. There was no physician order to crush these medications. Interviews with the LPN and the DON confirmed that the medications were crushed and that this was not in accordance with the physician's orders or facility policy.
Medication Error During Resident's Leave of Absence
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, specifically affecting one resident. Resident #27, who was cognitively intact and independent with activities of daily living, was admitted with diagnoses including coronary artery disease, heart failure, hypertension, and diabetes. On the morning of December 25, 2024, the resident did not receive his prescribed morning medications, which included Norvasc, Plavix, Pepcid, and several other medications, as they were left in the medication cart and not sent with him during his leave of absence. The resident confirmed that he had left the facility on a leave of absence after receiving his evening medications on December 24, 2024, but did not receive his morning medications for the following day. Upon realizing the omission, the resident contacted the facility, and it was confirmed by LPN #159 that the medications were still in the cart. The resident experienced vomiting and diarrhea on the morning of December 25, 2024, and was uncertain if these symptoms were related to the missed medications. This incident was investigated under Complaint Number OH00160745.
Failure to Ensure Privacy During Catheter Care
Penalty
Summary
The facility failed to provide urinary catheter care in a dignified manner for Resident #19, who was cognitively intact and required substantial maximal assistance for toileting and bathing. The resident had a suprapubic catheter due to neuromuscular dysfunction of the bladder and other related diagnoses. The care plan included specific interventions for catheter care, such as changing the Foley collection bag per facility policy and ensuring the catheter tubing was positioned correctly. However, during an observation, a CNA provided catheter care without ensuring the resident's privacy, as the curtain was not pulled, and the door was not closed, potentially exposing the resident to others in the hallway. The CNA acknowledged the oversight during an interview, and the Director of Nursing confirmed that privacy should have been maintained by pulling the curtain or closing the door. The facility's policy on Quality of Life-Dignity emphasized the importance of promoting and protecting resident privacy during personal care and procedures. This deficiency was identified during an investigation under Complaint Number OH00159216, highlighting a lapse in maintaining the resident's right to a dignified existence and privacy.
Failure to Document Catheter Care
Penalty
Summary
The facility failed to ensure that urinary catheter care was completed and documented as ordered for a resident with a suprapubic catheter. The resident, who had diagnoses including infection and inflammatory reaction due to a urinary catheter, neuromuscular dysfunction of the bladder, quadriplegia, and a history of sepsis, was dependent on staff for various activities and had an intact cognition with delusions. The plan of care included assisting with catheter care, educating the resident to report signs of infection, and monitoring for urinary tract infections. Despite a physician's order for catheter care every shift, the Treatment Administration Record (TAR) for June and July 2024 showed multiple instances where catheter care was neither documented as completed nor refused on the day shift. The Director of Nursing confirmed that the documentation was incomplete, which should have been recorded for the resident. This deficiency was investigated under a specific complaint number.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to adhere to physician orders for medication administration, affecting two residents. For Resident #30, there was a discrepancy in the administration of melatonin. The medical record showed two conflicting orders: one for a single 3 mg tablet and another for three 3 mg tablets at bedtime. The Medication Administration Record (MAR) for October 2024 indicated that both orders were followed, leading to an error in medication administration. The Director of Nursing (DON) confirmed that Resident #30 received melatonin incorrectly due to the presence of two orders for the same medication. For Resident #64, the facility did not consistently follow the physician's order to hold midodrine if the systolic blood pressure (SBP) was over 110 or if the blood pressure was not documented. The MAR showed multiple instances in May, June, July, and August 2024 where midodrine was administered without obtaining or documenting the required blood pressure readings, or when the SBP was elevated. The DON verified these discrepancies, acknowledging that the medication was not administered as ordered. The facility's policy on medication administration, dated November 2017, mandates adherence to physician orders and manufacturer recommendations, which was not followed in these cases.
Failure to Prime Insulin Pen Leads to Medication Error
Penalty
Summary
The facility failed to ensure that a staff member performed a safety test when using an insulin pen-injector, resulting in a significant medication error. This incident involved a resident with type one diabetes mellitus who was cognitively intact and received insulin injections. The physician's orders for the resident included specific dosages of Lantus SoloStar and Humalog Kwik Pen insulin to be administered subcutaneously. During an observation, an LPN was seen administering insulin to the resident without priming the insulin pen-injectors, which is a necessary step to ensure accurate dosing. The manufacturer's instructions for both the Lantus SoloStar and Humalog Kwik Pen require a safety test to be performed before each injection. This involves dialing a test dose, tapping the insulin reservoir, and ensuring insulin comes out of the needle. The facility's policy on medication administration also mandates adherence to manufacturer recommendations. However, the LPN confirmed during an interview that she did not perform the safety test before administering the insulin, leading to the medication error. This deficiency was identified during a complaint investigation.
Failure to Document Dietary Intake
Penalty
Summary
The facility failed to ensure accurate documentation of dietary intake for a resident who required staff assistance with meals. The resident, who had diagnoses including quadriplegia and a history of sepsis, was dependent on staff for eating and other activities of daily living. Despite being on a regular diet with thin liquids, the facility's records showed significant gaps in documenting the resident's meal consumption over a two-week period. Specifically, there were no recorded dietary intakes for several days and incomplete documentation for others. Interviews with the Registered Dietician and the Director of Nursing confirmed the lack of complete documentation. The Registered Dietician noted that the resident did not report any issues with meal support or missing meal trays, and the resident's weight stabilized after admission. However, the facility's policy on supporting activities of daily living, including dining, was not implemented as written, leading to this deficiency. This issue was investigated under a specific complaint number.
Medication Administration Errors Lead to 8% Error Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in an 8% error rate during the observed period. This deficiency was identified through the incorrect administration of medications to two residents. Resident #38, who has a history of hypertension and severe cognitive impairment, was supposed to have their blood pressure medication, Norvasc, withheld due to a low systolic reading of 107 mmHg. However, the LPN responsible for administering the medication placed the Norvasc in the medication cup and intended to administer it, despite having charted that it should be held. Resident #39, who is cognitively intact and has a history of acute respiratory failure, hypertension, and diabetes, was prescribed Senna for constipation. During medication administration, the LPN mistakenly gave Senna Plus, which includes an additional stool softener, instead of the prescribed Senna. The LPN confirmed the error upon review. These incidents highlight the facility's failure to adhere to its medication administration policy, which requires verification of medication details and adherence to physician orders, including holding medications when necessary.
Failure to Follow Enhanced Barrier Precautions
Penalty
Summary
The facility failed to adhere to infection control procedures for two residents, both of whom required Enhanced Barrier Precautions (EBP) due to their medical conditions. Resident #10, who had anoxic brain damage, anxiety, dependence on a ventilator, a tracheostomy, and seizures, was observed receiving medication via a gastrointestinal tube without the administering nurse wearing a gown, despite the presence of an EBP sign and an isolation cart with personal protective equipment (PPE) outside the room. The nurse confirmed the omission of the gown, acknowledging the EBP sign and isolation cart. Similarly, Resident #13, with acute and chronic respiratory failure, dependence on a ventilator, a spinal cord injury, and atrial fibrillation, was observed undergoing tracheostomy suctioning by a respiratory therapist who also failed to wear a gown. An EBP sign and an isolation cart with PPE were present outside the room. The respiratory therapist confirmed the lack of gown use during the procedure. The facility's policy on EBP, revised in June 2024, mandates gown and glove use during high-contact care activities, including device care such as tracheostomy and ventilator tubes.
Latest citations in Ohio
Surveyors found that multiple hazardous storage areas, including a closet near medical records, a beauty salon used to store chemical cases, a supply room in one nursing station, a room leading to a smoking area, a housekeeping room near therapy, and a lobby storage room, lacked required self-closing or automatic-closing doors. These conditions did not comply with NFPA 101 requirements for hazardous area enclosure and had the potential to affect all residents and staff in an emergency.
Surveyors found that the facility did not conduct fire drills on every shift each quarter and did not vary drill conditions as required by NFPA 101. Record review showed that one shift lacked a documented drill for an entire quarter, and the pattern of drill times and dates did not demonstrate varied conditions. The Maintenance Director confirmed the incomplete and noncompliant fire drill schedule, which affected all residents and staff emergency preparedness.
Surveyors found that the facility did not maintain clear egress corridors as required by NFPA 101, with a TV/video cart plugged into a corridor outlet and multiple unsecured chairs placed in the hallway near resident rooms and the secured unit dining room, including directly in front of a fire extinguisher. These items projected about 29 inches into an approximately eight-foot-wide corridor and were located in front of the handrail, potentially affecting 28 residents and staff’s ability to assist in an emergency. The Maintenance Director confirmed these corridor obstructions during the survey.
A resident with intact cognition receiving Medicare Part A skilled services for metabolic encephalopathy had services discontinued while benefit days remained, but the facility did not issue the required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN). The Social Services Director later confirmed that no SNF ABN was provided and reported she believed only a Notice of Medicare Non-Coverage (NOMNC) was needed when all skilled services were stopped. This practice conflicted with the facility’s written policy, which required SNF ABNs to be issued when extended care items or services were initiated, reduced, or terminated due to expected non-coverage by Medicare.
Surveyors identified that the facility exceeded the acceptable medication error rate when two residents with type 2 DM received insulin doses that were not administered according to orders or manufacturer instructions. In two separate observations, an LPN administered Novolog and another LPN administered insulin glargine and insulin lispro without priming the insulin pens, and the insulin lispro and Novolog were given after the residents had already consumed a significant portion of their breakfast meals, despite orders for administration before meals. Manufacturer information for both insulin products required priming before each injection to ensure accurate dosing, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and specified time frames.
A cognitively intact resident with behavioral issues, including physical aggression and noncompliance with care, was in a secured unit and was observed tapping on the window/door. A dietary aide, despite being told by a CNA and an RN not to enter the secured unit and that the resident’s assigned aide could assist, went onto the unit and interacted with the resident, including offering to buy a soda after seeing money in the resident’s hand. The resident struck the aide in the face, and the aide responded by punching the resident in the face; a CNA reported hearing the aide say, “I will hit you again,” and then observed the resident bleeding. The resident was later found at the hospital to have an open mandibular fracture and non-restorable teeth requiring extraction, and the facility’s investigation and policy definitions led to the incident being substantiated as staff-to-resident physical abuse.
A resident with severe cognitive impairment, osteoporosis, and total dependence for transfers was being moved from bed to wheelchair with a mechanical lift when CNAs reported that an undersized sling and a forceful pull on the lift caused the resident to fall feet‑first from the sling, with staff catching the upper body while both legs struck the floor and one leg bent behind. Witnesses heard a loud pop and observed immediate pain, bruising, swelling, and deformity of the leg, yet the responding LPN did not complete a thorough musculoskeletal assessment, did not document a fall, and the physician and resident representative were not promptly informed of a suspected injury. Through the night and into the next day, staff and the roommate reported the resident crying out in pain and an obviously abnormal leg, but nursing notes only reflected intermittent acetaminophen administration without clear pain documentation, and the physician was contacted primarily about yelling and behavior. Mobile X‑rays obtained later showed a displaced distal femur fracture, which was not reviewed until the following day, when hospital imaging confirmed a closed displaced comminuted femur fracture and a hand fracture. The facility’s internal investigation was incomplete and inaccurate, with leadership denying a fall, preparing a single typed statement minimizing the event, and having multiple staff sign it despite later testimony that the statement was false and that staff were told not to discuss the incident.
Surveyors found multiple instances of improper food storage and labeling, including undated and unlabeled opened dairy products, beverages, and prepared foods in the main walk-in cooler and freezer, as well as a serving scoop left resting directly on stored pasta. Additional issues included covered but undated pre-poured juices, milk, and thickened beverages in a reach-in cooler used for tray line, and a nurses' station refrigerator containing a dated bag of a resident’s food from over a week prior and three undated half-sandwiches. In a resident’s personal refrigerator, staff confirmed three undated bags of grapes with visible mold. These conditions did not comply with facility policies requiring cold foods to be stored off the floor, wrapped or covered, labeled, dated, and for resident refrigerators to be monitored daily with unsafe or moldy food discarded.
Surveyors found unsanitary kitchen conditions, including a dirty tray holding clean pitchers, soiled storage carts containing clean dishware and disposables, and multiple trays of open juice in a reach-in refrigerator that were unlabeled and undated. In a walk-in refrigerator, they observed a bag of bologna marked only with a freeze date, lacking a thaw or use-by date, and appearing slimy and discolored. Observation of the high-temp dishwasher showed rinse temperatures below the 180°F minimum required for hot water sanitizing, and review of several months of temperature logs revealed repeated sub-minimum wash and rinse temperatures and numerous missing entries. Facility policies required dishwashing to meet specified temperature standards and all refrigerated foods to be covered, labeled, and dated with a use-by date, but these requirements were not consistently followed.
Surveyors found that the facility did not maintain a safe, clean, and homelike environment as required by its policy. In one shared bedroom, wallpaper was peeling in several areas, including behind each bed, below a window, and near baseboards, and a black substance was present around the base of the toilet. A CNA confirmed these conditions. In addition, three cracked or broken light covers were observed in a hall restroom. These environmental issues affected two residents and had the potential to affect all residents.
Failure to Maintain Self-Closing Doors for Multiple Hazardous Storage Areas
Penalty
Summary
Surveyors identified a deficiency related to hazardous area protection and door requirements under NFPA 101, 2012 Edition. During facility tours, they observed that multiple hazardous storage areas did not have self-closing or automatic-closing doors as required for hazardous areas such as combustible storage and chemical storage. These areas included a closet next to medical records, a beauty salon being used to store cases of chemicals, a supply room in Station #2, and the room leading to the smoking area in Station #3. On a subsequent tour, surveyors observed additional hazardous areas without self-closing doors. The housekeeping room across from therapy and the lobby storage room were both noted to lack self-closing door mechanisms. The facility census at the time was 59 residents, and the surveyors stated that this deficient practice had the potential to affect all residents and staff's ability to assist in an emergency. The Maintenance Director verified these findings at the time they were observed.
Plan Of Correction
K 0321 This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be admissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as its allegation of substantial compliance as of 06/12/2026 K-0321 Doors with Self-Closing Devices Corrective action for resident/s: 1. The closet door next to medical records was lacking a self-closing door on 5/19/2026. Maintenance director to add self-closing device to closet door next to medical records on or before 06/12/2026 in accordance with applicable code. 2. The beauty salon had chemicals stored in it on 5/19/2026. Maintenance director moved chemicals from beauty salon on 05/20/2026 in accordance with applicable code. 3. The supply room on station 2 was lacking a self-closing door on 5/19/2026. Maintenance director to add self-closing door to supply room on station 2 on or before 06/12/2026 in accordance with applicable code. 4. The room to the smoking area on station 3 was lacking a self-closing door on 5/19/2026. Maintenance director to add a self-closing door to the smoking are on station 3 on or before 06/12/2026 in accordance with applicable code. 4. The housekeeping room across from therapy was lacking a self-closing door on 5/19/2026. Maintenance director to add a self-closing door to the housekeeping room across from therapy gym on or before 06/12/2026 in accordance with applicable code. 5. The lobby storage room was lacking a self-closing door on 5/19/2026. Maintenance director to add a self-closing door to the lobby storage room on or before 06/12/2026 in accordance with applicable code. Identification of other residents who may be affected: LNHA and Maintenance director/designee completed a full facility audit for doors with self-closing devices on 05/26/2026. Any corrective action, including, doors identified as needing self-closures will be added on or before 06/09/2026 in accordance with applicable code. Measures for systemic change: LNHA educated Maintenance Director on 05/26/2026 regarding NFPA 101-2012 sections 19.3.2.1 and 19.3.5.9 specifically regarding doors with self-closing devices. How Corrective Action will be monitored Ongoing "Doors with Self-Closing device audit" to be completed weekly x 2 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 06/12/2026
Failure to Conduct Required Quarterly Fire Drills on All Shifts
Penalty
Summary
The facility failed to conduct fire drills in accordance with NFPA 101, 2012 Edition, sections 19.7.1 through 19.7.1.8, specifically by not holding drills every shift each quarter and not varying drill conditions as required. Record review on 06/09/25 at approximately 10:32 A.M. showed there was no fire drill conducted for the first shift during the third quarter. The documented first-shift fire drills occurred on 01/30/26 at 2:42 P.M., 04/30/26 at 1:51 P.M., and 10/31/25 at 10:58 A.M., indicating a missed quarter. Second-shift fire drills were recorded on 02/26/26 at 5:20 P.M., 06/03/25 at 4:35 P.M., 08/29/25 at 3:46 P.M., and 11/25/25 at 5:09 P.M., and third-shift drills on 02/28/26 at 11:47 P.M., 05/30/25 at 12:18 A.M., 07/22/25 at 11:34 P.M., 09/26/25 at 11:40 P.M., and 12/15/25 at 5:17 A.M. The surveyor determined that drills were not conducted under varied conditions and that the required quarterly drill on each shift was not consistently performed. The Maintenance Director confirmed these findings at the time they were identified, and the deficiency had the potential to affect all 59 residents and staff response in an emergency. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency related to facility-wide emergency preparedness practices and documentation of fire drills.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 05/29/2026 K-0712 Fire Drills Corrective action for resident/s: There were no records of a fire drill for the first shift of the third quarter of 2025. First shift fire drill completed on 5/24/2026 by maintenance director/designee with no findings or corrective action necessary. Identification of other residents who may be affected: On 5/26/2026 Maintenance director/designee completed 100% audit of the scheduled fire drills to ensure a drill is scheduled quarterly each shift with no findings or corrective action necessary. Measures for systemic change: LNHA educated Maintenance Director on 05/26/2026 regarding NFPA 101-2012 section 19.7.1.4 through 19.7.1.7. specifically including fire drill frequency requirements. How Corrective Action will be monitored Ongoing "Fire Drill Audit" to be completed weekly x 2 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 05/29/2026
Obstructed Egress Corridors Due to Equipment and Chairs
Penalty
Summary
The facility failed to maintain required clear egress widths in corridors in accordance with NFPA 101, 2012 Edition, sections 19.2.3.4 through 19.2.3.5 and 7.3.2 through 7.3.2.3, creating projections into the egress corridor that exceeded allowable limits. Surveyors observed that on one day in Station #3, a cart with a television and video equipment was plugged into an outlet in the corridor by room 38, and five activity room chairs were placed in the corridor near the secured unit dining room directly in front of a fire extinguisher. On the following day, surveyors again observed chairs in the Station #3 corridor, with four by room 35 and four by the activities room, and the same television cart still in the corridor; the chairs were not secured. The corridor was approximately eight feet wide, and the projections extended approximately 29 inches into the corridor in front of the handrail. These conditions had the potential to affect 28 residents in the facility and the staff’s ability to assist in an emergency, and the Maintenance Director confirmed the observations at the time of discovery. No specific resident medical histories or conditions were described in the report, only that 28 residents were potentially affected and the facility census was 59.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be subsequent remedial measures and should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 05/29/2026 K-0232 Clear path of egress Corrective action for resident/s: 1. On 05/18/2026 station 3 had a cart with a television parked in the corridor by room 38 that exceeded allowable limits. Maintenance director/designee moved the TV cart into the activity room, out to the corridor on 05/18/2026 in accordance with applicable code. 2. On 5/18/2026 station 3 had 5 chairs in the corridor near the dining room directly in front of the fire extinguisher. Maintenance director/designee moved the chairs into the dining room, out of the corridor on 5/18/2026 in accordance with applicable code. 3. On 5/19/2026 station 3 had 4 chairs by the activity room and 4 by room 35. In addition, the TV cart was in the corridor. The maintenance director/designee moved the chairs and TV cart into the dining room, out of the corridor on 5/19/2026 in accordance with applicable code. Identification of other residents who may be affected: Maintenance director/designee completed a 100% facility audit for clear paths of egress on 5/26/26 with no findings or corrective action necessary. Measures for systemic change: Maintenance Director/designee educated staff on 5/26/2026 regarding NFPA 101-2012 section 19.2.3.4 and 19.2.3.5 specifically including maintaining a clear path of egress. How Corrective Action will be monitored Ongoing "Path of Egress Audit" to be completed weekly x 2 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 05/29/2026
Failure to Issue Required SNF ABN When Discontinuing Medicare Part A Services
Penalty
Summary
The deficiency involves the facility’s failure to issue a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) when Medicare Part A services were discontinued for a resident who still had available benefit days. The resident was admitted with a diagnosis of metabolic encephalopathy and had intact cognition per the Minimum Data Set assessment. The facility’s own SNF Beneficiary Notification Review documented that Medicare Part A skilled services began on 02/11/26 and the last covered day was 03/11/26, and that the facility initiated discharge from Medicare Part A services before the resident’s benefit days were exhausted. Despite this, no SNF ABN was provided to the resident or the resident’s representative. During interviews, the Social Services Director stated that the SNF ABN was issued hours prior to the last covered day but, upon reviewing her files, confirmed that no SNF ABN had actually been issued for this resident. She further explained that she believed an SNF ABN was only required if one skilled service remained and that if all skilled services were being discontinued, only the Notice of Medicare Non-Coverage (NOMNC) needed to be issued. The Administrator, however, stated that a resident should always receive both a SNF ABN and a NOMNC when Medicare Part A services are discontinued and benefit days remain. Review of the facility’s written policy dated 03/28/23 showed that the facility was required to issue SNF ABNs for initiation, reduction, or termination of extended care items or services when Medicare payment was not expected, which did not occur in this case.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as its allegation of substantial compliance as of 05/29/2026 F-0582 Corrective action for resident/s: On 5/14/26 Resident #34 was informed of rights and responsibilities related to Advanced Beneficiary Notice and voiced understanding of information for future reference by administrator. Identification of other residents who may be affected: Any resident receiving skilled services from nursing or therapy services. The Administrator audited all residents who were discharged from skilled services in the past 30 days to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary Notice on 5/29/26. No non-compliance was noted. Measures for systemic change: On 5/14/2026 Business Office Manager, Director of Rehab, Minimum Data Set nurse, Director of Nursing and Social Services Director were educated on proper procedure of issuing of Notice Of Medicare Non Coverage and Advanced Beneficiary Notice by administrator. All upcoming discharges from skilled services will be reviewed weekly at Utilization Review meeting to ensure notices will be delivered timely. How Corrective Action will be monitored: Administrator or designee to complete audits of all residents being discharged from skilled services to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 5/29/26
Insulin Administration Errors and Failure to Prime Insulin Pens
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5%, with surveyors identifying 3 errors out of 28 medication administration opportunities, resulting in a 10.71% error rate. For one resident with type 2 diabetes mellitus and moderate cognitive impairment, the physician’s order directed Novolog insulin 10 units via subcutaneous pen-injector to be given before meals. During an observed medication pass, the LPN administered 10 units of Novolog insulin without priming the pen and did so after the resident had already consumed approximately 50% of the breakfast meal. The LPN later confirmed she did not prime the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer instructions for the Novolog FlexPen specified that an air shot (priming) must be performed before each injection to ensure proper dosing. Another resident, also diagnosed with type 2 diabetes mellitus and with intact cognition, had orders for insulin glargine 35 units subcutaneously twice daily and insulin lispro 20 units subcutaneously before meals, plus 12 units subcutaneously if blood glucose was between 251 mg/dL and 300 mg/dL. During an observed medication administration, an LPN administered 35 units of insulin glargine and 32 units of insulin lispro without priming the insulin pens and after the resident had consumed approximately 90% of the breakfast meal, despite orders for insulin lispro to be given before meals. The LPN later stated she could not remember if she had primed the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer information for insulin lispro stated that the pen must be primed before each injection to confirm insulin delivery and remove air, and that failure to prime could result in too much or too little insulin. The DON confirmed the expectation that insulin be administered as ordered, including priming each pen with two units before dialing the prescribed dose, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and required time frames.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 5/29/2026. F-0759 Corrective action for resident/s: Residents #21 and #22 were assessed and evaluated by nurse and Director of Nursing 5/14/26. Resident #21 and #22 both denied any adverse effects and none were noted upon assessment by the Director of Nursing on 5/14/2026. Notification made to physician on 5/14/2026. LPN # 2 competency Eval on insulin administration with the Director of Nursing completed 5/14/2026. Identification of other residents who may be affected: Diabetic residents on assignment of LPN #2/station 2 have the potential to be affected and were assessed by the DON/Designee on 5/14/26 and found to be within normal limits. Measures for systemic change: All Nurses were educated by the Director of Nursing on the steps for Insulin administration per competency, diabetes clinical protocol policy, Medication and treatment orders policy, administering medications policy, and Obtaining fingerstick Glucose Level policy On 5/14/2026. How Corrective Action will be monitored: Director of Nursing and Assistant Director of Nursing will complete insulin administration audits on 5 nurses. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance: 5/29/2026
Staff-to-resident physical abuse resulting in jaw fracture and tooth loss
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from staff-to-resident physical abuse, resulting in serious injury. A dietary aide entered a secured unit where a cognitively intact resident with a history of behavioral issues, including physical aggression and noncompliance with care and medications, was located. The resident had been tapping or knocking on the window/door of the secured unit, drawing the attention of the dietary aide. Multiple staff, including a CNA and an RN, told the dietary aide not to go onto the secured unit, noting that the resident’s assigned aide could assist and that the resident had been agitated the previous day. Despite these instructions, the dietary aide went onto the secured unit. Witness statements and interviews indicate that upon entering the unit, the aide interacted with the resident, including offering to buy the resident a soda after seeing the resident holding money. According to staff statements and the aide’s own account, the resident then struck the aide in the face. The aide responded by punching the resident in the face. A CNA on the unit reported stepping between the two to attempt to deescalate the situation and then calling for the nurse due to the resident’s aggression. The CNA also reported hearing the aide tell the resident, “I will hit you again,” and then observed that the resident was bleeding. Following the punch, the resident was noted by staff to be bleeding from the nose and mouth. The resident was assessed by nursing and subsequently transported to the hospital. Hospital records documented that the resident sustained an open fracture of the right jaw, with a loose right lateral mandibular incisor and bleeding from the socket at the fracture site. The resident’s remaining 11 teeth were extracted because they could not be restored. A police report documented that staff reported the incident as an assault in which a staff member punched a resident after the resident had punched the staff member. The facility’s policy defined abuse as the willful infliction of injury resulting in physical harm, including physical abuse such as hitting and punching, and the facility substantiated that the dietary aide had physically abused the resident.
Failure to Ensure Safe Mechanical Lift Transfer, Timely Assessment, and Pain Management After Traumatic Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure safe mechanical lift transfers, adequate assessment, timely physician and representative notification, and appropriate pain management for a severely cognitively impaired, non‑ambulatory resident who required a mechanical lift with two‑person assistance for all transfers. The resident had multiple relevant diagnoses, including vascular dementia, osteoarthritis, a right hip prosthesis, chronic kidney disease, and a history of fractures and osteoporosis/osteopenia. On the morning of 04/22/26, during a mechanical lift transfer from bed to wheelchair, multiple CNAs reported that the sling appeared too small, the lift was pulled forcefully from under the bed, and the resident fell feet‑first out of the sling, with staff catching her upper body while both legs hit the floor and one leg bent behind her. A loud popping sound was heard, the resident screamed and cried out in pain, and witnesses observed immediate bruising, swelling, and apparent misalignment of the left knee/leg. Despite this, the nurse who responded did not perform a complete head‑to‑toe or range‑of‑motion assessment focused on the leg, and the incident was not documented as a fall from the lift. Following the incident, nursing staff actions and documentation were incomplete and inconsistent with the resident’s presentation. Progress notes on 04/22/26 documented only a skin tear to the left forearm and a head‑to‑toe assessment with no new areas, and there were no notes describing a fall, leg injury, or significant pain. Multiple CNAs and the resident’s roommate reported that the resident cried out in pain throughout the night and that her left leg appeared swollen, bruised, and deformed, yet nursing notes from the night shift only recorded administrations of acetaminophen without documenting the reason for administration, pain assessment findings, or any musculoskeletal concerns. One RN reported being asked to look at the resident on 04/22/26, noting swelling of the left leg but performing no further assessment. The physician was not notified within one hour of a suspected musculoskeletal injury as required by facility policy, and the resident’s representative was not informed that the resident had fallen from the mechanical lift. On 04/23/26, staff continued to report the resident’s ongoing pain and abnormal leg appearance, but the physician was contacted only about increased yelling and behavior, with a focus on agitation and prior hip/groin pain history rather than a new traumatic event. The DON later documented that a loud popping noise occurred during a Hoyer lift transfer with three staff present and that no abnormalities or signs of pain were noted, and the physician was asked to order bilateral hip and knee X‑rays as a precaution, without documenting a fall. Mobile X‑rays were obtained on 04/23/26, but the results, which showed a displaced distal femur fracture on a limited lateral view, were not reviewed until 04/24/26. Only then was the fracture acknowledged and discussed with the physician and resident representative. Subsequent hospital evaluation identified a closed displaced comminuted supracondylar fracture of the left femur and a distal fifth metacarpal fracture of the left hand. The facility’s internal investigation was incomplete and inaccurate: the DON denied a fall on 04/22/26, prepared a single typed statement describing only a popping sound while the resident was suspended over the bed, and had multiple staff sign it, even though at least two CNAs and an agency DON later reported that the statement was false and that staff felt intimidated and were told not to talk about the incident. The facility also failed to adequately manage the resident’s pain following the injury. Although the MAR shows acetaminophen administrations on 04/22/26 and early 04/23/26, there was no associated documentation of pain scores or clinical rationale in the progress notes for some doses, and staff interviews and the roommate’s account described the resident crying out in pain whenever touched and throughout the night. The physician later stated he was under the impression the fracture was non‑displaced and that, because the resident was bedbound, he did not feel she needed pain medication, and he was unaware of the severity of the femur fracture or the additional hand fracture. Overall, the facility did not follow its own physician communication policy for falls with musculoskeletal deformity or leg pain, did not perform and document thorough assessments at the time of the incident and during the subsequent night, did not promptly review diagnostic imaging, and did not conduct a complete, accurate investigation into the circumstances of the mechanical lift transfer and resulting injuries.
Improper Food Storage and Labeling in Facility and Resident Refrigerators
Penalty
Summary
Surveyors identified a failure to store food in accordance with professional standards and facility policy, creating the potential for foodborne illness for nearly all residents who received food from the kitchen. In the walk-in cooler, they observed multiple items that were opened and partially used without any open dates, including two cartons of heavy whipping cream, bins of individually poured and covered beverages, and a tray of covered fruit cocktail bowls. A large pan of pasta with ground meat was stored with the serving scoop resting directly on the food, covered with plastic wrap and not dated. A cart in the cooler held a 22-quart container of dark liquid with no label or date, and a pink plastic pitcher resting directly on the cart surface, which was coated with a dark unidentified material. A box of bacon was stored directly on the floor. The Director of Dietary Services confirmed the presence of undated, unlabeled, and improperly stored food items in the walk-in cooler. In the walk-in freezer, surveyors found an unsealed and undated bag of frozen chicken breasts and an unsealed and undated bag of pork pizza topping, which the Director of Dietary Services also confirmed. The reach-in cooler used for tray line contained a variety of pre-poured juices, milk, thickened beverages, and tea that were covered but not dated. At a nurses' station refrigerator, surveyors observed a plastic bag of food labeled with a resident’s name and dated more than a week earlier, along with three half-sandwiches wrapped in plastic without dates; the LPN present verified these findings. In a resident’s personal refrigerator, three undated bags of grapes with visible mold were found, and a CNA confirmed the grapes were moldy and undated. Facility policies required cold foods to be stored at least six inches above the floor, wrapped or in covered containers, labeled, and dated, and required resident refrigerators to be monitored daily, with food appropriately labeled and unsafe or moldy food discarded. These practices were not followed, resulting in the cited deficiency under the complaint investigation.
Unsanitary Kitchen Practices and Improper Dishwashing Temperatures
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service operations related to unsanitary kitchen conditions, improper food labeling and dating, and failure to operate the dishwasher according to manufacturer and policy requirements. During an initial kitchen tour, they observed a plastic tray holding clean pitchers with a brown-like substance on it, and three open, three-shelf carts with crumbs and debris on the shelves where clean insulated plate lids and sleeves of disposable bowls, cups, and lids were stored. Multiple trays of juice in a reach-in refrigerator were open, unlabeled, and undated. In the walk-in refrigerator, surveyors found a plastic bag of bologna with only a freeze date and no thaw or use-by date; the bologna appeared slimy and lighter in color. The facility census was 67, with one resident identified as not receiving meals from the kitchen, and the deficiency was noted as having the potential to affect all residents receiving food from the kitchen. Surveyors also observed the high-temperature dishwasher in use and recorded a wash temperature of 168°F and rinse temperatures of 160°F, 176°F, 178°F, 178°F, and 178°F over five cycles, despite the machine label and facility policy requiring a minimum wash temperature of 150°F and a minimum rinse temperature of 180°F for hot water sanitizing. A staff member confirmed the dishwasher had not been running earlier that morning, verified it was a high-temperature machine that should rinse at a minimum of 180°F, and acknowledged the observations regarding the dirty tray, soiled carts, unlabeled juice, and improperly dated bologna. The staff member stated that items in the reach-in refrigerator were normally prepped the night before and asserted that the bologna always had that color before discarding it. Review of the dishwasher temperature logs for January through April 2026 showed repeated failures to meet required wash and rinse temperatures and numerous instances of missing documentation. In January, multiple wash temperatures were below the 150°F minimum, and several meals lacked recorded wash and rinse temperatures. February logs showed at least one sub-minimum wash temperature and many missing wash and rinse entries for various meals. March logs included at least one meal with no documented wash or rinse temperatures. April logs documented several wash temperatures below 150°F and rinse temperatures below 180°F, along with multiple days and meals where wash and/or rinse temperatures were not recorded at all. Facility policies on sanitation, kitchen infection control, and food receiving and storage required dishwashing to meet temperature and sanitation standards and refrigerated foods to be covered, labeled, dated, and used, frozen, or discarded by their use-by date, which was not consistently followed according to the survey findings.
Environmental Maintenance and Cleanliness Deficiencies in Resident Room and Common Restroom
Penalty
Summary
Surveyors identified that the facility failed to maintain a safe, clean, comfortable, and homelike environment as required by its “Homelike Environment” policy. Observation of a shared bedroom for Residents #46 and #56 showed wallpaper peeling from the wall in multiple locations, including behind each resident’s headboard, below the window, and near the baseboards. In the same room’s bathroom, a black substance was observed around the base of the toilet. During an interview conducted concurrently with these observations, CNA #175 confirmed the presence of the peeling wallpaper and the black substance around the toilet base. Further observation with CNA #175 in the C hall restroom revealed that three light covers in that restroom were cracked or broken. The facility’s written policy, revised in February 2021, states that residents are to be provided with a safe, clean, comfortable, and homelike environment. The conditions observed in the residents’ bedroom, bathroom, and the C hall restroom were inconsistent with this policy and affected two identified residents, with the potential to affect all residents in the facility.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
