Forest Hills Healthcare Center.
Inspection history, citations, penalties and survey trends for this long-term care facility in Cincinnati, Ohio.
- Location
- 8700 Moran Road, Cincinnati, Ohio 45244
- CMS Provider Number
- 366389
- Inspections on file
- 39
- Latest survey
- April 30, 2026
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Forest Hills Healthcare Center. during CMS and state inspections, most recent first.
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.
The facility failed to effectively address and communicate follow-up on concerns raised in Resident Council meetings, leading several residents to stop attending because they felt nothing changed. Over several months, residents reported issues including nighttime noise, aides not staying on task, delays in getting out of bed for activities, inadequate bathroom and room cleaning, running out of ordered food, poor food flavor and temperature, and staff cell phone use during work time causing slow call light response. Meeting minutes showed no documented follow-up to these concerns, and residents reported no observable improvements. The Administrator acknowledged there was no standard process for handling Resident Council issues and that any actions taken were not formally communicated back to residents.
Surveyors determined that the facility did not develop a complete baseline care plan for a newly admitted resident with dementia and postprocedural intestinal obstruction. The MDS showed the resident had severely impaired cognition and required staff assistance with ADLs, but the baseline care plan only noted an ADL self-care performance deficit related to comorbidities without specifying the resident’s basic ADL care needs. An LPN confirmed the plan lacked essential information needed to provide care, and policy review showed that baseline care plans were required to include details on ADL assistance needs.
A resident with anoxic brain damage, persistent vegetative state, and type 2 DM was assessed on the MDS as having impaired ROM in all extremities and total dependence for all ADLs, but the comprehensive care plan did not include any interventions addressing the limited ROM. An MDS LPN confirmed that the ROM limitation was omitted from the care plan, despite facility policy stating that the care plan is the written treatment to provide optimal personalized care and services. This deficiency was identified for one of several residents with limited ROM in a larger facility census.
The facility failed to provide adequate ADL assistance, specifically nail care, to two residents who required staff support. One cognitively intact resident with diabetes, legal blindness, and adult failure to thrive needed partial/moderate help with bathing and personal hygiene and was observed on consecutive days with fingernails about one half inch long, which he stated interfered with using his TV remote; staff acknowledged the nails needed trimming but no assistance was provided by the next day. Another resident with anoxic brain damage and in a persistent vegetative state, fully dependent for all ADLs and with impaired ROM in all extremities, was observed with fingernails about one quarter inch long, and an LPN confirmed they needed trimming. These conditions occurred despite a facility policy stating that routine daily care includes assistance with ADLs.
Two residents with intact cognition and significant pain-related conditions did not receive scheduled opioid analgesic doses because the medications were not available. One resident with multiple vertebral compression fractures and COPD missed an ordered oxycodone dose, and another resident with polyneuropathy, DM2, prostate cancer, and anxiety disorder missed an ordered oxycodone-acetaminophen dose. In both cases, MAR review showed the 6:00 p.m. doses were not documented as given, the residents reported missed pain medication due to unavailability, and the DON confirmed the medications were not on hand for administration.
A laptop displaying private health information was left unattended on a medication cart, making multiple residents' medical records visible to passersby. An RN confirmed leaving the device open and accessible, in violation of facility policy requiring screens to be locked when unattended.
A resident with Alzheimer's disease and glaucoma did not receive a required eye doctor visit despite physician orders and a care plan indicating the need for vision services. Staff confirmed the resident had not been seen by an eye doctor since admission, and her glasses could not be located, contrary to facility policy requiring referrals for eye care.
Dietary staff did not follow hand hygiene protocols while preparing and serving meals, repeatedly touching their face, hair, and clothing before handling food and plates without washing or sanitizing their hands. Additionally, milk was not kept at or below 41°F on the tray line, with temperatures recorded above the required limit, contrary to facility policy and FDA Food Code expectations.
A resident with moderate cognitive impairment requested a change from full code to DNR Comfort Care, and signed the necessary DNR order form. However, the change was not transcribed into the EHR or updated in the resident's current orders, leaving the code status incorrectly listed as full code. Staff interviews indicated that the process for updating code status was not followed during a period of staff transition, resulting in the deficiency.
A facility failed to provide a resident's requested medical records to an attorney's office, despite the resident signing an authorization form. The administrator confirmed the request was not completed, and the facility's process of verifying and processing such requests within 30 days was not followed, leading to a deficiency.
The facility failed to conduct neurological checks for two residents after falls involving the head. One resident was found on the floor near a chair, and checks were not documented until days later. Another resident fell, sustaining facial injuries, but no neuro-checks were completed despite protocol requirements. The DON and NP confirmed the oversight.
A resident with severe cognitive impairment was administered Vancomycin for 10 days without documented positive C.diff results. The medication was prescribed based on a verbal report from a nurse to an NP, who issued a verbal order without reviewing written results, leading to unnecessary antibiotic use.
The facility failed to conduct ordered lab tests for two residents, affecting their care. A resident with severe cognitive impairment was not tested for C.diff as ordered, and another resident with multiple diagnoses did not receive a CBC due to a change in lab companies. The DON confirmed the lapses in documentation and testing.
A facility failed to ensure a resident was safely secured in a wheelchair during transport, resulting in the resident sliding out of the wheelchair and sustaining injuries. The transport driver did not follow proper protocols, leading to Immediate Jeopardy.
The facility failed to ensure medications were administered by qualified staff, affecting four residents. Two MTs administered medications without proper certifications from the OBN, and their employee files lacked necessary documentation. Despite this, no medication errors or incidents were reported.
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.
Failure to Address and Communicate Follow-Up on Resident Council Concerns
Penalty
Summary
Surveyors identified a deficiency related to the facility’s failure to respond to and follow up on concerns raised during Resident Council meetings, affecting multiple residents who attended these meetings and potentially all residents in the facility. Review of Resident Council minutes for three consecutive months showed residents repeatedly voiced concerns about noise at night, aides on night shift not staying on task, delays in being assisted out of bed in time for activities, bathrooms not being cleaned properly, running out of ordered food, and rooms not being cleaned on weekends. The minutes did not document any follow-up actions or responses to these concerns. Residents reported that Resident Council meetings had become poorly attended because residents felt that nothing changed when they brought up issues. Interviews with the Resident Council President and other residents confirmed that specific concerns, such as poor food flavor and temperature and staff cell phone use during work time leading to slow call light response and delayed tasks, had been raised in Resident Council but had not resulted in noticeable changes. One resident recounted that a former cook had attended a meeting, listened to food-related complaints, and stated he would make menu and preparation changes, but residents perceived no improvement in food quality afterward. Another resident confirmed that concerns about staff cell phone use had been discussed, but she was unaware of any action taken. The Administrator acknowledged there was no standard method for addressing Resident Council concerns and confirmed that, although concerns were addressed after minutes were completed, communication about any actions taken did not get back to the residents.
Failure to Include ADL Needs in Baseline Care Plan
Penalty
Summary
Surveyors found that the facility failed to implement an adequate baseline care plan addressing activities of daily living (ADL) needs for a newly admitted resident. The resident was admitted with diagnoses including postprocedural intestinal obstruction and dementia, and the MDS assessment documented severely impaired cognition and a need for staff assistance with ADLs. The baseline care plan, dated on the admission day, only noted that the resident had an ADL self-care performance deficit due to comorbidities and did not include further details about the resident’s basic ADL care needs. An interview with the MDS LPN confirmed that the baseline care plan lacked the basic information needed to care for the resident. Review of the facility’s Baseline Care Plan/48 Hour Care Plan policy showed that baseline care plans were required to include information regarding resident needs for assistance with ADLs, which was not done in this case. This deficiency was cited for one resident out of 13 reviewed for baseline care plans, with a facility census of 112 residents, and was investigated under Complaint Number 2963128.
Failure to Include Limited Range of Motion Needs in Comprehensive Care Plan
Penalty
Summary
The deficiency involves the facility’s failure to address a resident’s impaired range of motion in the comprehensive care plan. The resident was admitted with diagnoses including anoxic brain damage, persistent vegetative state, and type 2 diabetes mellitus. An MDS assessment documented that the resident was in a persistent vegetative state with no discernible consciousness, was dependent on staff for all ADLs, and had impaired range of motion in all extremities. Despite this, review of the resident’s care plan showed no interventions related to the limited range of motion. During an interview, the MDS LPN confirmed that the resident’s limited range of motion was not included on the care plan and acknowledged that this information should be present so staff are aware of the limitations. Facility policy stated that the care plan is the written treatment provided to enable optimal personalized care and services, but the resident’s range of motion needs were not incorporated, resulting in the cited deficiency. This deficiency was identified for one resident reviewed for limited range of motion, in the context of eight residents in the facility who had limited range of motion and an overall census of 112 residents. It was investigated under Complaint Number 2963128.
Failure to Provide Adequate Nail Care as Part of ADL Assistance
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate assistance with activities of daily living (ADLs), specifically nail care, for residents who were unable to perform these tasks independently. One resident with type 2 diabetes mellitus, legal blindness, and adult failure to thrive had an MDS assessment indicating intact cognition but a need for partial/moderate assistance with bathing and personal hygiene. On observation, this resident’s fingernails were long, extending approximately one half inch beyond the fingertips. The resident reported disliking the length of his fingernails because it interfered with his ability to press buttons on his TV remote. The Activity Director confirmed that the fingernails were long and needed trimming. A subsequent observation the next day showed the fingernails remained long, and the resident confirmed that no one had offered to cut his fingernails since the prior day. Another resident, admitted with anoxic brain damage, persistent vegetative state, and type 2 diabetes mellitus, had an MDS assessment indicating a persistent vegetative state with no discernible consciousness, dependence on staff for all ADLs, and impaired range of motion in all extremities. During an observation with an LPN, this resident’s fingernails were noted to be long, extending approximately one quarter inch beyond the fingertips, and the LPN verified that the fingernails were long and needed trimming. Review of the facility’s undated “Routine Resident Care” policy showed that the facility was responsible for providing routine daily care, including assistance with ADLs. The failure to ensure nail care for these residents constituted noncompliance and was investigated under multiple complaint numbers.
Failure to Ensure Availability of Ordered Opioid Analgesics
Penalty
Summary
The facility failed to ensure that ordered opioid analgesic medications were available for administration as prescribed, resulting in missed scheduled doses for two residents. One resident, admitted with wedge compression fractures of multiple thoracic vertebrae, muscle weakness, and COPD, had an order for oxycodone 10 mg every six hours. Review of the MAR showed the 6:00 p.m. dose on 04/27/26 was not signed as administered. The resident reported that the facility had recently run out of his routine oxycodone and that he missed a scheduled pain medication dose. The DON confirmed that the 6:00 p.m. oxycodone dose on 04/27/26 was not given because the medication was not available. Another resident, admitted with diagnoses including polyneuropathy, type 2 diabetes mellitus, prostate cancer, and anxiety disorder, had an order for oxycodone-acetaminophen 5-325 mg every six hours. Review of the MAR showed the 6:00 p.m. dose was not signed as administered. The resident reported that in the previous month there was a day when he did not receive his scheduled pain medication because it was not available. The DON confirmed that the 6:00 p.m. dose of oxycodone-acetaminophen on 03/16/26 was not administered due to the medication not being available. This deficiency was identified during complaint investigations under Complaint Numbers 2704502, 2656097, and 2673312.
Unattended Laptop Exposes Resident Health Information
Penalty
Summary
Staff failed to maintain the confidentiality of residents' medical records by leaving a laptop unattended on top of the medication cart in the 400 hall. The laptop was open and displayed a resident's name and medication list, making private health information visible to anyone passing by, including residents, staff, and visitors. This was directly observed during a survey, and the responsible RN confirmed leaving the laptop unattended with sensitive information accessible. Further observation revealed that the same unattended laptop displayed multiple resident records, again making confidential information accessible to unauthorized individuals. The facility's policy requires staff to turn off computer screens and not leave open medical records unattended, but this protocol was not followed. The administrator confirmed that nursing staff are expected to lock their laptop screens when stepping away from the medication cart to protect resident privacy.
Failure to Provide Vision Services as Needed
Penalty
Summary
The facility failed to ensure that a resident received necessary vision services as required. The resident, who had diagnoses including Alzheimer's disease, major depressive disorder, hypertension, and glaucoma, had a physician's order for an eye doctor visit as needed and was prescribed Latanoprost eye drops for glaucoma. The care plan identified impaired visual function and included interventions such as arranging consultations with an eye care practitioner. Despite a referral being sent in June for the resident to be seen by the facility eye doctor, the resident had not been seen by an eye doctor since admission in 2020. Interviews with staff confirmed that the resident had not received an eye doctor visit and that her glasses could not be located. The resident herself was unaware of the whereabouts of her glasses, and a CNA reported never having seen her wear glasses during nine months of employment. The facility's policy required referrals for eye care appointments as needed, but this was not followed, resulting in the resident not receiving appropriate vision services.
Failure to Ensure Hand Hygiene and Proper Cold Holding of Milk During Meal Service
Penalty
Summary
Dietary staff failed to perform proper hand hygiene during meal preparation and service, as observed on multiple occasions. One dietary aide was seen scratching her head and face, touching her clothes and pants, and then handling plates and food items without washing or sanitizing her hands. These actions were observed during both lunch and breakfast tray lines, and the aide continued to prepare and serve food after touching her face, hair, and clothing. The facility's policy required hand hygiene after such contact, and both the Dietary Manager and Administrator confirmed that staff were expected to follow these procedures. Additionally, the facility did not ensure that milk served on the tray line was maintained at the required temperature of 41 degrees Fahrenheit or less. During breakfast service, lactose-free milk was poured into cups and left on the tray line without being held in ice. When the temperature was checked, the milk measured 43 degrees Fahrenheit, above the acceptable limit. The Dietary Manager acknowledged that the milk could not be served at that temperature, and both the DON and Administrator stated their expectation that food and drink temperatures be kept within required ranges.
Failure to Update Advance Directive Order in Resident's Medical Record
Penalty
Summary
A deficiency occurred when the facility failed to properly transcribe and update a change in advance directive order for one resident. The resident, who had moderate cognitive impairment as indicated by a BIMS score of 12, was initially documented as a full code upon admission, meaning they wished to receive CPR. However, the resident later expressed a desire to change their code status to Do Not Resuscitate (DNR) Comfort Care, and signed the appropriate DNR order form. Despite this, the resident's electronic health record (EHR) and current orders continued to reflect full code status, and the change was not updated in the EHR as required. Interviews with staff revealed that the process for updating code status involved multiple roles, including the Director of Social Services (DSS), nursing staff, and the medical records nurse. The DSS and DON both stated that the change in code status should have been communicated and documented in the EHR, but this was missed during a period when the facility did not have a DSS. The former medical records nurse did not upload the DNR form or update the EHR, resulting in the resident's code status remaining incorrect in the medical record.
Failure to Provide Requested Medical Records
Penalty
Summary
The facility failed to provide copies of medical records as requested, affecting a resident who had been discharged. The resident, who was cognitively intact, had signed an authorization form requesting her complete medical records to be sent to an attorney's office. Despite the request being received and signed by the resident, there was no documentation to support that the request had been addressed or completed. The facility's administrator confirmed that the request had not been completed, acknowledging that the facility's process involves verifying the authenticity of the request and signature before processing the records within 30 days. However, this process was not followed in this instance. The facility's procedures for releasing clinical records require a properly executed authorization and compliance with HIPAA regulations, but these procedures were not adhered to, resulting in the deficiency.
Failure to Conduct Neurological Checks After Falls
Penalty
Summary
The facility failed to ensure that neurological checks were completed for residents who experienced unwitnessed falls or falls involving the head. This deficiency was identified in two residents. Resident #63, who had diagnoses including metabolic encephalopathy and dementia, experienced a fall where he was found sitting on the floor near his geri chair. Although the resident was assessed with no injuries, the required neurological checks were not signed off as completed until several days later by the Director of Nursing (DON), indicating a lapse in timely documentation and potentially in the execution of the checks. Resident #85, with a history of falling and moderately impaired cognition, fell while attempting to pick something up off the floor, resulting in facial abrasions and a broken lens of her glasses. Despite the involvement of the head in the fall, no neurological checks were completed following the incident. The DON confirmed that the facility's protocol required neuro-checks for such falls, but they were not ordered or documented. The Nurse Practitioner (NP) who assessed the resident after the fall also acknowledged that neuro-checks should have been conducted according to the facility's policy.
Unnecessary Antibiotic Administration Due to Lack of Positive C.diff Results
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary medications, specifically affecting a resident with a history of cellulitis, insomnia, cognitive communication deficit, and dysphagia. The resident was admitted with these diagnoses and later experienced an episode of diarrhea attributed to the administration of Miralax. Despite this, the resident was ordered to have their stool checked for Clostridium difficile (C.diff), and subsequently, Vancomycin was prescribed and administered for 10 days without documented evidence of a positive C.diff culture. The deficiency was identified during a complaint investigation, where it was revealed that the Director of Nursing confirmed the administration of Vancomycin without positive C.diff results. The medication was prescribed based on a verbal report from a nurse to a Nurse Practitioner, who then gave a verbal order for the antibiotic without reviewing written results. This oversight led to the unnecessary administration of antibiotics to the resident.
Failure to Conduct Ordered Lab Tests for Residents
Penalty
Summary
The facility failed to ensure that laboratory tests were conducted as ordered by physicians for two residents, which had the potential to affect all 108 residents in the facility. Resident #59, who had diagnoses including cellulitis, insomnia, cognitive communication deficit, and dysphagia, was ordered to have a stool test for Clostridium difficile (C.diff) after experiencing diarrhea. However, there was no documented evidence that the stool test was completed as ordered. The Director of Nursing (DON) confirmed the absence of documentation for the stool culture. Resident #109, who had diagnoses including dysarthria, aphasia, hemiplegia, hemiparesis following cerebral infarction, anxiety, depression, vascular dementia, and breast cancer, was ordered to have a complete blood count (CBC) with differential after complaining of weakness and fatigue. Despite the physician's order, there was no documented evidence that the CBC was completed. The DON verified that the CBC was not conducted due to a change in lab companies during that week, resulting in the resident's labs being missed. This deficiency was investigated under Complaint Number OH00160169.
Failure to Secure Resident During Transport
Penalty
Summary
The facility failed to ensure a resident dependent on staff was safely secured in a wheelchair with an appropriate seat belt during transportation in a facility van to a physician's visit. This resulted in Immediate Jeopardy when a transport driver abruptly stopped the facility van, causing the resident to come out of her wheelchair and land on the floor, sustaining a hematoma, increased pain, and lacerations that required sutures. The incident affected one of three residents reviewed for the use of assistive devices during transportation, with a total of 23 residents utilizing wheelchairs and the transport van who would require seat belts engaged. The resident involved was an elderly female with multiple diagnoses, including morbid obesity, fibromyalgia, disc degeneration, cerebral infarction, muscle weakness, gait abnormalities, chronic respiratory issues, polyarthritis, and hypertension. She was cognitively intact and required transportation via wheelchair. During the trip, the transport driver failed to properly secure the resident, and when the van stopped abruptly, the resident slid out of her wheelchair and landed on the floor. The driver then drove back to the facility with the resident lying unsecured on the floor, further endangering her. Upon returning to the facility, the resident was assessed and found to have a laceration on her right knee, which required sutures, and other injuries. The transport driver did not follow the facility's policy of calling 911 immediately after the incident and instead returned to the facility. The facility's investigation revealed that the driver had been previously educated on the proper transportation protocols but failed to adhere to them during this incident.
Removal Plan
- Resident#15 arrived back at the facility and was immediately assessed by Licensed Practical Nurse (LPN)/Unit Manager #37 and former DON #38.
- Nurse Practitioner (NP) #62 was notified and ordered Resident #15 to be sent to the ER.
- 911 was called by LPN #39.
- Former DON #38 notified Resident #15's family.
- EMS arrived at the facility and transported Resident #15 to the ER for further evaluation and treatment.
- Former DON #38 and LPN #39 updated Resident #15's care plan to include: Send Resident #15 to the ER, wheelchair safety education for the resident, provide an escort for all transport/appointments and skin/laceration care.
- The Administrator ceased all transportation for in-house facility transports.
- The Administrator and former DON #38 interviewed FTD #34 and an investigation started regarding the entire incident and actions that transpired during the incident.
- A van inspection was completed by Maintenance Director #41 and no mechanical issues or malfunctions were discovered.
- FTD #34 was interviewed, and a written statement was obtained. FTD #34 received a final level Corrective Action Form conducted for failure to follow transportation protocol. FTD #34 was suspended pending an investigation of the incident to allow for investigation, education, and ensure no other incidents had occurred. FTD #34 did not return to work and made no other transportation after this incident for the facility.
- The transportation policy was reviewed with the three staff members authorized to complete resident transports. Maintenance Director #41, Transportation Driver (TD) #30, and FTD #34.
- The designated facility TD will perform inspections for the transportation vehicle/equipment to ensure safe and functional operation every day prior to any transportation needs.
- These inspections are to be verified by Maintenance Director #41 after each inspection is completed for the next 30 days then the facility will transition to three times weekly for three months and then monthly ongoing.
- Should Maintenance Director #41 not be available to complete this verification, it will be performed by Regional Director of Maintenance #40/Designee.
- Central Supply Coordinator/Transportation Scheduler #31 conducted an audit of a 30-day lookback of all resident's transportation provided by facility to ensure no other incidents had occurred.
- No concerns were identified from this audit.
- Resident #15 was immediately switched to another transportation service. The Administrator secured an outside transportation company for all facility transports until further notice. All appointments were transferred to the outside provider.
- To monitor for ongoing compliance, Maintenance #41/Designee will audit the facility van three times weekly for three months and then will perform inspections monthly ongoing to ensure the transportation vehicle/equipment is safe and functioning.
- To monitor for ongoing compliance, Maintenance Director #41/Designee will audit via observations and return demonstrations of the facility transportation drivers weekly for one month and then monthly for three months to ensure residents are secured appropriately and safely.
- To monitor for ongoing compliance, Maintenance Director #41/Designee will supervise one transportation run monthly for one year to ensure appropriate transportation methods are in place per the facility's policy. This was implemented and started when in-house transports were resumed. All results of the audits will be included in each QAPI with any findings.
- Resident #15 was transported back to the facility. Resident #15 sustained a laceration on her right knee and seven sutures were placed. All other imaging and diagnostics tests were negative.
- Former DON #38 interviewed Resident #15 and received her verbal statement.
- Resident #15 stated she was riding in the transport van and when the driver (FTD #34) stopped, she slid out of her wheelchair. Resident #15 indicated she stayed on the floor of the van until the driver got back to the building and then she went to the hospital. Resident #15 was educated on safety during transports.
- Regional Director of Maintenance #40 conducted one-on-one (1:1) training, conducted competencies and check offs with a return demonstration with all three authorized transportation drivers (Maintenance Director #41, FTD #34 and TD #30) to ensure previous education was understood and to remain compliant with safety precautions. FTD #34 was not reinstated afterwards due to FTD #34 providing the facility with his resignation.
- Education included: Vehicle safety, Safety and Health Programs, Mandatory Transport Driver Training, Drivers Training Classroom Curriculum, Company Vehicle Driver Program (Fleet Safety Program), Safer Transportation of Wheelchair Passengers, Passenger Safety During Transport, New Driver Request Forms, Transport Staff Performance Agreement, Emergency Supplies Check list, Monthly Preventative Maintenance, and Quarterly Vehicle Inspection Reports and initiated immediately. The policy was reviewed again by Regional Director of Maintenance #40 with the Administrator, Maintenance Director #41, FTD #34 and TD #30. Regional Director of Maintenance #40 conducted competencies and check offs with a return demonstration to ensure previous education was understood and to remain compliant with safety precautions.
- The transportation policy was reviewed by the Administrator. All facility transportation remained stopped and no new changes were implemented to the policy. All facility transports were being conducted by an outside provider.
- A Post Traumatic Stress Disorder (PTSD) screen was completed on Resident #15 and added to the care plan by Director of Social Services #66. The following new interventions were added: To assist and identify what triggers PTSD episodes, encourage slow/deep breathing exercises, reassuring conversation with pleasant topics, observe for increased agitation, anxiety, and offer quiet areas and comfort items, observe resident in group situations and prevent resident from becoming over stimulated, sudden unexpected noises, and new/tv programming may also trigger resident incident, offer quiet area, speak in calm quiet voices and offer reassurance.
- An Ad Hoc Quality Assurance Performance Improvement (QAPI) meeting was held with attendees including: The Administrator, Former DON #38, Medical Director (MD) #64, LPN/Clinical Manager #70, Maintenance Director #41, LPN/Unit Manager #37, Central Supply Coordinator #31, LPN #39, [NAME] President of Risk Management #72, Regional Director of Clinical Operations (RDCO) #78, and Regional Director of Operations (RDO) #80 regarding this incident and discussion was held regarding transportation protocols and safety, falls, and steps the facility is taking moving forward to prevent further reoccurrence of the incident.
- The vehicle insurance company obtained a report of the incident and once the insurance started their investigation their findings were handled through the insurance. No results/findings have been returned to the facility.
- Resident #15 had an outside appointment at a physician's office and did not have any identified concerns during the transport via the outside provider.
- Interviews with TDs #30 and #58 and Maintenance Director #41, each stated they were in-serviced and educated on properly transporting residents and are utilizing the complete Q'Straint system.
- Review of four (#27, #50, #38 and #21) additional resident's medical records who required assistive devices for transportation revealed no concerns.
- Review of the facility's Transportation Safety Audits including Inspections and Ride Along's revealed the audits were performed as scheduled with no issues identified.
Unqualified Staff Administering Medications
Penalty
Summary
The facility failed to ensure medications were administered by qualified staff, affecting four residents. Medical record reviews revealed that two Medication Technicians (MTs) administered medications to residents without the proper certifications from the Ohio Board of Nursing (OBN). The Administrator, Unit Manager, and Director of Nursing confirmed that MTs #90 and #91 did not have the required certifications to administer medications in a Skilled Nursing Facility (SNF). The MTs were certified to administer medications in an Intermediate Care Facility (ICF), and the Administrator mistakenly believed these certifications were valid for SNFs as well. The MTs had been administering medications to residents without the proper qualifications, and their employee files lacked the necessary documentation from the OBN. The affected residents had various medical conditions, including acute respiratory failure, diabetes, congestive heart failure, dementia, hemiparesis, alcoholic liver disease, morbid obesity, dysphagia, anxiety, depression, pulmonary edema, chronic kidney disease, lupus, dysarthria, aphasia, bone density disorder, gout, acute kidney failure, low back pain, breast cancer, and chronic pain. Despite the lack of proper certification, there were no reported medication errors or incidents involving the MTs. The facility's policy stated that only licensed or authorized personnel could administer prescribed medication, and the job description for Certified Medication Technicians required state-approved training and certification, which the MTs did not possess.
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.
