Foundation Park Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Toledo, Ohio.
- Location
- 1621 S Byrne Rd, Toledo, Ohio 43614
- CMS Provider Number
- 365752
- Inspections on file
- 30
- Latest survey
- April 16, 2026
- Citations (last 12 mo.)
- 33 (1 serious)
Citation history
Health deficiencies cited at Foundation Park Care Center during CMS and state inspections, most recent first.
The facility failed to consistently document meal intakes for three cognitively impaired, staff-dependent residents whose care plans and MD orders required monitoring and recording of every meal. Over a review period, multiple meals for two residents with dementia and other comorbidities, including DM and dysphagia, had no recorded intake despite no nursing notes of meal refusals. A third recently admitted and discharged resident had variable documented intakes and several refusals, but nine meals lacked any intake documentation. A CNA reported that staff are expected to record meal percentages at each meal and notify the nurse of refusals, and the DON confirmed that meal intakes were not documented for each meal as required by the residents’ care plans and facility policy.
Food service sanitation failures were observed when a dietary staff member wore the same gloves while touching utensils, plates, drawer handles, and then ready-to-eat buns during meal service. The facility also stored emergency water in a shower stall used by residents, and a resident was served eggs with a foreign substance that the DON removed during breakfast.
The facility failed to fully implement its infection prevention program by not identifying site-specific water flow details in its Legionella risk assessment and by not documenting or carrying out listed Legionella monitoring measures such as flushing, shower head cleaning, and water heater inspections. Staff also did not consistently follow EBP PPE requirements: for one resident with an indwelling urinary catheter, CNAs assisted with catheter-related care and a transfer without gowns, and for another resident with a feeding tube and skin issue, multiple staff provided transfer and care without gowns or gloves, and the EBP sign was not posted. In addition, three CNAs did not complete annual Mantoux TB risk assessments.
Failure to monitor psychotropic medication effectiveness and side effects affected three residents receiving psychotropic meds. One resident with psychosis, mood disorder, anxiety, and dementia had orders for escitalopram, olanzapine, and mirtazapine, but no documented monitoring. Another resident with dementia, hallucinations, anxiety, restlessness, and agitation received PRN clonazepam six times with no evidence of monitoring. A third resident with dementia, Lewy body neurocognitive disorder, PTSD, and depression had orders for mirtazapine and clozapine, but the record showed no monitoring for adverse reactions, EPS, tardive dyskinesia, suicidal ideation, or unusual behavior.
Failure to assist dependent residents with ADLs. Two residents who were dependent for eating had breakfast trays left in their rooms while they remained in bed, and staff reported a CNA call-off left the section unreassigned. One resident was fed only after a delay by an LPN, and another was fed later by a CNA. Other residents were observed with unclean fingernails despite needing help with hygiene and grooming, and one resident was seen wearing the same soiled clothing on consecutive days.
Failure to implement ordered pressure-relief measures affected three residents with significant cognitive and mobility impairments. One resident with dementia, hemiplegia, dysphagia, and epilepsy was observed without ordered repositioning support, without the ordered washcloth in the hand, and later remained in a wheelchair beyond the ordered time limit with poor head support. Two other residents at risk for pressure ulcers were observed without ordered heel protectors in place, and staff confirmed the omissions, including not applying a protector to one heel and not knowing both heels were ordered for protection.
Staff did not follow menus and recipes for residents on a pureed diet. A dietary employee thinned pureed pasta with water instead of the recipe-specified liquid, and the DM directed use of leftover Philly cheesesteak meat rather than the fried fish listed on the menu; the employee also used an incorrect portioning method and added only one hamburger bun for 10 residents. In a separate finding, an LPN fed a resident with dementia, DM, epilepsy, anxiety, and TBI a meal that did not include the ordered double portions, despite the physician order for a regular diet with pureed textures, thin liquids, and double portions.
Dirty Floor Mat and Wheelchairs: The facility failed to keep a resident’s floor mat and two residents’ wheelchairs clean and sanitary. One resident with dementia, hemiplegia, dysphagia, and epilepsy had a stained, discolored bedside mat that was uncovered, and an LPN said it did not provide a homelike environment. Two residents who used wheelchairs had visible debris buildup, including food pieces on one wheelchair, despite a posted cleaning schedule; an AD confirmed the wheelchairs were dirty.
A resident with dementia, diabetes, a prior femur fracture, and warfarin therapy had a weekly skin assessment that documented no chest bruising, but a surveyor later observed a large healing green-and-yellow bruise on the upper chest. The resident denied knowing how it occurred, and the assigned LPN, CNA, and DON were unaware of the bruise at the time it was found.
Failure to maintain ordered fall precautions for a resident with Lewy body dementia, DM, and poor safety awareness. The resident was dependent for transfers and bed mobility, assessed as high fall risk, and had a care plan and MD order for a floor mat at bedside when in bed. During observation, the resident was in bed awake, but the mat was found across the room, and a CNA said staff likely removed it for breakfast and did not replace it.
Failure to secure an IUC: A resident with dementia, severe cognitive deficits, and urinary retention had an IUC in place, but no securement device was observed during catheter care. The care plan did not address catheter securement, a nurse note documented the resident disconnecting the catheter bag and being combative, and the DON and RN supervisor gave conflicting statements about whether securement was needed. CDC guidance reviewed by surveyors stated that IUC maintenance includes proper securement to prevent movement and urethral traction.
A resident with a gastrostomy tube, dementia, hemiplegia, dysphagia, and epilepsy was observed receiving the wrong tube feeding formula. The physician ordered Isosource HN at 80 ml/hr, but the resident was found on Fibersource HN at the same rate, and an LPN confirmed the formula mismatch and said the bag had been hung by the previous shift.
Oxygen Therapy Not Provided Per Physician Order: A resident with emphysema and continuous O2 needs was observed receiving oxygen at settings above the physician-ordered 2 L/min by NC. Staff interviews confirmed the oxygen settings were not at the ordered liters, and the facility policy stated oxygen must be administered by an LPN/RN per physician order.
Missing Dialysis Agreement and Inconsistent Dialysis Communication: A resident with ESRD, dementia, DM2, and hypertensive CKD received hemodialysis, but the facility had no prior agreement with the dialysis provider before the current annual survey. The care plan lacked communication interventions with the dialysis center, and review of dialysis records showed communication forms were present for only a few treatments. Staff described an unclear process, including uncertainty about a dialysis communication book and inconsistent exchange of paperwork between the facility and the dialysis center.
A resident with PTSD, dementia, and other diagnoses did not have specific trauma-informed interventions documented in the care plan. The POA reported the PTSD was related to a military assault and said only female caregivers should provide direct care to avoid triggering behaviors, but the chart had no such instruction. The DON and Social Services Director were unaware of the resident’s PTSD triggers, and a male CNA was observed providing personal care without knowledge of the resident’s request for female staff.
Inaccurate nutrition assessment and failure to update diet order information: A resident with dementia, DM2, epilepsy, anxiety, and TBI had a SLP evaluation for pocketing food and was ordered a regular diet with pureed textures and thin liquids, yet the quarterly nutrition assessment still listed a regular textured diet and a cookie snack. An LPN confirmed the resident continued to receive an oatmeal cookie despite the pureed diet, and the RD stated the assessment was inaccurate because she was unaware of the diet change and did not have access to the SLP notes in the EMR.
A resident with dementia, incontinence, mobility deficits, and multiple comorbidities developed a coccyx Stage II pressure ulcer that progressively worsened to an unstageable ulcer with necrotic tissue. Although the care plan and facility policy called for monitoring skin changes, notifying clinical staff, weekly skin assessments, barrier cream use, dietitian involvement, and wound specialist management, the record showed no reassessment of the resident’s condition or investigation of the ulcer’s source as it enlarged and deteriorated. Documentation lacked evidence of nutritional assessment or support, mechanical pressure relief devices, or off-loading strategies being implemented, and later wound specialist recommendations for pressure redistribution and nutrition monitoring were not promptly documented as carried out.
A resident with severe cognitive impairment and multiple comorbidities experienced an unwitnessed fall and was found unresponsive on the bathroom floor, diaphoretic and with a head laceration. An LPN initiated neuro checks but notified the physician only by fax rather than by phone, resulting in a delayed physician response, and the resident’s representative was not informed of the fall until several hours after the incident. Facility policy required immediate notification of the physician and resident representative for incidents involving injury and symptoms such as loss of consciousness, but this was not followed, as confirmed by the DON.
A resident with multiple comorbidities and a documented fall-risk care plan was found unresponsive on the bathroom floor with a head laceration after an unwitnessed fall. An LPN and other staff moved the unresponsive resident from the floor to the bed without contacting EMS, despite the observed head injury and lack of consciousness. Although neuro checks were initiated, documentation on the neurological observation form included only vital signs and omitted required assessments of pupillary response and hand grasps, and no additional neurological assessment was recorded. These actions and omissions resulted in a failure to provide appropriate treatment and care according to the resident’s orders and care plan following the fall.
A resident with severe cognitive impairment and multiple health conditions was lowered to the floor during wound care after becoming restless in a stand-up lift. Although the physician was notified, staff did not inform the resident's representative or hospice provider as required by facility policy, and this omission was confirmed through documentation review and staff interviews.
A resident with severe cognitive impairment and multiple comorbidities was not thoroughly assessed for injuries after being lowered to the floor during a mechanical lift transfer. Although staff noted no immediate injury, a comprehensive assessment, including range of motion, was not performed as required by facility policy. The following day, the resident was found to have a fractured and dislocated femur, highlighting the deficiency in post-incident evaluation.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
Nurses and nurse aides lacked the required competencies to provide care that maximizes each resident's well-being, resulting in residents not receiving individualized care that supports their highest level of well-being.
A resident with Alzheimer's and other conditions was accidentally hit with a dinner plate during an altercation between two other residents, resulting in a laceration and bruise. The facility failed to report the incident to the state agency as required by their policy, as confirmed by the DON and a nurse.
A resident with Alzheimer's disease was accidentally hit in the face with a dinner plate during an altercation between two other residents, resulting in a forehead laceration. The incident was not reported to the state agency as required by the facility's policy, which mandates reporting within 24 hours.
A resident with Alzheimer's and dementia received Nystatin powder without a physician's order, contrary to facility policy. The medication was applied after a STNA reported skin concerns due to the resident's bra. The DON confirmed the lack of a physician order during a complaint investigation.
The facility failed to follow prescribed portion sizes and recipes for diet textures, affecting 83 residents. Observations revealed that incorrect scoop sizes were used for serving baked turkey crunch, and bread and water were improperly added to pureed diets. Interviews with dietary staff confirmed these deviations, impacting the nutritional needs of residents.
The facility failed to maintain clean floors and ensure resident rooms were free from odors. Observations revealed sticky floors in multiple areas and a strong urine odor in a resident's room. Staff interviews confirmed these issues, and it was noted that the problem with the floors occurred yearly when the air conditioning was turned off.
The facility failed to ensure medications were secure and properly labeled, affecting thirteen residents. Medications were found unsecured in residents' rooms and inappropriately stored in a medication cart. Staff confirmed these practices were against facility policy.
The facility failed to include copies of advanced directives in the medical records of two residents, despite having policies requiring such documentation at admission. This was confirmed through staff interviews and medical record reviews.
The facility failed to document a resident's bruising upon admission, despite the hospital referral form indicating a traumatic wound. Subsequent observations and staff interviews confirmed the presence of bruising, which was not recorded during the initial assessment.
The facility failed to maintain appropriate physician orders, accurately assess dialysis access sites, and ensure a dialysis catheter site was covered for a resident requiring dialysis. Observations and interviews confirmed the resident's chest catheter was frequently uncovered, and the fistula did not have a thrill or bruit. The facility's policies on dressing changes and physician orders were not followed, leading to these deficiencies.
The facility failed to implement non-pharmacological interventions for a resident with dementia who frequently refused care, resulting in the resident being heavily soiled with urine and developing blisters. Staff were not provided with specific strategies to manage the resident's behaviors, and the care plan lacked individualized interventions.
A facility failed to ensure an accurate Nutritional Assessment for a resident with dementia and congestive heart failure. The resident's fluid restriction and specific diet orders were not accurately documented, leading to discrepancies in the resident's care plan. Interviews confirmed the oversight, highlighting a deficiency in the facility's food and nutrition services.
Failure to Consistently Document Meal Intakes for Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure complete documentation of meal intakes in the medical records for three residents with severe cognitive impairment who were dependent on staff for eating. One resident with vascular dementia, hemiplegia/hemiparesis after cerebral infarction, dysphagia, and hypertension had a care plan directing staff to monitor intake and record every meal, and a physician’s order for a regular diet with pureed texture and nectar-thick liquids. Review of this resident’s records over a specified period showed multiple missing entries for meal intakes across numerous dates and meals, with no nursing notes indicating that any meals were refused. A second resident with dementia, hypertension, and type 2 diabetes mellitus, also care planned for monitoring and recording every meal and ordered a regular mechanical soft diet with thin liquids, had the same pattern of missing meal intake documentation on the same dates and meals, again without any nursing documentation of meal refusals. A third resident, admitted and later discharged within the review period, had severe cognitive impairment, was dependent on staff for eating, and had a nutrition care plan to provide food, fluids, and supplements as ordered and to monitor and record every meal. This resident had a physician’s order for a regular diet with pureed texture and thin liquids. Review of this resident’s meal intake records showed variable documented intakes from 0 to 75 percent with seven documented meal refusals, but there was no documentation for nine meals. A CNA stated that staff are expected to document the percentage of meal intake for each resident at each meal and to notify the nurse if a resident refuses a meal. The DON confirmed that staff were not documenting meal intakes for each meal for the three residents and acknowledged that staff should have been documenting meal intakes for every meal as ordered. Facility policy on feeding residents required recording meal intakes on the resident meal intake log and reporting concerns to the charge nurse.
Food Service Sanitation and Meal Handling Deficiencies
Penalty
Summary
The facility failed to ensure the dishwashing machine was functional during observation of the high-temperature dishwasher used in dietary services. On 03/10/26, the Dietary Manager observed that no plastic or glass covers were over the washing and rinsing temperature gauges, and during two washing and rinsing cycles the gauge needles did not fluctuate. The Dietary Manager confirmed the gauges did not move while the machine was in use and stated an outside company had serviced the dishwasher. Review of the service report dated 01/27/26 showed appropriate washing and rinsing temperatures. On 03/11/26, new gauges with covers were observed in place, and the company representative stated he replaced both temperature gauges because the probes going into the gauges were rusted and had not been checked previously. The facility also failed to ensure appropriate hand hygiene was practiced during meal service, failed to ensure emergency water was stored in a sanitary environment, and failed to ensure a resident received food without foreign substances. During noon meal service, a staff member wore the same disposable gloves while touching service utensils, plates, drawer handles, and then handling ready-to-eat buns and placing meat into them; the staff member confirmed the gloves had touched multiple surfaces before touching the buns. Emergency water storage was observed in a shower stall in the A-Hall communal bathroom, separated from the rest of the bathroom only by a shower curtain, while residents used that bathroom for toileting and showering and soiled clothing was observed on the floor. During breakfast, a resident had eggs, toast, and sliced banana in front of her, was eating banana with her fingers, and a foreign substance was observed on her eggs. The DON confirmed the substance was on the eggs, removed it with the resident's fork, and the resident stated she did not want any more food.
Infection Control Failures in Legionella Monitoring, EBP PPE Use, and TB Screening
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program related to Legionella prevention. The facility’s Legionella risk assessment did not identify the facility water source or site-specific water flow systems throughout the building, including whether dead-end plumbing was present. Although the assessment listed control and monitoring measures such as weekly temperature checks, weekly flushing of low-use outlets, quarterly shower head cleaning, monthly water heater inspections, and routine cleaning of ice machines and aerators, the facility documentation only showed water temperature monitoring. There was no documentation for flushing or equipment cleaning, and the Maintenance Supervisor stated the facility was flushing unused outlets but was not documenting the monitoring and had no further monitoring in place for the listed control measures. The Administrator and Maintenance Supervisor also verified the control measures in the Legionella risk assessment were not being implemented. The facility also failed to ensure staff used proper PPE for residents on enhanced barrier precautions. Resident #11 had diagnoses including dementia, severe protein calorie malnutrition, obstructive and reflux uropathy, and benign prostatic hyperplasia with lower urinary tract symptoms, and had severe cognitive deficits, dependence for ADLs, and an indwelling urinary catheter. The care plan and physician order required staff to wear a gown and gloves for high-contact care, including dressing, bathing, transfers, hygiene, changing briefs, device care, and wound care. During observation, an LPN wore a gown and gloves while providing catheter care, but a CNA assisting with catheter-related care, brief fastening, and transfer wore only gloves and no gown. The CNA stated a gown was only needed for catheter care, and another CNA who assisted with the transfer also wore no gown. The Infection Preventionist confirmed CNAs should wear PPE when applying a brief and handling a urinary catheter drainage bag. Resident #22 had diagnoses including dementia, hemiplegia, gastrostomy status, dysphagia, and epilepsy, and was rarely or never understood, had impairment to both sides, and was dependent for transfers and all mobility and ADLs. The resident’s care plan and physician order required gown and gloves for high-contact care, including transfers and feeding tube care. During observation, the DON, RN Supervisor, IPRN, and a CNA were in the room providing care and assisting with a mechanical lift transfer, but no staff wore gowns and the DON was not wearing a gown or gloves. The IPRN confirmed staff should have worn a gown and gloves, disposable gowns were available in the room, and the RN Supervisor confirmed an EBP sign should have been posted outside the room but was not. The facility identified nine residents requiring EBP. The facility also failed to ensure annual Mantoux tuberculosis risk assessments were completed for three CNAs. Review of personnel files showed CNA #433, CNA #472, and CNA #493 did not complete the yearly risk assessment within the previous 12 months. The Human Resource Manager verified the yearly assessments had not been completed, and the facility policy stated the annual TB risk assessment would be completed each January.
Failure to Monitor Psychotropic Medication Effects and Side Effects
Penalty
Summary
The facility failed to ensure adequate monitoring for psychotropic medication effectiveness, side effects, and adverse effects for three residents reviewed for unnecessary medications. Resident #15, admitted with psychosis, mood disorder, anxiety, frontotemporal neurocognitive disorder, and dementia, had orders for escitalopram, olanzapine, and mirtazapine, and the care plan directed staff to monitor for side effects and effectiveness every shift, but the record contained no orders or documentation showing monitoring for effectiveness, adverse effects, or side effects from 02/01/26 through 03/09/26. The DON verified there was no documentation that Resident #15 was monitored for adverse effects or side effects of the psychotropic medications. Resident #35, admitted with dementia, hallucinations, anxiety, restlessness, and agitation, had a PRN clonazepam order for agitation that was administered six times in February, but the record showed no documentation of monitoring for potential side effects or effectiveness. Resident #10, admitted with dementia, type II diabetes mellitus, lumbar vertebra fracture, neurocognitive disorder with Lewy bodies, hypertension, PTSD, depression, transient ischemic attack, and cerebral infarction, had orders for mirtazapine and clozapine, and the care plan included monitoring for adverse reactions such as tardive dyskinesia, EPS, suicidal ideations, and unusual behavior symptoms; however, the medical record contained no evidence that these psychotropic medications were monitored for side effects or adverse reactions. The DON verified the lack of documentation for monitoring in Resident #10's record, and the facility policy stated that psychotropic medication use would be monitored for efficacy, side effects, and adverse consequences.
Failure to Assist Dependent Residents With ADLs
Penalty
Summary
The facility failed to ensure dependent residents received assistance with activities of daily living, affecting five of six residents reviewed for ADLs. Resident #65 had diagnoses including dementia, type II diabetes mellitus, epilepsy, anxiety, and traumatic brain injury, and was documented as rarely/never understood and dependent on staff for eating. Resident #82 had diagnoses of dementia and aphasia, was also rarely/never understood, and was dependent on staff for eating. On the morning of observation, breakfast trays for both residents were left in their rooms while they remained in bed with eyes closed, and staff stated a CNA had called off and no one had been reassigned to the residents in those rooms. Resident #65’s breakfast tray remained untouched and out of reach for an extended period before an LPN began feeding him after the section had still not been reassigned. Resident #82’s tray was observed on the nightstand with all items covered, and she was not fed until more than an hour after the tray was first seen in her room. A CNA later fed Resident #82 after the delay. Staff interviews confirmed that residents in the affected section who needed assistance with eating had not been fed when expected. Resident #73 had impaired cognition, was able to eat with setup or clean-up assistance, and was dependent on staff for personal hygiene. During breakfast, she was observed feeding herself while dark debris was visible under each fingernail, and the DON confirmed the condition of her fingernails. Resident #53 was dependent on staff for personal hygiene and grooming, yet was observed with visible dark debris under multiple fingernails, which staff identified as appearing to be feces, and the grooming need was not addressed during the observation period. Resident #11 had severe cognitive deficits and was dependent on staff for toileting hygiene, bathing, and dressing, yet was observed wearing the same clothing on consecutive days, including stained sweatpants, and staff confirmed the clothing appeared unchanged from the prior day.
Failure to Implement Ordered Pressure-Relief Measures
Penalty
Summary
The facility failed to ensure pressure-reducing measures were implemented as ordered for three residents reviewed for pressure ulcer prevention. Resident #22 had diagnoses including unspecified dementia, hemiplegia, gastrostomy status, dysphagia, and epilepsy, and was documented as rarely/never understood, at risk for skin breakdown, and dependent on staff for all ADLs and mobility. Physician orders required turning or repositioning every couple of hours around the clock, a washcloth in the left hand as tolerated, and no more than two hours in a chair at a time to relieve pressure from a buttock wound. Observations showed Resident #22 lying on his back without pillows or other offloading devices, and no washcloth in the left hand. A CNA and LPN stated a CNA had called off and the section had not been reassigned, and the LPN confirmed care had not been provided since the start of the shift. Later, Resident #22 was observed in a wheelchair with his head not supported by the headrest, and the LPN confirmed he had remained in the chair beyond the ordered two-hour limit. On another observation, the resident’s left palm was intact but no washcloth was in place, and the LPN confirmed the washcloth was not present. Resident #2 had severe cognitive impairment, was dependent for ADLs, incontinent of bowel and bladder, and assessed at moderate risk for pressure ulcers. The care plan directed staff to turn or reposition every couple of hours around the clock, and a physician order required heel protectors to both heels at all times while in bed. Multiple observations showed only the right heel protector in place, with no protector on the left heel, and a CNA confirmed the left heel protector had not been applied and stated she was unaware both heels were to be protected. Resident #5 had Lewy body dementia, diabetes mellitus, cellulitis of the abdominal wall, and lymphedema, was dependent for transfers and bed mobility, and had a history of bilateral heel skin alteration. Her orders required bilateral heel protectors while in bed, but she was observed in bed without them; a CNA verified the omission and found only one protector, with the second unable to be located. The facility policy stated heels require particular attention to reducing pressure because of their limited surface area.
Pureed Diet Menus and Ordered Portions Not Followed
Penalty
Summary
The facility failed to ensure staff followed menus and recipes for residents on a pureed diet. During observation of the midday meal, a dietary employee was seen pureeing parmesan pasta for 10 residents and added unmeasured hot water to thin it, even though the recipe directed that chicken broth be used and specifically stated that if thinning was needed, liquid other than water should be added to achieve the proper consistency. The Dietary Manager also directed the employee to puree leftover Philly cheesesteak meat from the prior evening instead of serving fried fish as listed on the menu, and no pureed fish was prepared. The employee used a 4-ounce scoop for the pureed Philly cheesesteak and later added one hamburger bun to the meat prepared for the 10 residents, while the recipe indicated the whole sandwich should be prepared and then pureed for each resident. Ten residents were identified as receiving the pureed diet. The facility also failed to ensure a resident received double portions as ordered by the physician. The resident had diagnoses including dementia, type 2 diabetes mellitus, epilepsy, anxiety, and traumatic brain injury, and was dependent on staff for eating. The current physician order specified a regular diet with pureed textures, thin liquids, and double portions. During breakfast observation, an LPN fed the resident and stated the meal ticket showed a pureed diet with double portions, but the resident was served one bowl of eggs, one bowl of an unidentified substance possibly bread, a bowl of oatmeal, and a bowl of pureed fruit. The LPN stated the resident did not receive double portions, and the resident consumed the meal without refusing it.
Dirty Floor Mat and Wheelchairs
Penalty
Summary
The facility failed to ensure floor mats and wheelchairs were maintained in a clean sanitary condition for three residents reviewed for environment. Resident #22, who had diagnoses including unspecified dementia, hemiplegia, gastrostomy status, dysphagia, and epilepsy, was observed lying in bed with a bedside floor mat next to the bed that was discolored and stained over approximately three-fourths of the mat. The resident’s physician order required a bedside floor mattress when in bed, and the LPN confirmed the mat was stained and discolored and did not provide a homelike environment; the LPN also stated the mat was usually covered with a fitted sheet, but this resident’s mat was uncovered. Resident #65, who had dementia, type 2 diabetes mellitus, epilepsy, anxiety, and traumatic brain injury, used a wheelchair for mobility and was dependent on staff for mobility. Although the posted wheelchair cleaning schedule indicated the wheelchair should have been cleaned during third shift, the wheelchair frame on both sides was observed dirty and covered in debris, and the AD confirmed the wheelchair was dirty with buildup of debris. Resident #82, who had dementia and aphasia and was dependent on staff for wheelchair mobility, also had a wheelchair that was observed with a buildup of debris and food on both sides of the rails, including pieces of food in the space between the seat and the frame. The AD confirmed the wheelchair was dirty with debris buildup and food pieces and stated it should have been cleaned on the previous night shift.
Inaccurate Skin Assessment and Unrecognized Chest Bruising
Penalty
Summary
The facility failed to ensure an accurate resident assessment was completed for a resident with Lewy body dementia, diabetes mellitus, cellulitis of the abdominal wall, and a left femur fracture who was dependent on staff for all ADLs and used a wheelchair. Her care plan identified her as being at risk for falls due to cognitive impairment, communication deficit, poor safety awareness, decreased judgment, impulsivity, history of falling, mobility and balance deficits, incontinence, and prescribed medications. She also had a fall risk evaluation indicating she was at risk for falls and had a physician order for warfarin sodium for atrial fibrillation. During a weekly skin assessment, the LPN documented that the resident was free of chest bruising. However, when the resident was observed shortly afterward, she had a large healing bruise below the mid clavicular area that was green and yellow in color and measured approximately four by four inches. The resident stated she was unaware of the bruise and did not know how she received it, denying any injury. The nurse assigned that morning and the CNA were unaware of the bruising, and the DON also confirmed the bruise during observation but was unaware of it. The LPN who completed the skin assessment verified that no bruising had been noted to the upper chest. The DON's nursing note documented that the discoloration was brought to nursing attention by the state surveyor, and the facility policy required weekly skin assessments and nurse visualization of each shower with documentation of a skin assessment in the medical record.
Failure to Maintain Ordered Fall Precautions
Penalty
Summary
The facility failed to implement fall safety precautions for a resident with Lewy body dementia, diabetes mellitus, cellulitis of the abdominal wall, and lymphedema. The resident’s change in condition MDS assessment showed moderate cognition, and she was dependent on staff for transfers and bed mobility. Her care plan identified her as at risk for falls due to cognitive impairment, communication deficits, decreased safety awareness, decreased judgment, impulsivity, history of falling, mobility and balance deficits, weakness, incontinence, prescribed medications that could affect balance, need for an assistive device, easy fatigue, and being wheelchair bound/non-ambulatory. Interventions included a bedside mattress to the floor when in bed. The resident’s fall risk assessment identified her as high risk for falls, and a physician order directed staff to place a floor mat next to the bed every shift when she was in bed because of poor safety awareness. During observation, the resident was lying in bed awake, but the bedside mat was found leaning against a chair on the opposite side of the room rather than in place at the bedside. A CNA confirmed the resident was in bed and the fall prevention floor mat was not in place, stating staff likely removed it when breakfast was served and did not replace it.
Failure to Secure Indwelling Urinary Catheter
Penalty
Summary
The facility failed to provide an indwelling urinary catheter securement device for a resident with an IUC. Resident #11 was admitted with diagnoses including unspecified dementia, severe protein calorie malnutrition, obstructive and reflux uropathy, and benign prostatic hyperplasia with lower urinary tract symptoms. The admission MDS showed a BIMS score of four, indicating severe cognitive deficits, and the resident was dependent on others for toileting hygiene, bathing, and dressing. The initial care plan identified the resident as having an IUC due to urinary retention and obstructive uropathy, but it did not include any interventions for securing the catheter tubing. The physician order specified an 18 French IUC for obstructive and reflex uropathy. A nurses note documented that the resident continued to disconnect the catheter bag and was physically combative with staff during care. During observation, an LPN performed IUC care and a CNA dressed the resident, and no IUC securement device was in place. The LPN confirmed the absence of a securement device and then obtained and applied one. The DON stated that a securement device was not necessarily needed and that if a resident arrived with one, the facility would continue its use, but also confirmed that if the resident was pulling at the IUC, a securement device should have been in place. An RN supervisor stated he was unsure of the standards of care for IUC securement devices and believed they could cause discomfort for residents with cognitive deficits. Review of CDC guidance showed that IUC maintenance includes proper securement to prevent movement and urethral traction, while the facility policy on catheter care provided no direction on securement devices.
Wrong Tube Feeding Formula Administered
Penalty
Summary
The facility failed to ensure that a resident received enteral nutrition as ordered by the physician. Resident #22 had diagnoses including unspecified dementia, hemiplegia, gastrostomy status, dysphagia, and epilepsy, and the MDS indicated the resident was rarely or never understood, had a gastrostomy tube, and relied on enteral nutrition for 51% or more of fluid and nutrition needs. The current physician order directed Isosource HN at 80 ml per hour, but during observation the resident was receiving Fibersource HN at 80 ml per hour instead. The tube feeding bag was dated 03/10/26 at 4:00 A.M., and an LPN confirmed the resident was receiving the wrong formula and stated the bag had been hung by the previous shift.
Oxygen Therapy Not Provided Per Physician Order
Penalty
Summary
The facility failed to ensure a resident was receiving oxygen therapy per physician orders. Resident #56 was admitted with diagnoses including vascular dementia, emphysema, Raynaud's syndrome, and peripheral vascular disease. Her quarterly MDS indicated she required continuous oxygen therapy, and her care plan directed oxygen by nasal cannula per physician orders for emphysema and a history of shortness of breath on exertion, when sitting, and when lying flat. A physician order dated 04/25/25 directed oxygen at 2 liters per minute by nasal cannula every shift for chronic respiratory deficit/shortness of breath/oxygen saturations less than 90% related to emphysema. During observation, Resident #56 was found in bed with her nasal cannula attached to a concentrator running at 5 liters per minute instead of the ordered 2 liters per minute. A CNA stated she had just been assigned to the hall and was unaware of the resident's ordered oxygen setting, and an LPN verified that the oxygen was not at the liters ordered by the physician. On a later observation, the resident was seen walking in the hall with a portable oxygen concentrator on her rollator walker, and the concentrator was set at 4 liters per minute. Another LPN verified that the portable oxygen setting was not at the ordered liters. The facility policy stated oxygen is administered by a licensed nurse and requires a physician order.
Missing Dialysis Agreement and Inconsistent Communication With Dialysis Center
Penalty
Summary
The facility failed to provide safe, appropriate dialysis care/services for a resident who required hemodialysis. Resident #12 was admitted with unspecified dementia with other behavioral disturbances, end stage renal disease, type 2 diabetes, and hypertensive chronic kidney disease. The care plan for end stage renal disease, revised 11/13/25, included assessment of the central line site every shift and dialysis on Tuesdays, Thursdays, and Saturdays, with the resident leaving the facility around 10:00 A.M. for an 11:00 A.M. chair time. However, there were no care plan interventions for communication with the dialysis center. Review of dialysis communication notes from 01/01/26 to 03/12/26 showed forms only for five dialysis treatments, with no communication forms for the remaining listed treatments during that period. Staff interviews showed confusion about the communication process and the absence of a consistent dialysis communication book. The DON stated the facility had a dialysis communication book but needed to locate it, and later verified that copies of past communication forms were not kept and that she had not called the dialysis center requesting daily communication forms. The RN supervisor stated the current process was to send a face sheet, blank progress note, medication list, and blank order form with the caregiver on dialysis days, and the Administrator stated that prior to the effective date of 03/12/26 on the dialysis agreement, there was no previous agreement between the facility and the dialysis provider used by the resident.
Failure to Document and Provide PTSD Trigger-Based Care
Penalty
Summary
The facility failed to ensure trauma-informed and culturally competent care for a resident with PTSD. Resident #10 was admitted with diagnoses including dementia, neurocognitive disorder with Lewy bodies, depression, and PTSD. The medical record showed a social history and assessment completed by Social Services that listed PTSD, but there was no additional documentation describing the cause or treatment of the PTSD. The social services plan of care addressed mood problems related to cognitive impairment, hallucinations, unspecified PTSD, major depressive disorder, and anxiety disorder, but it did not document specific PTSD triggers, causes, behaviors, or interventions. The resident’s POA stated that the resident’s PTSD was related to an assault while serving in the military and that staff had previously been informed that only female caregivers should provide direct care because male caregivers could trigger behaviors. The medical record contained no documentation directing caregivers to be female. The DON verified there was no knowledge of the resident’s PTSD trigger related to male assault in the military and confirmed the resident had previously received care from male caregivers. Social Services also stated they were unaware of the cause of the PTSD or any potential triggers and verified that no specific PTSD assessment or plan of care had been completed. During observation, a male CNA was providing morning personal care to the resident and stated he was unaware of any request for female direct care staff or PTSD-related care.
Inaccurate nutrition assessment and failure to update diet order information
Penalty
Summary
The facility failed to ensure nutrition assessments were completed accurately and updated with new diet orders for one resident reviewed for food and nutrition. Resident #65 was admitted with diagnoses including dementia, type 2 diabetes mellitus, epilepsy, anxiety, and traumatic brain injury. The quarterly MDS dated 02/11/26 showed the resident was rarely or never understood and was dependent on staff for eating. The resident had a physician order from 12/14/23 for a cream cookie twice daily for nutritional adequacy, and progress notes from 01/01/26 through 03/12/26 did not document incidents or concerns with eating, swallowing, or choking. A Speech Language Pathology evaluation and plan of treatment dated 01/07/26 documented that the resident was referred for therapy due to pocketing food, and a physician order initiated the same day showed a regular type diet with pureed textures and thin liquids with double portions. However, the quarterly nutritional assessment dated 02/06/26 stated the resident was on a regular textured diet and received a cookie for a snack. An LPN confirmed the resident would still receive an oatmeal cookie for snacks even though he was on a pureed diet. The RD later confirmed the assessment was completed inaccurately, stated she was unaware the resident was on a pureed diet at the time, and said the facility did not notify her of the diet change or provide access to the speech therapy notes through the EMR.
Failure to Reassess and Intervene as Pressure Ulcer Progressed to Unstageable
Penalty
Summary
The deficiency involves the facility’s failure to implement and adjust interventions to prevent a pressure ulcer from worsening in a resident who was initially assessed as low risk for pressure ulcer development. The resident had multiple diagnoses including dementia, Alzheimer’s disease, autonomic neuropathy, edema, and incontinence, and was dependent on staff for most activities of daily living. The care plan in place identified the resident as at risk for pressure ulcer development due to cognitive impairment, incontinence, mobility and balance deficits, weak gait, decreased activity, and medications affecting sensory perception. Planned interventions included monitoring and documenting skin changes, notifying appropriate clinical staff of new breakdown, weekly skin assessments, use of barrier cream, dietitian assessment for nutritional needs, and management by a wound specialist center. On a documented date, a CNA notified an RN that the resident had an open area on the coccyx, which the RN assessed as a Stage II pressure ulcer. Barrier cream was applied, and the wound care nurse was to assess the resident. The initial wound documentation described a small Stage II ulcer with scant serosanguinous drainage and epithelial tissue. A nursing plan of care was then developed to address the coccyx skin alteration, including topical treatments such as triad paste and chamosyn with honey. However, there was no evidence in the medical record of any reassessment of the resident’s overall condition or investigation into the source of the pressure ulcer at that time, and no nutritional interventions or evaluations were documented despite the resident’s identified risk for malnutrition. Subsequent weekly wound documentation showed that the coccyx pressure ulcer progressively increased in size and changed in tissue characteristics over several weeks. The ulcer measurements increased from 1 cm by 1.5 cm by 0.1 cm to 2.0 cm by 1.5 cm by 0.1 cm, with the development of slough tissue, and eventually to 3.0 cm by 4.0 cm by 2.0 cm with foul odor and moderate necrotic tissue, at which point it was assessed as an unstageable pressure ulcer. Throughout this period of worsening, the record lacked evidence of reassessment of the resident’s condition in response to the ulcer’s progression, lacked documentation of efforts to identify the possible source of pressure, and did not show implementation of mechanical pressure relief devices, off-loading strategies, or nutritional support and evaluation. Although a wound specialist later evaluated the ulcer and made recommendations including an air pressure mattress, repositioning, frequent incontinence checks, and nutritional monitoring, the medical record did not show that these recommendations were promptly implemented, and there continued to be no documented additional interventions for mechanical off-loading or nutritional evaluation. The facility’s own skin care and pressure management policy stated that any new pressure ulcer should trigger reevaluation of the prevention plan and interventions, but the infection preventionist/wound care nurse confirmed there was no documentation that the facility attempted to determine the origin of the ulcer or implement nutritional interventions as required by the care plan and policy. The deficiency affected one resident out of three reviewed for pressure ulcer prevention and wound healing, in a facility with a census of 89 residents. The resident’s Minimum Data Set assessment had identified severely impaired cognition, rejection of care on some days, dependence on staff for ADLs, always incontinent of bowel and bladder, and an in-house acquired unstageable pressure ulcer. Despite these identified risks and the facility’s policy requirements, the medical record showed that the facility did not reassess the resident’s condition or modify interventions in response to the development and worsening of the pressure ulcer, and did not complete nutritional assessments or implement nutritional support after the ulcer was first identified.
Failure to Timely Notify Physician and Representative After Unresponsive Fall With Head Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure timely notification of the physician and resident representative when a resident was found unresponsive on the floor with a head laceration. The resident had multiple diagnoses, including dementia, COPD, type 2 diabetes with neuropathy, bladder cancer, coronary artery disease, major depression with psychotic symptoms, anxiety disorder, osteoarthritis, history of TIA, and hypertension, and had been assessed with severe cognitive impairment but independent ambulation and transfer. The care plan for fall risk required that if the resident fell or was found on the floor, staff were to assess for injury and notify the MD and responsible party. On the morning of the incident, a CNA informed an LPN that the resident had an unwitnessed fall and was lying on the bathroom floor. The LPN found the resident on the bathroom floor with his head under the sink, diaphoretic, sweaty, clammy, with a laceration to the top of the head, and unable to perform ROM due to lack of consciousness. Neuro checks were initiated. Despite the resident’s loss of consciousness and head injury, the physician was notified only by fax at 9:00 a.m., and there was no immediate telephone contact. The physician’s faxed response to send the resident to the emergency room was not received until 12:45 p.m., approximately four hours and 45 minutes after the fall, by which time the resident had already been transported to the hospital. The resident’s representative (POA) was not notified of the fall until 10:45 a.m., about two hours and 45 minutes after the incident, and was later notified again regarding the transfer to the emergency room. The facility’s policy required immediate notification of the resident, physician, and resident representative when there is an accident, significant change in status, or symptoms such as loss of consciousness. In an interview, the DON confirmed that the physician was not contacted immediately and that a telephone call should have been made instead of relying on a fax, and also confirmed the delay in notifying the resident representative.
Failure to Provide Appropriate Post-Fall Neurological Assessment and Emergency Response
Penalty
Summary
The facility failed to provide appropriate treatment and neurological assessments after a resident was found on the bathroom floor unresponsive with a head laceration following an unwitnessed fall. The resident had multiple diagnoses including dementia, COPD, type 2 diabetes with neuropathy, coronary artery disease, major depression with psychotic symptoms, anxiety, osteoarthritis, history of TIA, and hypertension, and had a care plan identifying fall risk with interventions requiring assessment for injury and completion of neuro checks after a fall with possible head injury or unwitnessed fall. On the morning in question, a CNA found the resident unresponsive on the bathroom floor; an LPN observed the resident diaphoretic, sweaty, clammy, with a head laceration and unable to perform range of motion due to lack of consciousness. Staff, including the unit manager, LPNs, and CNAs, lifted the unresponsive resident from the floor and placed him in bed, and EMS was not contacted at the time of discovery. The neurological observation form initiated at 8:00 A.M. documented only vital signs at multiple time points and did not include any documentation of pupillary responses or hand grasps, despite these being required elements on the form and part of a post-fall neurological assessment. The medical record contained no additional neurological assessment or further documentation beyond these vital signs. The LPN faxed the physician about the fall and awaited a response, notified the POA later that morning, and the DON was notified of the fall and change in condition; however, the resident remained unresponsive and never regained consciousness. The DON confirmed that the post-fall neurological assessment only contained vital signs and that staff did not contact EMS when the resident was first found unresponsive with an observed head injury, instead moving him back to bed. This sequence of actions and omissions formed the basis of the cited deficiency for failure to provide appropriate treatment and care according to orders, resident preferences, and goals.
Failure to Notify Resident Representative and Hospice Provider After Incident
Penalty
Summary
The facility failed to ensure that required notifications were made to a resident's representative and hospice provider following an incident in which the resident was lowered to the ground during care. The resident involved had a history of dementia, type II diabetes, a recent right femur fracture, generalized anxiety disorder, major depressive disorder, anemia, and a terminal diagnosis of rectal cancer. The resident was severely cognitively impaired, dependent on staff for all activities of daily living, and was receiving hospice care at the time of the incident. On the day of the incident, staff were providing wound care to the resident using a stand-up lift. During the process, the resident became restless and managed to remove his arm from the sling, resulting in staff lowering him to the floor for safety. The resident then flung his body to the side before staff could unstrap his legs from the lift. He was subsequently assisted back into his wheelchair, and no injuries or pain were noted at the time. Documentation confirmed that the resident's physician was notified of the incident, but there was no evidence that the resident's spouse or hospice provider were informed. Interviews with staff involved in the incident, including a registered nurse and a licensed practical nurse, confirmed that neither the resident's family nor hospice provider were notified about the event. Review of facility policies indicated that it was required to notify the resident, physician, and resident representative in the event of an accident or significant change in status. The lack of documentation and staff confirmation established that the required notifications were not made following the incident.
Failure to Thoroughly Assess Resident After Mechanical Lift Incident
Penalty
Summary
A deficiency occurred when staff failed to thoroughly assess a resident for injuries after an incident involving a mechanical lift transfer. The resident, who had severe cognitive impairment, was dependent on staff for all activities of daily living and had a significant medical history including dementia, diabetes, a recent right femur fracture, and a terminal diagnosis of rectal cancer. During a wound care procedure, the resident became restless and managed to remove his arm from the lift sling, resulting in staff lowering him to the floor while his legs remained strapped in the lift. The resident then threw himself to the side before being fully released from the lift. Following the incident, staff assisted the resident back into his wheelchair and noted no immediate signs of pain or injury. However, there was no documentation of a comprehensive injury assessment, such as a range of motion evaluation, being performed at that time. Staff interviews confirmed that only a basic physical check was conducted, and no range of motion assessment was completed. The facility's policy required a thorough assessment for injuries after such incidents, but this was not followed. The following day, a hospice aide reported concerns about the resident's leg, which was then found to be rotated inward. An x-ray revealed a right femur fracture with severe dislocation, and the resident was sent to the hospital for further treatment. The deficiency was identified due to the lack of a thorough post-incident assessment as required by facility policy, despite the presence of multiple staff members during and after the event.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Inadequate Nursing Staff Competency
Penalty
Summary
Nurses and nurse aides did not demonstrate the necessary competencies to provide care that maximizes each resident's well-being. The deficiency was identified due to a lack of appropriate skills and knowledge among the nursing staff, which impacted their ability to meet the individualized needs of residents. This failure resulted in residents not receiving care in a manner that supports their highest level of well-being.
Failure to Report Resident-to-Resident Altercation
Penalty
Summary
The facility failed to implement its policy regarding the requirement to report a resident-to-resident altercation to the state agency. This incident involved a resident with Alzheimer's disease, chronic obstructive pulmonary disease, and atrial fibrillation, who was inadvertently hit in the face with a dinner plate during an altercation between two other residents. The incident resulted in a laceration and a large bruise on the resident's forehead. Despite the injury, the facility did not report the incident to the Ohio Department of Health as required by their policy. The Director of Nursing and a Registered Nurse confirmed that the resident was accidentally hit during the altercation, which was not directly involving her. The facility's policy mandates that all alleged violations involving mistreatment, neglect, abuse, exploitation, misappropriation of resident property, and injuries of unknown source must be reported to the state agency within 24 hours. However, this policy was not followed, as verified by the facility's Administrator.
Failure to Report Resident-to-Resident Altercation
Penalty
Summary
The facility failed to report a resident-to-resident altercation involving Resident #15, who was affected by the incident. Resident #15, diagnosed with Alzheimer's disease, chronic obstructive pulmonary disease, and atrial fibrillation, was in the dining room when an altercation between two other residents occurred. During the altercation, Resident #15 was accidentally hit in the face with a dinner plate, resulting in a cut to her forehead. The nursing staff assessed Resident #15, provided wound care, and initiated neurological checks. However, the incident was not reported to the state agency as required by the facility's policy. Interviews with the Director of Nursing and a Registered Nurse confirmed that Resident #15 was unintentionally struck by a plate during the altercation between two other residents. The Director of Nursing and the Administrator acknowledged that the incident was not reported to the Ohio Department of Health within the required timeframe. The facility's policy mandates that all alleged violations involving mistreatment, neglect, abuse, exploitation, misappropriation of resident property, and injuries of unknown source be reported to the state agency within 24 hours of the incident being known to staff.
Failure to Obtain Physician Order for Medication
Penalty
Summary
The facility failed to ensure that treatments were provided with a physician's order, affecting one resident who was reviewed for physician orders. The resident, diagnosed with Alzheimer's disease and dementia, had impaired cognition. A review of the medical records revealed that there were no physician orders for Nystatin powder, a medication used to treat fungal or yeast infections on the skin, from July 1, 2024, through the current date. Despite this, a progress note dated August 1, 2024, indicated that Nystatin powder was applied to the resident's skin without a documented physician order. The incident was discovered during a complaint investigation, where a State tested Nursing Assistant (STNA) reported finding marks on the resident's shoulders and under her breasts, which she attributed to the resident's bra being too tight or worn for too long. The STNA reported the skin concerns to a nurse, who then applied the Nystatin powder. The Director of Nursing confirmed that the nurse documented the application of the powder without a physician's order, which was against the facility's policy that requires medications to be administered only upon a written order from a licensed prescriber.
Failure to Follow Prescribed Portion Sizes and Recipes for Diet Textures
Penalty
Summary
The facility failed to ensure portion sizes were followed when serving all diet textures, affecting 83 residents who received food from the kitchen. Specifically, the facility did not adhere to the prescribed portion sizes for baked turkey crunch for residents on regular, mechanical soft, and pureed diets. Observations revealed that a size 16 scoop, which is two ounces, was used instead of the required 5 1/3 ounces for regular diets and four ounces for mechanical soft and pureed diets. Additionally, the preparation of pureed baked turkey crunch included the addition of five slices of bread and an unmeasured amount of water, contrary to the recipe instructions that specified using chicken broth and not water for thinning the mixture. Interviews with the dietary staff, including Cook #506 and Dietary Manager (DM) #501, confirmed these deviations from the prescribed recipes and portion sizes. Cook #506 admitted to adding extra scoops of food and using bread and water to achieve the desired texture for pureed diets. DM #501 verified that the incorrect scoop sizes were used during meal service and acknowledged that bread and water should not have been used in the preparation of pureed baked turkey crunch. This deficiency affected five residents with physician-ordered pureed diets and potentially compromised the nutritional needs of all residents receiving food from the kitchen.
Failure to Maintain Clean and Odor-Free Environment
Penalty
Summary
The facility failed to ensure that floors were adequately maintained, which had the potential to affect all 83 residents. Observations on multiple dates revealed sticky substances on the floors of the Bayview Dining Room, B Hall, and C Hall, causing shoes to stick and become tacky. Staff interviews confirmed the presence of sticky floors, and it was noted that this issue occurred yearly when the air conditioning was turned off. Additionally, it was revealed that housekeeping staff had been re-educated on the correct dilution for cleaning chemicals, but the floors remained sticky due to a staff member calling off on the day the floors were supposed to be cleaned with an auto floor scrubber. The facility also failed to ensure that resident rooms were free from odors, specifically affecting one resident with a diagnosis of dementia and incontinence issues. Observations of the resident's room on multiple occasions revealed a strong urine odor. Staff interviews confirmed the presence of the odor and indicated that the resident sometimes urinated in bed. The facility's policy for daily cleaning of care areas was reviewed, which stated that housekeeping, laundry, and maintenance staff were responsible for maintaining a sanitary and comfortable environment.
Medication Security and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure medications were secure and properly labeled, affecting thirteen residents. For Resident #69, a red pill identified as amitriptyline hydrochloride 100 mg was found on a plastic cup lid on the nightstand, indicating the medication was not taken as prescribed. The resident, who has neurocognitive disorder with Lewy bodies and other conditions, confirmed the pill was from the previous night. An LPN verified the medication and acknowledged that residents should be observed taking their medications. Additionally, a pink pill identified as Levothyroxine was found on the floor of Resident #36's room, who has severe cognitive impairment and multiple health conditions. An LPN confirmed the pill's identity and its inappropriate storage on the floor. Further observations revealed that an RN was administering medications from a cart containing a clear plastic cup with several unlabeled white tablets. The RN admitted the cup was present before her shift and attempted to return the tablets to a house stock bottle of acetaminophen, which was against facility policy. The DON confirmed that medications should not be removed from their original containers until administered. The facility's policy mandates that unused medications should be disposed of properly, and any medication refusals should be documented on the medication administration record.
Failure to Document Advanced Directives in Medical Records
Penalty
Summary
The facility failed to ensure that a copy of the advanced directives was included in the medical records of two residents. Resident #59, who was admitted with multiple diagnoses including type II diabetes mellitus, dementia, and chronic kidney disease, had a physician order and care plan indicating a Do Not Resuscitate Comfort Care - Arrest (DNRCC-Arrest) directive. However, the medical record did not contain a signed copy of the advanced directive, a fact confirmed by a Registered Nurse during an interview. Similarly, Resident #236, admitted with a diagnosis of dementia, did not have any advance directive order or code status documented in the electronic medical record. This was confirmed by a Licensed Practical Nurse, who also noted the absence of a paper copy of the advance directive. The facility's policy mandates that each resident should have an advance directive in place at admission, and these directives should be documented in the medical record, which was not adhered to in these cases.
Failure to Document Skin Condition Upon Admission
Penalty
Summary
The facility failed to ensure accurate skin assessments were completed upon admission for Resident #236, who was admitted with a diagnosis of dementia. Despite the hospital referral form indicating a traumatic face superior wound with edema and bruising, the Nursing Admission Screening completed on the admission date did not document any skin concerns. Subsequent observations and interviews revealed that Resident #236 had noticeable bruising on her face, which was not recorded during the initial assessment. This discrepancy was confirmed by multiple staff members, including LPNs and an RN, who noted the bruising in later assessments and interviews with the resident. The failure to document the bruising upon admission was highlighted during an interview with RN #514, who admitted to not observing or documenting the discoloration on Resident #236's face during the initial head-to-toe assessment. Further interviews with other staff members corroborated that the bruising was present shortly after admission, indicating that the initial assessment was incomplete. The facility's policy on assessments requires that any abnormalities be documented in the medical record, which was not adhered to in this case.
Failure to Maintain Appropriate Dialysis Care and Documentation
Penalty
Summary
The facility failed to maintain appropriate physician orders, accurately assess dialysis access sites, and ensure a dialysis catheter site was covered for a resident requiring dialysis. The medical record review revealed that the resident had orders to check thrill and bruit every shift and to assess and document the condition of the central line catheter site. However, there was no documentation of a sterile dressing change for the dialysis catheter site from 03/10/24 to 05/15/24. Observations confirmed that the resident's chest catheter was frequently uncovered, and the fistula did not have a thrill or bruit, which was also confirmed by the Director of Nursing (DON). Additionally, the medication administration record (MAR) and treatment administration record (TAR) did not reflect the correct catheter site, and the order to use a sterile dressing kit did not populate on the MAR/TAR as it should have. The facility's policies on dressing changes and physician orders were not followed, leading to these deficiencies. The resident involved had diagnoses including dementia, end-stage renal disease, and dependence on renal dialysis. The care plan indicated the need for dialysis three times a week and required monitoring for signs of acute failure, edema, and weight gain. Despite these requirements, the facility failed to ensure proper documentation and assessment of the dialysis access sites. Interviews with staff, including the DON and a registered nurse, confirmed the lack of proper documentation and adherence to physician orders. The facility's failure to follow its policies and procedures for dressing changes and physician orders contributed to the deficiencies observed during the survey.
Failure to Implement Non-Pharmacological Interventions for Resident with Behavioral Issues
Penalty
Summary
The facility failed to ensure non-pharmacological behavioral interventions were assessed or implemented to address a resident's resistance to care, resulting in a lack of timely care and treatment. Resident #46, who was moderately cognitively impaired and had multiple diagnoses including dementia, frequently refused care and medications. Despite the resident's care plan outlining various interventions for managing behavioral symptoms, there was no evidence that these non-pharmacological strategies were attempted or documented by the staff. The resident's medical record lacked specific interventions and assessments to determine the underlying cause of resistance to care. Observations and staff interviews revealed that Resident #46 frequently refused care, resulting in the resident being heavily soiled with urine and developing blisters on the left posterior thigh. Staff members confirmed that they were not provided with specific interventions to manage the resident's behaviors effectively. Despite some staff being able to provide care without resistance, these successful strategies were not communicated to other caregivers. The resident's room consistently had a strong urine odor, indicating a lack of timely and appropriate care. Further interviews with staff, including STNAs and the LPN, confirmed that there were no individualized interventions established to promote the resident's acceptance of care. The Director of Nursing and Licensed Social Worker also verified that the resident's plan of care lacked specific non-pharmacological interventions, and the medical record did not contain strategies for de-escalating behaviors. This deficiency in care led to the resident being frequently soiled, developing blisters, and experiencing a strong urine odor in the room, indicating a significant lapse in the quality of care provided.
Inaccurate Nutritional Assessment for Resident with Fluid Restriction
Penalty
Summary
The facility failed to ensure an accurate Nutritional Assessment for a resident diagnosed with dementia and congestive heart failure. The resident was admitted with specific diet orders, including a no added salt diet, low fat, 2000 mg sodium, low cholesterol, and a fluid restriction of 1500 ml per day. However, the Nutritional Assessment completed on 04/12/24 did not reflect the resident's fluid restriction and inaccurately stated that fluid was encouraged. This discrepancy was confirmed by interviews with the RN and the Director of Nursing, who acknowledged the resident's fluid restriction due to congestive heart failure and risk for weight gain from fluid intake. The Registered Dietitian admitted to being unaware of the fluid restriction and the two diet orders in place for the resident, leading to an inaccurate assessment of the resident's nutritional needs. Further review of the resident's medical records revealed conflicting diet orders and fluid restrictions, which were not accurately documented in the Nutritional Assessment. The resident's fluid restriction was updated to 1800 ml per day on 05/01/24, but the initial assessment failed to capture this critical information. The failure to accurately document and assess the resident's nutritional needs and fluid restrictions highlights a significant deficiency in the facility's food and nutrition services, impacting the resident's care and well-being.
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.
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