Galion Meadows Skilled Nursing And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Galion, Ohio.
- Location
- 935 Rosewood Dr, Galion, Ohio 44833
- CMS Provider Number
- 365351
- Inspections on file
- 26
- Latest survey
- December 11, 2025
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Galion Meadows Skilled Nursing And Rehabilitation during CMS and state inspections, most recent first.
Surveyors identified that the facility did not maintain a pleasant, homelike environment due to persistent strong urine odors in resident areas and unclean wheelchairs for several residents. Multiple staff, residents, and family members confirmed the ongoing odor and lack of wheelchair cleaning, despite facility policy stating wheelchairs should be cleaned regularly. Affected residents had conditions such as cognitive impairment, muscle weakness, hemiplegia, and Parkinson's disease.
Staff failed to follow infection prevention protocols, including not performing hand hygiene before and after resident care, not donning required PPE such as gowns and gloves for residents on Enhanced Barrier Precautions, and not disinfecting a glucometer between use on two residents. These deficiencies were confirmed through staff interviews, observations, and review of facility policies and CDC guidance.
A resident with severe cognitive impairment sustained a skin tear during a mechanical lift transfer, but the responsible party was not notified of the incident or new wound care orders. Staff interviews revealed confusion about notification responsibilities, and the facility's policy requiring timely notification of the resident's representative was not followed.
A resident with severe cognitive impairment and an indwelling catheter did not have urine output documented as ordered by the physician, and new areas of skin breakdown were not timely assessed or treated. Staff failed to record required information in the medical record, and multiple open wounds were observed without corresponding documentation or treatment orders. The Wound Care Nurse was unaware of the new wounds, and CNAs reported the wounds had been present for over a week.
A resident with severe mobility and cognitive impairments sustained a significant skin tear on the right foot during a transfer with a mechanical lift. The injury occurred when the resident's foot became caught under a wheelchair foot pedal while two CNAs were transferring the resident; one CNA was distracted by staff issues, and the other was occupied holding the resident's head due to the lack of a headrest on the manual wheelchair provided by therapy. The incident resulted in a painful wound with active bleeding.
A resident with diabetes received insulin injections from an RN who failed to prime the insulin pens before use, as required by both facility policy and manufacturer instructions. The RN also administered insulin doses later than ordered and delayed subsequent doses. These actions resulted in two medication errors out of 27 opportunities, causing the facility's medication error rate to exceed 5%.
A resident with type II diabetes mellitus received insulin injections from an RN who failed to prime the insulin pens before administration, despite facility policy and manufacturer instructions requiring priming before each use. The RN stated he only primed new pens, and the DON confirmed that priming should occur before every injection. This resulted in a significant medication error for the resident.
A resident with multiple chronic conditions experienced significant and ongoing weight increases over several months. Despite the dietitian's requests for re-weights after each significant gain, these were not completed in a timely manner, and a full nutritional assessment was not performed after the weight changes. Staff interviews and policy review confirmed that required procedures for monitoring and responding to significant weight changes were not followed.
A resident with multiple chronic conditions did not receive prescribed pregabalin for neuropathy due to the facility's failure to ensure a valid prescription was received and processed by the pharmacy. The medication was not administered for several days following the resident's return from the hospital, except for a brief period when an on-call CNP provided a short-term supply. The resident was not informed about the interruption in her pain medication, and facility leadership confirmed the medication was not available or given as ordered.
A resident with significant mobility deficits and a history of falls was injured during van transport when their electric wheelchair was not properly secured using the required four-point securement system and shoulder belt. The driver relied on the wheelchair's positioning belt, which is not intended for vehicle restraint, and there was no formal staff training or documentation on the use of the van's safety systems. The resident sustained injuries requiring hospital admission.
A resident's court-appointed guardian was not notified about the initiation or charges for therapy services, nor was informed consent obtained for dental services after the resident switched to private pay. The resident, who had significant cognitive and medical issues, received multiple therapy and dental services without proper guardian notification or updated consent documentation.
Two residents did not receive care as ordered: one did not have required lab tests completed before a nephrology appointment, resulting in the appointment being rescheduled, and another did not receive all required neurological assessments after a fall with a head injury while on anticoagulant therapy. Staff interviews and record reviews confirmed that care and monitoring were not provided as ordered, and notifications to family and medical staff were delayed.
A resident with severe cognitive impairment and multiple medical conditions received midodrine for hypotension despite physician orders to hold the medication if systolic blood pressure exceeded 120 mmHg. The medication administration record did not reflect the hold parameters, leading to 47 doses being administered when the resident's blood pressure was above the specified limit. The DON confirmed the discrepancy between the physician's order and the MAR.
A resident with multiple chronic conditions and severe cognitive impairment did not have physician-ordered laboratory tests completed prior to a scheduled specialist appointment. The omission was confirmed through medical record review, family interviews indicating missed or rescheduled appointments, and verification by the DON.
A resident with multiple chronic conditions and severe cognitive impairment received a wound dressing change during which the ADON did not change gloves or perform hand hygiene after removing a soiled dressing and before applying ointment to the wound, contrary to facility policy.
The facility's dishwasher failed to reach the required minimum temperature for proper sanitization, potentially affecting all residents receiving food from the kitchen. An observation revealed the dishwasher's wash temperature was 110°F, below the required 120°F. Missing temperature documentation was noted in the facility's Dish Machine log, and the issue was discovered during a complaint investigation.
The facility failed to provide scheduled showers for three residents who required assistance, missing multiple opportunities over nearly two months. One resident, with Parkinson's disease, received only four baths instead of the scheduled twice-weekly showers. Another resident, with schizophrenia and diabetes, also missed 11 scheduled showers. A third resident, with multiple sclerosis and quadriplegia, missed six scheduled showers due to staffing issues. Staff confirmed difficulties in completing ADL care timely due to increased demands.
A facility failed to ensure proper PPE use for a resident on COVID-19 precautions. Staff entered the resident's room without required eye protection and N-95 masks, despite clear signage. The resident, with COVID-19 and other health issues, required isolation. The facility's policies on PPE and transmission-based precautions were not followed, affecting the safety of all residents.
The facility did not have a registered nurse (RN) on duty for at least eight consecutive hours on two consecutive days, as required. This was confirmed through staff schedules, pay records, and interviews with the Administrator and DON. The absence of an RN had the potential to affect all 50 residents in the facility.
Failure to Maintain Clean Environment and Wheelchairs
Penalty
Summary
Surveyors found that the facility failed to maintain a safe, clean, and homelike environment for residents, as evidenced by persistent strong foul odors of urine throughout the North and South units and unclean wheelchairs for multiple residents. Observations and interviews with residents, family members, and staff confirmed that the odor was present in resident living areas over multiple days, and both nursing and housekeeping staff acknowledged the ongoing issue. The Director of Nursing also confirmed the presence of the odor during the survey. Additionally, the facility failed to ensure that residents' wheelchairs were clean. Three residents who used wheelchairs were observed to have wheelchairs with thick coatings of grime, dust, dirt, dried spills, food particles, and unidentified stains. Residents and family members reported that staff did not clean the wheelchairs, and staff interviews confirmed that cleaning was supposed to occur on shower days and as needed, but this was not being done. The affected residents had various diagnoses, including cognitive impairment, muscle weakness, hemiplegia, and Parkinson's disease.
Infection Control Failures in Hand Hygiene, PPE Use, and Equipment Disinfection
Penalty
Summary
Multiple deficiencies in infection prevention and control practices were observed among staff during medication administration, resident care, and use of medical equipment. A registered nurse failed to perform hand hygiene after exiting a resident's room and before preparing and administering insulin injections to another resident. The nurse also did not wash hands before donning gloves, exited the room with the same gloves, and handled medication equipment without performing hand hygiene. These actions were confirmed by the nurse during the interview. Certified nursing assistants did not follow Enhanced Barrier Precautions (EBP) when providing care to residents with indwelling catheters. Specifically, staff did not don isolation gowns or perform hand hygiene before or after providing catheter care, despite signage indicating EBP requirements. One CNA provided catheter care to a resident with an indwelling catheter and then entered another resident's room without washing or sanitizing hands. Another CNA and an LPN also failed to don gowns or perform hand hygiene as required during high-contact care activities for residents on EBP. A medication technician used a single glucometer for blood sugar assessments on two residents without cleaning or disinfecting the device between uses, contrary to CDC guidance and manufacturer instructions. The technician also failed to remove gloves or perform hand hygiene between residents. The Director of Nursing confirmed that staff were expected to clean glucometers between each use and to perform hand hygiene before and after resident care. Facility policies and CDC guidance reviewed during the investigation supported these requirements, but staff interviews and observations revealed consistent non-compliance.
Failure to Notify Resident Representative of Incident and Change in Condition
Penalty
Summary
The facility failed to notify a resident's representative of an incident involving the resident, specifically a skin tear sustained during a mechanical lift transfer. The resident, who had diagnoses including hemiplegia, hemiparesis following cerebral infarction, and cognitive communication deficit, was assessed as severely cognitively impaired. Documentation showed that the resident's son was listed as the responsible party and emergency contact. Despite this, there was no record that the son was informed of the skin tear or the subsequent new wound care orders. The son only learned of the injury days later during a visit, after inquiring about his father's comments regarding his foot. Staff interviews revealed confusion and inconsistency regarding notification responsibilities. The ADON stated she did not notify the family because she believed the resident was sometimes alert and oriented, and typically notified the resident directly. The DON admitted to not checking the responsible party information and assumed the resident was his own responsible party. Other staff confirmed the resident's cognitive status fluctuated, with orientation primarily to self and inconsistent recognition of others. Facility policy required notification of the resident's representative within 24 hours of any incident or change in condition, unless otherwise instructed by the resident, but this was not followed in this case.
Failure to Document Urine Output and Timely Assess Skin Breakdown
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders and the resident's needs for one resident. Specifically, staff did not document or record urine output as ordered by the physician for a resident with an indwelling catheter. Review of the medical record, Medication Administration Record (MAR), and Treatment Administration Record (TAR) showed no documentation of urinary output, and this was confirmed by the Regional Director of Clinical Services. The physician order required urine output to be recorded every shift, but this was not done. Additionally, the facility failed to timely assess and treat new areas of skin breakdown for the same resident. Observations revealed multiple open wounds and areas of redness and scabbing in the peri area, buttocks, thigh, and coccyx, which had been present for over a week. Certified Nursing Assistants (CNAs) reported the wounds but there was no documentation or treatment orders for these wounds in the medical record. The Wound Care Nurse was unaware of the new wounds and confirmed there were no treatment orders or documentation for them. The resident was severely cognitively impaired, dependent on staff for care, and had a history of resolved wounds, but the new wounds were not assessed or treated in a timely manner.
Resident Injury During Mechanical Lift Transfer Due to Inadequate Supervision
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment, hemiplegia, morbid obesity, and significant mobility deficits was injured during a transfer using a mechanical lift. The resident, who was dependent on staff for bed mobility and required two-person assistance for transfers, sustained a skin tear on the right foot after it was caught under the foot pedal of a manual wheelchair during the transfer. The incident happened while two CNAs were transferring the resident from a chair to bed using a Hoyer lift. One CNA was distracted due to interpersonal issues with another staff member and did not notice the resident's foot was caught, resulting in a skin tear with moderate bleeding. The resident's care plan specified the need for two-person assistance, and the transfer was being performed with two staff present, but one was preoccupied and failed to ensure the resident's safety. Further contributing factors included the use of a manual wheelchair without a headrest, which was provided by therapy after the resident experienced a decline and could no longer use his personal electric wheelchair with a headrest. During the transfer, one CNA had to hold the resident's head due to the lack of a headrest, limiting her ability to ensure the resident's extremities were clear of hazards. The wound was later assessed as a large skin tear with bruising and active bleeding, causing pain to the resident. Staff interviews confirmed that the distraction and the need to support the resident's head during the transfer contributed to the incident.
Medication Error Rate Exceeds 5% Due to Improper Insulin Pen Administration
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as two errors were identified out of 27 observed opportunities, resulting in a 7.4% error rate. The errors involved a resident with type II diabetes mellitus who was severely cognitively impaired and required daily insulin injections. During medication administration, a registered nurse did not prime either of the two insulin pens before administering them to the resident, contrary to manufacturer instructions and facility policy. The nurse stated that he only primed insulin pens if they were brand new, and did not perform the priming step for pens that had been previously used. Additionally, the nurse administered the resident's morning insulin doses significantly later than the prescribed times and delayed the next scheduled dose due to the late administration. The DON confirmed that insulin pens should be primed before each use and that medications should be administered according to physician orders. Facility policy and insulin pen manufacturer instructions both require priming before each injection to ensure proper dosing and function.
Failure to Prime Insulin Pens Prior to Administration
Penalty
Summary
A deficiency was identified when nursing staff failed to prime insulin pens prior to administering insulin to a resident with type II diabetes mellitus. The resident, who was severely cognitively impaired and required daily insulin injections, had physician orders for Basaglar and Admelog insulin pens to be administered at specific times. During an observed medication administration, a registered nurse attached new needles to both insulin pens, dialed in the prescribed doses, but did not perform the required priming procedure before injecting the insulin subcutaneously. The nurse later confirmed that he only primed insulin pens if they were brand new, contrary to manufacturer instructions and facility policy, which require priming before each use to ensure proper dosing. Further review of the resident's care plan and physician orders confirmed the necessity of administering medications as prescribed and in a timely manner. The Director of Nursing verified that insulin pens should be primed before every use and that medications must be given according to physician orders. The facility's policy and the insulin pen instruction manuals both specify the need for priming before each injection to ensure the pen and needle are functioning correctly and to deliver the correct dose. The failure to prime the insulin pens constituted a significant medication error affecting the resident.
Failure to Timely Complete Nutritional Assessments and Re-Weights for Significant Weight Gain
Penalty
Summary
The facility failed to timely complete nutritional assessments and obtain re-weights for a resident who experienced significant and continued weight increases. The resident, who had multiple diagnoses including chronic kidney disease, morbid obesity, type II diabetes, and other chronic conditions, showed a pattern of substantial weight gain over several months. Despite documented requests from the dietitian for re-weights following significant weight increases, these re-weights were not performed in a timely manner. For example, after a 5.6% weight increase in one month, a re-weight was requested but not completed until nearly a month later. Similarly, after another significant weight gain, a re-weight was again delayed by several weeks. Additionally, a full nutritional assessment was not completed after any of the significant weight increases, with the last assessment having been done months prior to the continued weight gains. Staff interviews confirmed that nurse aides obtain weights as directed by nursing staff, and that the dietitian relies on timely notification and completion of re-weights to perform further assessments. The facility's policy requires monthly weights and timely evaluation of significant weight changes by the multidisciplinary team, but these procedures were not followed. The dietitian confirmed that her requests for re-weights were not completed within her preferred timeframe, and that she was not notified promptly of significant weight changes. This resulted in a lack of timely intervention and assessment for the resident experiencing ongoing weight increases.
Failure to Obtain and Administer Ordered Medication
Penalty
Summary
The facility failed to obtain and administer a prescribed medication, pregabalin, to a resident following their return from a hospital admission. The resident, who had diagnoses including chronic kidney disease, convulsions, morbid obesity, type II diabetes mellitus, anxiety disorder, major depressive disorder, and lymphedema, had a care plan that included pain management with medications as ordered by a physician. Upon readmission, a physician ordered pregabalin 75 mg twice daily for neuropathy, but the medication was not administered from the evening of admission through several days, as documented in the medication administration record and progress notes. The lack of administration was due to the facility's failure to ensure a valid prescription was received and processed by the pharmacy. The pharmacy required a new prescription for the changed dosage, but did not receive it despite notifications to the facility's nurse practitioner and follow-up attempts. The resident did not receive pregabalin for multiple days, except for a brief period when an on-call nurse practitioner provided a three-day supply. The resident was unaware of the reason for the interruption in her pain medication, and facility leadership confirmed the medication was not available or administered as ordered during the specified periods.
Failure to Properly Secure Resident During Transport Results in Injury
Penalty
Summary
A deficiency occurred when a resident with multiple complex medical conditions, including congestive heart failure, diabetes, and a history of falls, was not properly secured during transport in the facility's van. The resident, who was cognitively intact but required extensive assistance for mobility and used an electric wheelchair, was being transported to an outside appointment. During the trip, the van driver had to make a sudden stop, causing the resident's wheelchair to tip forward and the resident to fall, resulting in injury. The incident led to the resident being admitted to the hospital for pain control and monitoring after sustaining a head injury and significant back pain. The investigation revealed that the resident's wheelchair was equipped with a positioning belt, which is not designed for use as a seatbelt in a motor vehicle. The facility's transport van was equipped with a four-point wheelchair securement system (Q'Straint) and a shoulder and pelvic belt restraint, which are required to be used together for safe transport. However, the driver only used the wheelchair's positioning belt and did not secure the resident with the van's shoulder belt. There was also uncertainty about whether the wheelchair was properly attached to the van floor at the time of the incident, as conflicting accounts were given by staff and the resident. Further review found that the facility did not have a formal training policy or documentation for staff responsible for operating the van and its securement systems. Training was informal and undocumented, with no checklists or records of topics covered. The lack of proper use of the securement system and inadequate staff training directly contributed to the resident's injury during transport.
Failure to Notify Guardian and Obtain Informed Consent for Therapy and Dental Services
Penalty
Summary
The facility failed to notify a resident's court-appointed guardian about the initiation and potential charges for therapy services, as well as failed to obtain informed consent prior to starting dental services. Record review showed that the resident, who had multiple diagnoses including Parkinson's disease, dementia, and malnutrition, was rarely or never understood and had a guardian appointed. Despite multiple therapy orders and treatments, there was no documentation that the guardian was informed of the therapy evaluations, treatments, or the associated charges. Billing statements confirmed that charges were incurred for occupational, speech, and physical therapy, but the guardian was not notified. Additionally, after the resident switched from Medicaid to private pay, there was no evidence that updated consent was obtained for dental services or that the guardian was notified of a dental visit. The previous ancillary consent form had been signed by the resident's wife for other services while the resident was on Medicaid, but no updated consent was documented after the change in payor status. The administrator confirmed that no updated informed consent was obtained and that billing for ancillary services was handled by the service providers, not the facility.
Failure to Complete Physician-Ordered Labs and Neurological Assessments
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders and resident needs in two separate cases. For one resident with severe cognitive impairment and multiple chronic conditions, the facility did not complete physician-ordered laboratory tests, including a urinalysis and several blood draws, prior to a scheduled nephrology appointment. As a result, the laboratory work was not available for the appointment, leading to the appointment being rescheduled. Family interviews confirmed that missed or delayed laboratory tests had resulted in rescheduled or missed appointments for this resident. The Director of Nursing verified that the laboratory tests were not completed as ordered. In another case, a resident with severe cognitive impairment, multiple diagnoses, and on anticoagulant therapy experienced a fall resulting in a head injury. The care plan required neurological assessments at specific intervals following the fall. While initial 15-minute checks were completed, subsequent 30-minute and hourly checks were missed or incomplete. Documentation showed that the nurse responsible was passing medications on another hall during the missed assessments. Additionally, at one assessment time, only vital signs were taken, and the resident could not be fully assessed as she was sleeping. The Director of Nursing confirmed that the neurological checks were not completed as required and that family and medical staff notifications about the fall and injury were delayed. Interviews with staff and review of records confirmed that the required care and monitoring were not provided according to physician orders and facility protocols. The deficiencies affected two of three residents reviewed for quality of care and treatment, as verified by the Director of Nursing and staff interviews.
Failure to Follow Medication Hold Parameters for Blood Pressure Medication
Penalty
Summary
The facility failed to ensure that the parameters for administering midodrine, a medication used to treat low blood pressure, were correctly entered into the medical record and followed during administration for a resident with multiple diagnoses including Alzheimer's disease, neuromuscular dysfunction, dysphagia, type 2 diabetes, schizoaffective disorder/bipolar type, and depressive disorder. The physician's order specified that midodrine should be held if the resident's systolic blood pressure (SBP) was greater than 120 mmHg. However, review of the medication administration records showed that the resident received 47 doses of midodrine when their SBP was above this threshold, with the highest recorded blood pressure at the time of administration being 169/103 mmHg. The Director of Nursing confirmed that the hold parameters were present in the physician's order but were not reflected on the medication administration record, resulting in the medication being given contrary to the specified parameters.
Failure to Complete Physician-Ordered Laboratory Tests
Penalty
Summary
The facility failed to obtain physician-ordered laboratory tests for one resident with multiple chronic conditions, including Alzheimer's disease, dementia, chronic obstructive pulmonary disease, and chronic heart failure. The resident, who had severely impaired cognition, was admitted on 01/15/25 and had a follow-up nephrology appointment scheduled for 07/20/25, with laboratory tests ordered to be completed on 07/14/25. These tests included a complete blood count, hepatic function panel, magnesium, microalbumin/creatinine ratio, renal function panel, sodium, protein/creatinine ratio, and urinalysis. Review of the medical record showed no evidence that the laboratory tests were completed as ordered. Family interviews confirmed that the facility had not completed the ordered tests prior to appointments, resulting in rescheduled or missed appointments. The Director of Nursing verified that the laboratory tests were not completed as ordered.
Failure to Follow Infection Control Protocol During Wound Care
Penalty
Summary
During a wound dressing change for Resident #28, who had diagnoses including Alzheimer's disease, type 2 diabetes, major depressive disorder, and chronic kidney disease, the Assistant Director of Nursing (ADON) failed to follow established infection control procedures. The resident, who had severe cognitive impairment, was being treated for a skin tear on the right lower leg. The ADON removed the soiled dressing while wearing gloves, placed the soiled dressing on a paper towel on an over-bed table, and did not remove her gloves or perform hand hygiene before proceeding to the next steps of the wound care process. The ADON then used her gloved finger, which may have been contaminated from removing the soiled dressing, to apply ointment directly to the wound before covering it with a new dressing. At the time of observation, the ADON confirmed that she did not change gloves or perform hand hygiene between removing the old dressing and applying the new treatment. Review of the facility's wound care policy indicated that gloves should be changed and hand hygiene performed between these steps, but these procedures were not followed during the observed dressing change.
Dishwasher Temperature Deficiency
Penalty
Summary
The facility failed to ensure that the dishwasher reached the minimum temperature required to properly sanitize dishware, which had the potential to affect all residents receiving food from the kitchen. During an observation, the dishwasher, model ES 2400, was noted to have a wash temperature of 110 degrees Fahrenheit and a rinse cycle of 130 degrees Fahrenheit. Dietary Aide #200 confirmed that the wash cycle was only 110 degrees Fahrenheit and believed it should be at 120 degrees Fahrenheit. A review of the facility's Dish Machine log for November 2024 showed missing temperature documentation for several days and meals, while other entries recorded temperatures of 120 degrees Fahrenheit. The dishwasher guidelines specified a minimum wash temperature of 120 degrees Fahrenheit. This issue was discovered incidentally during a complaint investigation.
Failure to Provide Scheduled Showers for Dependent Residents
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADL) for residents who required help with bathing and showers. This deficiency affected three residents who were dependent on staff for these services. Resident #38, diagnosed with Parkinson's disease and other conditions, was scheduled for showers twice a week but only received four baths over nearly two months, missing 11 scheduled opportunities. The resident expressed a preference for bed baths due to her inability to get out of bed, but the facility did not document reasons for missed baths. Resident #52, with diagnoses including schizophrenia and diabetes, also required substantial assistance for showers. Despite being scheduled for showers twice weekly, he only received four showers over the same period, missing 11 opportunities. The resident expressed a desire for timely showers, but again, there was no documentation explaining the missed care. Resident #41, who has multiple sclerosis and quadriplegia, was similarly affected. Scheduled for showers twice a week, he only received two showers in a month, missing six opportunities. The resident reported being told that showers were missed due to staffing issues, despite a recent schedule change intended to accommodate him. Interviews with staff confirmed that they were unable to complete ADL care timely due to increased demands following the closure of a dementia unit.
Inadequate PPE Use for Resident on COVID-19 Precautions
Penalty
Summary
The facility failed to implement its infection control policies, specifically regarding the use of personal protective equipment (PPE) for staff entering the room of a resident on droplet/contact precautions due to a positive COVID-19 test. Observations revealed that staff, including a physical therapist, a rehab services manager, and a state-tested nurse assistant, entered the resident's room without the required eye protection and N-95 masks, despite a sign on the door indicating the need for such precautions. Interviews with the staff confirmed the lack of appropriate PPE, and the Director of Nursing acknowledged that eye protection was not available for the resident in question or another resident in contact isolation. The resident involved had been admitted with diagnoses including hypoxic ischemic encephalopathy, hemiplegia, and COVID-19 acute respiratory disease. The resident was cognitively intact and required varying levels of assistance for daily activities. The facility's policy on PPE and transmission-based precautions was not followed, as PPE was not maintained outside the resident's room for easy access. This deficiency was identified during a complaint investigation and had the potential to affect all 52 residents in the facility.
Failure to Maintain RN Coverage
Penalty
Summary
The facility failed to comply with the requirement of having a registered nurse (RN) on duty for at least eight consecutive hours a day, seven days a week. This deficiency was identified during a review of the nursing staff schedule and pay records, which revealed that no RN was present or working in the facility on 06/15/24 and 06/16/24. Interviews with the Administrator and the Director of Nursing (DON) confirmed the absence of an RN on these dates. This non-compliance had the potential to affect all 50 residents residing in the facility, as the facility census was 50.
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Surveyors found that multiple hazardous storage areas, including a closet near medical records, a beauty salon used to store chemical cases, a supply room in one nursing station, a room leading to a smoking area, a housekeeping room near therapy, and a lobby storage room, lacked required self-closing or automatic-closing doors. These conditions did not comply with NFPA 101 requirements for hazardous area enclosure and had the potential to affect all residents and staff in an emergency.
Surveyors found that the facility did not conduct fire drills on every shift each quarter and did not vary drill conditions as required by NFPA 101. Record review showed that one shift lacked a documented drill for an entire quarter, and the pattern of drill times and dates did not demonstrate varied conditions. The Maintenance Director confirmed the incomplete and noncompliant fire drill schedule, which affected all residents and staff emergency preparedness.
Surveyors found that the facility did not maintain clear egress corridors as required by NFPA 101, with a TV/video cart plugged into a corridor outlet and multiple unsecured chairs placed in the hallway near resident rooms and the secured unit dining room, including directly in front of a fire extinguisher. These items projected about 29 inches into an approximately eight-foot-wide corridor and were located in front of the handrail, potentially affecting 28 residents and staff’s ability to assist in an emergency. The Maintenance Director confirmed these corridor obstructions during the survey.
A resident with intact cognition receiving Medicare Part A skilled services for metabolic encephalopathy had services discontinued while benefit days remained, but the facility did not issue the required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN). The Social Services Director later confirmed that no SNF ABN was provided and reported she believed only a Notice of Medicare Non-Coverage (NOMNC) was needed when all skilled services were stopped. This practice conflicted with the facility’s written policy, which required SNF ABNs to be issued when extended care items or services were initiated, reduced, or terminated due to expected non-coverage by Medicare.
Surveyors identified that the facility exceeded the acceptable medication error rate when two residents with type 2 DM received insulin doses that were not administered according to orders or manufacturer instructions. In two separate observations, an LPN administered Novolog and another LPN administered insulin glargine and insulin lispro without priming the insulin pens, and the insulin lispro and Novolog were given after the residents had already consumed a significant portion of their breakfast meals, despite orders for administration before meals. Manufacturer information for both insulin products required priming before each injection to ensure accurate dosing, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and specified time frames.
A cognitively intact resident with behavioral issues, including physical aggression and noncompliance with care, was in a secured unit and was observed tapping on the window/door. A dietary aide, despite being told by a CNA and an RN not to enter the secured unit and that the resident’s assigned aide could assist, went onto the unit and interacted with the resident, including offering to buy a soda after seeing money in the resident’s hand. The resident struck the aide in the face, and the aide responded by punching the resident in the face; a CNA reported hearing the aide say, “I will hit you again,” and then observed the resident bleeding. The resident was later found at the hospital to have an open mandibular fracture and non-restorable teeth requiring extraction, and the facility’s investigation and policy definitions led to the incident being substantiated as staff-to-resident physical abuse.
A resident with severe cognitive impairment, osteoporosis, and total dependence for transfers was being moved from bed to wheelchair with a mechanical lift when CNAs reported that an undersized sling and a forceful pull on the lift caused the resident to fall feet‑first from the sling, with staff catching the upper body while both legs struck the floor and one leg bent behind. Witnesses heard a loud pop and observed immediate pain, bruising, swelling, and deformity of the leg, yet the responding LPN did not complete a thorough musculoskeletal assessment, did not document a fall, and the physician and resident representative were not promptly informed of a suspected injury. Through the night and into the next day, staff and the roommate reported the resident crying out in pain and an obviously abnormal leg, but nursing notes only reflected intermittent acetaminophen administration without clear pain documentation, and the physician was contacted primarily about yelling and behavior. Mobile X‑rays obtained later showed a displaced distal femur fracture, which was not reviewed until the following day, when hospital imaging confirmed a closed displaced comminuted femur fracture and a hand fracture. The facility’s internal investigation was incomplete and inaccurate, with leadership denying a fall, preparing a single typed statement minimizing the event, and having multiple staff sign it despite later testimony that the statement was false and that staff were told not to discuss the incident.
Surveyors found multiple instances of improper food storage and labeling, including undated and unlabeled opened dairy products, beverages, and prepared foods in the main walk-in cooler and freezer, as well as a serving scoop left resting directly on stored pasta. Additional issues included covered but undated pre-poured juices, milk, and thickened beverages in a reach-in cooler used for tray line, and a nurses' station refrigerator containing a dated bag of a resident’s food from over a week prior and three undated half-sandwiches. In a resident’s personal refrigerator, staff confirmed three undated bags of grapes with visible mold. These conditions did not comply with facility policies requiring cold foods to be stored off the floor, wrapped or covered, labeled, dated, and for resident refrigerators to be monitored daily with unsafe or moldy food discarded.
Surveyors found unsanitary kitchen conditions, including a dirty tray holding clean pitchers, soiled storage carts containing clean dishware and disposables, and multiple trays of open juice in a reach-in refrigerator that were unlabeled and undated. In a walk-in refrigerator, they observed a bag of bologna marked only with a freeze date, lacking a thaw or use-by date, and appearing slimy and discolored. Observation of the high-temp dishwasher showed rinse temperatures below the 180°F minimum required for hot water sanitizing, and review of several months of temperature logs revealed repeated sub-minimum wash and rinse temperatures and numerous missing entries. Facility policies required dishwashing to meet specified temperature standards and all refrigerated foods to be covered, labeled, and dated with a use-by date, but these requirements were not consistently followed.
Surveyors found that the facility did not maintain a safe, clean, and homelike environment as required by its policy. In one shared bedroom, wallpaper was peeling in several areas, including behind each bed, below a window, and near baseboards, and a black substance was present around the base of the toilet. A CNA confirmed these conditions. In addition, three cracked or broken light covers were observed in a hall restroom. These environmental issues affected two residents and had the potential to affect all residents.
Failure to Maintain Self-Closing Doors for Multiple Hazardous Storage Areas
Penalty
Summary
Surveyors identified a deficiency related to hazardous area protection and door requirements under NFPA 101, 2012 Edition. During facility tours, they observed that multiple hazardous storage areas did not have self-closing or automatic-closing doors as required for hazardous areas such as combustible storage and chemical storage. These areas included a closet next to medical records, a beauty salon being used to store cases of chemicals, a supply room in Station #2, and the room leading to the smoking area in Station #3. On a subsequent tour, surveyors observed additional hazardous areas without self-closing doors. The housekeeping room across from therapy and the lobby storage room were both noted to lack self-closing door mechanisms. The facility census at the time was 59 residents, and the surveyors stated that this deficient practice had the potential to affect all residents and staff's ability to assist in an emergency. The Maintenance Director verified these findings at the time they were observed.
Plan Of Correction
K 0321 This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be admissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as its allegation of substantial compliance as of 06/12/2026 K-0321 Doors with Self-Closing Devices Corrective action for resident/s: 1. The closet door next to medical records was lacking a self-closing door on 5/19/2026. Maintenance director to add self-closing device to closet door next to medical records on or before 06/12/2026 in accordance with applicable code. 2. The beauty salon had chemicals stored in it on 5/19/2026. Maintenance director moved chemicals from beauty salon on 05/20/2026 in accordance with applicable code. 3. The supply room on station 2 was lacking a self-closing door on 5/19/2026. Maintenance director to add self-closing door to supply room on station 2 on or before 06/12/2026 in accordance with applicable code. 4. The room to the smoking area on station 3 was lacking a self-closing door on 5/19/2026. Maintenance director to add a self-closing door to the smoking are on station 3 on or before 06/12/2026 in accordance with applicable code. 4. The housekeeping room across from therapy was lacking a self-closing door on 5/19/2026. Maintenance director to add a self-closing door to the housekeeping room across from therapy gym on or before 06/12/2026 in accordance with applicable code. 5. The lobby storage room was lacking a self-closing door on 5/19/2026. Maintenance director to add a self-closing door to the lobby storage room on or before 06/12/2026 in accordance with applicable code. Identification of other residents who may be affected: LNHA and Maintenance director/designee completed a full facility audit for doors with self-closing devices on 05/26/2026. Any corrective action, including, doors identified as needing self-closures will be added on or before 06/09/2026 in accordance with applicable code. Measures for systemic change: LNHA educated Maintenance Director on 05/26/2026 regarding NFPA 101-2012 sections 19.3.2.1 and 19.3.5.9 specifically regarding doors with self-closing devices. How Corrective Action will be monitored Ongoing "Doors with Self-Closing device audit" to be completed weekly x 2 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 06/12/2026
Failure to Conduct Required Quarterly Fire Drills on All Shifts
Penalty
Summary
The facility failed to conduct fire drills in accordance with NFPA 101, 2012 Edition, sections 19.7.1 through 19.7.1.8, specifically by not holding drills every shift each quarter and not varying drill conditions as required. Record review on 06/09/25 at approximately 10:32 A.M. showed there was no fire drill conducted for the first shift during the third quarter. The documented first-shift fire drills occurred on 01/30/26 at 2:42 P.M., 04/30/26 at 1:51 P.M., and 10/31/25 at 10:58 A.M., indicating a missed quarter. Second-shift fire drills were recorded on 02/26/26 at 5:20 P.M., 06/03/25 at 4:35 P.M., 08/29/25 at 3:46 P.M., and 11/25/25 at 5:09 P.M., and third-shift drills on 02/28/26 at 11:47 P.M., 05/30/25 at 12:18 A.M., 07/22/25 at 11:34 P.M., 09/26/25 at 11:40 P.M., and 12/15/25 at 5:17 A.M. The surveyor determined that drills were not conducted under varied conditions and that the required quarterly drill on each shift was not consistently performed. The Maintenance Director confirmed these findings at the time they were identified, and the deficiency had the potential to affect all 59 residents and staff response in an emergency. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency related to facility-wide emergency preparedness practices and documentation of fire drills.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 05/29/2026 K-0712 Fire Drills Corrective action for resident/s: There were no records of a fire drill for the first shift of the third quarter of 2025. First shift fire drill completed on 5/24/2026 by maintenance director/designee with no findings or corrective action necessary. Identification of other residents who may be affected: On 5/26/2026 Maintenance director/designee completed 100% audit of the scheduled fire drills to ensure a drill is scheduled quarterly each shift with no findings or corrective action necessary. Measures for systemic change: LNHA educated Maintenance Director on 05/26/2026 regarding NFPA 101-2012 section 19.7.1.4 through 19.7.1.7. specifically including fire drill frequency requirements. How Corrective Action will be monitored Ongoing "Fire Drill Audit" to be completed weekly x 2 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 05/29/2026
Obstructed Egress Corridors Due to Equipment and Chairs
Penalty
Summary
The facility failed to maintain required clear egress widths in corridors in accordance with NFPA 101, 2012 Edition, sections 19.2.3.4 through 19.2.3.5 and 7.3.2 through 7.3.2.3, creating projections into the egress corridor that exceeded allowable limits. Surveyors observed that on one day in Station #3, a cart with a television and video equipment was plugged into an outlet in the corridor by room 38, and five activity room chairs were placed in the corridor near the secured unit dining room directly in front of a fire extinguisher. On the following day, surveyors again observed chairs in the Station #3 corridor, with four by room 35 and four by the activities room, and the same television cart still in the corridor; the chairs were not secured. The corridor was approximately eight feet wide, and the projections extended approximately 29 inches into the corridor in front of the handrail. These conditions had the potential to affect 28 residents in the facility and the staff’s ability to assist in an emergency, and the Maintenance Director confirmed the observations at the time of discovery. No specific resident medical histories or conditions were described in the report, only that 28 residents were potentially affected and the facility census was 59.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be subsequent remedial measures and should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 05/29/2026 K-0232 Clear path of egress Corrective action for resident/s: 1. On 05/18/2026 station 3 had a cart with a television parked in the corridor by room 38 that exceeded allowable limits. Maintenance director/designee moved the TV cart into the activity room, out to the corridor on 05/18/2026 in accordance with applicable code. 2. On 5/18/2026 station 3 had 5 chairs in the corridor near the dining room directly in front of the fire extinguisher. Maintenance director/designee moved the chairs into the dining room, out of the corridor on 5/18/2026 in accordance with applicable code. 3. On 5/19/2026 station 3 had 4 chairs by the activity room and 4 by room 35. In addition, the TV cart was in the corridor. The maintenance director/designee moved the chairs and TV cart into the dining room, out of the corridor on 5/19/2026 in accordance with applicable code. Identification of other residents who may be affected: Maintenance director/designee completed a 100% facility audit for clear paths of egress on 5/26/26 with no findings or corrective action necessary. Measures for systemic change: Maintenance Director/designee educated staff on 5/26/2026 regarding NFPA 101-2012 section 19.2.3.4 and 19.2.3.5 specifically including maintaining a clear path of egress. How Corrective Action will be monitored Ongoing "Path of Egress Audit" to be completed weekly x 2 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 05/29/2026
Failure to Issue Required SNF ABN When Discontinuing Medicare Part A Services
Penalty
Summary
The deficiency involves the facility’s failure to issue a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) when Medicare Part A services were discontinued for a resident who still had available benefit days. The resident was admitted with a diagnosis of metabolic encephalopathy and had intact cognition per the Minimum Data Set assessment. The facility’s own SNF Beneficiary Notification Review documented that Medicare Part A skilled services began on 02/11/26 and the last covered day was 03/11/26, and that the facility initiated discharge from Medicare Part A services before the resident’s benefit days were exhausted. Despite this, no SNF ABN was provided to the resident or the resident’s representative. During interviews, the Social Services Director stated that the SNF ABN was issued hours prior to the last covered day but, upon reviewing her files, confirmed that no SNF ABN had actually been issued for this resident. She further explained that she believed an SNF ABN was only required if one skilled service remained and that if all skilled services were being discontinued, only the Notice of Medicare Non-Coverage (NOMNC) needed to be issued. The Administrator, however, stated that a resident should always receive both a SNF ABN and a NOMNC when Medicare Part A services are discontinued and benefit days remain. Review of the facility’s written policy dated 03/28/23 showed that the facility was required to issue SNF ABNs for initiation, reduction, or termination of extended care items or services when Medicare payment was not expected, which did not occur in this case.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as its allegation of substantial compliance as of 05/29/2026 F-0582 Corrective action for resident/s: On 5/14/26 Resident #34 was informed of rights and responsibilities related to Advanced Beneficiary Notice and voiced understanding of information for future reference by administrator. Identification of other residents who may be affected: Any resident receiving skilled services from nursing or therapy services. The Administrator audited all residents who were discharged from skilled services in the past 30 days to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary Notice on 5/29/26. No non-compliance was noted. Measures for systemic change: On 5/14/2026 Business Office Manager, Director of Rehab, Minimum Data Set nurse, Director of Nursing and Social Services Director were educated on proper procedure of issuing of Notice Of Medicare Non Coverage and Advanced Beneficiary Notice by administrator. All upcoming discharges from skilled services will be reviewed weekly at Utilization Review meeting to ensure notices will be delivered timely. How Corrective Action will be monitored: Administrator or designee to complete audits of all residents being discharged from skilled services to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 5/29/26
Insulin Administration Errors and Failure to Prime Insulin Pens
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5%, with surveyors identifying 3 errors out of 28 medication administration opportunities, resulting in a 10.71% error rate. For one resident with type 2 diabetes mellitus and moderate cognitive impairment, the physician’s order directed Novolog insulin 10 units via subcutaneous pen-injector to be given before meals. During an observed medication pass, the LPN administered 10 units of Novolog insulin without priming the pen and did so after the resident had already consumed approximately 50% of the breakfast meal. The LPN later confirmed she did not prime the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer instructions for the Novolog FlexPen specified that an air shot (priming) must be performed before each injection to ensure proper dosing. Another resident, also diagnosed with type 2 diabetes mellitus and with intact cognition, had orders for insulin glargine 35 units subcutaneously twice daily and insulin lispro 20 units subcutaneously before meals, plus 12 units subcutaneously if blood glucose was between 251 mg/dL and 300 mg/dL. During an observed medication administration, an LPN administered 35 units of insulin glargine and 32 units of insulin lispro without priming the insulin pens and after the resident had consumed approximately 90% of the breakfast meal, despite orders for insulin lispro to be given before meals. The LPN later stated she could not remember if she had primed the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer information for insulin lispro stated that the pen must be primed before each injection to confirm insulin delivery and remove air, and that failure to prime could result in too much or too little insulin. The DON confirmed the expectation that insulin be administered as ordered, including priming each pen with two units before dialing the prescribed dose, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and required time frames.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 5/29/2026. F-0759 Corrective action for resident/s: Residents #21 and #22 were assessed and evaluated by nurse and Director of Nursing 5/14/26. Resident #21 and #22 both denied any adverse effects and none were noted upon assessment by the Director of Nursing on 5/14/2026. Notification made to physician on 5/14/2026. LPN # 2 competency Eval on insulin administration with the Director of Nursing completed 5/14/2026. Identification of other residents who may be affected: Diabetic residents on assignment of LPN #2/station 2 have the potential to be affected and were assessed by the DON/Designee on 5/14/26 and found to be within normal limits. Measures for systemic change: All Nurses were educated by the Director of Nursing on the steps for Insulin administration per competency, diabetes clinical protocol policy, Medication and treatment orders policy, administering medications policy, and Obtaining fingerstick Glucose Level policy On 5/14/2026. How Corrective Action will be monitored: Director of Nursing and Assistant Director of Nursing will complete insulin administration audits on 5 nurses. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance: 5/29/2026
Staff-to-resident physical abuse resulting in jaw fracture and tooth loss
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from staff-to-resident physical abuse, resulting in serious injury. A dietary aide entered a secured unit where a cognitively intact resident with a history of behavioral issues, including physical aggression and noncompliance with care and medications, was located. The resident had been tapping or knocking on the window/door of the secured unit, drawing the attention of the dietary aide. Multiple staff, including a CNA and an RN, told the dietary aide not to go onto the secured unit, noting that the resident’s assigned aide could assist and that the resident had been agitated the previous day. Despite these instructions, the dietary aide went onto the secured unit. Witness statements and interviews indicate that upon entering the unit, the aide interacted with the resident, including offering to buy the resident a soda after seeing the resident holding money. According to staff statements and the aide’s own account, the resident then struck the aide in the face. The aide responded by punching the resident in the face. A CNA on the unit reported stepping between the two to attempt to deescalate the situation and then calling for the nurse due to the resident’s aggression. The CNA also reported hearing the aide tell the resident, “I will hit you again,” and then observed that the resident was bleeding. Following the punch, the resident was noted by staff to be bleeding from the nose and mouth. The resident was assessed by nursing and subsequently transported to the hospital. Hospital records documented that the resident sustained an open fracture of the right jaw, with a loose right lateral mandibular incisor and bleeding from the socket at the fracture site. The resident’s remaining 11 teeth were extracted because they could not be restored. A police report documented that staff reported the incident as an assault in which a staff member punched a resident after the resident had punched the staff member. The facility’s policy defined abuse as the willful infliction of injury resulting in physical harm, including physical abuse such as hitting and punching, and the facility substantiated that the dietary aide had physically abused the resident.
Failure to Ensure Safe Mechanical Lift Transfer, Timely Assessment, and Pain Management After Traumatic Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure safe mechanical lift transfers, adequate assessment, timely physician and representative notification, and appropriate pain management for a severely cognitively impaired, non‑ambulatory resident who required a mechanical lift with two‑person assistance for all transfers. The resident had multiple relevant diagnoses, including vascular dementia, osteoarthritis, a right hip prosthesis, chronic kidney disease, and a history of fractures and osteoporosis/osteopenia. On the morning of 04/22/26, during a mechanical lift transfer from bed to wheelchair, multiple CNAs reported that the sling appeared too small, the lift was pulled forcefully from under the bed, and the resident fell feet‑first out of the sling, with staff catching her upper body while both legs hit the floor and one leg bent behind her. A loud popping sound was heard, the resident screamed and cried out in pain, and witnesses observed immediate bruising, swelling, and apparent misalignment of the left knee/leg. Despite this, the nurse who responded did not perform a complete head‑to‑toe or range‑of‑motion assessment focused on the leg, and the incident was not documented as a fall from the lift. Following the incident, nursing staff actions and documentation were incomplete and inconsistent with the resident’s presentation. Progress notes on 04/22/26 documented only a skin tear to the left forearm and a head‑to‑toe assessment with no new areas, and there were no notes describing a fall, leg injury, or significant pain. Multiple CNAs and the resident’s roommate reported that the resident cried out in pain throughout the night and that her left leg appeared swollen, bruised, and deformed, yet nursing notes from the night shift only recorded administrations of acetaminophen without documenting the reason for administration, pain assessment findings, or any musculoskeletal concerns. One RN reported being asked to look at the resident on 04/22/26, noting swelling of the left leg but performing no further assessment. The physician was not notified within one hour of a suspected musculoskeletal injury as required by facility policy, and the resident’s representative was not informed that the resident had fallen from the mechanical lift. On 04/23/26, staff continued to report the resident’s ongoing pain and abnormal leg appearance, but the physician was contacted only about increased yelling and behavior, with a focus on agitation and prior hip/groin pain history rather than a new traumatic event. The DON later documented that a loud popping noise occurred during a Hoyer lift transfer with three staff present and that no abnormalities or signs of pain were noted, and the physician was asked to order bilateral hip and knee X‑rays as a precaution, without documenting a fall. Mobile X‑rays were obtained on 04/23/26, but the results, which showed a displaced distal femur fracture on a limited lateral view, were not reviewed until 04/24/26. Only then was the fracture acknowledged and discussed with the physician and resident representative. Subsequent hospital evaluation identified a closed displaced comminuted supracondylar fracture of the left femur and a distal fifth metacarpal fracture of the left hand. The facility’s internal investigation was incomplete and inaccurate: the DON denied a fall on 04/22/26, prepared a single typed statement describing only a popping sound while the resident was suspended over the bed, and had multiple staff sign it, even though at least two CNAs and an agency DON later reported that the statement was false and that staff felt intimidated and were told not to talk about the incident. The facility also failed to adequately manage the resident’s pain following the injury. Although the MAR shows acetaminophen administrations on 04/22/26 and early 04/23/26, there was no associated documentation of pain scores or clinical rationale in the progress notes for some doses, and staff interviews and the roommate’s account described the resident crying out in pain whenever touched and throughout the night. The physician later stated he was under the impression the fracture was non‑displaced and that, because the resident was bedbound, he did not feel she needed pain medication, and he was unaware of the severity of the femur fracture or the additional hand fracture. Overall, the facility did not follow its own physician communication policy for falls with musculoskeletal deformity or leg pain, did not perform and document thorough assessments at the time of the incident and during the subsequent night, did not promptly review diagnostic imaging, and did not conduct a complete, accurate investigation into the circumstances of the mechanical lift transfer and resulting injuries.
Improper Food Storage and Labeling in Facility and Resident Refrigerators
Penalty
Summary
Surveyors identified a failure to store food in accordance with professional standards and facility policy, creating the potential for foodborne illness for nearly all residents who received food from the kitchen. In the walk-in cooler, they observed multiple items that were opened and partially used without any open dates, including two cartons of heavy whipping cream, bins of individually poured and covered beverages, and a tray of covered fruit cocktail bowls. A large pan of pasta with ground meat was stored with the serving scoop resting directly on the food, covered with plastic wrap and not dated. A cart in the cooler held a 22-quart container of dark liquid with no label or date, and a pink plastic pitcher resting directly on the cart surface, which was coated with a dark unidentified material. A box of bacon was stored directly on the floor. The Director of Dietary Services confirmed the presence of undated, unlabeled, and improperly stored food items in the walk-in cooler. In the walk-in freezer, surveyors found an unsealed and undated bag of frozen chicken breasts and an unsealed and undated bag of pork pizza topping, which the Director of Dietary Services also confirmed. The reach-in cooler used for tray line contained a variety of pre-poured juices, milk, thickened beverages, and tea that were covered but not dated. At a nurses' station refrigerator, surveyors observed a plastic bag of food labeled with a resident’s name and dated more than a week earlier, along with three half-sandwiches wrapped in plastic without dates; the LPN present verified these findings. In a resident’s personal refrigerator, three undated bags of grapes with visible mold were found, and a CNA confirmed the grapes were moldy and undated. Facility policies required cold foods to be stored at least six inches above the floor, wrapped or in covered containers, labeled, and dated, and required resident refrigerators to be monitored daily, with food appropriately labeled and unsafe or moldy food discarded. These practices were not followed, resulting in the cited deficiency under the complaint investigation.
Unsanitary Kitchen Practices and Improper Dishwashing Temperatures
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service operations related to unsanitary kitchen conditions, improper food labeling and dating, and failure to operate the dishwasher according to manufacturer and policy requirements. During an initial kitchen tour, they observed a plastic tray holding clean pitchers with a brown-like substance on it, and three open, three-shelf carts with crumbs and debris on the shelves where clean insulated plate lids and sleeves of disposable bowls, cups, and lids were stored. Multiple trays of juice in a reach-in refrigerator were open, unlabeled, and undated. In the walk-in refrigerator, surveyors found a plastic bag of bologna with only a freeze date and no thaw or use-by date; the bologna appeared slimy and lighter in color. The facility census was 67, with one resident identified as not receiving meals from the kitchen, and the deficiency was noted as having the potential to affect all residents receiving food from the kitchen. Surveyors also observed the high-temperature dishwasher in use and recorded a wash temperature of 168°F and rinse temperatures of 160°F, 176°F, 178°F, 178°F, and 178°F over five cycles, despite the machine label and facility policy requiring a minimum wash temperature of 150°F and a minimum rinse temperature of 180°F for hot water sanitizing. A staff member confirmed the dishwasher had not been running earlier that morning, verified it was a high-temperature machine that should rinse at a minimum of 180°F, and acknowledged the observations regarding the dirty tray, soiled carts, unlabeled juice, and improperly dated bologna. The staff member stated that items in the reach-in refrigerator were normally prepped the night before and asserted that the bologna always had that color before discarding it. Review of the dishwasher temperature logs for January through April 2026 showed repeated failures to meet required wash and rinse temperatures and numerous instances of missing documentation. In January, multiple wash temperatures were below the 150°F minimum, and several meals lacked recorded wash and rinse temperatures. February logs showed at least one sub-minimum wash temperature and many missing wash and rinse entries for various meals. March logs included at least one meal with no documented wash or rinse temperatures. April logs documented several wash temperatures below 150°F and rinse temperatures below 180°F, along with multiple days and meals where wash and/or rinse temperatures were not recorded at all. Facility policies on sanitation, kitchen infection control, and food receiving and storage required dishwashing to meet temperature and sanitation standards and refrigerated foods to be covered, labeled, dated, and used, frozen, or discarded by their use-by date, which was not consistently followed according to the survey findings.
Environmental Maintenance and Cleanliness Deficiencies in Resident Room and Common Restroom
Penalty
Summary
Surveyors identified that the facility failed to maintain a safe, clean, comfortable, and homelike environment as required by its “Homelike Environment” policy. Observation of a shared bedroom for Residents #46 and #56 showed wallpaper peeling from the wall in multiple locations, including behind each resident’s headboard, below the window, and near the baseboards. In the same room’s bathroom, a black substance was observed around the base of the toilet. During an interview conducted concurrently with these observations, CNA #175 confirmed the presence of the peeling wallpaper and the black substance around the toilet base. Further observation with CNA #175 in the C hall restroom revealed that three light covers in that restroom were cracked or broken. The facility’s written policy, revised in February 2021, states that residents are to be provided with a safe, clean, comfortable, and homelike environment. The conditions observed in the residents’ bedroom, bathroom, and the C hall restroom were inconsistent with this policy and affected two identified residents, with the potential to affect all residents in the facility.
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