Gardens Of Euclid Beach
Inspection history, citations, penalties and survey trends for this long-term care facility in Cleveland, Ohio.
- Location
- 16101 Euclid Beach Blvd, Cleveland, Ohio 44110
- CMS Provider Number
- 365594
- Inspections on file
- 35
- Latest survey
- September 23, 2025
- Citations (last 12 mo.)
- 43 (2 serious)
Citation history
Health deficiencies cited at Gardens Of Euclid Beach during CMS and state inspections, most recent first.
A resident with multiple serious health conditions and a documented Full Code status was found unresponsive. Facility staff, including an LPN, failed to initiate CPR or promptly call EMS, despite the resident's wishes for all life-saving measures. The hospice nurse confirmed the resident's death, and no resuscitative efforts were made by staff prior to EMS arrival, resulting in a deficiency related to emergency response and code status verification.
The facility failed to assess and respond promptly to residents experiencing acute changes in condition, including not notifying physicians, delaying EMS calls, and not following proper CPR protocols. In several cases, staff did not check for a pulse before starting CPR, did not use a backboard, and left residents unattended while seeking help. Inadequate staffing and lack of effective communication systems further delayed emergency response, resulting in actual harm and deaths.
Significant turnover in administrative and nursing leadership led to widespread failures in care planning, environmental maintenance, documentation, and timely medical interventions. Multiple residents were affected by lapses such as missed oxygen care, unsanitary conditions, incomplete bathing and skin assessments, delayed lab work, and lack of emergency response, with some incidents resulting in immediate jeopardy and death.
Surveyors found that the facility did not ensure a clean and homelike environment, with multiple rooms exhibiting peeling wallpaper, damaged walls, dirty bathrooms, and built-up dirt and debris. Staff interviews revealed inconsistent cleaning schedules, short-staffing in housekeeping, and lapses in routine maintenance checks. Facility records showed ongoing issues with building upkeep and a lack of regular oversight, resulting in non-compliance with standards for a safe and comfortable environment.
Multiple residents dependent on staff for bathing did not consistently receive scheduled showers or proper documentation of care. Residents with significant medical and functional needs, including those with cognitive impairment and mobility limitations, were affected. Staff interviews and record reviews revealed missed showers due to staffing shortages, lack of clear delegation, and incomplete documentation, resulting in residents going extended periods without proper hygiene assistance.
Two residents with complex medical needs experienced critical events where staff failed to provide timely and appropriate emergency care due to insufficient staffing, lack of clear emergency procedures, and inadequate training. In both cases, delays in calling 911, confusion about emergency protocols, and absence of necessary equipment contributed to poor outcomes, with both residents ultimately passing away after being transported to the hospital.
Surveyors found loose, unlabeled pills of various types in several medication carts. Nursing staff, including RNs and LPNs, confirmed they could not identify the medications or their intended recipients. This failure to store drugs in their original packaging was observed across multiple carts and had the potential to affect numerous residents.
Several residents with personal refrigerators had food stored without consistent temperature monitoring or proper labeling, and expired food items were found during observations. Staff interviews revealed confusion over responsibility for monitoring, and the facility's policy lacked clear procedures for temperature checks, resulting in non-compliance with safe food storage practices.
The facility did not ensure timely physician notification when two residents experienced significant changes in condition. In one case, a resident on hospice with full code status had acute symptoms, but only hospice was notified, not the physician. In another case, a resident reported chest pain before being found unresponsive, and the physician was not informed. Both incidents were contrary to facility policy requiring physician notification of significant changes.
A resident with severe cognitive impairment and diabetic retinopathy was not provided with corrective lenses or scheduled vision care appointments as ordered by physicians. The resident's glasses were missing, the prescription had expired, and there was no documentation of attendance or rescheduling of required eye appointments. Staff interviews confirmed a lack of documentation and awareness regarding the resident's vision needs, and the facility could not provide a policy for managing vision appointments or following physician orders.
The facility did not provide required supervision for two residents assessed as needing monitoring while smoking and failed to prevent them from possessing smoking materials, despite facility policy and staff orientation protocols. Both residents were found with cigarettes or lighters in their possession, and staff confirmed these items should not have been accessible to them.
A resident with multiple medical conditions and moderate cognitive impairment did not receive physician-ordered BMP and CBC lab tests as scheduled, with the last tests completed several months prior to the required date. Facility leadership confirmed the lapse and could not provide a policy on following physician orders.
Failure to Initiate CPR and Timely EMS Response for Full Code Resident
Penalty
Summary
A deficiency occurred when facility staff failed to initiate Cardiopulmonary Resuscitation (CPR) or promptly call Emergency Medical Services (EMS) for a resident who had advance directives indicating Full Code status. The resident, who had multiple significant medical diagnoses including chronic obstructive pulmonary disease, diabetes, heart failure, and was receiving hospice services, was found unresponsive. Despite the resident's documented wishes to receive all life-saving measures, no CPR was started by staff, and EMS was not called until nearly an hour after the resident was pronounced deceased. At the time of the incident, the resident was under hospice care but had explicitly chosen to remain a Full Code, as documented in both the physician's orders and the care plan. Staff present at the scene, including an LPN and other aides, failed to recognize or act upon the resident's code status. The hospice nurse who arrived at the scene found the resident with no vital signs and confirmed death after auscultating for a heart rate for three minutes. The crash cart was not brought to the room until much later, and there was confusion among staff regarding the resident's code status and the appropriate emergency response. Interviews and record reviews revealed that the LPN on duty did not know the resident's code status and did not initiate CPR. Other staff members, including another LPN and CNAs, were either unsure of the actions taken or did not participate in resuscitative efforts. Documentation was inconsistent, and there was evidence that staff attempted to retroactively document or misrepresent the provision of CPR. The facility's failure to follow established emergency procedures and to verify and act on the resident's code status resulted in the resident not receiving the life-saving interventions to which they were entitled.
Removal Plan
- Managerial staff, Regional Director of Clinical Services (RDCS) #601, the Administrator, and the DON reviewed data collaboratively, conducted a root cause analysis, and identified that LPN #521 did not know Resident #13's code status and did not initiate CPR.
- The Administrator and DON received education from President of Clinical Services (VPCS) #618 and President of Operations (VPO) #617 on where to locate advanced directives, CPR policy, Code Blue Flow Sheet, that hospice was not a code status and that advanced directives still need checked.
- Staff were educated to check the bed board, with a new process to add code status for staff and contracted service providers.
- Staff were educated to check the bed board, change of condition, communication during a code, the crash cart, and staffing assignments.
- An Ad Hoc Quality Assurance and Performance Improvement (QAPI) meeting was held with management to review education on advanced directives, CPR policy, Code Blue Flow Sheet, hospice not being a code status, and the new bed board process.
- Contracted service providers would be educated to check the bed board, change of condition, communication during a code, crash cart, and staffing assignments.
- Each service provider would receive a memo upon entering the building stating the facility's new process, sign off on receipt and understanding, and memos would also be emailed to appropriate service providers.
- 32 Certified Nurse Aides (CNAs), 19 LPNs, four Registered Nurses (RN), seven housekeepers, six receptionists, 16 therapists, and 2 activity employees were educated on where to locate advanced directives, CPR policy, Code Blue Flow Sheet, hospice not being a code status, and the new bed board process.
- Contracted service providers will be educated to check the bed board, change of condition, communication during a code and crash cart, and staffing assignments by ADON #615 and the DON.
- A whole house audit for 58 residents' code status orders was reviewed for accuracy by ADON #615. This would be reviewed during clinical meetings, and the DON/designee would update and check the code status for new admissions.
- 58 resident care plans were reviewed for accuracy by MDS Coordinator #613.
- ADON #615 audited all current nurse's CPR certification records to ensure nursing staff had current CPR certification. No nurses were permitted to work until their active CPR certification was verified by Administration.
- Former Director of Nursing (FDON) #604 ran the audit report on 58 residents to assess for change of condition that was not addressed. No issues were identified. The DON/designee would audit the report.
- The DON and ADON #615 audited the three LPNs and four CNAs on duty and had them locate in the electronic medical record where the resident's code status was located.
- The DON/designee completed a mock code blue drill to identify areas of struggle.
- The Administrator, RDCS #601, and Regional Director of Operations (RDO) #599, administered a hands-on and written post-test for all nurses working.
- RDCS #601 and RDO #599 went to the units and demonstrated how to use the overhead page, how and where to look in the electronic medical record for code status, and how to use the walkie talkies. Staff performed a return demonstration of locating code status in the electronic medical record.
- An audit of the bed board code status would be reviewed and updated by the DON. Results of the audit would be reviewed through the facility's QAPI process.
- Mock code blue drills would be conducted on alternating shifts. Staff participating in the mock codes would document on the code blue documentation nurses note form. The mock codes would be overseen by the DON or designee. Results would be reviewed through the facility's QAPI process.
- A code blue drill would be conducted on alternating shifts. These audits would be completed by the DON or designee using the code response form.
- The DON or designee would begin auditing reports from the electronic medical record system to audit for any resident changes in condition, to ensure changes in condition were appropriately addressed. Results would be reviewed through the facility's QAPI process.
- Interview questionnaires would be conducted with first floor staff on how to obtain help during emergency situations on alternating shifts. These interviews would be conducted by the DON or designee. Results would be reviewed through the facility's QAPI process.
- The crash cart would be audited by the DON or designee to ensure all needed supplies are contained in the crash cart. The audits would take place on alternating shifts. Results would be reviewed through the facility's QAPI process.
- The DON or designee would audit the first-floor staffing, to ensure scheduled staff members are present as scheduled, on random shifts. Results would be reviewed through the facility's QAPI process.
- RDCS #601 provided additional one-on-one education to LPN #521 regarding what the Code Blue form is and when to utilize it. LPN #521 verbalized understanding.
Failure to Provide Timely Medical Intervention and Emergency Response
Penalty
Summary
The facility failed to accurately assess and provide timely and necessary medical intervention for residents experiencing acute changes in condition. In multiple instances, staff did not notify physicians or provide adequate interventions when residents exhibited significant symptoms such as low oxygen saturation, shortness of breath, hypotension, and altered mental status. For example, one resident with a history of diabetes, COPD, heart disease, and dependence on supplemental oxygen was found with an oxygen saturation as low as 71%, but the nurse on duty did not notify the physician or escalate care. The resident's condition did not improve after initial interventions, and there was no evidence of further medical action before the resident was later found unresponsive. The facility also failed to provide basic life support (BLS) and cardiopulmonary resuscitation (CPR) in accordance with standards of practice. In several cases, staff initiated CPR without first checking for a pulse, did not use a backboard to ensure effective compressions, and delayed calling emergency medical services (EMS). In one incident, a nurse took over 30 minutes to call 911 after a resident was found unresponsive, and in another, a nurse left an unresponsive resident alone to seek help from another floor, further delaying emergency response. Staff interviews revealed a lack of knowledge regarding code team assignments, CPR protocols, and the use of emergency equipment such as crash carts and AEDs. Additionally, the facility did not maintain adequate staffing or effective systems for emergency response. There was no staffing plan for a newly opened unit, and staff had to physically leave the unit to obtain assistance during emergencies due to the absence of a communication system. Observations confirmed that at times, no staff were present on certain units, and some staff were not CPR certified. These failures resulted in actual harm and subsequent deaths for multiple residents who experienced acute changes in condition.
Removal Plan
- Educated the Administrator, DON, RDCS, and RDO on the facility CPR policy, emergency response processes, and code blue flow sheets related to how to respond to emergency situations and to notify others for help by use of walkie-talkie or overhead paging system.
- Provided education to department heads (Activities Director, Housekeeping Services Director, Assistant Director of Nursing, Medical Records Director, Maintenance Director, Director of Social Services, Minimum Data Set Director, Dietary Manager, Human Resources Director, Wound Care Nurse) on the CPR policy, emergency response processes, and code blue flow sheets.
- Educated all staff (CNAs, LPNs, RNs, housekeeping, receptionists, therapists, activities staff) on the facility CPR policy, emergency response processes, and code blue flow sheets.
- Assessed all residents for any acute changes in condition.
- Provided CPR recertification to nurses; removed nurses from the schedule until they received updated CPR recertification.
- Audited crash carts to ensure they were stocked and readily available for an emergency situation.
- Educated all clinical staff and validated that code statuses were updated; updated code status orders for three residents.
- Met to discuss future staffing for when closed units opened.
- Initiated education to all clinical staff, scheduler/HR, DON, and Administrator to ensure there was always a minimum of one staff member on the first floor.
- Implemented mock code blues on alternating shifts; audits to be documented on the code blue flow sheet and reviewed during QAPI.
- Added CPR policy training to new hire orientation and with staff; DON responsible for ensuring all new hires received the information and monitoring education.
- Added education topics to all new hire orientation training; ensured employees oriented at sister facilities completed all education topics prior to starting on the floor.
- Reviewed all resident care plans for accuracy.
- Ran audit report on all residents to assess for change of condition that was not addressed; DON/designee to audit reports.
- Completed a mock code blue drill to identify areas of struggle.
- Administered a hands-on and written post-test for all nurses working; demonstrated use of overhead page, locating code status in the electronic medical record, and use of walkie talkies; staff performed return demonstration.
- Initiated audit of the bed board code status to be reviewed and updated by the DON; results reviewed through QAPI.
- DON or designee to audit reports from the electronic medical record system to audit for any resident changes in condition; results reviewed through QAPI.
- Conducted interview questionnaires with first floor staff on how to obtain help during emergency situations; results reviewed through QAPI.
- Audited crash cart by the DON or designee to ensure all needed supplies are contained; results reviewed through QAPI.
- Audited first-floor staffing to ensure scheduled staff members are present as scheduled; results reviewed through QAPI.
- Provided additional one-on-one education to LPN #521 regarding what the Code Blue form was and when to utilize it.
Widespread Administrative and Care Failures Due to Leadership Instability
Penalty
Summary
The facility failed to administer operations in a manner that enabled effective and efficient use of resources to attain or maintain the highest practicable well-being of each resident. There was significant turnover in key administrative positions, with seven administrators, four Directors of Nursing (DON), and three Maintenance Directors within a year. This instability contributed to a lack of consistent oversight and failure to establish and maintain effective systems for compliance with federal, state, and local requirements. The facility did not provide evidence that administrative staff, including the Administrator and DON, had effective systems in place to timely identify and correct quality, care, and environmental concerns. Survey findings included multiple deficiencies across various domains of care and facility operations. These included failures in care planning for oxygen use, maintaining a clean and sanitary environment, proper garbage disposal, timely initiation of CPR or calling EMS, completion and documentation of showers and bathing, timely completion of physician-ordered labs, and accurate medical record documentation. There were also failures in ensuring an updated facility assessment for sufficient staffing, provision of corrective lens and vision care, complete orientation for new staff, sufficient competent staffing, and proper functioning of the quality assurance committee. Additional deficiencies were noted in monitoring resident food storage, supervision during smoking times, dating of oxygen tubing, completion of pharmacy reviews, physician notification of changes in condition, covering catheter drainage bags, and securing medications. Several of these deficiencies directly affected residents, including failure to initiate CPR or call EMS resulting in immediate jeopardy and death, lack of weekly skin assessments and documentation of change of condition and death, and failure to provide appropriate quality of care resulting in immediate jeopardy and death. The report documents that these failures had the potential to affect all residents in the facility, with specific residents identified as being directly impacted by the deficiencies.
Failure to Maintain Clean, Sanitary, and Homelike Environment
Penalty
Summary
Surveyors identified that the facility failed to provide a clean, sanitary, and homelike environment for its residents, as evidenced by multiple observations of unaddressed maintenance and housekeeping issues throughout the building. During several tours, surveyors noted peeling wallpaper, missing or damaged baseboards, exposed and damaged walls, stained and wet ceiling tiles, chipped and peeling paint, rust around sinks, and heating units with built-up dirt or missing covers. Bathrooms were found with dirty toilets, built-up dirt rings, and peeling wallpaper, while several rooms had visible dirt and debris behind doors, soiled privacy curtains, and improperly hung window or privacy curtains. Gnats were observed in one room, and there were reports of full urinals left hanging off garbage cans. These findings were verified by facility staff, including the Housekeeping and Laundry Supervisor, President of Plant Operations, and Maintenance Director. Interviews with facility staff revealed gaps in routine maintenance and cleaning practices. The President of Plant Operations admitted to not conducting regular site visits for general upkeep and cleanliness, and the Maintenance Director was new to the role. Housekeeping staff reported being short-staffed, which resulted in deep cleaning of resident rooms not being performed as scheduled. Documentation review showed that room rounds and inspections were inconsistently conducted, with no room checks recorded after mid-July, and the Regional Director of Operations was unable to confirm the frequency of these rounds due to being new in the position. Additionally, the deep cleaning schedule did not include the first-floor units, and daily cleaning checklists, while present, were undated and not consistently followed. Further review of facility records and communications indicated ongoing issues with the building's overall appearance and maintenance, including unaddressed cosmetic repairs, poor landscaping, and exterior disrepair. An email to facility leadership highlighted a backlog of cosmetic repairs that could be addressed with basic maintenance, and the TELS system for logging building repairs was not being addressed daily. The facility's policy on providing a homelike environment emphasized the importance of cleanliness and order, but the observed conditions and lack of consistent oversight and staffing led to non-compliance with this standard, potentially affecting all residents in the facility.
Failure to Provide Scheduled Showers and Bathing Assistance to Dependent Residents
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADLs), specifically showering and bathing, to multiple residents who were dependent on staff for these tasks. Record reviews, staff and resident interviews, and direct observations revealed that 12 residents did not consistently receive scheduled showers or appropriate documentation of bathing over a period of several months. In many cases, residents were scheduled for showers two times per week, but records showed only sporadic or single instances of showers or bed baths, with some residents going weeks without documented bathing. For example, one resident was scheduled for showers on specific days but only received one shower in a 30-day period, while another resident had no showers documented for two consecutive months. The affected residents had significant medical conditions and functional limitations, including end stage renal disease, hemiplegia, morbid obesity, chronic obstructive pulmonary disease (COPD), dementia, and quadriplegia, which made them dependent on staff for personal hygiene. Several residents were cognitively intact and able to report that they were not receiving showers as scheduled, while others were severely cognitively impaired and unable to advocate for themselves. Observations included residents appearing unkempt, with oily hair and signs of not having been bathed for an extended period. Documentation in both the facility's shower book and electronic medical record (EMR) was incomplete or missing for many scheduled showers, and staff interviews confirmed that showers were not always provided as required. Staff interviews revealed systemic issues contributing to the deficiency, such as inadequate staffing, lack of a dedicated shower aide on certain days, and unclear delegation of shower responsibilities when the assigned aide was unavailable. Staff reported being pulled to cover other duties, resulting in missed showers for residents. The facility's own policy required documentation of all showers, refusals, and interventions, but this was not consistently followed. The Director of Nursing confirmed that the available documentation accurately reflected the showers that were actually provided, indicating that the lack of care was not simply a documentation error but a failure to deliver the required assistance with ADLs.
Failure to Maintain Sufficient Competent Staff and Emergency Response Procedures
Penalty
Summary
The facility failed to maintain sufficient levels of competent staff to ensure residents received the care needed to maintain the highest quality of life. Two residents were directly affected, with six others at risk, due to inadequate staffing and lack of proper emergency response procedures. In one case, a resident with multiple complex medical conditions, including diabetes, COPD, schizophrenia, and dependence on supplemental oxygen, experienced a significant drop in oxygen saturation. The nurse on duty administered inhalers and BiPAP, but the resident's oxygen levels remained below normal. There was no evidence that the physician was notified or that adequate interventions were taken. When the resident was later found unresponsive, CPR was initiated, but there was a delay in calling 911 due to staff confusion and lack of familiarity with the facility's emergency procedures and equipment. The resident was ultimately pronounced dead at the hospital. In another incident, a resident with a history of pneumonia, COPD, diabetes, CHF, and severe cognitive impairment became short of breath and requested assistance. The nurse provided inhalers and attempted to obtain oxygen equipment from another floor, leaving the resident unattended. Upon return, the resident was found unresponsive. The nurse had to leave the floor again to seek help, as there was no immediate way to call for assistance. CPR was started without checking for a pulse, and the facility lacked an AED. The resident was transported to the hospital and later pronounced deceased. Staff interviews revealed that nurses and aides were often responsible for residents on multiple floors, and there was confusion about emergency protocols, including the existence of a code team and the use of code blue documentation. Observations and interviews further indicated that staff were not consistently present on the first-floor unit, and some staff were not CPR certified or aware of emergency response roles. The facility's assessment stated that staff training and competencies were to be maintained, but interviews with staff and review of records showed gaps in training, orientation, and emergency preparedness. The lack of clear procedures, insufficient staffing, and inadequate training contributed to delays and errors in emergency response, directly impacting resident care and outcomes.
Loose, Unlabeled Medications Found in Multiple Medication Carts
Penalty
Summary
Surveyors observed that multiple medication carts contained loose, unlabeled pills of various shapes and colors in their bottoms. Specifically, 15 loose pills were found in the Sycamore Hall cart, 20 in the Crystal Hall cart, and 5 in the Carousel Hall cart. Nursing staff, including RNs and LPNs, confirmed the presence of these loose pills and stated they were unable to identify the medications or determine to whom they were prescribed. These findings were corroborated through direct observation and staff interviews. A review of the facility's policy on medication storage indicated that drugs and biologicals should be kept in their original packaging, and nursing staff are responsible for maintaining proper storage. The failure to store medications in their original containers and the inability to identify the loose pills had the potential to affect 30 residents who received medications from the reviewed carts. The facility census at the time was 53.
Failure to Monitor and Maintain Safe Food Storage in Resident Room Refrigerators
Penalty
Summary
The facility failed to implement and enforce its policy regarding the use and storage of food in resident room refrigerators, specifically in relation to temperature monitoring for food safety. Observations and interviews revealed that several residents had personal refrigerators in their rooms, but there was inconsistency and confusion among staff regarding who was responsible for monitoring refrigerator temperatures. Some staff believed it was the responsibility of maintenance, others thought it was the CNAs, and some stated it was the nurses' responsibility. Multiple residents reported that their refrigerators were either not checked regularly or they were unaware of any monitoring taking place. Direct observations of the refrigerators in the rooms of four residents found that temperature monitoring logs were either missing, incomplete, or outdated. In one instance, a refrigerator contained expired food items, including a container of beef stew past its expiration date and a container of parmesan cheese that had expired over a year prior. The facility's policy required that food items be labeled, dated, and discarded after three days, and that unsafe or expired foods be removed by staff, but did not specify procedures for maintaining or monitoring refrigerator temperatures. The lack of clear procedures and consistent monitoring led to a situation where food safety could not be assured for residents storing personal food in their room refrigerators. The facility identified seven residents with personal refrigerators, but there was no systematic approach to ensure compliance with the policy or to safeguard against the storage of expired or unsafe food items.
Failure to Notify Physician of Significant Change in Resident Condition
Penalty
Summary
The facility failed to ensure timely physician notification of significant changes in condition for two residents. For one resident with multiple complex diagnoses, including COPD, diabetes, heart failure, and cancer, there was an order for full code status and hospice admission. The resident experienced coffee ground emesis, hypotension, and tachycardia, and while hospice was notified, there was no documentation that the physician was informed of these acute changes. The medical director later confirmed he was not made aware of the resident's deteriorating condition and stated that, had he been notified, he would have recommended transfer to the emergency room for evaluation. In a separate incident, another resident with a history of diabetes, COPD, heart disease, and stroke reported chest pain and constipation to an LPN during morning medication administration. The LPN checked vital signs and advised the resident to go to the ER, but the resident refused. Later, the resident was found unresponsive on the bathroom floor, and CPR was initiated before EMS arrived. There was no documentation that the physician was notified of the resident's chest pain prior to the unresponsive event. The medical director confirmed he was not informed of the chest pain, despite the resident's history of noncompliance with care. Facility policy required nursing staff to notify the physician of significant changes in a resident's condition, including accidents, injuries, adverse reactions, and major declines in health status. In both cases, the required physician notification did not occur as outlined in policy, resulting in a deficiency related to communication of changes in resident condition.
Failure to Provide Vision Services and Corrective Lenses as Ordered
Penalty
Summary
Resident #29, who has a history of diabetes mellitus with proliferative diabetic retinopathy and severe cognitive impairment, was not provided with corrective lenses or vision care appointments as ordered by physicians. The resident's care plan included interventions to arrange consultations with an eye care practitioner as required, and there were physician orders for both glasses and scheduled eye appointments. However, medical record review showed no documentation that the resident attended the scheduled optometrist or ophthalmologist appointments, nor was there evidence that these appointments were rescheduled or reasons documented for the missed visits. Additionally, the resident's prescription for glasses had expired, and there was no follow-up to obtain a new prescription or replacement glasses after the resident's glasses were reported missing. Interviews with facility staff, including the DON and regional directors, confirmed a lack of documentation regarding the missed appointments and the absence of a facility policy related to vision appointments or following physician orders for ancillary services. The resident's POA reported the missing glasses and noted that the resident did not have them during a leave of absence or recent visits. Observations confirmed the resident was not wearing glasses, and staff were unaware of their absence. The facility was unable to provide evidence of compliance with physician orders for vision care or corrective lenses for this resident.
Failure to Supervise Residents Requiring Smoking Supervision and Control Smoking Materials
Penalty
Summary
The facility failed to provide appropriate supervision for residents who required monitoring while smoking and did not ensure that residents did not possess smoking items in their personal belongings. Observations revealed that three residents were smoking outside without staff supervision during designated smoking times, despite facility policy requiring direct supervision for residents with restricted smoking privileges. The Administrator confirmed that staff supervision was absent and was unsure if the residents required supervision, but acknowledged that staff should have been present if supervision was needed. Medical record reviews for two residents showed that both had been assessed as requiring supervision for safe smoking and had signed contracts indicating that they were not permitted to keep cigarettes or smoking articles in their possession. Despite these requirements, one resident was found with an empty cigarette pack and a lighter in his room, and another resident was found with a pack of cigarettes hidden in his wheelchair cushion. Both instances were confirmed by the Director of Nursing, who acknowledged that these residents were not supposed to have smoking items in their possession. The facility's policy and staff orientation materials clearly outlined the need for supervision and restrictions on possession of smoking materials for certain residents. However, the facility did not enforce these policies, as evidenced by unsupervised smoking and residents retaining smoking items. The deficiency was identified during a complaint investigation and affected multiple residents who had been assessed as requiring supervision while smoking.
Failure to Complete Physician-Ordered Labs as Scheduled
Penalty
Summary
A physician order was placed for a resident to receive a Basic Metabolic Panel (BMP) and Complete Blood Count (CBC) every three months. Review of the resident's medical record showed that these laboratory tests were not completed as ordered on the specified date, with the last documented completion occurring several months prior. The care plan for the resident, who had multiple diagnoses including hemiplegia, type II diabetes, depression, and a history of substance abuse, included interventions to obtain lab results as ordered and notify the physician of abnormal values. However, there was no evidence that the required labs were performed as scheduled. Further review revealed that the resident had moderate cognitive impairment and was receiving several medications, including antidepressants, antiplatelets, and anticonvulsants. During interviews, facility leadership confirmed the lapse in completing the ordered labs and were unable to provide a facility policy regarding adherence to physician orders. This deficiency was identified during a complaint investigation and affected one resident among those reviewed for physician orders.
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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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