Highland Pointe Health & Rehab Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Highland Heights, Ohio.
- Location
- 402 Golf View Lane, Highland Heights, Ohio 44143
- CMS Provider Number
- 366440
- Inspections on file
- 32
- Latest survey
- January 20, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Highland Pointe Health & Rehab Center during CMS and state inspections, most recent first.
A resident with intact cognition, admitted for post-surgical care and mobility limitations, was listed as their own responsible party with only a sister documented as emergency contact. Despite this, staff discussed the resident’s pain medications, therapy goals, discharge plans, and other care details with the resident’s daughter and another family member, including via phone, an in-room care conference, and text messages. The resident later stated a preference that the facility not call the daughter, and there was no documentation authorizing these disclosures, contrary to the facility’s HIPAA privacy policy.
Two cognitively intact residents who required assistance with ADLs did not receive routine showers as ordered or care planned, with documentation showing only a single shower for each over multiple months. One resident reported having had only two showers since admission and described staff providing only bed wipe-downs and giving excuses when showers were requested, while a CNA stated she was unaware of the resident’s scheduled shower days. Another resident reported not being assisted out of bed or given a shower for about a month after a room change, with staff telling her she was not on a list; observation noted matted, greasy hair and a slight odor. A regional RN confirmed the absence of documented showers for both residents, despite facility policy requiring staff to perform ADL care including personal hygiene and transfers.
Two cognitively intact, fully dependent residents with bowel and bladder incontinence were not provided timely incontinence and toileting care as required by their care plans and facility policy. One resident reported being left soiled for hours on multiple nights despite using the call light, including an instance where an aide stated she could not provide care due to a lack of linens, and was later found by a CNA saturated in urine requiring a full bed change. Another resident, who served as resident council president, reported that multiple residents complained of prolonged periods without toileting assistance and herself was not changed overnight, later requiring a complete bed change. Staff interviews, including CNAs, an LPN, and a regional RN, confirmed that residents were found heavily soiled at the start of the day shift and that the CNA assigned during the prior evening and night failed to check and change residents, contrary to the facility’s ADL and toileting policy.
A resident with intact cognition, osteoarthritis, and a later-confirmed left hip/femur fracture had PRN orders for Tylenol and Methocarbamol for pain and spasms. During care, CNAs observed the resident’s leg in an abnormal position with visible bruising, and the resident was yelling in pain; an LPN assessed the resident and notified the physician, who ordered an x-ray. However, there was no documented comprehensive pain assessment at the time of the severe pain, and the MAR showed that only one dose of Methocarbamol was given several hours after the pain was first reported, with no Tylenol administered in the interim. Despite the facility’s pain management policy and the care plan interventions, PRN pain medication was not provided or documented in a timely manner following the resident’s complaints of severe pain.
A resident with dementia, mild cognitive impairment, and hallucinations was found with two unattended cups of medications in their room, one on a dresser and one on a nightstand, despite facility policy prohibiting leaving medications unattended and requiring observation of medication consumption. The resident reported not knowing when the medications were delivered and stated staff sometimes brought medications while the resident was sleeping. An LPN stated they had administered the resident’s morning medications and believed they were taken, later confirming that one cup contained the resident’s morning medications and that they did not know the origin of the other cup with three white pills.
Surveyors found that garbage bags containing soiled briefs, gloves, wipes, plasticware, and food were left on the ground around dumpsters with open lids and doors, allowing raccoons to access and scatter the waste. A resident and an LPN confirmed the ongoing issue with raccoons tearing open the bags, and it was noted that the facility lacked a policy for maintaining a sanitary dumpster area.
Surveyors observed debris such as utensils, gloves, paper straws, and linen on the floors throughout the halls, as well as food trays left on carts in resident areas and the dining room. A medication cart was also found with a powder-like substance along its bottom. These findings were confirmed by LPNs, and it was noted that there was no facility policy for daily maintenance of communal areas.
A resident on Coumadin for atrial fibrillation had an elevated INR, indicating excessively thin blood. Despite this, nursing staff failed to notify the physician or stop the medication, leading to the resident experiencing nose and gum bleeding. The resident called 911 and was hospitalized, where the INR was found to be critically high, requiring treatment with Vitamin K. The facility's failure to monitor and act on the elevated INR placed the resident at significant risk.
The facility failed to meet the care needs of residents, leading to multiple non-emergent calls to emergency services. Residents, including those with cognitive impairments, reported unmet needs such as unanswered call lights and lack of assistance with pain management and basic care. Despite awareness of the issue, the facility did not implement effective interventions to prevent residents from contacting emergency services for routine care.
A facility failed to provide sufficient nursing staff and timely access to electronic health records, resulting in delayed medication administration for 15 residents. An LPN, called in to cover a shift, did not receive EHR access until late, causing medications scheduled for the evening to be administered after 2:00 A.M. Residents and family members reported untimely care and unresponsive staff, with external entities like the fire department being contacted due to staff unavailability.
A facility failed to administer prescribed skin treatments for a resident with osteomyelitis, diabetes, and anemia. The resident's lac-hydrin cream was not documented as applied from early April to mid-May, and wound care for the left calcaneus was not completed as ordered. Interviews and records confirmed the facility's lack of awareness of new orders and the resident's non-compliance with care. Observations showed the resident had an air mattress and prafo boots, but treatments were not followed through, resulting in a deficiency.
A facility failed to administer pain medications as ordered for a resident with charcot neuroarthropathy and post-surgical pain. The resident was prescribed oxycodone ER and hydromorphone, but the medications were not administered according to the discharge orders due to incorrect transcription. The resident reported inadequate pain control, and a CNP confirmed the error. The facility lacked a specific Pain Management Policy.
A facility failed to maintain a medication error rate below five percent, resulting in a 6.66% error rate. A resident with dementia, hypertension, and depression received aspirin in the wrong form and an incorrect dose of vitamin C. A nurse confirmed these errors, which violated the facility's medication administration policy.
Failure to Protect Resident Health Information Confidentiality
Penalty
Summary
The deficiency involves the facility’s failure to maintain the privacy and confidentiality of a resident’s protected health information (PHI) by sharing medical and care information with an individual who was not documented as an authorized contact. The resident had been admitted for post-surgical care with difficulty walking and a need for personal care assistance, and an MDS assessment showed intact cognition. The resident’s demographic sheet listed the resident as their own responsible party, with only a sister documented as the emergency contact and no other contacts listed. Despite this, a nurse documented a phone call with the resident’s daughter in which the nurse discussed the resident’s pain medications, pain level, and use of PRN pain medication, and encouraged the daughter to call daily for updates. A subsequent progress note by social services documented that a care conference was held in the resident’s room with the daughter present, during which medications, orders, therapy goals, and discharge plans were discussed. Further documentation showed that the facility administrator later noted the resident’s daughter had called requesting a return call from the DON, and the resident stated he would update his daughter himself and preferred that the facility not call her at that time. Communication records in the form of text messages between social services and a family member of the resident showed additional disclosures of PHI, including information about the therapy appeal process, an upcoming appointment, discharge plans, and home health care. During interview, the social services staff member stated that at the time of the care conference the resident had allowed his daughter to receive information, but later asked that she not receive any more information, and that the resident had given permission to share information with his family member. The social services staff member confirmed there was no documentation of the resident’s permission to share information. Review of the facility’s HIPAA privacy policy showed that PHI may not be disclosed except as specifically permitted, indicating the documented disclosures were not supported by documented authorization.
Failure to Provide Ordered Routine Bathing and ADL Assistance
Penalty
Summary
The facility failed to provide routine bathing and personal hygiene care as ordered and care planned for two cognitively intact residents who required assistance with activities of daily living (ADLs). One resident, admitted with diagnoses including muscle weakness and need for personal care assistance, had a care plan indicating self-care deficits and interventions for assistance with grooming and dressing. The MDS showed this resident was dependent for bathing, personal hygiene, and toileting, and physician orders specified showers on Tuesdays and Fridays during day shift. Review of plan of care documentation for several months showed only one documented shower in January, with no showers documented in November or December. During interview, the resident reported having received only two showers since admission and stated that staff instead performed bed wipe-downs and often gave excuses when she requested a shower. A CNA interviewed at the same time stated she was unaware of the resident’s scheduled shower days, though she knew the resident had complained about not receiving showers. A second resident, also with muscle weakness and need for personal care assistance, required moderate assistance with bathing, personal hygiene, and bed mobility and was dependent for transfers. The care plan required assistance with ADLs and allowing extra time to complete them, and physician orders specified showers on Tuesdays and Fridays. Review of documentation for December and into January showed only one documented shower in January and none in December. During interview, this resident reported not being assisted out of bed or given a shower for about a month and stated that since changing rooms, staff told her she was not on a list and therefore had not been gotten out of bed. Observation at the time of interview noted the resident’s hair appeared matted and greasy and the resident had a slight odor. A regional RN confirmed the lack of documented showers for both residents. Facility policy on ADLs required appropriate staff to perform ADL care, including personal hygiene and transferring.
Failure to Provide Timely Incontinence and Toileting Care
Penalty
Summary
The deficiency involves the facility’s failure to provide timely incontinence care and toileting assistance to residents who were dependent on staff for these activities. One resident, admitted with muscle weakness and a need for personal care assistance, was care planned and assessed as incontinent of bowel and bladder and dependent on staff for toileting, with intact cognition. This resident reported being left soiled for several hours on multiple occasions, including one night when her call light for incontinence care remained on from 1:00 A.M. to 3:45 A.M. without staff response, and another night when she was not changed from approximately 5:00 P.M. until about 7:00 A.M. the next morning. She stated that when she requested help during the night, an aide told her she could not provide incontinence care due to a lack of linens, and the resident remained incontinent until the day shift provided care. A CNA confirmed that on a morning shift she found this resident saturated in urine and requiring a full bed change, and also stated she had frequently observed residents soiled at the start of her 7:00 A.M. shifts and that management was aware. Another resident, admitted with a history of stroke with left-sided weakness and muscle weakness, was also documented as cognitively intact, incontinent of bowel and bladder, and dependent on staff for toileting, with a care plan intervention to provide incontinence care after each episode. This resident, who served as resident council president, reported that multiple residents had complained about not receiving timely toileting assistance and remaining soiled for long periods. On a specific evening and night, this resident reported not being changed, and a CNA who arrived for the day shift stated that both this resident and another had been left incontinent overnight and required complete bed changes due to being heavily soiled. An LPN acknowledged being made aware that residents had not been changed during the evening and night shift, and a regional RN and the administrator confirmed that the CNA assigned to these residents during that time had failed to check and change residents on her assignment. Facility policy required staff to perform ADL care, including personal hygiene and toileting, but the observed and reported care did not meet these expectations.
Failure to Timely Assess and Manage Severe Pain for Resident With Hip Fracture
Penalty
Summary
The deficiency involves the facility’s failure to comprehensively assess and timely manage severe pain for a resident with a left hip/femur fracture. The resident, who had intact cognition and required extensive assistance with mobility and personal care, had PRN orders for Tylenol 650 mg every six hours and Methocarbamol 500 mg twice daily for pain and muscle spasms. The care plan identified the resident as being at risk for pain related to osteoarthritis, with interventions to administer medications as ordered and evaluate their effectiveness. On the evening in question, CNAs observed the resident’s left leg to be abnormally positioned, with the hip protruding and the resident yelling out in pain during incontinence care and repositioning. They immediately notified an LPN, who assessed the resident and noted the leg was rotated, with yellow-tinged bruising at the left hip, and the resident reporting pain in the left groin area. The physician was notified and an x-ray was ordered. Record review showed no evidence that a comprehensive pain assessment, including a pain rating and description of pain quality, was completed at the time the severe pain was identified. The x-ray later suggested a left hip fracture, and the resident was subsequently ordered to be sent to the hospital. The MAR indicated that only one dose of Methocarbamol was administered that day at 9:00 p.m., despite the resident having been yelling out in pain at approximately 6:30 p.m., and there was no documentation that Tylenol was given between the onset of pain and the resident’s transfer to the hospital. The self-reported incident and facility investigation initially indicated that pain medication had been administered, but review of the MAR confirmed that PRN pain medications were not given in a timely manner after the resident’s complaints of severe pain, and that documentation of pain assessment and pharmacologic intervention did not align with facility pain management policy.
Unattended Medications Left in Cognitively Impaired Resident’s Room
Penalty
Summary
The deficiency involves the facility’s failure to prevent medications from being left unattended in a resident’s room, contrary to facility policy requiring that medications not be left unattended and that staff observe residents consuming medications. Resident #19, admitted on 05/25/25 with diagnoses including dementia, mild cognitive impairment, and hallucinations, had an MDS assessment indicating impaired cognition. On 01/14/26 at 12:38 P.M., surveyors observed two separate medication cups in the resident’s room: one on a dresser under the television containing three white pills, and another on the nightstand next to the bed containing eight medications. During the observation, Resident #19 stated she was unaware of when the medications had been delivered and reported that staff sometimes brought medications while she was sleeping, leaving her unaware they were present. At 12:42 P.M., LPN #234 reported having administered the resident’s morning medications between 8:00 A.M. and 9:00 A.M. and stated she had observed the resident consume them. Upon observing the two medication cups, LPN #234 confirmed that the cup with eight pills contained the resident’s morning medications and acknowledged she did not know what the three white pills were, as she had not administered them. LPN #234 acknowledged that medications should not be left unattended in resident rooms. This failure to ensure medications were not left unattended affected one resident out of four observed for unattended medications during the complaint investigation.
Unsanitary Dumpster Area and Lack of Policy
Penalty
Summary
The facility failed to maintain a sanitary area around the garbage dumpsters, as observed during a survey. Several large bags of garbage containing soiled briefs, latex gloves, wipes, plasticware, and food were found on the ground surrounding three dumpsters. The dumpster doors and lids were left open, which allowed raccoons to access and pull out the garbage. These findings were confirmed by both a resident and an LPN, who stated that raccoons frequently come from the woods and tear open the bags. Additionally, a review of facility policies revealed that there was no policy in place regarding the maintenance of a sanitary dumpster area. This deficiency was identified during a complaint investigation and had the potential to affect all residents in the facility.
Failure to Maintain Sanitary and Homelike Environment
Penalty
Summary
The facility failed to maintain a sanitary and homelike environment for its residents, as evidenced by observations of miscellaneous items and debris scattered on the floors throughout the halls, including silverware, plastic utensils, latex gloves, paper straws, and linen. Dinner trays full of food were left on carts in resident halls and in the dining room, and a medication cart was found with a powder-like substance along its bottom. These conditions were verified by two LPNs during interviews, who acknowledged the presence of debris and noted that the medication cart drawers had been cleaned only a few days prior. Additionally, a review of facility policies revealed that there was no policy in place regarding the daily maintenance of communal areas by staff. The facility census at the time was 77 residents.
Failure to Respond to Elevated INR in Resident on Coumadin
Penalty
Summary
The facility failed to appropriately respond to an elevated International Normalized Ratio (INR) for a resident receiving Warfarin (Coumadin) for atrial fibrillation. On a specific date, the resident's INR was reported as abnormally high at 4.9, indicating that the resident's blood was too thin. Despite this, the nursing staff did not notify the physician or stop the administration of Coumadin, continuing to administer the medication on subsequent days. This oversight led to the resident experiencing nose and gum bleeding, prompting the resident to call 911 for emergency transport to the hospital. Upon arrival at the hospital, the resident's INR was found to be critically high at 7.2, necessitating treatment with Vitamin K to counteract the effects of the anticoagulant. The resident was hospitalized for ongoing care and treatment. The facility's failure to monitor and act on the elevated INR results placed the resident at significant risk for bleeding and continued blood loss. The deficiency was identified through a review of the resident's medical records, hospital records, and other documentation. It was found that the nursing staff, including specific LPNs, did not check the resident's PT/INR levels before administering Coumadin and failed to notify the medical provider of the abnormal INR levels in a timely manner. This lack of action and communication contributed to the resident's adverse health event.
Removal Plan
- Resident #11 was discharged to the hospital.
- The Director of Nursing (DON), Assistant Director of Nursing (ADON) #918 and Registered Nurse (RN) Unit Manager (UM) #922 reviewed Resident #11's medical record, medication administration record (MAR), progress notes and laboratory results (labs) to identify the root cause related to the bleeding incident.
- The facility identified the root cause as nursing staff including Licensed Practical Nurse (LPN) #883 and LPN #963 failed to check Resident #11's PT/INR level prior to administering Coumadin 7.5 mg to Resident #11 and failed to notify medical doctor (MD)/Certified Nurse Practitioner (CNP) #980 of Resident #11's abnormal INR level in a timely manner.
- The DON, ADON #918, RN UM #922 and Regional RN (RRN) #979 completed an in house audit and confirmed four residents resided in the facility who receive Coumadin including Residents #38, #44 #76 and #82.
- Resident records for Residents #38, #44, #76 and #82 were reviewed which included the lab reports, medication administration records (MARs), progress notes and care plans to ensure that abnormal labs were reported to Nurse Practitioner (NP) #980 in a timely manner and that Coumadin was not administered to residents with a PT/INR greater than 3.0, without negative findings.
- The DON, RN ADON #918, RN UM #922 and Regional RN #979 completed assessments/skin checks on Residents #38, #44, #76 and #82 (receiving Coumadin) to ensure the residents did not have signs of bleeding or bruising.
- RRN #979 completed competencies, in person with return demonstration, with the DON, ADON #918 and RN UM #922 to review PT/INR blood work prior to administering Coumadin and education was provided on reporting of abnormal labs to CNP #980 of the specific resident by the end of the shift.
- LPN #883 and LPN #963 (two nurses who were out of compliance related to the Immediate Jeopardy) were educated (in person) by the DON, with return demonstration, on checking residents PT/INR blood work prior to administering Coumadin and on reporting of abnormal labs to CNP #980 of the specific Resident by end of shift.
- RRN #979 completed an audit of the lab work for Residents #38, #44, #76 and #82. NP #980 was notified of all lab results.
- The audit revealed Resident #76's PT/INR lab work had an INR of 3.6 and the NP was notified and ordered to hold the Coumadin dose and repeat the INR.
- The DON, ADON #918 and RN UM #922 completed competencies with LPN #883 and LPN #963, in person with return demonstration, on checking residents PT/INR prior to giving Coumadin and to ensure that the lab results are reported to CNP #980 of the specific Resident by end of shift.
- The facility held an emergency Quality Assurance Performance Improvement (QAPI) meeting.
- The QAPI meeting was held to review the root cause, reviewed the facility abatement plan due to the nurses administering Coumadin prior to checking Resident #11's PT/INR labs and not notifying NP #980 responsible for Resident #11's care, by the end of the shift.
- The DON developed and implemented a PT/INR Coumadin flow sheet.
- ADON #918 and RN UM #922 were educated on the form, how to implement the form, when to use the form and what to do for abnormalities identified on the form.
- Both nurses would print Coumadin lab reports five days a week at Clinical Morning Meetings to review any changes in orders due to any abnormal lab results & to ensure the CNP of the specific resident was notified of the results by the end of the reporting shift.
- The Coumadin flow sheet was implemented by ADON #918 and RN UM #922.
- The form would be completed each time a blood draw was ordered with results received for each resident on Coumadin.
- The abnormal results would be reported to CNP #980 of the specific resident by end of the reporting shift.
- The DON, ADON #918 and RN UM #922 completed education in person and via phone to all 17 staff LPNs and all six staff RNs on checking residents' PT/INR results prior to giving Coumadin and to ensure that the lab results were reported to NP #980 of the specific resident by the end of the reporting shift.
- All 37 staff State tested Nursing Assistants (STNA) were educated on observing for abnormal effects of Coumadin including bleeding, bruising and black tarry stools and reporting abnormalities to the nurse.
- The facility also used agency staffing including four agency RN's, eight agency LPN's and five agency STNA's who work as needed in the facility.
- RRN #979 confirmed the agency staff members were educated over the phone and would not work in the facility unless they had received the education prior to their next scheduled shift.
- The facility indicated all new hires would receive the education during orientation.
- The DON, ADON #918 and RN UM #922 completed competencies to ensure 17 LPNs and six RNs were checking residents PT/INR prior to giving Coumadin and to ensure that the lab results are reported to NP #980 in a timely manner.
- To ensure ongoing compliance, the DON/ADON/UM/Designee would audit PT/INR lab results and timely notification of the residents' NP four times a week for three weeks.
- The audits would be completed beginning and the facility would then continue a monthly audit for the next two months, during clinical morning meetings, for verification the PT/INR results were reviewed and reported to the residents' NP as needed.
- The results of the audits would be forwarded to the facility QAPI committee for additional review and recommendations.
Residents Contact Emergency Services Due to Unmet Care Needs
Penalty
Summary
The facility failed to adequately and timely meet the care needs of its residents, leading to multiple instances where residents contacted local emergency services for assistance. This deficiency affected eleven residents, who made non-emergent calls to the police and fire departments due to unmet care needs, such as unanswered call lights and lack of assistance with pain management, basic care, and other routine needs. For example, one resident with dementia and moderate cognitive impairment called the police due to unaddressed leg pain, resulting in unnecessary hospitalization. Another resident with intact cognition called the police for help, but there was no evidence of assessment by the facility staff following the call. The report highlights several incidents where residents, including those with cognitive impairments and intact cognition, resorted to calling emergency services due to unmet care needs. One resident with dementia called the police twice in two days for assistance with a bedpan and vomiting, leading to hospitalization. Another resident reported abuse by a staff member, and yet another resident called the police to report a stolen wallet, which was not initially reported to the facility staff. These incidents indicate a pattern of residents feeling neglected or mistreated, prompting them to seek external help. Interviews with local police and fire department personnel revealed ongoing concerns about the frequency of calls from the facility's residents. The facility's administration acknowledged awareness of the issue but failed to implement effective interventions or measures to prevent residents from contacting emergency services for routine care and assistance. Despite attempts to investigate and address the root cause of the problem, the facility could not identify a specific pattern or cause for the increase in resident calls to emergency services.
Staffing and EHR Access Issues Lead to Delayed Medication Administration
Penalty
Summary
The facility failed to ensure sufficient nursing staff with the appropriate competencies and skills were on duty, which resulted in delayed medication administration for 15 residents. On the night of June 4th, 2024, LPN #401 was called in to replace another LPN who reported off duty. However, LPN #401 did not receive timely access to the facility's electronic health records (EHR), delaying the start of medication administration until around 10:00 P.M. This delay affected the administration of medications scheduled between 7:00 P.M. and 11:00 P.M., with some medications not being administered until after 2:00 A.M. the following day. The report highlights specific instances where residents did not receive their medications as ordered due to the lack of access to the EHR system. For example, Resident #5's medications, including Atorvastatin and Travoprost eye drops, were administered hours late. Similarly, Resident #12's medications, which included several critical prescriptions such as Atorvastatin and Levetiracetam, were also delayed. These delays were consistent across multiple residents, indicating a systemic issue related to staffing and access to necessary systems. Interviews with residents and their family members further corroborated the issue of insufficient staffing, with reports of untimely care and unresponsive staff during the night shift. Additionally, external entities such as the fire department were contacted by residents due to unresponsive staff, further emphasizing the severity of the staffing inadequacies. The facility's policies on staffing and medication administration were not adhered to, contributing to the deficiencies observed during the survey.
Failure to Administer Skin Treatments as Ordered
Penalty
Summary
The facility failed to administer non-pressure skin treatments as ordered for a resident, leading to a deficiency. The resident, who was admitted with osteomyelitis, diabetes, and anemia, had a care plan that included interventions for skin breakdown. However, the facility did not document the administration of lac-hydrin cream to the resident's feet as ordered by the podiatrist from April 1 to May 13. Additionally, the wound care treatment for the resident's left calcaneus was not completed as ordered from April 1 to May 23. The resident's medical records and interviews revealed that the facility was unaware of new orders for the left heel dressing changes after the resident's wound clinic visit. The resident reported that the dressings on his feet were not changed from April 1 to May 23, and the lac-hydrin cream was not applied as ordered. The facility's records confirmed the lack of evidence for the completion of these treatments. Interviews with facility staff and outside wound clinic personnel indicated that the resident's wounds were vascular in nature and not pressure-related. The resident was noted to be non-compliant with care, including turning, repositioning, and bathing. Observations showed that the resident had an air mattress and prafo boots in place, but the facility failed to follow through with the prescribed treatments, leading to the deficiency.
Failure to Administer Pain Medications as Ordered
Penalty
Summary
The facility failed to administer pain medications as ordered for a resident who had been discharged from the hospital with specific instructions for pain management. The resident, who had a history of charcot neuroarthropathy and had undergone left ankle fusion with an external fixator, was prescribed oxycodone ER and hydromorphone for pain management. However, the facility did not administer these medications according to the discharge orders. The resident's pain levels were monitored and recorded, showing varying levels of pain, but the administration of the prescribed medications was inconsistent and not in line with the orders. The issue was identified when a Certified Nurse Practitioner (CNP) assessed the resident and discovered that the hospital discharge orders had been transcribed incorrectly, leading to improper administration of the oxycodone ER. The resident reported that his pain was not being managed as effectively as before, and the CNP confirmed that the staff had not administered the narcotic pain medications as ordered. The facility's Medication Admin policy required medications to be administered according to prescribed times, but there was no specific Pain Management Policy available. This deficiency was investigated under multiple complaint numbers.
Medication Error Rate Exceeds Acceptable Limit
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent, resulting in a rate of 6.66%. This deficiency affected one resident, who was admitted with diagnoses including unspecified dementia, essential hypertension, and depression. The resident had physician orders for aspirin chewable 81 mg to be administered once daily and vitamin C 500 mg to be administered as two tablets once daily. However, during a medication administration observation, a registered nurse administered aspirin in an enteric-coated form instead of chewable and only one vitamin C tablet instead of the prescribed two. The nurse confirmed these errors during an interview. The facility's medication administration policy requires medications to be administered according to the physician's orders, which was not adhered to in this instance.
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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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