Liberty Retirement Community Of Lima Inc
Inspection history, citations, penalties and survey trends for this long-term care facility in Lima, Ohio.
- Location
- 2440 Baton Rouge Avenue, Lima, Ohio 45805
- CMS Provider Number
- 365936
- Inspections on file
- 34
- Latest survey
- March 19, 2026
- Citations (last 12 mo.)
- 24 (1 serious)
Citation history
Health deficiencies cited at Liberty Retirement Community Of Lima Inc during CMS and state inspections, most recent first.
A ventilator-dependent resident with a tracheostomy experienced an unrecognized and unmanaged decannulation during personal care when a CNA found the trach tube out and notified an agency LPN. The LPN, who reported having no orientation to the unit, no training on trach/vent care or decannulation procedures, and no knowledge of the location of emergency equipment, unsuccessfully attempted to reinsert the trach, then began chest compressions without providing supplemental O2 or using an Ambu-bag. When the RT and EMS arrived, they found the resident completely decannulated, dusky, and receiving compressions only; the RT reinserted the trach and initiated bagging with O2 while EMS continued CPR and transported the resident. EMS and hospital records documented that staff could not provide a history or send information with the resident, and hospital documentation and the death certificate attributed the subsequent cardiac arrest and death to hypoxic respiratory failure following trach dislodgement.
The deficiency involves multiple breakdowns in infection prevention and control, including improper handling of soiled linen, failure to follow Enhanced Barrier Precautions (EBP), and lack of an annual TB risk assessment. A resident with incontinence routinely placed saturated soiled laundry on the floor in a room corner, and housekeeping staff added wet soiled items directly to this floor pile before CNAs collected them. Two residents with orders for EBP—one with profound intellectual disabilities and tube feeding, and another with an indwelling urinary catheter and ESBL—received high-contact care such as incontinence care, dressing, transfers, and catheter bag handling from CNAs and an LPN who used gloves but did not don gowns, despite posted EBP signage and available PPE. The facility also lacked documentation of a required annual TB risk assessment for one year, which was confirmed by the IP despite a policy mandating yearly completion.
The facility failed to include required staffing analyses in its annual facility assessment. The assessment, covering a census of 47 residents, did not document staffing levels or the number and competencies of staff needed to provide necessary care and treatment. It also lacked consideration of specific staffing needs for each resident unit and each shift, and did not address how staffing would be adjusted based on changes in the resident population. The Administrator confirmed that the assessment did not contain the required staffing information.
Surveyors found a strong, pervasive urine odor on one hall, traced to a cognitively intact resident with incontinence whose soiled clothing and linens were routinely placed in a pile on the floor near the room door for staff to collect. The resident reported this occurred daily and that additional soiled items were added after housekeeping cleaned. CNAs and an LPN confirmed the malodor, the presence of saturated laundry on the floor, and a bagged soiled comforter the resident refused to have laundered, noting the odor was an ongoing problem and that some residents kept their doors closed because of it. Fourteen other residents lived on the same hall, despite a facility policy requiring a safe, clean, comfortable, and homelike environment with neutral scents.
The facility failed to prevent an accident hazard in meal service and to document resident falls as required. A cognitively intact resident with multiple chronic conditions was served chicken noodle soup that contained an approximately two‑inch chicken bone, which she discovered while eating alone in her room; dietary staff had used leftover fried chicken that was manually deboned for the soup, and several residents received this soup. In a separate issue, another cognitively intact resident with chronic respiratory and psychiatric diagnoses had unwitnessed falls that were recorded only in Risk Management documents, while IDT notes referenced fall investigations without dates, times, resident condition, or involved staff, and no corresponding nursing notes were entered despite facility policy requiring detailed fall documentation in the medical record.
Surveyors identified that an LPN administered two different ophthalmic solutions consecutively to a resident with glaucoma without waiting the manufacturer-recommended five minutes between drops, and the LPN stated she had not been trained to wait between eye drop applications. In a separate case, a resident with hypertension and a care plan for CVA related to hypertension had multiple documented systolic blood pressure readings above the ordered threshold for PRN clonidine, yet the MAR and progress notes contained no documentation that the PRN antihypertensive was administered on those occasions. The resident reported feeling his blood pressure was often too high, stated he did not recall receiving medication for high blood pressure, and reported that his cardiologist was not being informed of abnormal blood pressure readings, which the DON confirmed were not accompanied by documentation of PRN medication administration.
Surveyors found that staff failed to notify physicians and family representatives of significant changes in condition for two residents. One resident with hypertension and a PRN order for clonidine had multiple episodes of markedly elevated SBP documented over several months, without corresponding documentation that the MD or cardiologist was notified, despite care plan directives to report significant vital sign abnormalities. The resident reported feeling his blood pressure was often too high and stated his cardiologist said abnormal readings were not being reported. Another resident with severe cognitive impairment and multiple comorbidities experienced a documented significant weight loss, but the record contained no evidence that the physician was informed, contrary to facility policy requiring MD notification of significant weight changes. Leadership staff (DON and ADON) confirmed the lack of notification documentation in both cases.
A resident with severe cognitive impairment, dementia, and behavioral symptoms including wandering was observed seated in a wheelchair at the dining table on multiple occasions with the wheelchair locked on one side. A CNA reported that the resident could not operate the wheelchair locks and that staff locked the wheelchair to keep the resident at the table and prevent wandering during meals, despite acknowledging staff were not supposed to lock it. Facility policy states residents must be free from physical restraints not required to treat a medical symptom, making this use of the wheelchair lock a noncompliant restraint.
A resident with cognitive impairment and multiple comorbidities had recurrent redness and rash under the breasts, in the groin, and other skin folds documented repeatedly on shower sheets over an extended period, with notes that the condition had worsened and been present for months. A Wound NP later assessed the resident and diagnosed extensive fungal dermatitis with detailed measurements of affected areas. Despite this ongoing skin impairment and the facility policy requiring a comprehensive person-centered care plan with measurable objectives and timetables, no such care plan or documented interventions specific to the rash were found in the medical record, as confirmed by the MDS nurse.
A resident with cerebral palsy, profound intellectual disabilities, severe cognitive impairment, and total dependence for ADLs had a care plan calling for individualized, cognitively stimulating, and social activities, including room visits two to four times weekly and adapted activities based on assessed needs and preferences. Over several months, activity documentation showed only sporadic hand massages, occasional time sitting in a common living room, brief room visits, a single holiday party, and one instance of listening to music, with no evidence of consistent, care-planned programming. Surveyor observations twice found the resident sitting in front of a television in a common area without staff interaction. The AD confirmed that records did not support that the resident was offered or provided activities as outlined in the care plan, despite a facility policy requiring an ongoing, individualized activity program.
The facility failed to consistently assess, document, and follow up on wounds and skin conditions for three residents. One resident with multiple comorbidities had a left heel wound variably documented as a DM ulcer, pressure ulcer, and surgical site, with no ongoing measurements for an extended period and no follow-up wound clinic appointment scheduled despite a request from the clinic. Another resident with neurologic and psychiatric conditions had progressive redness and fungal dermatitis under the breasts, groin, abdomen, and buttocks repeatedly noted on shower sheets, while weekly skin assessments documented no issues and treatment for some affected areas was delayed; an antibiotic ordered by Urgent Care was also not administered. A third resident with DM and other complex conditions had a documented non-pressure traumatic sacral wound with ordered treatments provided, but the record lacked any documentation of the cause or type of trauma to the sacrum.
A resident with severe cognitive impairment and an indwelling catheter had documented purulent and greenish drainage, pain with urination, and UA results consistent with UTI, followed by a culture showing heavy pseudomonas growth and a handwritten Bactrim DS order that was never administered per the MAR. Over the following weeks, provider notes did not address urinary status, and no repeat UAs were obtained. Later, the resident complained of inability to void, had no catheter output, a distended hard abdomen, green foul-smelling penile discharge, and dark, odorous urine after catheter change, yet there was no documentation of physician notification or UTI-focused lab orders at that time. The resident was subsequently hospitalized and diagnosed with UTI, while facility policies required monitoring urine output and reporting changes in condition to the physician.
The facility failed to prevent significant medication errors for four residents. One resident returned from an outside visit with new orders for an antibiotic that was never documented as administered. Another resident with an indwelling catheter had a positive urine culture for pseudomonas and a physician order for Bactrim DS, but the MAR showed no doses given. A third resident with breast cancer had an oncology prescription for Verzenio that was not acted upon for several weeks despite the resident reporting she should be on a new cancer medication and staff contacting the oncology office without documented follow-up. A fourth resident with DM received Humalog insulin doses on several occasions when blood glucose values were below the ordered parameters, as confirmed by an RN.
A resident with multiple comorbidities, severe cognitive impairment, and an indwelling catheter had a urine culture that returned positive for MRSA following a physician-ordered UA. The abnormal result was obtained but not communicated to the physician for an extended period, and documentation showed the physician was not notified until much later, when an antibiotic was finally ordered for a UTI. The ADON confirmed the absence of timely notification in the record, despite a facility policy requiring nurses to review lab results and promptly notify the physician of significant abnormalities.
A resident with multiple chronic conditions, who was assessed as cognitively intact, was discharged without any documentation in the medical record of their discharge disposition, recapitulation of stay, or discharge arrangements. The record lacked a discharge summary, nursing discharge note, and post-discharge plan of care. The DON confirmed these omissions, which were inconsistent with the facility’s own policy requiring nursing to obtain discharge orders, prepare a discharge summary and post-discharge plan, and complete a discharge note prior to discharge.
A resident with chronic pain, ESRD on hemodialysis, heart disease, and mildly impaired cognition was found unresponsive, received CPR, and was transferred to a hospital where death was later confirmed. Although a nurse’s progress note described the event and attempts to phone family, the facility did not complete a discharge/transfer summary, did not document written notice of the transfer/discharge to the resident’s representative, and did not document that required discharge information was communicated to the receiving hospital. The SW and ADON both confirmed the absence of a discharge summary and other required transfer documentation in the medical record, resulting in a deficiency related to discharge documentation and communication requirements.
A resident with end stage renal disease, sexual dysfunction, major depressive disorder, and liver cirrhosis, who was cognitively intact and receiving dialysis, was not seen by a physician within the required initial 30-day period after admission. The first documented physician assessment occurred several months later, even though the resident had been seen by an NP and a PA during that time. Review of records and staff interview confirmed the absence of a timely physician visit, resulting in noncompliance with required physician visit frequency and timeliness.
The facility did not ensure timely and appropriate action on pharmacist drug regimen reviews for two residents. For one resident with multiple comorbidities receiving doxycycline, magnesium oxide, and ferrous sulfate, the pharmacist and physician agreed to separate administration times to improve absorption, but nursing staff did not change the MAR administration time for magnesium oxide as ordered. For another cognitively intact resident with DM, mental health diagnoses, paraplegia, and breast cancer, pharmacy recommendations for a gradual dose reduction of amitriptyline and clarification of two PRN lorazepam orders received limited physician responses and no further documented follow-up, despite facility policy requiring timely review, documentation of actions or rationale, and transcription of new orders.
Surveyors found that two residents received antibiotics without adequate justification, documentation, or defined duration. One resident with multiple chronic conditions and an indwelling catheter was given Cephalexin twice daily for infection prevention over an extended period with an indefinite stop date, no supporting lab results, and no current UTI, and the prescribing specialist was unaware of the ongoing therapy. Another resident with severe cognitive impairment and total dependence for ADLs was started on Cefdinir for a UTI by an NP, but the record contained no abnormal urinary signs, symptoms, or test results, and no urine culture was obtained before treatment. These practices did not follow the facility’s antibiotic stewardship policy requiring clear indications, start/stop dates, and appropriate clinical information for antibiotic use.
Surveyors observed a medication cart where two open multi-dose insulin vials for two residents (Lantus and Novolog) were not dated, and another insulin vial (Humalog) for a resident remained in use beyond the 28-day discard period. In the same cart compartment, fifteen small round yellow pills were found loose and unidentified. An LPN confirmed the vials were opened and undated or past the allowable use period and could not identify the loose pills. Facility policies required multi-dose vials to be dated and discarded within 28 days and all medications to be stored in their original containers, which was not followed in these instances.
A cognitively intact resident with multiple chronic conditions and identified risk for oral/dental problems received an initial dental exam, cleaning, and full mouth x-ray, with a note indicating possible need for an oral surgeon referral. The resident reported being told she would be notified when the dentist returned but was never informed of a follow-up visit, and no oral surgery appointment was scheduled despite her need for multiple tooth extractions and ongoing tooth pain managed with Tylenol. When the dentist later returned to the facility, the resident was not placed on the list to be seen, and facility staff could not explain the omission, contrary to facility policies requiring assistance with needed dental services and appointments.
A cognitively intact resident with multiple chronic conditions, including DM2, mental health disorders, paraplegia, and breast cancer, did not consistently receive preferred food items as indicated on meal tickets and as known by staff. On multiple observed meals, items such as 2% milk, cranberry juice, and yogurt were missing or provided in lesser quantities than ordered or routinely requested, leading the resident to refuse at least one meal. A CNA and an LPN confirmed that the resident’s usual preference for two milks and two yogurts at each meal was not consistently honored, despite facility policy requiring nutrition care consistent with individual preferences.
A resident with paraplegia and multiple comorbidities, who was cognitively intact and required set-up/clean-up assistance with eating, had meal tickets specifying the use of built-up utensils. On multiple observed meals, the resident’s trays did not include the ordered adaptive utensils, despite this requirement being clearly documented on the meal tickets and in facility policy. Staff interviews confirmed that the resident did not receive the built-up utensils as ordered.
The facility failed to timely treat and assess pressure wounds for two residents, leading to a deficiency. One resident returned from hospitalization with a pressure wound on the coccyx, but there was no treatment for 11 days, and wound assessments were inconsistent. Another resident was admitted with a sacral wound, but initial assessments lacked measurements and staging, with a significant gap in assessments. Interviews confirmed the lack of timely wound assessments, contrary to facility policy.
A resident with multiple health conditions did not receive their prescribed Diltiazem medication on several occasions due to a lack of communication and clarification between the facility and pharmacy. This resulted in the resident being sent to the hospital for a rapid heart rate. The facility's policy on medication administration was not followed, leading to a significant medication error.
The facility failed to honor meal preferences for two residents, both moderately cognitively impaired, by serving them items they explicitly disliked, such as eggs and sausage, despite these preferences being noted on their meal tickets. This was confirmed by CNAs and contradicted the facility's policy encouraging resident choice.
A facility failed to document and treat a resident's wounds accurately. The resident, with multiple diagnoses including dementia, had a care plan for potential wounds. A skin assessment noted rash areas on the hip, but subsequent documentation was incomplete. Staff interviews revealed a lack of official diagnosis or referral, despite treatment orders. The facility's wound management policy was not followed, leading to a deficiency investigation.
A facility failed to document and treat pressure wounds for a resident with multiple diagnoses, including dementia and end-stage renal disease. Despite a care plan for potential wound development, a pressure area on the resident's heel was not properly documented or staged. Subsequent assessments lacked necessary details, and the resident was not referred to a wound nurse practitioner, violating the facility's wound management policy.
The facility failed to employ a qualified dietary manager, affecting all residents who received food from the kitchen. The current Dietary Manager, promoted without a ServeSafe certification, confirmed she was in the process of taking the course. The previous Dietary Manager left the facility earlier in the month. The facility census was 51, with two residents not receiving food by mouth.
The facility failed to follow procedures for Legionella prevention and proper transportation of soiled linens. The Maintenance Director could not provide documentation of required visual checks, and a Nursing Assistant was observed carrying unbagged soiled linen and a soiled brief through a hallway near the dining room where a resident was eating breakfast.
The facility failed to appropriately store food and ensure the dishwasher was sanitizing, potentially affecting all residents who received food from the kitchen. Observations revealed expired items in the refrigerator, improperly stored frozen food, and a dishwasher that did not reach the required sanitization temperature. Staff confirmed these deficiencies, and the facility's policies were not adhered to.
The facility failed to prevent pungent urine odors from permeating common areas and the dining room, affecting all residents. Observations and interviews confirmed the presence of these odors over several days, despite housekeeping efforts. The facility did not adhere to its policy on maintaining a homelike environment with pleasant scents.
The facility failed to provide a dignified dining experience by not supplying knives with meals, forcing residents to struggle with cutting their food using only forks and spoons. This policy, attributed to a previous dietary manager, was not clearly understood or justified by current staff and affected residents' sense of dignity and self-determination.
The facility failed to follow menus and provide appropriate substitutions for 12 residents, and did not adhere to correct serving sizes for 10 residents. Incorrect meal components and portions were served, failing to meet residents' nutritional needs.
The facility failed to provide appropriate and engaging activities in the memory care unit, affecting multiple residents. Observations and interviews revealed that residents were often left watching television without engagement in meaningful activities, despite care plans indicating specific preferences and needs. The facility's policy on dementia care was not effectively implemented, leading to this deficiency.
A resident's request for instant macaroni and cheese was not promptly accommodated, resulting in a delay of over an hour and forty minutes. The STNA went on break without fulfilling the request, and the LPN did not ensure the request was promptly addressed, contrary to the facility's policy on person-centered care.
The facility failed to ensure timely documentation of code status for a resident with multiple serious diagnoses. The resident's hard chart lacked code status information, and the Ohio DNR CC form was not signed by a physician. The facility did not obtain a signed copy from the discharging hospital or ensure the medical director signed the current form, contrary to their policy.
The facility failed to implement timely interventions to prevent skin impairment for a resident with stage 4 pressure ulcers and did not ensure wound measurements were completed upon readmission. Despite the care plan indicating the need for frequent repositioning, the resident reported not being repositioned regularly, and staff interviews confirmed this lack of care. Observations over multiple days showed the resident remained in the same position for extended periods, and staff did not offer repositioning as required.
The facility failed to provide adequate supervision for two residents while they were smoking, despite both being assessed to require supervision and smoking aprons. Both residents were observed smoking without staff supervision, contrary to the facility's Resident Smoking Policy.
A facility failed to monitor medication for potential side effects, toxicity, and effectiveness for a resident with multiple diagnoses, including Parkinsonism and chronic kidney disease. The resident's medical record lacked necessary lab work to monitor cholesterol levels, kidney or liver enzymes, and Vitamin D levels, as confirmed by the DON.
The facility failed to ensure that lab tests were completed as per physician orders for three residents. The DON confirmed that the required tests were not conducted at the specified intervals, affecting residents with various medical conditions.
The facility failed to ensure pureed foods were made of appropriate consistency for two residents on a pureed diet. Observations revealed that the pureed meatloaf was soup-like and gritty, and the pureed mixed vegetables contained inadequately blended pieces. These issues were confirmed by staff interviews and taste tests.
The facility did not prominently post the location of the state survey results, affecting all 51 residents. Multiple residents were unaware of where to find the survey results, and observations confirmed the absence of such postings. The DON verified the lack of postings, although the survey results book was available at the front desk.
Failure to Provide Life-Sustaining Respiratory Care and Effective CPR After Tracheostomy Decannulation
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary life-sustaining respiratory services and effective CPR to a ventilator-dependent resident with a tracheostomy. The resident had diagnoses including acute and chronic respiratory failure, ventilator dependence, obstructive sleep apnea, pulmonary hypertension, and malnutrition, and was documented as a Full Code receiving invasive ventilation via a tracheostomy cannula. Her care plan included interventions to ensure trach ties were secured, to keep an extra trach cannula and obturator at the bedside, and a specific "cannula out" procedure directing staff to open the stoma with a hemostat, attempt reinsertion, monitor for respiratory distress, elevate the head of the bed, stay with the resident, and obtain medical help immediately if reinsertion was not possible. On the night of the incident, an agency LPN was assigned to the resident’s care. The LPN later reported she had not previously worked with the facility’s ventilator residents, had not been oriented to the unit or to the resident’s care plans, and had not received education on tracheostomy care, decannulation procedures, or the location of emergency equipment such as the crash cart and Ambu-bag. A CNA alerted the LPN that the resident’s trach had come out while care was being provided. When the LPN entered the room, she found the tracheostomy cannula lying on the resident’s chest and the resident unresponsive. The LPN attempted to reinsert the cannula but was unsuccessful, instructed the CNA to call the respiratory therapist and 911, and then began chest compressions when she could not obtain a pulse. During this period, the LPN did not provide supplemental oxygen and verified she did not know where the crash cart or Ambu-bag were located. The respiratory therapist, who had left the building at midnight after providing earlier trach and ventilator care and documenting that the resident was stable, was called back and arrived with EMS. Upon arrival, the respiratory therapist found the resident completely decannulated, very dusky, and with the LPN performing chest compressions but not providing oxygen via Ambu-bag or any other means. The respiratory therapist was able to reinsert the trach cannula, independently located the Ambu-bag in the gray basket on the ventilator, connected it to oxygen, and began ventilating the resident through the trach while EMS took over compressions. EMS documentation indicated that staff at the facility were unable to provide a history or information about the resident and that no information packet accompanied the resident to the hospital. Hospital records documented that the resident arrived in cardiac arrest secondary to hypoxic respiratory failure after the trach had been out for an undisclosed period of time, with initial blood gases showing respiratory acidosis and a clinical picture consistent with hypoxic respiratory failure leading to cardiac arrest. The death certificate listed anoxic brain injury secondary to cardiac arrest and hypoxic respiratory failure as the cause of death. Additional interviews and observations supported that staff were not adequately trained or prepared to manage tracheostomy emergencies. The agency LPN repeatedly told the respiratory therapist and EMS that she did not know where anything was for the resident or how to care for the trach when it became dislodged, despite having current CPR certification. The respiratory therapy manager confirmed there was no official training for agency nurses on caring for residents with tracheostomies on ventilators and stated that guidance was only contained in the care plans. A resident interview indicated awareness that a ventilator-dependent resident had died and that staff working that night were not trained to care for ventilator residents, and that there were no respiratory therapists in the building at night. Policy review showed that the facility’s CPR policy required provision of breaths via Ambu-bag after compressions, and the decannulation policy required calling 911, calling for a crash cart, attempting to reinsert the trach or establish an airway, and using an Ambu-bag with oxygen if there were no spontaneous breaths. Despite these written procedures and the presence of emergency supplies such as Ambu-bags and crash carts in the building, they were not effectively used during the resident’s decannulation and cardiac arrest, resulting in the identified deficiency.
Plan Of Correction
F695 On 10/05/25, Resident #54 was transferred to the hospital. On 10/05/25 at 6:00 A.M., Respiratory Therapist Manager (RTM) #242 verbally in-serviced both agency nurses, LPN #288 and LPN #302. Both nurses returned demonstration and reviewed printed policies and procedures in the agency binder after the incident occurred. This education included suctioning (both open and closed), how to measure the placement of the suction catheter, decannulation, how to use Ambu-bag and the competency checklist for respiratory nursing care for residents on ventilators and residents who have tracheostomy and the location of crash carts and Automated External Defibrillator (AED). On 10/07/25, CCO #300 and former Human Resource Manager (HRM) #303 in-serviced RNs and LPNs on Respiratory policies, CPR, supplemental oxygen, Trach and Decannulation. Policies and procedures were sent to all nurses via text message for immediate review. There was no documentation of receipt of the text to the staff.. On 10/07/25, CCO #300 and former HRM #303, in-serviced CNAs on personal care for residents with tracheostomies. Policies and procedures were sent to all CNAs via text for immediate review. There was no documentation of receipt of the text to the staff.. On 03/12/26 at 10:30 A.M., the Administrator and CCO #300 educated RTM #242 on the facility's requirements for nurses training for ventilator dependent residents, supplemental oxygen, tracheostomy care and emergency procedures. On 03/12/26 at 10:30 A.M., RTM #242 implemented an education binder to track and audit all facility and agency staff education documents. Beginning on 03/12/26 at 10:30 A.M., RTM #242 or designated Respiratory Therapist will train agency nursing staff on ventilator dependent residents care plans, protocols for tracheostomy care and emergency procedures for ventilator dependent and/or trach residents prior to providing care to residents. Competency checklist to be completed by Respiratory Therapist. This is a new standard practice going forward without an end date. On 03/12/26 at 10:45 A.M., RTM #242 re-educated and completed check-off on Competency Checklist for Respiratory Care for Nursing, Decannulation and Emergency Procedures for Registered Nurses (RNs) and LPNs. Education/Training included verbal, return demonstration and printed procedures. This was completed on 03/13/26. On 03/12/26 at 12:30 P.M., a Quality Assurance (QA) meeting was held immediately following notification of Immediate Jeopardy. This included CCO #300, the Administrator, LNHA, DON, Assistant DON, Minimum Data Set (MDS) Nurse, RTM #242, Infection Preventionist/Wound Nurse, Scheduler, Business Office Manager, Social Services, Activity Director, Maintenance Director, Dietary Manager, Therapy Manager, Housekeeping/Laundry Supervisor who met to discuss the 10/05/26 incident, education needed, policies and procedures to put into place. Beginning on 03/12/26 at 12:45 P.M., RTM #242 will complete a respiratory assessment for all at risk residents and ensure that residents are provided with respiratory care by trained staff. Completed by 03/13/26 at 4:00 P.M. Beginning on 03/12/26 at 1:30 P.M., the Director of Nursing (DON) and RTM #242, uploaded the acknowledgement procedure electronically to the Clipboard staffing agency to notify agency employees that our facility has vent/trach residents that require care outside of normal routine care. Agency staff must be trained by an RT on ventilator dependent resident care plans, protocols for tracheostomy care and emergency procedures for ventilator dependent residents and read and sign the Agency Nurse Binder at the nurse's station before starting their shift. This training will include verbal, return demonstration and printed procedures. Acknowledgement must be signed before the facility job positing applications will allow agency staff to pick up a shift at facility. DON verified posting on 03/13/26 8:05 P.M. On 03/13/26 at 3:00 P.M., RTM #242 completed Competency checklist and decannulation training for tracheostomy residents with Liberty Dialysis nurses. Training included verbal, return demonstration and printed procedures for respiratory needs of residents with tracheostomies. Completed on 03/12/26. Beginning on 03/12/26, LPN Scheduler #255, DON, and RTM #242 will attempt to schedule at least one facility licensed nurse trained by respiratory therapist per shift. LPN Scheduler #255 will notify DON and RTM #242 of any shifts that do not have a facility nurse trained by RT. In the unplanned event the facility would have two agency nurses working, the facility will have RT coverage or another licensed facility nurse in the facility who has completed training with a Respiratory Therapist for the duration of the shift. This will be ongoing practice, unless there are no residents with vents/traches in the facility. Beginning on 03/12/26, the DON or designated nurse manager and designated Respiratory Therapist will monitor schedule daily to ensure scheduling compliance with RTs and agency staff. Beginning on 03/13/26, the RTM #242 or designated Respiratory Therapist will monitor agency education binder daily to ensure all education documents are completed. This will be ongoing. Beginning on 03/13/26, the DON or designated nurse manager will audit the education binder weekly to ensure that Respiratory Therapist has trained all facility and agency staff. This will be ongoing. Beginning on 03/19/26 at 1:45 P.M., during the monthly Quality Assurance and Performance Improvement (QAPI) meeting with the Medical Director, a review of correction plan to ensure the training has been completed for all RNs, LPNs, agency and will be ongoing as needed. This will be reviewed at the quarterly QAPI meeting starting May 2026 and ongoing if the facility has residents that are ventilator dependent or have tracheostomy. Respiratory Department will provide additional training as needed outside of the regularly scheduled trainings. Beginning 04/01/26 and ongoing monthly, RTM #242 or the designated Respiratory Therapist will attend the monthly nurse and CNA meetings to provide ongoing education, review competency checklist and to ensure that staff are knowledgeable of policies and procedures related to residents on life sustaining mechanical devices and/or requiring CPR. This training will include verbal, return demonstration and printed procedures.
Removal Plan
- Transferred Resident #54 to the hospital.
- Respiratory Therapist Manager (RTM) #242 in-serviced agency nurses LPN #288 and LPN #302; both completed return demonstration and reviewed printed policies/procedures in the agency binder (suctioning open/closed, suction catheter placement measurement, decannulation, Ambu-bag use, respiratory nursing competency checklist for vent/trach residents, and location of crash carts/AED).
- Chief Compliance Officer (CCO) #300 and former Human Resource Manager (HRM) #303 in-serviced RNs and LPNs on respiratory policies, CPR, supplemental oxygen, trach care, and decannulation; policies/procedures were sent to all nurses via text message for immediate review.
- CCO #300 and former HRM #303 in-serviced CNAs on personal care for residents with tracheostomies; policies/procedures were sent to all CNAs via text for immediate review.
- Administrator and CCO #300 educated RTM #242 on facility requirements for nurse training for ventilator-dependent residents, supplemental oxygen, tracheostomy care, and emergency procedures.
- RTM #242 implemented an education binder to track and audit all facility and agency staff education documents.
- RTM #242 (or designated Respiratory Therapist) will train agency nursing staff on ventilator-dependent resident care plans, tracheostomy care protocols, and emergency procedures prior to providing care; Respiratory Therapist to complete competency checklist.
- RTM #242 re-educated and completed competency check-offs for RNs and LPNs on respiratory care, decannulation, and emergency procedures using verbal instruction, return demonstration, and printed procedures.
- Held a QA meeting with interdisciplinary team to discuss the incident, needed education, and policies/procedures to implement.
- RTM #242 will complete respiratory assessments for all at-risk residents and ensure respiratory care is provided by trained staff.
- DON and RTM #242 uploaded an acknowledgement procedure to the Clipboard staffing agency to notify agency employees that the facility has vent/trach residents requiring care beyond routine care.
- Required agency staff to be trained by an RT on ventilator-dependent resident care plans, tracheostomy care protocols, and emergency procedures and to read/sign the Agency Nurse Binder before starting shift; acknowledgement must be signed before agency staff can pick up a shift at the facility.
- RTM #242 completed competency checklist and decannulation training for Liberty Dialysis nurses caring for tracheostomy residents (verbal instruction, return demonstration, printed procedures).
- Scheduler, DON, and RTM #242 will attempt to schedule at least one facility licensed nurse trained by an RT per shift; scheduler will notify DON/RTM #242 of shifts without a facility nurse trained by RT.
- If two agency nurses are working unexpectedly, the facility will provide RT coverage or another licensed facility nurse who has completed RT training for the duration of the shift.
- Will not admit any resident with a tracheostomy or ventilator needs until an RT is present in the facility.
- Will not admit ventilator or tracheostomy residents off-hours or on weekends if an RT is not available.
- DON (or designated nurse manager) and RTM #242 (or designated RT) will monitor the schedule daily to ensure compliance with RT and agency staffing requirements.
- RTM #242 (or designated RT) will monitor the agency education binder daily to ensure all education documents are completed.
- DON (or designated nurse manager) will audit the education binder weekly to ensure a Respiratory Therapist has trained all facility and agency staff.
- During QAPI meeting with Medical Director, review the correction plan to ensure training completion for all RNs, LPNs, and agency staff; continue review at QAPI meetings while the facility has vent/trach residents.
- RTM #242 (or designated RT) will attend nurse and CNA meetings to provide ongoing education, review competency checklists, and ensure staff knowledge of policies/procedures for residents on life-sustaining mechanical devices and/or requiring CPR (verbal instruction, return demonstration, printed procedures).
Failure to Follow EBP, Handle Soiled Linen Properly, and Complete Annual TB Risk Assessment
Penalty
Summary
The deficiency involves failures in the facility’s infection prevention and control program related to handling of soiled linen, adherence to Enhanced Barrier Precautions (EBP), and completion of the annual tuberculosis (TB) risk assessment. For one resident with acute and chronic respiratory failure with hypoxia, type 2 diabetes with hyperglycemia, chronic kidney disease stage 3, and mixed bladder incontinence, the resident reported placing soiled laundry on the floor in the corner of the room every day for staff to collect. On one occasion, housekeeping staff also picked up the resident’s wet soiled laundry and placed it directly on the floor in the same corner. A CNA later confirmed the laundry was saturated and had not been previously known to be on the floor, verifying that soiled linen was being stored on the floor of the resident’s room. The facility also failed to follow its own EBP policy for two residents who had orders for EBP. One resident with cerebral palsy, profound intellectual disabilities, seizures, hypertension, and dysphagia had an order for EBP and tube feeding via Isosource 1.5. An EBP sign and PPE (gown, gloves, goggles) were present at the room, and staff acknowledged the resident was on EBP. However, during incontinence care and tube feeding administration, the CNA and LPN only used hand hygiene and gloves and did not don gowns as required for high-contact care activities under EBP. Another resident with hemiplegia, type 2 diabetes, bladder dysfunction, hypertension, an indwelling urinary catheter, and ESBL colonization also had an order for EBP. During dressing, transfer with a sit-to-stand lift, and handling of the urinary catheter collection bag, two CNAs wore gloves but did not wear gowns, despite signage and available PPE and their acknowledgment that gowns should be used for EBP care. Additionally, the facility did not complete the TB risk assessment on an annual basis as required by its policy. Documentation showed a TB risk assessment was completed on one date in 2026, but there was no documentation that a TB risk assessment had been completed in 2025. The Infection Preventionist confirmed the absence of documentation for a 2025 TB risk assessment, despite the facility’s policy stating that a TB risk assessment shall be conducted annually to determine appropriate administrative, environmental, and respiratory protection controls based on the current TB risk classification.
Plan Of Correction
F880 Infection Prevention and Control The PoC will what corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice. Resident # 3 no longer has linen on the floor. Employee #239 removed the linen on 3-11-2026. The linen is removed with each change by STNA's as all nursing was in-service by Ip by 3-31-26. STNA audits were started 3-31-26 and are ongoing. Enhanced barrier precautions for residents #39 and 40 are posted and PPE are placed on their doors. On 3-31-2026 the signs were verified as posted by the infection preventionist. Education to all nurses by 4-9-26 and audits per IP ongoing. Currently EBP are being used for these residents. The TB Risk Assessment was completed day of survey by the infection preventionist. IP in-serviced by corporate nurse on day of survey to complete annually. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. All 47 residents have the potential to be affected by this deficient practice. The sweep completed byIP of these residents didn't yield any further deficiencies. completed 3-25-26. What measures will be put into place or what systemic changes you will make to ensure that the deficient practice does not recur. All staff including cna#245,#230,#282 and LPN #202. have been in-serviced by DON/designee for a time ending 4-9-2026 to properly handle linen, and education of enhanced barrier precautions. The TB risk assessment was in-serviced to the infection preventionist and DON by corporate nurse on 3-13-26. How the corrective action will be monitored to ensure the deficient practice will not recur. Audits began 3-19-2026 by infection preventionist nurse observing that observations of staff providing care for three residents with EBP are being conducted five times a week to ensure staff are using PPE, 5 x a week for 4 weeks and rounds are in place to ensure soiled linen is not on the residents floor, 5xa week for 4 weeks both done per nursing management. Annual audit of TB risk assessment is in place every march by QAPI team. Results of all the above submitted weekly to QAPI committee until substantial compliance is achieved. If concerns are identified during the audits staff will be rein serviced.
Failure to Include Required Staffing Analysis in Facility Assessment
Penalty
Summary
The deficiency involves the facility’s failure to include required staffing assessments in its annual facility-wide assessment. The facility assessment, updated in March 2026, did not document staffing levels needed to ensure there were a sufficient number of staff with appropriate competencies and skill sets to provide the necessary care and treatment for the resident population. The assessment lacked information on how staffing needs were determined based on the care required by the 47 residents in the facility, as required by the regulation. The assessment also did not contain any documented consideration of specific staffing needs for each resident unit or how staffing would be adjusted based on changes in the resident population. In addition, there was no documentation addressing specific staffing needs for each shift (day, evening, night) in relation to changes in resident acuity or population. During an interview, the Administrator confirmed that the facility assessment did not contain the required information regarding specific staffing required for the resident population.
Plan Of Correction
F838 Facility assessment The building administrator has completed a facility-wide assessment as of 4-9-2026 and determined the resources necessary to care for its residents completely during day-to-day operations, including nights weekends and emergencies. Also including staffing numbers and staff with appropriate competencies and skill. The administrator was in serviced the expectations of what is included in the Facility 3-17-26 by corporate nurse. This could affect 47 out of 47 residents. Sweep of the residents completed 3-28-2026 by management team didn't reveal any negative outcomes as a result of this practice. The administrator will audit for the changes needed in the facility assessment monthly, to begin 4-9-2026. The facility assessment will be submitted to the monthly QAPI for approval. and monitored in quarterly QAPI
Failure to Maintain Clean, Odor-Free Environment on Resident Hall
Penalty
Summary
The deficiency involves the facility’s failure to provide a clean, sanitary, and homelike environment on one hall, particularly in the room of Resident #3. Resident #3, who was cognitively intact and admitted with diagnoses including acute and chronic respiratory failure with hypoxia, type 2 diabetes mellitus with hyperglycemia, and stage 3 chronic kidney disease, required set-up/clean-up assistance with toileting, showering, and personal hygiene and had mixed bladder incontinence. Her care plan directed staff to check frequently for incontinence, cleanse the perineum, apply barrier cream, change clothing as needed, and encourage the use of a chux pad and open brief in the chair during the day, with the resident notifying staff when she needed changing. Surveyors observed a strong, pervasive urine odor on the 600 hall during the initial tour and again on a later date, and staff confirmed the odor was coming from Resident #3’s room. Upon entering Resident #3’s room, surveyors observed a pile of laundry near the door. The resident reported that she places soiled laundry on the floor near the door every day for an aide to collect, and that the pile present had been there since earlier that morning; she also stated that when housekeeping came to clean, additional soiled laundry was added to the pile. CNAs confirmed the hall was malodorous, verified the presence of soiled clothing, and reported there was a bagged soiled down comforter in the room that the resident would not allow the facility to launder and was awaiting family pick-up. One CNA stated the odor on the hall was always a problem and that some residents had requested their doors be shut due to the odor; she also stated she had not known the soiled linen was on the floor until the survey and later verified that the collected laundry was saturated. Another resident on the hall confirmed preferring her door shut at times because of the odor. Fourteen other residents lived on the same hall, and the facility’s Homelike Environment policy required a safe, clean, comfortable environment with pleasant, neutral scents.
Plan Of Correction
F584 Safe/Clean/Comfortable/Homelike The PoC will what corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice. Resident # 3 met with the care conference team on 3-25-26 to discuss plans to manage the resident's mattress pad when soiled and a plan to manage behaviors related to toileting assistance. Nursing staff are rounding, monitoring linen placed on the floor by the resident, and removing linen when providing care. These rounds began 3-20-26. Resident # 3 has improved, clean, comfortable /homelike as of 3-26-26. The mattress pad is being laundered by the facility as of 4-9-26. Resident #3 was assessed for any negative effects from this deficient practice and she made it very clear that she is fine and does not believe she has any odor. Resident has no infection control concerns as a result of soiled linen and odor in her room. The assessment was completed by Infection preventionist nurse by 4-9-26. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. Residents affected by the odor on the 600 hall are a total of 17. The residents involved are (#2, #4, #9, #12, #13, #17, #21, #25, #33, #34, #35, #40, #42, #49 and all per interview state, they do not notice any pervasive odors. All 600 hall residents have been interviewed by the social services/designee and none are complaining of a pervasive odor as of 3-19-2026. What measures will be put into place or what systemic changes you will make to ensure that the deficient practice does not recur. Education for nursing and housekeeping to provide a clean and sanitary environment, and odor control. was completed on 4-9-2026 by DON and the housekeeping director. The mattress cover will now be laundered in the facility laundry and rounds in place by nursing and housekeeping to prevent soiled linen on the floor and to frequently mop the floor. How the corrective action will be monitored to ensure the deficient practice will not recur. Daily round audits began 3-30-26 by housekeeping 5x a week x4 weeks by housekeeping director or designee, resident #3s room, and a random 5 rooms on the 600 hall for linens on the floor or soiled floors. Nursing rounds are routinely conducted throughout the 600 hall, monitoring for soiled linen, clothes on the floor and pervasive smells. CNA rounds are routine and ongoing audits beginning 4-9-26. The social worker began 4-8-26 to interview 5 residents a day, 5 xs a week for 4 weeks, for complaints of odor. If concerns arise, the social worker will notify housekeeping and nursing managers to review what has caused the odors. If nursing or housekeeping audits reveal concerns, the room will be cleaned, and laundry pursued with staff reeducated. Results submitted to the weekly QAPI with further follow through. Random social service audits are completed daily, interviewing residents on the 600 hall 5x a week X 4 weeks
Failure to Prevent Food Choking Hazard and to Document Resident Falls
Penalty
Summary
The deficiency involves the facility’s failure to ensure meals were free from choking hazards and to maintain required documentation of resident falls. One cognitively intact resident with multiple chronic conditions, including COPD, heart failure, diabetes, hypothyroidism, and major depressive disorder, was observed eating lunch alone in her room with the door closed. After the meal, an approximately two‑inch chicken bone was found in her soup bowl. The resident confirmed she had eaten chicken noodle soup and discovered the bone while eating. A staff member verified the presence of the bone, and the Dietary Manager reported that leftover fried chicken from a recent meal had been deboned by dietary staff for use in the soup. A facility-provided list showed that eight residents were served chicken noodle soup at that meal. The facility’s food and nutrition policy stated that food would be prepared to be nutritious, palatable, attractive, and safe to meet individual needs. The facility also failed to follow its fall policy and document falls in the medical record for a cognitively intact resident with chronic respiratory failure, obstructive sleep apnea, delusional disorders, and anxiety. Interdisciplinary team notes on two separate dates indicated that fall investigations had been completed and interventions reviewed, but these notes did not include the date or time of the falls, the resident’s condition after the falls, or the staff involved. Nursing notes contained no documentation of these falls. Risk Management documents, labeled as not part of the medical record and not to be copied, showed the resident had unwitnessed falls on two dates. The DON confirmed there was no nursing documentation related to these falls in the electronic medical record, and the ADON confirmed that, per the facility’s fall policy, nurses should document falls in the nurse’s notes, including assessments and details of the circumstances of the fall.
Plan Of Correction
F0689 Free of Accident Hazards/Supervision/Devices The PoC will what corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice. Resident #34 per the interview with the resident by the administrator, she found that the bone in her soup, but the resident stated she had not been harmed by it, she had not eaten it, and would prefer that type of soup. Residents #3, #4, #8, #15, #21, #41, and #46 were served the same chicken soup on the day of the survey, but per social services, all of those residents did not see any bones in their soup and didn't choke or have any negative effects from the soup. No other resident in the facility received chicken soup that day.no other residents had potential to be affected by the deficient practice n 3/10/26 Resident #6 was sent to the hospital post fall and a nurse wrote an IDT note written upon return 12/2/25 with interventions. She has healed s/p fall at this time. The PA stated on 4-9-26 that the resident's injuries from fall are currently healed. Falls sweep was conducted by DON and Adon going back a week. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. All facility of falls post survey on March 26,2026 has identified that all residents that have fallen have documentation, interventions, and post-fall follow-up. The potential to be affected by the deficient practice was no one else other than the affected resident and the additional seven who had been served soup that day; no other residents had the potential to be affected by the deficient practice on 3-10-26 per the dietary manager. As of 3-10-26 shredded chicken has been purchased, and the dietary manager has been monitoring for bones in the shredded chicken with each meal a day 5x days a week X4 weeks. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur. DON/designee in-serviced all nurse to write the post-fall nurse's notes to include head-to-toe assessment of the resident, the position observed, from bed or chair, in room, bathroom, etc, and what the resident was doing, transferring from bed to chair, attempting to walk to the bathroom, etc. Describe any injury observed; skin tears, laceration, bruising, swelling, limited range of motion, suspected fractures. The in-service was completed 4-9-2026.Fall investigation to include witness statements and root cause analysis as well as IDT note. Dietary manager did an in-service for her kitchen staff to verify that the food will be prepared in a form to accommodate resident allergies, intolerances, and personal, religious, and cultural preferences based on reasonable efforts. Provided food and drink will be nutritious, palatable, attractive, and at a safe and appetizing temperature to meet individual needs. And a decision made only shredded chicken has been purchased on 3-33-26 for chicken soup and checked by DM/designee for chicken bones before preparation. How the corrective action will be monitored to ensure the deficient practice will not recur. The dietary manager/designee has an audit of food quality and presentation 5x a week x 4 weeks, including monitoring shredded chicken for bones to ensure the food is safe to eat. Submit findings to the weekly QAPI Committee. DON/designee audit all falls daily 5X a week X4 weeks falls documentation written description of fall root cause analysis idt note with intervention and post-fall note to ensure there are no repeat falls or inuries. Findings are submitted to the weekly QAPI committee if concerns are found, a follow-up investigation is completed, and further education is done for nurses involved.
Failure to Follow Ophthalmic Administration Guidelines and PRN Antihypertensive Orders
Penalty
Summary
The deficiency involves failures in pharmacy services and medication administration, including not following manufacturer instructions for ophthalmic medications and not administering an ordered PRN antihypertensive medication when clinical parameters were met. For one resident with diagnoses including unspecified dementia, essential hypertension, chronic kidney disease, mixed hyperlipidemia, and glaucoma, physician orders directed the use of brimonidine tartrate ophthalmic solution and dorzolamide-timolol ophthalmic solution, each to be instilled as one drop in both eyes twice daily. Manufacturer instructions for both ophthalmic products specified that when more than one topical ophthalmic drug is used, they should be administered at least five minutes apart. An LPN reported she did not know she was supposed to wait five minutes between eye drops, stated she does not wait, and that no one who trained her waited between eye drop applications. Surveyor observation confirmed that the LPN administered the two different eye drop solutions consecutively without waiting five minutes, and the LPN verified she did not wait between administrations. The deficiency also includes failure to administer a PRN antihypertensive medication as ordered for another resident. This resident had a history including pelvic fracture, chronic pain, PTSD, depression, epilepsy, hypertension, and a care plan focus for cerebrovascular accident related to hypertension, with interventions to monitor vital signs, notify the physician of significant abnormalities, and administer medications as ordered. A physician order directed clonidine 0.1 mg by mouth every eight hours as needed for systolic blood pressure (SBP) greater than 170. Review of the MAR showed multiple dates on which the resident’s SBP exceeded 170 (including readings of 219, 206, 183, 172, and 175), with no documentation that the PRN clonidine was administered on those dates. Further review of the resident’s progress notes from December through February revealed no documentation of administration of the ordered PRN clonidine during the periods when elevated SBP values were recorded. The resident reported concern that his blood pressure was often too high, stated that staff were monitoring his blood pressure, and reported that his cardiologist indicated no one from the facility was reporting blood pressure abnormalities. The resident also stated he could not recall receiving medications for his high blood pressure. The DON confirmed there was no documentation in the medical record of the resident receiving the PRN blood pressure medication on the dates when SBP readings were above the ordered threshold and that there were no explanatory notes corresponding to a MAR notation to “see notes.”
Plan Of Correction
F755 Pharmacy Srvcs/Procedures/Pharmacist/Records The PoC will what corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice. Resident 22 is receiving ophthalmic drops per order with a 5-minute wait time between drops. An assessment of resident #22 was completed on 4-9-26 by the infection preventionist with no negative effects. The order was written to remind the nurses to wait 5 min between medication administration. the order was rewritten on 3/31/26 by unit manager. Resident #24 was audited on 3-31-26 by the DON and continues to receive clonidine as prescribed related to BP parameters. Resident #24 was assessed for negative effects on 4-9-26 by the infection preventionist, and none were identified How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. All the residents in the facility that have eye gtt orders, there are 3 and have bp with parameters, there are 3, have the potential for this practice. A sweep of all residents with eye gtts was done 3/29/26 by nurse manager and a sweep of BP with established parameters completed 3/29/26 by the DON. These residents are in compliance with med pass. The eye gtt orders have been reviewed and written to include proper sequence of administration by MDS and ADON . Residents who have established medication parameters for blood pressure medication could also be affected by this practice but have been educated and are currently being audited for compliance What measures will be put into place or what systemic changes you will make to ensure that the deficient practice does not recur. DON/designee in-service all nurses in eye gtt sequencing and leave the insert with the medication to review. Additionally, nurses were in- serviced to monitor the MAR for identified parameters and follow the guidance and document. This in-service was completed 4-9-2026 How the corrective action will be monitored to ensure the deficient practice will not recur. On 3/29/26 DON/designee are auditing all residents with eye gtts 3X a week X 4 weeks for observation of medication administration with 5 min between multiple eye gtts. All of the residents with BP parameters are being audited by observation of administration and MAR 3x a week by the DON for medicating residents according to BP parameters all to ensure administration of residents with multiple eye drops will be administered at least five minutes between medicated eye drops and medication was administered according to BP parameters) Results are presented to QAPI committee weekly. If the audit reveals concerns, the nursing will be reeducated post audit.
Failure to Notify Physicians and Families of Significant Changes in Condition
Penalty
Summary
The deficiency involves the facility’s failure to notify physicians and family representatives of residents’ changes in condition as required by policy. For one resident with diagnoses including pelvic fracture, chronic pain, PTSD, depression, epilepsy, and hypertension, the care plan directed staff to monitor vital signs and notify the medical doctor of significant abnormalities. Physician orders included clonidine 0.1 mg by mouth every 8 hours as needed for systolic blood pressure greater than 170. Vital sign records showed multiple elevated systolic blood pressures, including 171, 174, 206, and 219 over several months. Progress notes from early December through mid-March contained no documentation that the physician was notified of the elevated blood pressures on specific dates when readings were 206 and 219. The resident reported concern that his blood pressure was often too high and stated that his cardiologist had informed him that no one from the facility was reporting abnormal blood pressure readings. The DON confirmed there was no documentation of notification to the primary physician or cardiologist regarding these high blood pressures. The deficiency also includes failure to notify the physician of a significant weight loss for another resident with diagnoses including diabetes mellitus, Down’s Syndrome, Hirschsprung’s disease, and morbid obesity, who had severe cognitive impairment and was dependent on staff for activities of daily living. A weight loss note documented that this resident’s weight decreased from 241 pounds to 183.7 pounds over several months, constituting a significant weight loss. The medical record did not contain documentation that the physician was notified of this significant weight loss. The ADON confirmed the absence of documentation supporting physician notification. Facility policy on impaired nutrition and unplanned weight loss required staff to report any significant weight gains or losses or abrupt or persistent changes from baseline appetite or food intake to the physician. This deficiency was investigated under a specific complaint number.
Plan Of Correction
This plan of correction constitutes a written allegation of substantial compliance with federal Medicare and Medicaid Requirements. Submission of this plan of correction does not constitute an agreement that the deficiencies actually exist, nor is it an admission that they existed. This submission is a good-faith expression of the facility's desire to fully comply with Medicare and Medicaid requirements. F580 Notify of changes The PoC will determine what corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice. Resident #24 continues to be monitored for blood pressure as ordered, and the physician, cardiologist, and resident have been notified of the ongoing results per ADON beginning 3-24-26. Resident #24 was assessed by the DON for any negative effects on 4-9-26, and none were identified. Resident # 51 is no longer in the facility. How will you identify other residents having the potential to be affected by the same deficient practice, and what corrective action will be taken? All residents in the building who have a change in condition could be affected by this practice. A sweep of residents on 3-28-26 by Nursing managers identified that the MD and the responsible party had been called to the physician and family by the MDS nurse starting 3-24-26. What measures will be put into place or what systemic changes you will make to ensure that the deficient practice does not recur The DON/Designee educated all nursing staff by 4-9-2026, to notify physicians and responsible parties of any changes in conditions. The weekly Nutrition at Risk meeting results were called to the physician and family by the MDS nurse starting 3-24-26. What measures will be put into place or what systemic changes you will make to ensure that the deficient practice does not recur The DON/Designee educated all nursing staff by 4-9-2026, to notify physicians and responsible parties of any change in condition, including parameters set by the physician. Weekly/ monthly weights are discussed in the weekly nutrition at Risk meeting and MDS nurse/designee was trained by DON on 3-31-36 to notify significant changes to MD and family/resident. Corrective actions will be monitored to ensure the deficient practice will not recur. During daily morning clinical and standdown the DON/designee reviews all progress notes, labs, and assessments and verifies that the physician and responsible part is notified of any change in condition, significant weight loss or gains and abnormal results identified with established parameters. DON/designee audit 5x w X 4 weeks with results submitted to QAPI committee weekly.If any concerns are identified with the audits the issue is immediately corrected (notifications completed) and parties involved reeducated.
Improper Use of Wheelchair Lock as Physical Restraint During Meals
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from physical restraints not required to treat a medical symptom. The resident was admitted on 10/06/23 with diagnoses including unspecified dementia, hyperlipidemia, recurrent major depressive disorder, anxiety disorder, and cognitive communication deficit. A Minimum Data Set (MDS) assessment dated 02/02/26 documented that the resident was severely cognitively impaired, required set-up/clean-up assistance with eating, and was dependent for toileting, showering, and personal hygiene. The resident also exhibited occasional behaviors of physical aggression, verbal aggression, other behaviors, rejection of care, and wandering. On 03/11/26 at 10:34 A.M., the resident was observed alert, seated in a wheelchair at the dining room table, with the wheelchair locked on the left side. A subsequent observation at 11:49 A.M. the same day showed the resident still at the dining room table eating lunch in the same location, with the wheelchair again noted to be locked on the left side. During an interview at 2:22 P.M., a CNA stated that the resident was not able to lock or unlock the wheelchair and explained that staff locked the wheelchair to ensure the resident remained at the table and did not wander during meals. The CNA also verified that staff were not supposed to lock the wheelchair. The facility’s abuse and neglect policy states residents must be free from any physical restraint not required to treat a medical symptom, indicating that the practice of locking the wheelchair for behavior control was inconsistent with facility policy.
Plan Of Correction
F604 Right to be free of physical restraints The PoC will what corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice. Resident # 30 is free of restraint. Resident #30 was assessed by the DON for any negative effects from being placed at the table with the WC locked on one side on 3-17-26, with no negative outcomes. On 3-17-26, going forward, the residents' chair is not locked when sitting at the table. How will you identify other residents having the potential to be affected by the same deficient practice, and what corrective action will be taken? Reviews of residents who resided on the same unit with a dementia diagnosis have the potential for the same practice. An audit of these residents done by the MDS nurse or DON began on 3-24-2026 and resulted in no evidence of restraint use. On-going, there will be a random sample of 5 residents five days a week for four weeks. The audits began 3/24/26, and if any concerns are noted, they will be immediately corrected and staff re-inserviced. What measures will be put into place or what systemic changes you will make to ensure that the deficient practice does not recur. On or by 4-9-2026 DON/designee educated nursing staff in "The right to be free of any physical restraints". Reminder notice for nursing staff placed at the nurses' station by the DON on 4-8-26 that no residents shall have their wheelchairs locked while sitting at the dining tables. How the corrective action will be monitored to ensure the deficient practice will not recur. An audit is in place to review residents on Florence for their wheelchairs that they are not being locked when the residents are seated independently The auditor is the RN MDS nurse, The DON ensures the audits are being completed. The audits began 3/24/26, and if any concerns are noted, they will be immediately corrected and staff re-inserviced. A random sampling of 5 residents, 5 days a week X4 weeks, with results submitted weekly to QAPI meeting for the QAPI team to evaluate the success of if any further guidance is needed.
Failure to Develop Comprehensive Care Plan for Ongoing Fungal Dermatitis
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan addressing an ongoing skin rash for a resident with multiple medical conditions, including cerebral infarction with left hemiplegia, mood disorder, HTN, and epilepsy. A quarterly MDS assessment documented moderate cognitive impairment and a need for staff assistance with ADLs, but indicated no skin issues. However, repeated shower sheet documentation over the course of two months noted redness under both breasts and in the groin area, with staff recording that the redness had worsened and that it had been present for months. Interventions documented on the shower sheets were limited to lotion, powder, and brief notations, without evidence of a formal, measurable care plan. Further review of the medical record showed that a Wound NP later evaluated the resident and diagnosed extensive fungal dermatitis involving the skin folds under both breasts, the periumbilical area, groin, and buttocks, with specific measurements recorded for several affected areas. Despite this documented, ongoing rash and subsequent wound evaluation, there was no evidence in the medical record that a comprehensive person-centered care plan with measurable objectives and timetables was developed to address the skin impairment. The MDS nurse confirmed the absence of such a care plan or documented interventions to treat or prevent worsening of the rash, and the facility’s care plan policy required a comprehensive person-centered care plan for each resident to meet physical, psychosocial, and functional needs.
Plan Of Correction
F656 Comprehensive Care Plans The PoC will what corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice. Resident # 10 has a new care plan that contains a comprehensive person-centered care plan to address an ongoing rash and interventions in place to treat/prevent worsening of the rash per MDS nurse on 3-12-26. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. A review of all like residents with wounds supports that they all have care plans related to their wounds in place.Completed by MDS nurse on 3-24-26. What measures will be put into place or what systemic changes you will make to ensure that the deficient practice does not recur. Corporate nurse in-service the MDS nurse on 3-24-26 that the facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident issues. The care plan must be done immediately upon collecting the information. How the corrective action will be monitored to ensure the deficient practice will not recur.audits began on 3/25/26 by DON/designee. All residents with skin conditions will be audited weekly by the DON to ensure that there is a care plan in place to address the skin condition . DON is doing a weekly audit reviewing all skin conditions X4 weeks X 2 months. Findings submitted to weekly QAPI committee. If a concern is found during the audit correction will be done by the MDS nurse and further redirection and education done.
Failure to Provide Care-Planned, Individualized Activities for a Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide activities that met a resident’s assessed needs, preferences, and cognitive capabilities. The resident had cerebral palsy, profound intellectual disabilities, seizures, hypertension, and dysphagia, with an MDS showing severe cognitive impairment and total dependence on staff for ADLs. The care plan dated 01/23/24 documented that the resident was dependent on staff for emotional, physical, spiritual, creative, and community activities, with goals to maintain involvement in cognitive stimulation and social activities and to participate in room visit programming two to four times weekly. Interventions included inviting the resident to scheduled activities, ensuring activities were compatible with physical and mental capacities and adapted as needed, and monitoring room visits and providing sensory-stimulating interventions. Activity documentation from January through March 2026 showed limited and infrequent activities for the resident, consisting mainly of occasional hand massages, being up in the living room, room visits, small chats, and one Valentine’s Day party and one instance of listening to music in the room. No other activities were documented beyond these few entries in each month. Observations on two separate days in March showed the resident sitting in a common area in front of a television, with no staff interaction noted and, at one time, no staff present while the resident and others watched television. In an interview, the Activity Director confirmed that the documentation from January to early March 2026 did not support that the resident was offered or provided activities as care planned for the resident’s preferences and needs, and that activities provided on some days were limited to being up in the living room, in the room with music on the television, and hand massages. This was inconsistent with the facility’s activity policy requiring an ongoing program based on each resident’s comprehensive assessment, care plan, and preferences.
Plan Of Correction
F0679 activities The POC will what corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice. Resident # 40 has a new activities plan based on her particular needs utilizing the comprehensive assessment , care plan and preferences were done on 3-18-26 by the activities director. The new activities plan was created by the activities director on 3-18-26. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. Residents identified with similar cognitive and physical delays have been screened for appropriate activity plans. Residents who are identified with intellectual disabilities by diagnosis or low BIM scores and have community and individual activities ongoing to meet their needs. Sweep done 3-19-26. The activity director did the sweep and there were no negative concerns during the sweep. What measures will be put into place, or what systemic changes you will make to ensure that the deficient practice does not recur. The activities director was educated on 3-17-26 by administrator that the facility has an on-going program to support residents in their choice of activities, both facility sponsored groups and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community considering the residents level of functioning. How the corrective action will be monitored to ensure the deficient practice will not recur. Audits of proper activities began 3-19-26 The administrator/designee is auditing for activities that meet the needs of the residents with cognitive and intellectual delays, utilizing proper activity programming weekly X 4 weeks. Results being submitted to the QAPI committee. Concerns identified from the audit will be addressed, and the activity director will be further directed in proper activities by the administrator or classes.
Failure to Consistently Assess, Document, and Follow Up on Wounds and Skin Conditions
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate treatment and care according to orders, and to accurately and consistently assess and document skin conditions and wounds for multiple residents. For one resident with acute osteomyelitis, DM, PVD, CHF, and anemia, the medical record showed inconsistent documentation of a left heel wound, alternately described as a DM ulcer, a pressure ulcer, and a surgical site. The quarterly MDS did not document a surgical wound, despite other records indicating the presence of a left heel wound that had been debrided in the hospital and categorized as a surgical wound with serosanguinous drainage. A wound clinic note documented a left heel pressure ulcer with surgical site and sutures, but a later wound physician note contained no documentation that the facility addressed the left heel wound. For this same resident, the facility had a physician order to cleanse the left heel and apply petroleum gauze and a silicone bordered dressing three times per week and as needed, and the wound nurse confirmed that these treatments were being performed. However, the wound nurse also stated that the facility had not measured the left heel wound from the time the resident was last seen at the wound clinic until the survey date, because they relied on the wound clinic to monitor the wound. The outpatient wound RN reported that the resident was last seen at the wound clinic in mid-January for evaluation of a left heel pressure ulcer with surgical site, and that the clinic had called the facility in early March to schedule a follow-up appointment but did not receive a return call. This resulted in a lack of ongoing wound measurements and a missed follow-up wound clinic appointment for the resident’s left heel wound. Another resident, admitted with cerebral infarction with left hemiplegia, mood disorder, HTN, and epilepsy, had repeated documentation on shower sheets over multiple dates indicating redness under both breasts and in the groin area, with notes that the redness had worsened and that powder had not worked and had been present for months. Despite this, weekly skin assessments during the same period documented no skin issues. A weekly wound observation later identified fungal areas under both breasts and the belly button, but without measurements. Physician orders existed for miconazole cream under the breasts, later changed to antifungal powder, and additional orders were written for antifungal cream to the buttocks, oral Diflucan, and later Benadryl for itching. A wound NP note documented extensive fungal dermatitis under the breasts, in the groin, umbilicus, and buttocks, with erythema and odor, and provided specific measurements for several areas. The DON confirmed that weekly skin assessments in January and February did not document the rash and that no treatment was initiated for the groin or umbilical rash until late February, and also confirmed that Keflex ordered by Urgent Care for fungal infection of the skin and candidal intertrigo was not administered. A third resident with DM, Down’s Syndrome, Hirschsprung’s disease, and morbid obesity had a non-pressure wound to the left sacrum documented by a wound NP as a trauma/injury with specific measurements and moderate serous exudate and slough, later described as a full-thickness trauma wound that underwent surgical debridement. A physician order directed daily cleansing of the sacral wound and application of calcium alginate with bordered gauze, and records showed treatments were completed as ordered. However, the medical record did not contain documentation of what caused the trauma or what type of trauma occurred to the sacrum. The MDS nurse confirmed that there was no documentation in the record to identify the cause or type of trauma to the sacral area. These combined findings for three residents demonstrate failures in ongoing assessment, timely and accurate documentation, and follow-through with ordered or recommended wound-related care and evaluations.
Plan Of Correction
F684 Quality of Care The PoC will what corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice. Resident #2 wound is healed per wound nurse 4-31-26.No further follow-up wound clinic appointment was needed or scheduled. Resident #10 has a treatment for rash which was ordered by the wound CNP and written by the wound nurse this order was written 3/18/26 which is demonstrating improvement and resident #51 is no longer in the facility. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? All residents in the facility have the potential for an identified practice census of 47. A sweep of residents to include any skin and wound conditions was done by 3-25-2026 by the wound nurse and certified wound nurse practitioner. The wound nurses look for any skin issues, and the wound nurse practitioner sees all residents with any skin concerns. (treatment order was in place, follow-up appointments with wound clinic had been scheduled), accurate assessments were in place, and the cause of wound injury/trauma had been The facility has no residents requiring treatment from an outside wound clinic; all current skin/ wound conditions have been described and measured. What measures will be put into place or what systemic changes you will make to ensure that the deficient practice does not recur. DON/designee in-service all nurses in proper management of skin and wound issues. The resident's wounds must be reported, documented, and the MD notified. The areas F 0684 must be assessed completely and described in progress notes with origin. Treatment order in place. Residents going to the wound clinic are expected to be measured in the facility and assessed by the wound nurse with proper documentation. Education includes the importance of scheduling follow-up appointments. This is an oversight by the wound care nurse. The in-service period is ongoing, ending 4-9-2026. Wound nurse and DON were in-serviced 3-26-26 by the corporate nurse this inservicing also includes the need to schedule follow-up appointments. How the corrective action will be monitored to ensure the deficient practice will not recur. Weekly audits 5x week for 4 weeks per wound nurse /designee for residents with wounds. The audit includes observation of the wound and documentation.to ensure wounds are being accurately and continually assessed and the cause of trauma is being documented. The daily audit of all shower sheets to identify any new skin concerns to ensure there is no skin issue that goes without being identified and treated, reported to MD and the responsible party. The daily shower sheet is are audited by the wound nurse, and the wound nurse reports findings from the daily audit sheets in the morning clinical meeting. Weekly assessment of skin for all residents per wound nurse/designee. The shower sheet audit is reported in the morning clinical meeting and if any issues are identified, the wound nurse immediately calls the CNP and educates caregivers. Audits for skin are 5x week, ongoing. Results submitted to the QAPI committee. any concerns corrected and reeducation completed. Wound clinic appointments are monitored by the wound nurse and schedule is reported in morning clinical. monitored weekly by DON.
Failure to Manage Catheter-Associated UTI and Notify Physician for Change in Urinary Status
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary care and treatment for a resident with an indwelling urinary catheter who exhibited signs and symptoms of a urinary tract infection (UTI). The resident had multiple medical diagnoses including diabetes mellitus, Down’s syndrome, Hirschsprung’s disease, and obstructive and reflux uropathy, and was severely cognitively impaired and dependent on staff for ADLs. The resident had an order for a 16 French catheter to straight drain with catheter care every shift and as needed. On 04/09/25, nursing documentation noted purulent drainage from the catheter site, a small amount of grey-green drainage from the catheter, and the resident’s complaint of pain with urination. A UA with reflex culture was ordered on 04/11/25, and the UA showed yellow, turbid urine with positive hemoglobin, nitrates, WBCs, and RBCs, and a urine culture was ordered. On 04/14/25, the physician progress note documented the resident was seen for a UA concerning for UTI and that an antibiotic was being started, with no other complaints. The catheter was changed on 04/16/25 per the monthly schedule. The 04/16/25 urine culture showed greater than 100,000 pseudomonas, and the paper copy of the culture had a handwritten order for Bactrim DS twice daily for seven days with an illegible signature. However, the April 2025 MAR contained no documentation that Bactrim or any other antibiotic was administered, and subsequent physician notes on 04/22/25 and 04/30/25 did not address urinary status. The NP monthly note dated 05/19/25 also did not address urinary status. The MDS nurse later confirmed that Bactrim was not administered as ordered and that no repeat UAs were obtained in April or May 2025. On 05/23/25 at 5:30 A.M., a nurse’s note documented that the resident yelled out that he could not urinate, the catheter had no output, the abdomen was distended and hard, and a CNA reported no urine output for the entire shift. The nurse removed the old Foley catheter, observed a large amount of green foul-smelling discharge from the penis, inserted a new catheter using sterile technique, and obtained 500 cc of dark, odorous urine, with a culture collected. There was no documentation that the physician was notified of these UTI symptoms or decreased urinary output, and the only new order on 05/23/25 was for a genital culture, which later showed normal flora, with no orders for UA or other labs related to UTI symptoms. The record also lacked documentation of physician notification or the reason for the resident’s transfer to the hospital on 05/28/25, where the resident was diagnosed with UTI, atypical pneumonia, and GERD and prescribed Levofloxacin. Facility policies on urinary catheter care and change of condition required observation and reporting of changes in urine output and resident condition to a nurse and physician, but the documented care and communication did not reflect adherence to these policies.
Plan Of Correction
F690 Bowel/Bladder Incontinence, Catheter, UTI The PoC will what corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice. Resident #51 is no longer in the facility. How you will identify other residents having the potential to be affected by the same deficient practice, and what corrective action will be taken? Residents residing in the facility with indwelling catheters may be affected by the same practice. There are currently 7 residents with catheters in the building. All seven have been assessed on 4-2-26 for symptoms of UTI by the infection preventionist and none have current symptoms of UTI 4-2-26. At the time of assessments, there were no concerns What measures will be put into place or what systemic changes you will make to ensure that the deficient practice does not recur. DON/designee educated the nursing staff on or before 4-9-2026 about the necessary care and treatment of catheter care to prevent catheter-associated urinary tract infections (UTI). This education includes symptoms of UTI. Nurses and STNAs were educated to identify and report a change in a resident's baseline mental, behavioral, or physical status to a nurse and a medical doctor. The nurse would assess the resident's condition based on the information reported. Staff were inserviced on symptoms of UTI. Emergency care for the residents would be provided if appropriate and /or necessary, the physician would be notified if warranted, emergency services would be contacted for transport if warranted, and the party responsible would be notified of a change in mediation or treatment or if the resident was transferred for acute care . Monitor closely for medications ordered. The facility will ensure that the deficient practice does not recur. How the corrective action will be monitored to ensure the deficient practice will not recur. Audits of residents all 7 residents with catheters are being audited weekly by DON/ or designee. If there are more catheters in place they will be added to the number of residents with catheters being audited. The DON/designee will audit for care and signs of infection by observation of the resident, interview with the resident and reviewing progress notes. audit started 4-1-2026 and are ongoing 5xaweek for 4 weeks. Results are supplied to the QAPI team weekly. If concerns are identified, the MD will be notified and staff reeducated in the process of assessing for uti and care and treatment to prevent UTIs.
Failure to Prevent Significant Medication Errors for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were free from significant medication errors, affecting four residents reviewed for medication administration. One resident with cerebral infarction, left hemiplegia, mood disorder, HTN, and epilepsy was seen at Urgent Care for a widespread rash and excoriation, where Keflex and Diflucan were ordered for a fungal skin infection and candidal intertrigo. The resident returned to the facility with these new orders, but the medical record contained no documentation that Keflex was ever administered as ordered, which was confirmed by the DON. Another resident with DM, Down’s syndrome, Hirschsprung’s disease, morbid obesity, and an indwelling catheter had purulent and grey-green drainage from the catheter site and complained of pain with urination. A UA with reflex culture was ordered, and the culture later showed greater than 100,000 pseudomonas, with a handwritten physician order on the report for Bactrim DS twice daily for seven days. Review of the MAR for that month showed no documentation that Bactrim was administered, and the MDS nurse confirmed the antibiotic was not given as ordered for the urinary tract infection. A third resident with breast cancer, HTN, major depressive disorder, and osteoarthritis had an oncology order and prescription for Verzenio 150 mg PO twice daily for cancer treatment. The resident later told nursing staff she was supposed to be on a new oncology medication, and the oncology office was called with a message left, but there was no documented follow-up or clarification. Subsequent oncology documentation showed the resident still had not received Verzenio, and the drug was not ordered by the facility physician or administered until several weeks after the original prescription date. A fourth resident with acute and chronic respiratory failure with hypoxia, type 2 DM with hyperglycemia, and CKD stage 3 had insulin orders specifying administration only when blood sugar exceeded certain thresholds, yet insulin doses of 18 units and 2 units were administered on multiple dates when blood glucose values were below the ordered parameters. A nurse interview verified that insulin had been given outside the prescribed parameters.
Plan Of Correction
F760 Residents are Free of Significant Med Errors The PoC will what corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice. Resident #51 is no longer in the facility. Resident # 10 received an order from a visit to urgent care, Keflex, that was never taken off and 3/18/26 the wound CNP stated to not take off the Keflex order but continue with Diflucan instead due to the diagnosis of fungal rash on 3/18/26. Resident #10 was assessed by the wound CNP, and the rash is improving per wound CNP on 4-7/26. Resident #3 has blood sugar parameters for insulin coverage the previous order was revised by ADON PA on 3/27/26. Resident assessed by MDS on 4-9-26-26 with blood sugars stable over the last month. Staff have been in-serviced, and audits support the resident is receiving correct doses of insulin. ADON reviewed and revised blood sugar orders 3/27/26 Resident #53 is no longer in the facility How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. All residents in the facility have the potential for the same practice. An audit of all orders on 3-19-26 ensures orders are correct and medication is in place. Parameters for glucose administration reviewed and revised 3/27.26 by ADON. A sweep of antibiotics prescribed was completed 3/25/26 with all having a diagnosis and stop date. This was completed by DON. What measures will be put into place or what systemic changes you will make to ensure that the deficient practice does not recur. DON/designee in serviced nursing staff to 1. Retrieve and review any orders from appointments 2. Monitor closely and follow parameters set for insulin coverage. 3. To medicate residents within the accepted standards of practice, applying state local and standard laws. also Nurses were in serviced on what a significant med error is and details of antibiotic stewardship including diagnosis to support the antibiotic. Completed 4/9/26 How the corrective action will be monitored to ensure the deficient practice will not recur. A daily audit is in place done by DON or designee began on 3/26/25 to review MARs to ensure insulin had not been administered outside parameters. an audit begun 3/31/26 to review orders received from all appointments are written per DON/designee, an audit began 3/31/26 to ensure a diagnosis is in place to support the antibiotic order per unit manager and an audit begun 3/31/26 to verify labs have written orders DON/designee. All audits listed are being done 5xaweek X 4 audits and will ensure diagnosis will support a diagnosis to support insulin administration, labs have orders in place, orders from appointments are taken offand insulin is given within parameters. weeks with oversight submitted to QAPI committee weekly. Concerns identified will be corrected and staff reeducated.
Failure to Timely Notify Physician of Abnormal Lab Results
Penalty
Summary
The deficiency involves the facility’s failure to notify a physician in a timely manner of abnormal laboratory results for a resident. The resident was admitted with diagnoses including diabetes mellitus, Down’s Syndrome, Hirschsprung’s disease, and morbid obesity, and had severe cognitive impairment and dependence on staff for activities of daily living, as well as an indwelling catheter. A physician order for a urinalysis was dated 06/11/25, and a urine culture completed on 06/14/25 showed a positive result for Methicillin Resistant Staphylococcal Aureus (MRSA). Despite the abnormal culture result on 06/14/25, review of the medical record showed no documentation that the physician was notified of these results until 06/27/25, when an order was obtained for Macrobid 100 mg by mouth twice daily for seven days for a urinary tract infection. During an interview, the ADON confirmed that the medical record did not contain documentation supporting timely notification of the physician regarding the abnormal lab results. The facility’s policy on lab and diagnostic test results required nursing staff to review results upon receipt, determine the urgency of communication based on the seriousness of abnormalities and the resident’s condition, and notify the physician using various possible communication methods.
Plan Of Correction
F773 Lab Srvcs Physician Order/Notify of Results The PoC will what corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice. Resident #51 is no longer in the facility How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. Any of the residents receiving lab draws in the facility could be affected by this practice. A sweep of all residents receiving labs was done by DON/designee back to 3/2/2026 and the physician has been notified of all abnormal labs. Completed 3/25/26 Residents were not negatively affected as noted on the sweep. What measures will be put into place or what systemic changes you will make to ensure that the deficient practice does not recur. DON/designee in-serviced all nursing staff about notification of abnormal labs timely completed on 4/9/2026. The corrective action will be monitored to ensure the deficient practice will not recur. Daily audit of lab draws over the previous days not audited for MD and resident /family notification and follow through, are audited and DON/ADON are auditing that the physician is being notified next day any of all abnormal labs to ensure labs are not being missed. audits began 3/25/2026. All lab draws are audited daily. This audit is done 5xa week for 4 weeks with results presented to QAPI committee. concerns are corrected and staff reeducated.
Failure to Document Resident Discharge Disposition and Post-Discharge Plan
Penalty
Summary
The deficiency involves the facility’s failure to document a resident’s discharge disposition and required discharge information in the medical record. Surveyors reviewed the closed medical record of a resident who had been admitted with diagnoses including breast cancer, hypertension, major depressive disorder, and osteoarthritis. The resident was documented as cognitively intact on a quarterly MDS assessment completed shortly before discharge. Despite this, the record lacked documentation of where the resident went after discharge and did not contain the required discharge-related entries. Further review of the resident’s closed record showed there was no recapitulation of the resident’s stay and no progress notes concerning discharge arrangements. The medical record did not include a discharge summary or a post-discharge plan of care, and there was no nursing discharge note describing the resident’s disposition. These omissions meant that the medical record did not reflect the basis for the discharge, the discharge planning process, or the resident’s post-discharge care arrangements as required by regulation. During an interview, the DON confirmed that there was no documentation of the resident’s discharge disposition in the medical record. The DON also confirmed that there was no documented recapitulation of the stay and no nursing notes about the resident’s discharge disposition, and that a post-discharge plan was not documented. Review of the facility’s policy titled “Transfer or Discharge, Preparing a Resident for,” revised in 2016, showed that the policy requires development of a post-discharge plan for each resident prior to transfer or discharge, review of this plan with the resident and/or family at least 24 hours before discharge, and that nursing services are responsible for obtaining discharge orders, preparing the discharge summary and post-discharge plan, and completing a discharge note in the medical record. These required elements were not present in this resident’s record.
Plan Of Correction
F627 Inappropriate Discharge The PoC will what corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice. Resident # 53 no longer resides in the facility. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. All residents residing in the facility have the potential to be discharged. Census of 47. There are currently no residents being discharged from the facility as of 3/25/26 sweep completed by nurse manager. What measures will be put into place or what systemic changes you will make to ensure that the deficient practice does not recur. DON/designee in-serviced nursing management staff and social worker completed on 4/9/2026 a post-discharge plan is developed for each resident prior to his or her transfer or discharge. This plan will be reviewed with the resident, and/or his or her family, at least twenty-four (24) hours before the resident's discharge or transfer from the facility. Nursing services is responsible for obtaining orders for discharge or transfer, as well as the recommended discharge services and equipment, preparing the discharge summary and post-discharge plan, and completing discharge notes in the medical record. How the corrective action will be monitored to ensure the deficient practice will not recur. An audit of all discharged residents for a proper discharge plan and documentation is in place 5x a week X4 weeks per DON/designee. If there are concerns identified with the discharge audit, the concern will be corrected at that time, and the nurse involved will be educated in the area of improvement. Results are presented to QAPI team weekly to evaluate areas of improvement.
Failure to Document and Communicate Required Discharge Information for Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to properly document and communicate a resident’s transfer and discharge information when the resident was sent to the hospital and subsequently died. The resident had diagnoses including chronic pain, end-stage renal disease requiring hemodialysis, and heart disease, and had mildly impaired cognition per a comprehensive MDS assessment. The resident’s designated family contacts were listed in order as a sister, another sister, and then a brother. On the date of the incident, a nurse documented in a progress note that the resident was found unresponsive in the room in the early morning hours, CPR was initiated, and emergency services were notified. The note indicated staff attempted to notify the resident’s brother and then sister as the resident was being transferred to the hospital, and that a follow-up call to the receiving hospital revealed the resident had passed away. However, beyond this progress note, there was no documentation in the medical record regarding the resident’s transfer to the hospital. Record review showed there was no written notice of the transfer/discharge to the resident’s representative, no discharge/transfer summary, and no documentation of required discharge information being communicated to the receiving hospital. The social worker confirmed there was no discharge summary and was unaware of any written notification to the family or documentation regarding collection of the resident’s belongings after death. The ADON also verified there was no discharge summary and no evidence of the required transfer documentation in the resident’s medical record, resulting in noncompliance with the discharge documentation and communication requirements.
Plan Of Correction
F0628 Discharge Process The PoC will what corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice. Resident #56 is no longer in the facility. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? Any of the 47 residents residing in the facility have the potential for this practice. The residents who have been recently transferred or discharged had the potential to be affected. A sweep of these residents over a month, completed by nurse managers on 3-25-26, residing in the facility, revealed that residents requiring transfer/discharge are documented in the record with proper information and have not been affected by ths practice What measures will be put into place or what systemic changes you will make to ensure that the deficient practice does not recur. All nurses and the social worker were educated by DON/designee over a period completed by 4/9/2026. Education included facility transfers or discharges of a resident; the facility must ensure that the transfer or discharge is documented in the resident's medical record and appropriate information is communicated to the receiving health care institution or provider. Notify the resident and the resident's representative(s) of the transfer or discharge, and the facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman. How the corrective action will be monitored to ensure the deficient practice will not recur. DON/Designee audit that each transfer/discharge is properly documented in the resident's chart daily 5x a week X 4 weeks. The information for transfer and discharge includes an e-interact transfer form and bed hold form as well as notification of reason for transfer and significant other notification etc. Results of the audit will be presented to the QAPI team weekly. Audits are done in real time, and if there is a concern, the DON/designee corrects the issue and reeducates the staff involved. Audits in place to ensure discharge forms are done with any discharge by DON/admin and follow-up if missed/re-education for the social services as needed.
Failure to Provide Timely Initial Physician Visit After Admission
Penalty
Summary
The facility failed to ensure that a resident was seen by a physician within the first 30 days after admission, as required by §483.30(c). The resident was admitted on 06/25/25 with diagnoses including end stage renal disease, sexual dysfunction, major depressive disorder, and liver cirrhosis, and a quarterly MDS documented that the resident was cognitively intact and received dialysis. Review of the medical record showed that the first documented physician assessment did not occur until 12/10/25, well beyond the required initial 30-day timeframe. Although the resident was assessed by a nurse practitioner and a physician assistant prior to that date, there was no documentation of a timely physician visit. In an interview, the MDS nurse confirmed that the resident had not been assessed by a physician within the first 30 days after admission and that the first physician assessment at the facility occurred on 12/10/25. This deficiency affected one of three residents reviewed for physician visits, in a facility with a census of 47 residents.
Plan Of Correction
Physician Visits-Frequency/Timeliness/Alt NPP The PoC will what corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice. Resident # 28 has been seen by the facility physician on 3-18-2026. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken A sweep of new admissions to the facility has been completed by 4-1-26 by the ADON and the physician has seen all new admissions within the first 30 days of admission. The sweep included the last 30 days audit of residents that they have been seen by the physician. all have been seen. What measures will be put into place or what systemic changes you will make to ensure that the deficient practice does not recur. DON/designee has in-serviced nursing management and nurses that they must ensure residents are assessed by a physician within the first 30 days after admission. Inservice completed on 3-31-2026. Medical director was in serviced that he will need to see new admissions within 30 days of admission on 3-18-26 by the DON. How the corrective action will be monitored to ensure the deficient practice will not recur. DON/designee is auditing new admissions for compliance with physician visit within 30 days weekly x 2 months and submitted to the weekly QAPI committee. The audits began 3-31-26. If any concerns are noted, the MD will be alerted to come in to see the resident in a timely. The audits will alert the adon that the time limit is approaching.
Failure to Act on Pharmacist Drug Regimen Reviews and Orders
Penalty
Summary
The facility failed to ensure appropriate and timely response to pharmacist drug regimen reviews for two residents. For one resident with acute osteomyelitis, DM, PVD, CHF, and anemia, the pharmacist recommended on 12/09/25 that doxycycline administration be separated by at least two hours from magnesium oxide and ferrous sulfate to optimize absorption. The physician reviewed and signed this recommendation on 12/10/25. However, review of the December 2025 MAR showed the resident continued to receive doxycycline at 8:00 A.M. and 8:00 P.M., magnesium oxide at 8:00 A.M., and ferrous sulfate at 12:00 P.M., with no documentation that the magnesium oxide administration time was changed as recommended and ordered. The DON confirmed that staff had not changed the magnesium oxide administration time in accordance with the pharmacy recommendation and physician order. For another cognitively intact resident with type 2 DM, anxiety disorder, major depressive disorder, schizoid personality disorder, paraplegia, and malignant neoplasm of the breast, pharmacy recommendations dated 01/27/26 included a gradual dose reduction trial for amitriptyline and addressing two PRN lorazepam orders. The physician documented on the recommendation that dose reduction was contraindicated due to likely increased distressed behavior and added handwritten notes disputing the characterization of the resident as "psych." For the lorazepam recommendation, the physician renewed the duration of therapy for 14 days and again added handwritten notes referencing hospice and disputing "psych" labeling. The DON verified there had been no additional physician follow-up for these January 2026 pharmacy recommendations. Facility policy stated that physician recommendations from medication regimen reviews are to be distributed to the physician within two working days, reviewed within 30 days, and documented with actions taken or rationale for no change, with new orders transcribed and forwarded to pharmacy.
Plan Of Correction
F756 Drug Regimen Review. The PoC will what corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice. Resident #2 recommendation for a change in magnesium order was not needed as the antibiotic that was a conflict is no longer ordered.MD notified 3/31/26. Resident #4 MD stated a dose reduction for amitriptyline is contraindicated and will not make a change at this time for fear of worsening of condition MD order 4/1/26. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. Like residents, are residents in the facility who are reviewed by the pharmacy consultant. A sweep of the pharmacy recommendations in coordination with the medical director resulted in all recommendations have been reviewed and signed off on 3-26-26. The sweep went back to February 2026.conducted by ADON. What measures will be put into place or what systemic changes will you make to ensure that the deficient practice does not recur. DON and ADON in-service by corporate nurses to obtain follow-up to the pharmacy recommendations in a timely manner. Also, in-service to assist MD when the resident has a psychiatrist or counselor. In-service was done on 3-27-26. MD inservice by ADON on 4/1/26 to complete pharmacy recommendations timely. How the corrective action will be monitored to ensure the deficient practice will not recur. DON is auditing, starting 4/1/26, for completed responses with signatures from MD and nurses, follow-up to ensure all recommendations are responded to by MD within a week after receiving recommendations,and the pharmacy recomentations are written. monthly X2, and submitting findings to QAPI committee. If concerns are noted, DON will approach MD and ADON to correct the issue and to prevent further issues.
Unjustified and Poorly Documented Antibiotic Use for Two Residents
Penalty
Summary
The facility failed to ensure residents’ drug regimens were free from unnecessary antibiotics, resulting in antibiotic use without adequate indications, monitoring, or defined duration. One resident with hemiplegia, type 2 diabetes, bladder dysfunction, hypertension, and an indwelling urinary catheter had a physician order for oral Cephalexin 500 mg twice daily “for prevention of infection” with an indefinite end date. A pharmacy note requested clarification of a stop date, but the medication was administered continuously for several months. The medical record contained no documentation justifying extended use of Cephalexin, no related laboratory results, and the resident did not currently have a UTI. The Infection Preventionist confirmed the antibiotic had been ordered and administered for an extended period, had not appeared on the ordered antibiotic list, and that the urology office had not ordered or been aware of the ongoing Cephalexin use, with no documented justification for its continual use. Another resident with cerebral palsy, profound intellectual disabilities, seizures, hypertension, dysphagia, severe cognitive impairment, and total dependence for ADLs received Cefdinir suspension ordered by a nurse practitioner for a UTI. Nursing documentation noted the NP visit and the new Cefdinir order, and the medication was administered as ordered. However, the medical record lacked documentation of abnormal urinary signs or symptoms or any test results to support the antibiotic use. The Infection Preventionist confirmed there was no documentation to support Cefdinir as treatment for a UTI and that a urine culture was not obtained prior to starting the antibiotic. These practices were inconsistent with the facility’s “Antibiotic Stewardship” policy, which requires complete antibiotic orders including indication and duration, and specific clinical information to be communicated when a nurse contacts a prescriber about a suspected infection.
Plan Of Correction
F757 Unnecessary drugs The PoC will what corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice. Resident # 39 has been reviewed by physician on March 14, 2026, for ongoing use of antibiotic with justification of use to prevent UTI. Resident # 40 as of Feb 22, 2026, is no longer receiving this antibiotic. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. Residents in the facility who have antibiotics without stop dates being used as a prophylactic treatment would be like residents. The sweep completed by the infection preventionist on 3/25/26 of current residents did not identify such residents. Any residents receiving antibiotics require documentation of the reason for antibiotic use. What measures will be put into place or what systemic changes you will make to ensure that the deficient practice does not recur. Inservice for nurse managers and licensed nurses to follow the antibiotic stewardship protocol a. Drug name; b. Dose; c. Frequency of administration; d. Duration of treatment: (1) Start and stop date; or (2) Number of days of therapy; route of administration; and f. Indications for use. The policy also stated that when the nurse calls a physician/prescriber to communicate a suspected infection, he/she would have the following info: when symptoms first observed, the resident's hydration status, current medication list, and the infection type. Inservice per DON/designee and completed by 4-9-2026. Residents with antibiotics ordered must have reason for the antibiotic identified. How the corrective action will be monitored to ensure the deficient practice will not recur. Daily audit of orders for antibiotics without stop dates began 3/25/26 by infection preventionist all antibiotic orders and will be audited weekly x 4 weeks by DON/designee to ensure all antibiotics have automatic stop dates Results are submitted to QAPI committee weekly. Concerns identified will be corrected at the time of audit, and education of nurses will be done to remind them that we need to have a stop date for any antibiotics ordered.
Improper Labeling and Storage of Insulin Vials and Loose Medications
Penalty
Summary
The deficiency involves failures in labeling and storing drugs and biologicals, specifically multi-dose insulin vials and loose pills in a medication cart. During observation of a medication cart on the 600 hall, surveyors found two open multi-dose insulin vials, one of Lantus for Resident #4 and one of Novolog for Resident #25, that were not dated. They also found a 10 ml vial of Humalog for Resident #12 that had been opened and dated 02/14/26, indicating it remained in use beyond the 28-day discard timeframe. Additionally, fifteen small round yellow pills were found loose and unidentified in the same compartment that contained the insulin vials. An interview with an LPN confirmed that the insulin vials for two residents were opened and undated, and that the insulin vial for another resident was open past 28 days. The LPN also confirmed the presence of the 15 loose yellow pills and was unable to identify them. Review of the facility’s “Injectable Medications” policy showed that multi-dose vials are required to be labeled with the date opened and the initials of the healthcare professional, and discarded within 28 days unless otherwise specified by the manufacturer. Review of the “Medication Storage” policy showed that medications must be kept and stored in their original containers and not transferred from one container to another, except under limited circumstances not applicable here.
Plan Of Correction
F761 Label/Store Drugs and Biologicals The PoC will what corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice. Multidose medication for residents 4 and 25 were replaced on 3/25/26 and have been dated by nurse manager. The loose medication found were destroyed in a medication buster by nurse manager also on 3/25/26. Residents #4 and # 25 both were assessed for any negative outcomes from the practice of not dating vials or loose medications and both residents Residents were not affected by medications not dated, assessed by nurse manager on 4/9/26 with no negative effects. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. Like residents are residents on 600 hall with multidose vials. A sweep of the 600 hall for all multidose vials has been completed and all are properly dated by 3-25-26. Nurse manager identified residents receiving medications from multi dose vials all assessed on 3/25/26 and there were no negative effects determined. What measures will be put into place or what systemic changes you will make to ensure that the deficient practice does not recur. DON/Designee in-serviced licensed nurses that all mutli dose vials must be dated and discarded after 28 days. And also inserviced on preventing loose pills in the cart, discarding any loose pills and proper procedure for that. Inservice completed 4-9-26 How the corrective action will be monitored to ensure the deficient practice will not recur. Audit of all multidose vials began 3/26/26 and completed weekly X4 by DON or designee Loose pills in carts are done at the same time both to ensure multiuse vials are dated when opened and discarded after 28 days of being opened and medications are properly stored. Results submitted to QAPI committee weekly. Identified concerns will be corrected and staff reeducated.
Failure to Arrange Needed Dental Follow-Up and Oral Surgery Referral
Penalty
Summary
The facility failed to ensure that a resident received needed dental services as required by regulation and facility policy. The resident, who was cognitively intact and admitted with diagnoses including COPD, heart failure, type 2 diabetes mellitus, hypothyroidism, and major depressive disorder, had a care plan identifying potential for oral/dental health problems due to poor oral hygiene, with interventions to coordinate dental care and monitor for oral problems. A dental visit in July 2025 documented an initial exam, cleaning, full mouth x-ray, and a note for a possible oral surgeon referral. The resident reported that a few months after admission she met with the dentist and was told she would be notified when the dentist returned, but she was never notified of a return visit or a follow-up appointment. Despite the dentist returning to the facility in December 2025, the resident was not placed on the list to be seen, and the social services staff member interviewed could not explain why the resident was omitted. The resident reported ongoing concerns with her teeth and stated she needed four teeth removed by an oral surgeon, but no appointment had been scheduled. She also verified that she had requested Tylenol to help alleviate tooth pain. Facility policies stated that residents shall be offered dental services as needed and that routine and emergency dental services are available in accordance with the assessment and care plan, with social services responsible for assisting with appointments and transportation, but these processes were not carried out for this resident.
Plan Of Correction
F791 Dental Services The PoC will what corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice. Resident #34 has been scheduled by social worker on3-26-2026 for the closest dental care in an acute care setting as referred by her dentist. Resident refused on 3-26 2026 to go to the setting scheduled and wants to wait until next visit by the dentist in the facility The social Worked placed resident on the list for next dental visit. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. Residents residing in the facility have a potential need for dental care. A sweep of the facility residents to determine any residents needing dental care was done by interviews chart review and the dentist list. scheduled revealed that residents have been scheduled to see the dentist. except for those who have refused in the past. Those residents who have refused in the past. Those residents have been offered to schedule a visit. Completed 4-7-26 per SW. What measures will be put into place or what systemic changes you will make to ensure that the deficient practice does not recur. Administrator conducted an in-service for the social worker on 3-17-26 to include need to timely find dental services as needed for the residents and what is available for the residents needing routine dental care. How the corrective action will be monitored to ensure the deficient practice will not recur. Weekly audit began 4-7-2026 of new admissions and any residents requesting needing dental services or complaining of dental pain to ensure all residents are scheduled for dental care per social services X 2 months.Results submitted to QAPI committee.Concerns identified are immediatly resolved and reeducation of staff completed by social worker/administrator.
Failure to Consistently Honor Resident Food Preferences
Penalty
Summary
A cognitively intact resident with multiple diagnoses, including type 2 diabetes mellitus, anxiety disorder, major depressive disorder, schizoid personality disorder, paraplegia, and breast cancer, did not consistently receive food items according to documented preferences and meal tickets. The resident’s medical record showed admission on 07/01/25, and the MDS dated 01/08/26 confirmed intact cognition. The facility’s meal ticket for breakfast on 03/09/26 indicated the resident was to receive two 2% milks, cranberry juice, and yogurt; however, observation showed the tray was missing both milk and cranberry juice, leading the resident to refuse the meal due to not having the requested items. The facility’s policy stated that the Food and Nutrition Services Department would promote optimal nutrition status consistent with each individual’s needs and personal preferences. Further review of meal tickets and observations on subsequent dates showed repeated failures to provide the resident’s preferred items. A lunch meal ticket dated 03/12/26 indicated the resident was to receive two 2% milks and yogurt, but observation revealed only one milk and one yogurt were provided. The resident reported that although the meal ticket showed one yogurt, the dietary department knew she wanted two milks and two yogurts at every meal. A CNA confirmed that the resident always wanted two milks and two yogurts at each meal and verified that the resident did not receive them per preference. On 03/16/26, the lunch meal ticket again showed two 2% milks and yogurt, but observation revealed no yogurt on the tray, which an LPN also verified. These findings demonstrated that the facility did not consistently provide food that accommodated the resident’s stated preferences as required.
Plan Of Correction
F806 Resident Allergies, Preferences, Substitutes The PoC will what corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice. As of 3-17-2026 Resident #4 is ensured by the dietary Manager that she is now receiving requested 2 milks and 2 yogurts and cranberry juice with each tray. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. Dietary manager has done a sweep of all facility residents and determined likes and ensured these likes are on their meal tickets. Completed 3-17-26 What measures will be put into place or what systemic changes you will make to ensure that the deficient practice does not recur. DM in serviced dietary staff in reading and following dietary tickets In-service completed 3-17-2026. How the corrective action will be monitored to ensure the deficient practice will not recur. DM/designee auditing all trays for compliance with meal tickets 5 x a week X4 weeks during lunch and dinner. Results submitted to QAPI committee.to ensure all residents receive the requested diet. Identified concerns by audits are immediately corrected and staff reeducated.
Failure to Provide Ordered Adaptive Eating Utensils
Penalty
Summary
The facility failed to provide ordered adaptive eating utensils to a resident who required them. The resident, admitted with diagnoses including type 2 diabetes mellitus without complications, anxiety disorder, major depressive disorder, schizoid personality disorder, paraplegia, and malignant neoplasm of the female breast, was documented on a recent MDS assessment as cognitively intact and needing set-up/clean-up assistance with eating. The facility’s own policy on adaptive eating devices stated that special eating equipment and utensils would be provided as appropriate and that adaptive devices should be noted on each individual’s meal identification ticket. The resident’s meal tickets for multiple meals specified that built-up utensils (one each) were to be provided. Despite these documented requirements, surveyor observations on several meal occasions showed that the resident did not receive the ordered built-up utensils on the meal trays. On one breakfast and two lunch observations, the resident’s trays lacked the built-up utensils that were listed on the corresponding meal tickets. During these observations, the resident was seen eating meals in the room without the adaptive utensils. Staff interviews with Social Services and a CNA confirmed that the resident had not received the built-up utensils on the lunch trays, corroborating the surveyor’s findings that the facility did not follow the documented meal ticket instructions or its own policy regarding adaptive eating devices.
Plan Of Correction
F810 Assistive Devices - Eating Equipment/Utensils The PoC will what corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice. Resident # 4 now has a a dietary recommendation, care plan and an MD order obtained by hospice for adaptive equipment she is receiving the requested adaptive equipment with meal trays. The dietary manager verified resident # 4 has adaptive equipment as of 3-24-2026. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. DM audited on 3-19-2026 all residents' records and meal tickets for requested adaptive equipment; no additional adaptive equipment was needed. What measures will be put into place or what systemic changes you will make to ensure that the deficient practice does not recur. DM in-serviced staff to provide any adaptive equipment noted on the meal tickets to the residents. Inservice completed 3-17-26 by the dietary manager. How the corrective action will be monitored to ensure the deficient practice will not recur. DM is auditing all meal tickets daily 4Xaweek X2 months audits began 3-19-1026 that the meal trays are being audited to ensure the adaptive equipment on the meal trays matches the meal ticket in regards to adaptive equipment being provided. The audit will include all trays including all trays with adaptive equipment. Results of audits submitted to QAPI committee weekly.Any concerns identified will result in immediate correction and re education.
Failure to Timely Treat and Assess Pressure Wounds
Penalty
Summary
The facility failed to timely treat and assess pressure wounds for two residents, leading to a deficiency. Resident #10, who had diagnoses including end-stage renal disease and diabetes, returned from hospitalization with a documented pressure wound on the coccyx. However, there was no wound treatment in place for 11 days, and the wound assessments were inconsistent, with missing documentation on the wound's staging and measurements. Interviews with staff confirmed the lack of treatment orders during this period. Resident #12, with similar medical conditions, was admitted with a pressure wound on the sacrum. Initial assessments lacked measurements and staging, and there was a significant gap in wound assessments from December to January. A late entry progress note documented the wound's presence and characteristics, but further assessments were delayed. Interviews confirmed the late documentation and lack of timely wound assessments. The facility's policy required accurate and timely wound assessments, which were not adhered to, leading to this deficiency.
Failure to Administer Medication as Prescribed
Penalty
Summary
The facility failed to ensure that a resident was administered medication as ordered by the physician, resulting in a significant medication error. The resident, who had diagnoses including end-stage renal disease, congestive heart failure, and hypertension, was prescribed Diltiazem to manage hypertension. However, the Medication Administration Record (MAR) indicated that the medication was not administered on multiple occasions over a period of several weeks. This lapse in administration was linked to the resident being sent to the hospital for a rapid heart rate. Interviews with facility staff and pharmacy personnel revealed that there was a lack of communication and clarification regarding the medication orders. The pharmacy had requested clarification on a change in the medication order, but this was not resolved until several weeks later. During this time, the medication was unavailable, and the facility's Pyxis system did not dispense the correct dosage for the resident. The Assistant Director of Nursing confirmed that the medication was not administered as prescribed, which was a violation of the facility's medication administration policy.
Failure to Honor Resident Meal Preferences
Penalty
Summary
The facility failed to ensure that residents were provided meals according to their preferences, affecting two residents. Resident #20, who was moderately cognitively impaired, had a dietary order specifying no eggs, French toast, or oatmeal. Despite this, Resident #20 was repeatedly served scrambled eggs, which she disliked and had explicitly mentioned on her meal ticket. This issue was confirmed by a CNA who acknowledged that Resident #20 often received eggs despite her stated preferences. Similarly, Resident #21, also moderately cognitively impaired, had dietary preferences indicating no sausage or pork. However, she was served a breakfast that included a sausage link, contrary to her meal ticket instructions. This discrepancy was verified by a CNA who confirmed that Resident #21's meal ticket indicated her dislike for sausage and pork. The facility's policy encouraged the development of menus that met guidelines while allowing for resident choice, but this was not adhered to in these cases.
Failure to Document and Treat Resident's Wounds
Penalty
Summary
The facility failed to accurately document and treat wounds for a resident, which was identified during a review of records, facility policy, and staff interviews. The resident, who had diagnoses including end-stage renal disease, anemia, dementia, and early-onset Alzheimer's Disease, was admitted with no documented pressure ulcers. A care plan was initiated to monitor potential wounds, requiring weekly documentation of skin breakdown measurements. However, a skin assessment revealed three rash areas on the resident's right hip, with incomplete measurements lacking depth. Subsequent assessments and progress notes failed to provide further descriptions or measurements of the rash. Interviews with facility staff, including an LPN and the ADON, revealed that the resident had a treatment order for the rash, but there was no official diagnosis or referral to a wound nurse practitioner. The ADON acknowledged the lack of documentation and was unable to explain why a referral or notification had not been made. The facility's wound management policy required accurate and timely wound documentation and communication with healthcare providers, which was not adhered to in this case. This deficiency was investigated under a specific complaint number.
Failure to Document and Treat Pressure Wounds
Penalty
Summary
The facility failed to accurately document and treat pressure wounds for a resident, leading to a deficiency. The resident, who was admitted with multiple diagnoses including end-stage renal disease, dementia, and early-onset Alzheimer's Disease, was dependent on assistance for mobility and hygiene. Upon admission, no pressure ulcers were documented, and a care plan was initiated to monitor potential wound development. However, a skin assessment on June 11 revealed a pressure area on the resident's right heel, but the stage of the wound was not documented. Subsequent assessments and progress notes failed to provide further staging or measurements of the wound. The facility's skin observation tool required detailed documentation of wounds, including measurements and staging, which was not adhered to in this case. Additionally, the facility's policy on wound management emphasized accurate and timely documentation and communication with healthcare providers, which was not followed. The Assistant Director of Nursing acknowledged the lack of documentation and the failure to refer the resident to a wound nurse practitioner. This deficiency was investigated under Complaint Number OH00155214.
Unqualified Dietary Manager Employed
Penalty
Summary
The facility failed to employ a qualified dietary manager, affecting all residents who received food from the kitchen. The personnel files review revealed that the current Dietary Manager was hired on 06/09/23 and promoted on 04/21/24 but did not possess a ServeSafe certification. The previous Dietary Manager left the facility on 04/01/24. During an interview on 05/05/24, the current Dietary Manager confirmed she was in the process of taking the ServeSafe course, with plans to complete it by the end of the month. Another interview with the Resident Care Coordinator verified that the current Dietary Manager did not have the ServeSafe certification. The facility census was 51, with two residents not receiving food by mouth.
Failure to Follow Legionella Prevention and Proper Linen Transport Procedures
Penalty
Summary
The facility failed to follow procedures for Legionella prevention and proper transportation of soiled linens. The Legionella Water Management Plan required daily visual checks of sinks, showers, and toilets, weekly checks of eye wash stations, and monthly checks of ice machines. However, the Maintenance Director was unable to provide documentation that these checks had been completed. Additionally, a State tested Nursing Assistant was observed carrying soiled linen and a soiled brief in her hands, without bagging them, through a hallway and into a soiled utility room located near the dining room where a resident was eating breakfast. The facility's policy required all soiled laundry and bedding to be bagged prior to transportation to prevent infection.
Food Storage and Dishwasher Sanitization Deficiencies
Penalty
Summary
The facility failed to appropriately store food and ensure the dishwasher was sanitizing, potentially affecting all residents who received food from the kitchen. During an initial kitchen tour, it was observed that prepackaged frozen meatloaf was thawing in the refrigerator with a sticky note indicating it was to be used for dinner on a previous date. Additionally, there were expired items in the refrigerator, such as hard-boiled eggs and bologna, and multiple boxes of frozen food items stored improperly in the refrigerator. In the freezer, there was an open bag of beef fritters and three cracked eggs without shells on the floor. In the storage area, two large trays of unfrosted cupcakes were covered with dirty cardboard. Dietary Aide #313 confirmed these observations and stated that frozen meal items were moved to the refrigerator the day prior to assist with cooking times. The facility's food storage policy required all food to be covered, labeled, and dated, and to be routinely monitored to ensure safe consumption dates, which was not adhered to in this case. The facility also failed to ensure the dishwasher was sanitizing properly. Observations revealed that the high-temperature dishwasher's final rinse cycle only reached a high temperature of 168 degrees Fahrenheit, below the required 180 degrees Fahrenheit for proper sanitization. Dietary Aide #321 confirmed that the rinse cycle should reach 180 degrees Fahrenheit, but the highest recorded temperature was 168 degrees Fahrenheit. The dish machine temperature log showed that the rinse cycle had never reached 180 degrees Fahrenheit, with most documented temperatures ranging from 170 to 175 degrees Fahrenheit. The facility's policy and the dishwasher manual both specified that the final rinse should reach 180 degrees Fahrenheit for proper sanitization. The Assistant Director of Nursing and a Resident Care Coordinator confirmed these findings, and a repairman was called to address the issue, but the deficiency remained at the time of the survey.
Persistent Urine Odor in Common Areas and Dining Room
Penalty
Summary
The facility failed to ensure that pungent smells of urine did not permeate into common areas and the dining room, potentially affecting all residents. Observations over several days revealed a consistent presence of urine odor in the 300/400 hall nurses station/common area and dining room, as well as the 600 hallway. The urine smell was noted at various times of the day, with some areas also having a musty odor. Interviews with staff, family members, and the ombudsman confirmed the presence of these odors, despite the use of cleaning products and air fresheners by housekeeping staff. The facility's policy on maintaining a homelike environment, which includes pleasant and neutral scents, was not adhered to. The deficiency was identified during a complaint investigation, highlighting the facility's non-compliance with ensuring a clean and odor-free environment. The facility census at the time was 51 residents, and the issue was documented under Complaint Number OH00152901.
Failure to Provide Dignified Dining Experience
Penalty
Summary
The facility failed to provide residents with a dignified dining experience by not supplying knives with their meals. Observations during a lunch meal revealed that residents were given only forks and spoons, making it difficult for them to cut their food, such as baked chicken. Multiple residents expressed frustration and a sense of indignity due to the lack of proper utensils, stating that they felt infantilized and mistrusted. Staff interviews confirmed that knives were not provided to residents, and even staff members were not given knives to assist residents in cutting their food. The decision to withhold knives was attributed to a previous dietary manager's policy, which was not clearly understood or justified by current staff members. Further interviews revealed that even residents in the memory care unit, who were deemed capable of using knives safely, were not provided with them. A review of the facility's policies showed that knives were prohibited in the memory care unit to protect resident safety, but staff were supposed to have access to sharp utensils to assist residents, which was not the case in practice. This failure to provide appropriate dining utensils compromised the residents' right to a dignified existence and self-determination, as outlined in the facility's resident rights policy.
Failure to Follow Menus and Serve Correct Portions
Penalty
Summary
The facility failed to ensure that menus were followed and appropriate substitutions were made for 12 residents. During a lunch meal, the facility ran out of Italian green beans and mashed potatoes, leading the dietary aide to serve leftover pasta salad and rice instead. The dietary manager was unaware of these substitutions, and the dietician confirmed that pasta salad was not an appropriate substitute for green beans. The facility's policy on menu substitutions was not followed, as substitutions were made without consulting the director of food and nutrition services or a designee. Additionally, the facility did not adhere to the correct serving sizes for 10 residents during another lunch meal. The menu specified a 3-ounce scoop for sloppy joe meat and a 4-ounce spoodle for corn, but the facility used a 4-ounce scoop for the meat and a 2-ounce scoop for the corn. The dietary manager confirmed that the facility did not have the correct scoop sizes and used incorrect portions as a result. These actions led to residents receiving incorrect meal components and serving sizes, failing to meet their nutritional needs as outlined in the menu.
Failure to Provide Engaging Activities in Memory Care Unit
Penalty
Summary
The facility failed to provide appropriate and engaging activities in the memory care unit, affecting five residents and potentially impacting an additional five residents. The activity calendar for the memory care unit showed limited and repetitive activities, which did not align with the individualized care plans and preferences of the residents. For instance, Resident #20, who was rarely understood and had a care plan emphasizing simple structured activities, was observed sitting in front of the television without engagement in meaningful activities. Staff interviews revealed a lack of awareness of the resident's activity preferences, further highlighting the deficiency in personalized care. Resident #30, who was severely cognitively impaired, had not had a quarterly activities assessment since June 2023. Despite the care plan indicating a need for activities compatible with the resident's capabilities and interests, the resident was observed watching television throughout the day without participation in other activities. Staff interviews indicated that the resident enjoyed music, but there was no evidence of music-related activities being provided. Resident #36, who had Alzheimer's disease and was interested in attending church services, was not included in the scheduled church activities. Similarly, Resident #38, who valued music, animals, and religious activities, was not included in the church service and was observed sitting alone during the activity time. Resident #43, who had unspecified dementia with behavioral disturbances, was marked as participating in activities simply for walking around and watching television, without engagement in meaningful or preferred activities. The facility's policy on dementia care emphasized individualized care and activities, but the observations and interviews revealed a significant gap in the implementation of this policy, leading to the deficiency.
Failure to Accommodate Resident's Food Request in a Timely Manner
Penalty
Summary
The facility failed to reasonably accommodate a resident's request for food, affecting one resident who was cognitively intact and required substantial assistance for eating. The resident, who had multiple diagnoses including quadriplegia and bipolar disorder, requested instant macaroni and cheese instead of the provided lunch tray. Despite the resident's request being made at approximately 1:20 P.M., the food was not delivered until 3:03 P.M., over an hour and forty minutes later. The delay occurred because the State tested Nursing Assistant (STNA) who took the request went on break without fulfilling it, and the Licensed Practical Nurse (LPN) who was informed of the situation did not ensure the request was promptly addressed. The resident's call light was observed to be on at 2:16 P.M., and the resident confirmed she had been waiting for her food for nearly an hour. The LPN informed the STNA of the resident's request upon her return from break, but the STNA did not immediately fulfill the request, further delaying the resident's meal. The facility's policy on providing a homelike environment and person-centered care was not followed, as the resident's preference for instant macaroni and cheese was not promptly accommodated, leading to an extended wait time for her meal.
Failure to Ensure Timely Documentation of Code Status
Penalty
Summary
The facility failed to ensure timely documentation of code status for Resident #247. The resident, admitted with chronic obstructive pulmonary disease, malignant neoplasm of the left breast, secondary malignant neoplasm of the brain, depression, and anxiety, had no code status information in their hard chart as verified by a Registered Nurse (RN). Although there was an electronic order for Do Not Resuscitate Comfort Care Arrest (DNR-CCA) dated 04/29/24, the hard chart only had a label indicating Comfort Care (CC). An interview with a Licensed Practical Nurse (LPN) revealed that the facility had an electronic DNR CCA order from the discharging hospital, but the Ohio DNR CC form was only signed by the resident and not by a physician. The facility did not obtain a signed copy of the DNR form from the discharging hospital or ensure the medical director signed the current form. The facility's policy required obtaining a copy of any existing advance directive for the medical record, which was not followed in this case.
Failure to Implement Timely Interventions for Pressure Ulcers
Penalty
Summary
The facility failed to implement timely interventions to prevent skin impairment for a resident with stage 4 pressure ulcers and did not ensure wound measurements were completed upon readmission. Resident #197, who was cognitively intact and dependent on staff for bed mobility and dressing, had multiple pressure ulcers and other skin conditions. Despite the care plan indicating the need for frequent repositioning, the resident reported not being repositioned regularly, and staff interviews confirmed this lack of care. Observations over multiple days showed the resident remained in the same position for extended periods, and staff did not offer repositioning as required. The medical record review revealed that upon readmission, no measurements of the resident's wounds were documented, contrary to the facility's policy. The weekly wound observation tool showed the resident had several pressure ulcers, including stage IV ulcers on the sacrum and gluteal folds, and a stage III ulcer on the left upper posterior thigh. Despite these documented conditions, the resident's care plan was not followed, and staff failed to reposition the resident every two hours as required. Interviews with various staff members, including STNAs and LPNs, confirmed that the resident was not repositioned regularly, and there were no reports of the resident refusing care. The Assistant Director of Nursing verified that the care plan required frequent repositioning and acknowledged that no wound measurements were completed upon the resident's readmission. The facility's policies on repositioning and skin assessment were not adhered to, leading to the deficiency in care for Resident #197.
Failure to Provide Adequate Supervision for Smoking Residents
Penalty
Summary
The facility failed to provide adequate supervision for residents while they were smoking, affecting two residents who were reviewed for smoking. Resident #1, who has multiple diagnoses including multiple sclerosis and chronic obstructive pulmonary disease, was assessed to require supervision and a smoking apron while smoking. Despite these requirements, Resident #1 was observed smoking without staff supervision, although wearing a smoking apron. Similarly, Resident #6, who has diagnoses including schizoaffective disorder and chronic obstructive pulmonary disease, was also assessed to need supervision and a smoking apron. Resident #6 was found smoking without staff supervision, although wearing a smoking apron, and had previously been noted to have burn holes in his clothing and wheelchair. On the day of observation, both residents were seen in the smoking area without any staff present to supervise them. A State Testing Nursing Assistant (STNA) confirmed that no staff was supervising the residents and acknowledged that staff should be present while residents smoke. The facility's Resident Smoking Policy mandates direct supervision for residents assessed to need it, but this policy was not followed, leading to the deficiency.
Failure to Monitor Medication Side Effects and Effectiveness
Penalty
Summary
The facility failed to monitor medication for potential side effects, toxicity, and effectiveness for Resident #28, who was admitted with diagnoses including Parkinsonism, chronic kidney disease, hyperlipidemia, and type two diabetes mellitus. The resident's medical record revealed a physician's order for Pravastatin 40 mg for hyperlipidemia, but there was no lab work ordered to monitor cholesterol levels, kidney or liver enzymes. Additionally, the resident was prescribed Ergocalciferol 50000 units weekly, but no lab work was ordered to monitor Vitamin D levels. The Director of Nursing confirmed that no current lab work was ordered and that the last lipid panel was conducted on 08/23/23, the last kidney function test on 12/13/23, and no liver panel or Vitamin D level tests were documented as completed. The DON stated that nurses were expected to notify the physician for routine lab work and that the expectation was for vitamin levels, kidney monitoring, and lipid and liver panels to be checked during medication administration. The deficiency was identified through medical record review, staff interview, and review of the National Center for Biotechnology Information (NCBI) National Library of Medicine guidelines. The facility's failure to order and monitor necessary lab work for Resident #28's medications, including cholesterol and Vitamin D supplements, resulted in a lack of monitoring for potential side effects, toxicity, and effectiveness. This oversight affected one of the five residents reviewed for unnecessary medications, highlighting a significant lapse in the facility's medication management and monitoring protocols.
Failure to Complete Laboratory Tests as Ordered
Penalty
Summary
The facility failed to ensure that laboratory tests were completed as per physician orders for three residents. Resident #10, who has multiple diagnoses including diabetes and chronic pain, had orders for various lab tests to be conducted at specific intervals. However, the last recorded tests were not completed as scheduled, with the most recent tests being conducted in August 2023 and February 2024, missing several required tests. The Director of Nursing (DON) confirmed that the lab tests were not completed as ordered. Resident #26, with diagnoses including hypothyroidism and chronic kidney disease, also had orders for regular lab tests. The review showed that the required tests were not conducted every three months as ordered, with the last BMP drawn in July 2023 and no microalbumin tests documented. The DON verified the failure to complete these tests. Similarly, Resident #17, who has diagnoses including seizures and hyperlipidemia, had orders for lab tests every six months, but the last tests were conducted in August 2023. The DON confirmed that these tests were not completed as ordered.
Inadequate Consistency of Pureed Foods
Penalty
Summary
The facility failed to ensure pureed foods were made of appropriate consistency for two residents who were identified as receiving a pureed diet. On the day of the survey, the lunch menu included meatballs, noodles, mixed vegetables, and bread and butter. However, the facility substituted meatballs for meatloaf. During the preparation of the pureed meatloaf, the dietary aide added meatloaf, thickener, and an unknown amount of hot water to the blender. The resulting mixture was soup-like and gritty, which was confirmed by a taste test and verified by the Director of Therapy. The dietary aide revealed they were trained to make purees with a soup-like texture. Additionally, the preparation of pureed mixed vegetables was observed. The dietary manager added mixed vegetables and an unknown amount of hot water to the blender. The mixture was not adequately pureed, as evidenced by a carrot piece approximately the size of a pencil eraser found in the spoonful. This was verified by the dietary manager, who then discarded the vegetable puree and remade it with broccoli. The dietary manager confirmed that the two residents receiving a pureed diet were affected by these inadequacies in food preparation.
Failure to Post State Survey Results
Penalty
Summary
The facility failed to prominently post the location of the state survey results for residents to view, affecting all 51 residents. During a resident group meeting, multiple residents denied knowing where to find the state survey results. Observations of the hallway posting board and the front desk revealed no documentation regarding the location of the state survey results book. The Director of Nursing confirmed that there was no posting for residents or their families indicating where to locate the state survey results, although the book was available at the front desk.
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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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