Majestic Care Of Clyde
Inspection history, citations, penalties and survey trends for this long-term care facility in Clyde, Ohio.
- Location
- 700 Helen Street, Clyde, Ohio 43410
- CMS Provider Number
- 365740
- Inspections on file
- 28
- Latest survey
- April 15, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Majestic Care Of Clyde during CMS and state inspections, most recent first.
A cognitively intact resident with psychiatric and respiratory diagnoses was on a speaker-phone call with family in a common area where multiple people could hear the conversation, and the resident stated she could not move to a private location. An unknown staff member then intervened, told the family they would need to come in and speak with the DON if they wished to talk to the resident, and abruptly ended the call. The Administrator and Social Services Designee confirmed that the resident was not offered or provided a private place for the call and that staff terminated the conversation, contrary to the facility’s written policy guaranteeing residents private access to telephone communication.
Surveyors found that the kitchen floor was coated with unidentified brown and white substances and scattered food and non-food debris, which a dietary aide confirmed, in violation of the facility’s Kitchen Sanitation policy requiring clean and contamination-free food preparation areas. In the dry storage room, surveyors also observed multiple large dented canned food items, including pineapple tidbits, collard greens, and baked beans, which were not separated, labeled, or disposed of as required by facility policy for dented cans. All residents were receiving meals prepared in this kitchen.
A resident with severe cognitive impairment, multiple comorbidities, and a confirmed COVID-19 infection was placed on contact and droplet precautions with clear signage requiring hand hygiene, gown, gloves, and face/eye protection for anyone entering the room. An LPN entered the room to obtain vital signs and administer medications wearing only a surgical mask and gloves, without a gown or eye protection, despite the posted instructions. In interview, the LPN acknowledged not using the required PPE and stated she did not believe it was necessary, contrary to the facility’s infection prevention and PPE policies.
The facility failed to provide adequate supervision to prevent sexual contact between two cognitively impaired residents on a secured memory care unit. A female resident with severe dementia, dependent for ambulation and with a history of sexual behaviors and poor impulse control, was in a wheelchair in a common area when a male resident with severe cognitive impairment, independent ambulation, and a similar behavioral history was observed standing over her, holding her shirt open and placing his hand down the front of her shirt. A CNA witnessed and reported the incident and did not believe it was consensual, while the DON and Administrator confirmed the physical contact but characterized it as consensual based on the female resident’s baseline hypersexual behavior and lack of combative response. The facility’s abuse policy defined sexual abuse as non-consensual sexual contact of any type with a resident, and the event occurred despite both residents having guardians and known histories of sexual behaviors and poor impulse control.
Three cognitively impaired residents were subjected to repeated sexual abuse by another resident with a history of inappropriate sexual behavior, including exposure and physical contact, as confirmed by staff interviews, medical records, and facility documentation. The incidents involved public masturbation, exposure, and inappropriate touching, with staff and witness statements substantiating the events.
The facility did not ensure timely reporting of multiple abuse allegations involving a resident with moderate cognitive impairment who exposed himself and engaged in inappropriate behavior with other residents. Despite staff observations and documentation, required self-reported incidents were not filed promptly or at all, as confirmed by the DON and in violation of facility policy.
The facility did not thoroughly investigate multiple allegations of abuse involving a resident with cognitive and psychiatric conditions who exposed himself and engaged in inappropriate behavior toward two other residents, both of whom had significant cognitive impairments. Staff confirmed the incidents, but the required investigations were not conducted, and law enforcement was not notified as per facility policy.
A facility failed to maintain a clean and sanitary environment in the west shower room, affecting all residents on the west unit. Observations revealed a hot, humid room with a musty odor and black mold-like spots on the walls and ceiling. The Maintenance Director confirmed the presence of moisture and a lack of an exhaust fan, which may have contributed to the mold, along with a constantly running shower. The facility's policy required maintenance to ensure a sanitary environment, but the Maintenance Director was unaware of the issue due to a lack of staff notification.
The facility failed to report and investigate an abuse allegation involving a resident with cognitive impairment and the misappropriation of Ozempic affecting three residents. The alleged perpetrator was not immediately removed, and the incidents were not reported to the state agency. Investigations were delayed, with missing documentation and untimely assessments, leading to non-compliance with regulatory requirements.
A resident with diabetes was not administered her prescribed Ozempic injections on several occasions, and the physician was not notified of these omissions as required by facility policy. The resident was aware of the missed doses but was not informed of the reasons. The facility's policy mandates timely notification of medication omissions, which was not followed.
A facility failed to report and investigate an abuse allegation involving a resident with cognitive impairment and did not immediately remove the alleged perpetrator. Additionally, the facility did not report or investigate the misappropriation of Ozempic affecting three residents, with missing doses and pens not accounted for. The facility did not adhere to its policy of reporting such incidents to the Department of Health.
A facility failed to provide adequate grooming care for a resident with Parkinson's disease, who was dependent on staff for activities of daily living. Despite the care plan indicating a need for assistance with personal hygiene, observations showed the resident's toenails were excessively long and untrimmed. An LPN confirmed the oversight, and the resident reported that staff had not performed the necessary nail care.
Two residents in an LTC facility experienced medication administration errors. One resident received daily doses of Ozempic instead of weekly due to an incorrect order entry, while another resident missed several weekly doses because the medication was unavailable, and the physician was not consistently notified. Both residents have type two diabetes mellitus, and the facility's policy on medication administration was not followed.
The facility failed to serve food at acceptable temperatures, affecting 20 residents on the 200 hall. Two residents reported meals were sometimes cold, and a test tray confirmed shrimp and french fries were below required temperatures. The Director of Nutritional and Food Services acknowledged the issue, which violated the facility's food production policy.
The facility failed to serve palatable spaghetti, affecting residents who received it with their lunch meal. Observations and interviews revealed that the spaghetti tasted sour and had a gummy texture. The Corporate Dietary Manager confirmed the acidity, and several residents reported the spaghetti as unappetizing and mushy, tasting like it came from a can. The facility's policy requires food to be prepared and served to preserve palatability, monitored through test tray evaluations and resident feedback.
The facility failed to maintain the memory care unit in good condition, affecting several residents. Observations revealed issues such as a spider web in a window, dust buildup on bathroom fans, scrapes on walls, unfinished patches on a bathroom door, and unsanitary bathroom conditions. Additionally, the dining room floors were sticky and not clean. These deficiencies were verified by staff, indicating a failure to adhere to the facility's housekeeping policy.
The facility failed to ensure residents had access to their call lights, affecting three residents. One resident, who was cognitively intact, could not locate her call light, which was out of reach. Another resident, moderately cognitively impaired, also had an out-of-reach call light. A third resident, with severe cognitive impairment, had a call light positioned between the bed rail and mattress, contrary to their care plan and facility policy.
A resident with severe cognitive impairment and multiple diagnoses did not receive adequate oral hygiene care, as evidenced by a white residue buildup on their teeth over consecutive days. Despite the facility's policy requiring assistance with oral care, staff interviews revealed inconsistencies in care delivery, with no documentation of the resident's refusal of care.
The facility failed to provide necessary medications for two residents, leading to deficiencies in pharmaceutical services. A resident with a history of migraines did not receive her PRN Excedrin due to unaccounted tablets, while another resident did not receive her prescribed Risperdal Consta injections. The facility did not adhere to its medication administration policy, resulting in the unavailability of essential medications.
A resident in a LTC facility, who was cognitively intact and required dental extractions before hip surgery, did not receive necessary dental care. Despite the facility's policy to coordinate healthcare appointments, no dentist or oral surgeon was contacted for the resident, even though the facility's dentist visited five times since the resident's admission.
A resident with severe cognitive impairment was found with unexplained bruising on the neck, which the facility failed to report as required by their policy. Initial assessments suggested a pustule, but further evaluations confirmed it was bruising. The facility did not report the incident to the Ohio Department of Health within the mandated timeframe.
A resident with severe cognitive impairment was found with bruising on the neck, but the facility failed to investigate the injury of unknown origin as required by their policy. Staff initially thought the bruise was related to a pustule, but a wound physician later confirmed it was bruising. No self-reported incidents were submitted, indicating non-compliance with the facility's policy.
The facility failed to ensure required RN coverage, affecting all 48 residents. Staff schedules and BIPA documentation showed no RN was present on specific dates, confirmed by the DON, who noted a lack of RN coverage every other weekend.
The facility failed to serve palatable meals, affecting multiple residents. Observations showed that the Mexican corn was tough, and a resident received a chicken breast that was too tough to eat. Other residents reported that meals were often inedible, with some opting for alternative food options. The facility's policy on palatability and nutritive value was not followed.
The facility failed to provide scheduled showers to three residents who were dependent on staff for assistance. One resident, moderately cognitively impaired, received only one shower in thirty days without any documented refusals. Another resident, cognitively intact, also had one shower documented, expressing a desire for more frequent showers. A third resident, fully dependent and rarely understood, had only one documented shower, with staff believing more occurred than recorded. Interviews confirmed the lack of adherence to scheduled showers, contrary to the facility's ADL policy.
The facility failed to provide adequate staffing, affecting residents' personal hygiene needs. A resident with vascular dementia received only one shower in thirty days, while another with cognitive impairment also had insufficient bathing. Interviews revealed staffing shortages, with call-offs and difficulty in finding replacements, leading to delays in care. Staff confirmed that inadequate staffing often resulted in missed showers for residents.
A resident requested a burger instead of the dinner meal, but the facility was out of hamburger meat and offered a peanut butter sandwich instead. The resident, who disliked tacos, chose to skip dinner. Another resident reported similar issues with meal substitutions. The facility's policy required nutritionally comparable menu items to be available, but this was not followed.
Failure to Provide Resident Privacy During Telephone Communication
Penalty
Summary
The facility failed to ensure a resident had privacy during a telephone call with family, as required by resident rights and the facility’s own policy. The resident, admitted in mid-February 2026, had diagnoses including schizophrenia, anxiety, adjustment disorder with mixed anxiety and depression, and emphysema, and was documented as cognitively intact on the admission MDS. An audio recording of a family-initiated call to the facility’s telephone showed that the resident accepted the call and identified herself, along with her son and daughter-in-law. During the call, the resident told her family she was on speaker phone with many people around listening. When her son asked if she could go somewhere private, the resident stated she could not. The audio recording further revealed that an unknown facility employee intervened in the call, told the family that if they wished to speak with the resident they would need to come to the facility and speak with the DON, and then abruptly ended the call. The Administrator confirmed that the recording involved the resident, her family, and an unknown staff member, and verified that privacy was neither offered nor provided and that a staff member abruptly terminated the call. The Social Services Designee reported being contacted by the night shift nurse about the family’s request to speak with the resident and stated she had advised that if the resident wanted to speak with her family, staff could not stop her. She also verified that the resident was not provided a private place for the call and that an unknown staff member abruptly ended the conversation. Review of the facility’s Resident-Patient Rights policy, revised February 2026, showed that residents were to have access to telephone communication with privacy, which was not afforded in this incident.
Unsanitary Kitchen Conditions and Improper Storage of Dented Canned Foods
Penalty
Summary
Surveyors identified a deficiency related to food procurement, storage, preparation, and sanitation practices in the facility kitchen. During an early morning observation, the kitchen floor was found to be coated with unidentified brown and white substances and scattered with miscellaneous unidentified food and non-food debris. A concurrent interview with a dietary aide confirmed the presence of these substances and debris on the kitchen floor. The facility’s own Kitchen Sanitation policy required that good sanitary food handling practices be maintained at all times and that food preparation and serving areas be kept clean, organized, and free of contamination, spills, mold, or buildup. Further observation of the dry storage room revealed multiple dented canned food items, including two large cans of pineapple tidbits with large dents on the sides, one large can of collard greens with a large dent in the top ring, and one large can of baked beans with a large dent in the top ring. The dietary aide confirmed the dents observed on these canned food items. The facility policy specified that dented cans or contaminated food items must be separated, labeled "Dented Cans - Do Not Use," and disposed of accordingly. All residents in the facility, with a census of 64, were identified as receiving meals prepared by this kitchen.
Failure to Use Required PPE for Resident on Contact and Droplet Precautions
Penalty
Summary
The deficiency involves a failure to follow the facility’s infection prevention and control program and PPE policies for a resident on transmission-based precautions. The resident had multiple medical diagnoses, including cerebral infarction with aphasia and hemiplegia, dysphagia, asthma, heart disease, obesity, bipolar disorder, depression, and the presence of a prosthetic heart valve, and had a BIMS score of 03 indicating severe cognitive impairment. The electronic medical record showed the resident tested positive for SARS CoV-2 (COVID-19) and had a physician order for droplet precautions. Signage posted outside the resident’s room indicated both contact and droplet precautions were in place, requiring hand hygiene before entering and upon exiting, donning gloves and a gown prior to room entry, discarding gloves and gown before exiting, using dedicated or properly disinfected equipment, and ensuring eyes, nose, and mouth were fully covered with appropriate face protection prior to room entry and removed before exiting. Despite these posted requirements and facility policies, an LPN was observed entering the resident’s room to obtain vital signs and administer medications while wearing only a surgical mask and gloves, without a gown or eye protection as required by the contact and droplet precaution signage. During interview, the LPN confirmed she provided care without the appropriate PPE and stated she did not believe PPE was required while providing care to this resident, even though she acknowledged the presence of the contact and droplet precaution signage outside the room. The facility’s written Infection Prevention and Control Program policy required residents with infections or communicable diseases to be placed on transmission-based precautions in accordance with CDC guidelines, and the PPE policy required appropriate use of PPE to prevent transmission of pathogens to residents, visitors, and staff. The observed actions and statements of the LPN demonstrated noncompliance with these established precautions and policies.
Failure to Protect Cognitively Impaired Resident From Sexual Contact in Memory Care Unit
Penalty
Summary
The facility failed to ensure adequate supervision to protect a resident on the secured memory care unit from sexual abuse. A resident with vascular dementia, severe cognitive impairment (BIMS score 0/15), dependence for ambulation, and a history of sexual behaviors and poor impulse control was seated in a wheelchair in the common area of the memory care unit. Another resident with severe cognitive impairment (BIMS score 6/15), independent ambulation, and a similar history of sexual behaviors and poor impulse control was observed standing over her, holding her shirt open with one hand and placing his other hand down the front of her shirt. Both residents had guardians and resided on the secured memory care unit at the time of the incident. The incident was witnessed by a CNA returning to the unit, who immediately reported that the male resident’s hand was inside the female resident’s shirt while both were in the common area. The CNA stated she did not feel the interaction was consensual, although she could not recall whether the female resident displayed her usual combative or rejecting behaviors when she did not want someone in her space. The DON and Administrator confirmed that the male resident’s hand was inside the front of the female resident’s shirt. The DON stated that the interaction was considered consensual based on the female resident’s baseline hypersexual behavior, lack of combative response, and lack of distress or memory of the event shortly afterward. The facility’s abuse policy defined sexual abuse as non-consensual sexual contact of any type with a resident, and the facility determined the allegation of sexual abuse to be unsubstantiated and inconclusive, despite both residents having severe cognitive impairment and documented histories of sexual behaviors and poor impulse control.
Failure to Prevent Sexual Abuse Among Cognitively Impaired Residents
Penalty
Summary
The facility failed to prevent sexual abuse involving three residents with moderate cognitive impairment and histories of inappropriate or aggressive behaviors. One resident, with diagnoses including schizoaffective disorder and cognitive communication deficit, had a documented history of sexually inappropriate actions such as exposing himself, masturbating in public areas, and entering female residents' rooms. On multiple occasions, this resident was found in another resident's room with his penis exposed, and was observed touching the other resident's breast over her clothing. Staff interviews and witness statements confirmed these incidents, including the resident exposing himself and masturbating in common areas and in front of other residents. Another resident involved had diagnoses of dementia and obsessive-compulsive disorder, and was also moderately cognitively impaired. This resident was found in situations where she was exposed to the inappropriate behaviors of the first resident, including being touched and exposed to indecent acts. The resident did not recall the incident during interview but was identified as a victim in the facility's self-reported incident and staff statements. A third resident, with vascular dementia and major depressive disorder, was also subjected to the first resident's inappropriate sexual behaviors, including exposure and masturbation in their presence. Staff interviews corroborated that the first resident repeatedly exposed himself and engaged in sexual acts in front of other residents. The facility's policy defined such actions as sexual abuse, and the events were substantiated through medical record review, staff and resident interviews, and facility documentation.
Failure to Timely Report Allegations of Abuse
Penalty
Summary
The facility failed to ensure that all allegations of abuse were reported and reported in a timely manner, as required by policy. In one incident, a resident with moderate cognitive impairment and multiple diagnoses, including schizoaffective disorder and major depressive disorder, was found in another resident's room with his penis exposed and was observed touching the other resident's breasts over her clothing. This incident was documented in a nursing progress note, but was not reported as a self-reported incident (SRI) until the following day, after it was discovered during a clinical review meeting. The Director of Nursing confirmed the delay in reporting. In a separate incident, the same resident was observed touching himself in front of another resident, who was rarely understood and had diagnoses including vascular dementia and major depressive disorder. Staff interviews confirmed that the resident had exposed himself to this other resident on more than one occasion. Despite these observations and documentation in the nursing progress notes, there was no SRI filed for these allegations of abuse. The Director of Nursing verified that these incidents were not reported as required by the facility's abuse policy, which mandates immediate reporting to the Administrator and the Department of Health.
Failure to Investigate Alleged Abuse Incidents
Penalty
Summary
The facility failed to ensure that all allegations of abuse were thoroughly investigated for three residents. In one incident, a resident with moderate cognitive impairment and multiple diagnoses, including schizoaffective disorder and major depressive disorder, was found in another resident's room with his penis exposed and was observed touching the other resident's breasts over her clothing. Both residents involved were moderately cognitively impaired. The incident was documented in the medical record, and staff interviews confirmed the details. However, the police were not notified of the alleged abuse, and there was no evidence that a thorough investigation was conducted as required by facility policy. In a separate incident, the same resident was observed exposing himself and touching his penis in front of another resident who was rarely understood and had vascular dementia and other significant health conditions. Staff interviews confirmed that this behavior had occurred, but the DON verified that an investigation was not conducted for this allegation of abuse. Facility policy requires that an investigation be conducted once the Administrator and Department of Health are notified, but this was not followed in these cases.
Failure to Maintain Sanitary Environment in Shower Room
Penalty
Summary
The facility failed to maintain a clean and sanitary environment for residents on the west unit, as observed during a survey. The west shower room was found to be very hot and humid with a musty odor. A black irregular shaped area with moist spots was observed on the wall and ceiling, resembling black dust. This was confirmed by a Certified Nurses Aide (CNA) and the Maintenance Director, who also identified a dinner plate size black stain on the ceiling near the window and along the wall/ceiling area on the north wall of the shower room. The Maintenance Director acknowledged the presence of moisture and the lack of an exhaust fan, which may have contributed to the mold, as well as a constantly running shower due to a faulty shut-off mechanism. The facility's Infection Control information indicated one case of respiratory illness diagnosed as pneumonia during the review period. The facility's policy on maintaining a safe and homelike environment stated that housekeeping and maintenance services should be provided as necessary to ensure a sanitary, orderly, and comfortable environment. However, the Maintenance Director was unaware of the mold issue due to a lack of notification from staff, indicating a breakdown in communication and adherence to the facility's policy. This deficiency was investigated under Complaint Numbers OH00163559 and OH00162562.
Failure to Report and Investigate Abuse and Medication Misappropriation
Penalty
Summary
The facility failed to report and thoroughly investigate an allegation of abuse involving a resident with mild cognitive impairment. The incident occurred when a CNA reported that another CNA physically abused the resident by grabbing and threatening them. Despite the report, the alleged perpetrator was not immediately removed from the unit, and the incident was not reported to the state agency. The resident was not assessed for injuries until two days after the incident, and the investigation was delayed, with interviews and assessments not conducted in a timely manner. Additionally, the facility failed to report and investigate the misappropriation of the medication Ozempic, affecting three residents. The medication was noted as unavailable for several scheduled doses, and missing pens were reported. Despite the missing medications being reported to the DON and Administrator, a thorough investigation was not conducted, and the incident was not reported to the state agency. The facility did not have documentation of staff interviews or statements regarding the missing medications. The facility's policy required immediate reporting of such incidents to the Department of Health and a thorough investigation within five working days. However, these procedures were not followed, leading to a lack of documentation and delayed response to both the abuse allegation and the medication misappropriation. The failure to adhere to these protocols resulted in non-compliance with regulatory requirements.
Failure to Notify Physician of Medication Omissions
Penalty
Summary
The facility failed to notify the physician of medication omissions for a resident, which is a deficiency in their care protocol. Resident #42, who has diagnoses including type two diabetes mellitus, hypertension, and chronic obstructive pulmonary disease, was not administered her prescribed Ozempic injections on multiple occasions. Specifically, the medication was not given on 01/10/25, 01/17/25, 01/24/25, 01/31/25, 02/07/25, and 02/22/25, as per the physician's orders. The facility's electronic medication administration record notes indicated that the Ozempic was unavailable on these dates, yet the physician was not notified of the omissions on 01/10/25, 01/24/25, 02/07/25, and 02/22/25. Interviews conducted during the investigation revealed that the Director of Nursing confirmed the medication was not administered on the specified dates and that the physician was not informed of the omissions. Additionally, Resident #42 was aware that her weekly injections were not administered but was not informed of the reasons for the omissions. The facility's policy on medication administration and change in condition physician notification requires that medications be administered as ordered and that the physician be notified of any omissions within 24 hours, which was not adhered to in this case.
Failure to Report and Investigate Abuse and Medication Misappropriation
Penalty
Summary
The facility failed to report and thoroughly investigate an allegation of abuse involving a resident with mild cognitive impairment. The incident occurred when a CNA reported that another CNA physically abused the resident by grabbing and threatening him. Despite the report, the alleged perpetrator was not immediately removed from the unit, and the incident was not reported to the state agency. The resident was not assessed for injuries until two days after the incident, and there was no documentation of immediate assessment or follow-up actions by the nursing staff. Additionally, the facility failed to report and investigate the misappropriation of the medication Ozempic, affecting three residents. The medication was noted as unavailable for several scheduled doses, and missing pens were reported to the DON and Administrator. However, there was no documentation of a thorough investigation or staff interviews regarding the missing medications. The missing Ozempic pens were not reported to the state agency, and the facility did not provide documentation of reimbursement for the missing medication. The facility's policy required immediate reporting of allegations involving neglect, exploitation, and misappropriation of resident property to the Department of Health. However, the facility did not adhere to this policy, as the incidents were not reported within the required timeframe. The lack of timely reporting and investigation of these incidents represents a significant deficiency in the facility's compliance with regulatory requirements.
Failure to Provide Adequate Grooming Care for a Resident
Penalty
Summary
The facility failed to provide adequate grooming care for a dependent resident, identified as Resident #45, who was under hospice care and had an intact cognitive function. The resident was diagnosed with Parkinson's disease, bipolar disorder, peripheral vascular disease, and chronic obstructive pulmonary disease, and was dependent on staff for activities of daily living. The resident's care plan indicated a need for assistance with personal hygiene, including nail care. However, observations revealed that the resident's toenails were excessively long and in need of trimming, which had not been completed as required on shower days. Interviews with the Licensed Practical Nurse (LPN) confirmed the need for nail trimming and acknowledged that the care should have been provided. The resident also expressed that staff had failed to trim her toenails, and her daughter had to attempt to do so during visits. The facility's policy on activities of daily living stated that necessary services would be provided for grooming, but this was not adhered to in the case of Resident #45. This deficiency was investigated under Complaint Numbers OH00162562.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to ensure that medications were administered according to physician orders, affecting two residents. Resident #64, who has type two diabetes mellitus, hypertension, and hyperlipidemia, was administered Ozempic daily instead of weekly due to an incorrect entry in the electronic record. This error was not identified until several days later, despite the resident receiving multiple doses. The physician was notified, and the order was corrected, but the pharmacy did not question the daily dose, and no side effects were reported by the resident. Resident #42, also diagnosed with type two diabetes mellitus, hypertension, and chronic obstructive pulmonary disease, did not receive her prescribed weekly Ozempic injections on several occasions. The medication was unavailable on these dates, and the physician was not consistently notified of the omissions. The resident was aware of the missed doses but was not informed of the reasons. The facility's policy requires medications to be administered as ordered and timely notification of omissions to the physician, which was not adhered to in these cases.
Facility Fails to Serve Food at Acceptable Temperatures
Penalty
Summary
The facility failed to ensure that residents were served food at an acceptable temperature, affecting 20 residents who received meal trays on the 200 hall. During an interview, two residents reported that meals were sometimes served cold, and they either asked staff to reheat the food or consumed it cold. An observation of the meal tray service revealed that the food cart arrived at the hall, and trays were served promptly. However, a test tray checked for food temperature showed that the shrimp was 100 degrees Fahrenheit and the french fries were 118 degrees Fahrenheit, both below the required serving temperatures. The Director of Nutritional and Food Services confirmed these temperatures and acknowledged they were below the required levels. The facility's policy on food production emphasized preparing food to conserve nutritive value and enhance flavor, which was not adhered to in this instance.
Facility Fails to Serve Palatable Spaghetti
Penalty
Summary
The facility failed to serve reasonably palatable food, specifically affecting residents who received spaghetti with their lunch meal. Observations and interviews conducted on November 4th and 5th, 2024, revealed that several residents expressed concerns about the palatability of the food. During a test tray evaluation, the spaghetti was found to taste sour and had a gummy texture. The Corporate Dietary Manager confirmed the spaghetti tasted acidic. Multiple residents reported that the spaghetti was not good, describing it as mushy and tasting like it came from a can. The facility's policy on Palatability and Nutritive Value, dated June 27, 2023, states that food should be prepared, held, and served in a manner that preserves its nutritive value and palatability, with food service staff monitoring palatability at the point of service through periodic test tray evaluations and resident council reviews.
Environmental Deficiencies in Memory Care Unit
Penalty
Summary
The facility failed to maintain the memory care unit in good condition, affecting six out of seven residents reviewed for environmental concerns. Observations revealed various deficiencies, including a spider web in a resident's window, dust buildup on bathroom fans, large scrapes on walls, unfinished patches on a bathroom door, and unsanitary conditions in a bathroom. These issues were verified by the Director of Housekeeping and the Director of Maintenance, who acknowledged the lack of maintenance and cleaning in these areas. Additionally, the dining room floors in the memory care unit were found to be sticky and not clean, as confirmed by administrative staff. The facility's housekeeping policy, dated April 2018, stated that resident rooms and common areas should be cleaned and maintained, yet these observations indicate a failure to adhere to this policy. The facility census was 54, and the deficiencies had the potential to affect all residents residing in the memory care unit.
Failure to Ensure Resident Access to Call Lights
Penalty
Summary
The facility failed to ensure that residents had access to their call lights, affecting three residents. Resident #40, who was cognitively intact and required assistance with functional abilities, was observed unable to locate her call light, which was out of reach. This was confirmed by both the resident and administrative staff. Similarly, Resident #42, who was moderately cognitively impaired and required partial to moderate assistance, could not locate his call light, which was also out of reach. This was verified by administrative staff. Resident #21, who had severe cognitive impairment and was dependent for toileting, was observed with a call light positioned out of reach between the bed rail and mattress. The care plan for Resident #21 included ensuring the call light was within reach, but this was not adhered to. The facility's policy on answering call lights emphasized the importance of keeping call lights within easy reach, which was not followed in these instances.
Inadequate Oral Hygiene for Resident with Cognitive Impairment
Penalty
Summary
The facility failed to ensure adequate hygiene and personal care for a resident with severe cognitive impairment, affecting their oral hygiene. The resident, diagnosed with vascular dementia, hypertension, and peripheral vascular disease, required setup assistance for personal hygiene and oral care. Observations on consecutive days revealed a white residue buildup on the resident's bottom teeth, indicating a lack of proper oral care. Interviews with State Tested Nursing Assistants (STNAs) confirmed the presence of the residue and acknowledged that the resident's teeth should be cleaned twice daily. One STNA mentioned that the resident sometimes refused care, necessitating multiple attempts to provide assistance, but there was no documentation of such refusals in the resident's progress notes. The facility's policy required staff to assist residents with oral care, including brushing teeth or cleaning dentures as needed.
Medication Availability Deficiency
Penalty
Summary
The facility failed to ensure the availability of medications for two residents, leading to deficiencies in pharmaceutical services. For Resident #22, who has a history of delusional disorders, hypertension, and other conditions, the facility did not have the PRN Excedrin available, which was crucial for managing her severe migraine headaches. Despite receiving a shipment of 30 Excedrin tablets on 10/15/24, only 12 doses were administered, and the remaining 18 tablets were unaccounted for. The resident reported the absence of her medication to multiple staff members, but the issue remained unresolved, as confirmed by the Assistant Director of Nursing and the Director of Nursing. Resident #56, with diagnoses including Parkinsonism and bipolar disorder, did not receive her prescribed Risperdal Consta injections since her admission. Although the medication was received on 10/01/24, it was not administered as per the physician's orders. The facility failed to notify the physician about the non-administration of the medication, and there was no clarification sought regarding the continuation of the medication, which the resident had been on long-term. The Director of Nursing confirmed the oversight and the lack of documentation regarding the physician's notification. The facility's policy on the administration and documentation of medications, revised in 10/2022, mandates that medications be ordered timely and that a 3-day supply be maintained to prevent delivery issues. However, the facility did not adhere to this policy, resulting in the unavailability of essential medications for the residents. This deficiency highlights a significant lapse in the facility's medication management and procurement processes.
Failure to Provide Necessary Dental Care
Penalty
Summary
The facility failed to assist residents in obtaining necessary dental care, specifically affecting one resident who required dental extractions before undergoing hip surgery. The resident, who was cognitively intact with a BIMS score of 14, had been admitted with multiple diagnoses including chronic obstructive pulmonary disease, type two diabetes mellitus, and major depressive disorder. Despite the care plan indicating that the facility would coordinate dental care and transportation, the resident had not been evaluated by a dentist since admission. Interviews and record reviews revealed that no oral surgeons or dentists had been contacted for the resident, even though the facility's dentist had visited five times since the resident's admission. The facility's policy required a review of medical records upon admission to schedule necessary follow-up appointments, but this was not adhered to in the case of the resident, leading to a delay in necessary dental care and subsequent hip surgery.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an injury of unknown origin for a resident, which is a violation of their policy on abuse, mistreatment, neglect, exploitation, and misappropriation of resident property. The resident, who was severely cognitively impaired and dependent for all activities of daily living, was found to have bruising on the left side of the neck. Despite the presence of this unexplained injury, the facility did not submit a self-reported incident to the Ohio Department of Health within the required timeframe. The medical record review and staff interviews revealed that the bruising was initially thought to be a pustule that drained white material. However, upon further assessment by a physician and a wound physician, it was determined that there was no open area or pustule present, and the area appeared to be bruising. The facility's policy requires that all incidents of unknown source be reported immediately to the administrator and the Ohio Department of Health, but this protocol was not followed in the case of this resident.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to investigate an injury of unknown origin for a resident, which was identified during a review of medical records, observations, staff interviews, and policy review. The resident, who was severely cognitively impaired and dependent on staff for all activities of daily living, was found to have bruising on the left side of the neck. Despite the presence of this injury, no self-reported incidents were submitted by the facility for the injury of unknown origin. The facility's policy requires investigation of all alleged violations, including injuries of unknown source, but this was not adhered to in this case. Interviews with staff, including an LPN and a physician, revealed that the bruising was initially thought to be related to a pustule that had drained white material. However, upon further assessment by a wound physician, it was confirmed that there was no open area or pustule present, and the area appeared to be bruising. The wound physician also noted that bruising would be distinct from an infected area, which would have a red appearance. The failure to investigate the injury as per the facility's policy represents non-compliance, as documented under the complaint number provided.
Failure to Ensure Required RN Coverage
Penalty
Summary
The facility failed to ensure the required Registered Nurse (RN) coverage, as mandated by regulations, which had the potential to affect all 48 residents. A review of staff schedules and Benefits Improvement and Protection Act (BIPA) documentation revealed that there was no RN working in the facility on specific dates: 05/05/24, 05/18/24, 05/19/24, and 05/25/24. This was confirmed during an interview with the Director of Nursing (DON) on 06/26/24, who verified the absence of RN coverage on these dates and reported that there is typically no RN coverage every other weekend. This deficiency was investigated under Master Complaint Number OH00154702 and Complaint Number OH00154290.
Failure to Serve Palatable Meals
Penalty
Summary
The facility failed to serve palatable meals to its residents, affecting 33 individuals who received the dinner vegetable and one resident who received the chicken breast. The dinner menu included two beef tacos in a soft shell, cilantro lime rice, Mexican corn, and a seedless watermelon wedge. Observations revealed that the Mexican corn was not cooked well and felt tough while chewing. This was confirmed by the Corporate Dietary Manager, who acknowledged that the corn did not meet palatability standards. Additionally, a resident expressed dissatisfaction with a tough chicken breast that was served, which was so difficult to eat that she resorted to eating chocolate instead. The Dietary Manager verified that the chicken breast was indeed very tough. Other residents also reported that the meals were not edible, with one resident frequently opting for a peanut butter and jelly sandwich instead. Another resident mentioned that the vegetables and pasta were often over or undercooked, and yet another resident expressed their dissatisfaction with the food by making a gagging motion. The facility's policy on palatability and nutritive value, reviewed in June 2023, states that food should be prepared, held, and served in a manner that preserves nutritive value and palatability, which was not adhered to in this instance.
Failure to Provide Scheduled Showers to Dependent Residents
Penalty
Summary
The facility failed to provide adequate showering assistance to three residents who were dependent on staff for their activities of daily living. Resident #33, who was moderately cognitively impaired and required substantial assistance, only received one documented shower in the last thirty days, despite no records of refusal. Similarly, Resident #58, who was cognitively intact and required moderate assistance, only had one shower documented in the same period, with the resident expressing a desire for more frequent showers and noting staff's lack of time as a barrier. Resident #22, who was rarely understood and fully dependent on staff for bathing, also had only one documented shower, with staff believing more showers occurred than were recorded. Interviews with the residents and staff, including a Corporate Registered Nurse and the Director of Nursing, confirmed the lack of adherence to scheduled showers. The facility's policy on Activities of Daily Living, revised in January 2022, mandates that resident bathing and other ADLs be incorporated into daily activities as much as possible. This deficiency was investigated under Complaint Number OH00154290, highlighting a significant lapse in the facility's compliance with its own policies and the needs of its residents.
Inadequate Staffing Leads to Deficient Resident Care
Penalty
Summary
The facility failed to provide adequate staffing to meet the needs of its residents, affecting three residents who were reviewed for staffing and activities of daily living. Resident #22, who has multiple diagnoses including vascular dementia and major depressive disorder, was found to have only received one shower in the last thirty days, with no documentation of refusal. Similarly, Resident #33, who requires substantial assistance due to cognitive impairment, also received only one shower in the same period, despite the care plan indicating the need for more frequent bathing. Resident #58, who is cognitively intact and prefers showers on the night shift, was also found to have not received adequate showers, with only one documented shower in the last thirty days. Interviews with residents and staff revealed a consistent theme of inadequate staffing, with reports of call-offs and difficulty in finding replacements. Residents expressed concerns about the lack of showers and the overworked staff, while staff members, including STNAs, LPNs, and RNs, confirmed that staffing shortages often led to delays in resident care, including bathing. The facility's staffing schedules for June 2023 showed frequent call-offs without replacements, contributing to the deficiency in meeting residents' needs for personal hygiene.
Failure to Provide Meal Substitutions
Penalty
Summary
The facility failed to provide meal substitutions that accommodated resident preferences, affecting one resident who was reviewed for preferences. During an observation, a State tested Nursing Assistant (STNA) called the kitchen on behalf of a resident who requested a burger instead of the dinner meal. The kitchen staff informed the STNA that there were no burgers available and offered a peanut butter sandwich as an alternative. The resident, who did not like tacos, expressed dissatisfaction with the peanut butter sandwich option and chose to skip dinner, leaving the meal tray untouched. Further interviews revealed that meal substitutions were not consistently available, as another resident also reported similar issues. The facility's Always Available Menu listed several substitutions, including a cheeseburger on a bun, deli sandwich, roasted chicken breast, side salad, chef salad, peanut butter and jelly sandwich, and grilled cheese sandwich. However, the facility was out of hamburger meat, and no hamburgers were made, as confirmed by the Dietary Manager. The facility's policy stated that nutritionally comparable menu items should be available to accommodate resident food preferences, but this was not adhered to in this instance.
Latest citations in Ohio
Surveyors found that multiple hazardous storage areas, including a closet near medical records, a beauty salon used to store chemical cases, a supply room in one nursing station, a room leading to a smoking area, a housekeeping room near therapy, and a lobby storage room, lacked required self-closing or automatic-closing doors. These conditions did not comply with NFPA 101 requirements for hazardous area enclosure and had the potential to affect all residents and staff in an emergency.
Surveyors found that the facility did not conduct fire drills on every shift each quarter and did not vary drill conditions as required by NFPA 101. Record review showed that one shift lacked a documented drill for an entire quarter, and the pattern of drill times and dates did not demonstrate varied conditions. The Maintenance Director confirmed the incomplete and noncompliant fire drill schedule, which affected all residents and staff emergency preparedness.
Surveyors found that the facility did not maintain clear egress corridors as required by NFPA 101, with a TV/video cart plugged into a corridor outlet and multiple unsecured chairs placed in the hallway near resident rooms and the secured unit dining room, including directly in front of a fire extinguisher. These items projected about 29 inches into an approximately eight-foot-wide corridor and were located in front of the handrail, potentially affecting 28 residents and staff’s ability to assist in an emergency. The Maintenance Director confirmed these corridor obstructions during the survey.
A resident with intact cognition receiving Medicare Part A skilled services for metabolic encephalopathy had services discontinued while benefit days remained, but the facility did not issue the required Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN). The Social Services Director later confirmed that no SNF ABN was provided and reported she believed only a Notice of Medicare Non-Coverage (NOMNC) was needed when all skilled services were stopped. This practice conflicted with the facility’s written policy, which required SNF ABNs to be issued when extended care items or services were initiated, reduced, or terminated due to expected non-coverage by Medicare.
Surveyors identified that the facility exceeded the acceptable medication error rate when two residents with type 2 DM received insulin doses that were not administered according to orders or manufacturer instructions. In two separate observations, an LPN administered Novolog and another LPN administered insulin glargine and insulin lispro without priming the insulin pens, and the insulin lispro and Novolog were given after the residents had already consumed a significant portion of their breakfast meals, despite orders for administration before meals. Manufacturer information for both insulin products required priming before each injection to ensure accurate dosing, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and specified time frames.
A cognitively intact resident with behavioral issues, including physical aggression and noncompliance with care, was in a secured unit and was observed tapping on the window/door. A dietary aide, despite being told by a CNA and an RN not to enter the secured unit and that the resident’s assigned aide could assist, went onto the unit and interacted with the resident, including offering to buy a soda after seeing money in the resident’s hand. The resident struck the aide in the face, and the aide responded by punching the resident in the face; a CNA reported hearing the aide say, “I will hit you again,” and then observed the resident bleeding. The resident was later found at the hospital to have an open mandibular fracture and non-restorable teeth requiring extraction, and the facility’s investigation and policy definitions led to the incident being substantiated as staff-to-resident physical abuse.
A resident with severe cognitive impairment, osteoporosis, and total dependence for transfers was being moved from bed to wheelchair with a mechanical lift when CNAs reported that an undersized sling and a forceful pull on the lift caused the resident to fall feet‑first from the sling, with staff catching the upper body while both legs struck the floor and one leg bent behind. Witnesses heard a loud pop and observed immediate pain, bruising, swelling, and deformity of the leg, yet the responding LPN did not complete a thorough musculoskeletal assessment, did not document a fall, and the physician and resident representative were not promptly informed of a suspected injury. Through the night and into the next day, staff and the roommate reported the resident crying out in pain and an obviously abnormal leg, but nursing notes only reflected intermittent acetaminophen administration without clear pain documentation, and the physician was contacted primarily about yelling and behavior. Mobile X‑rays obtained later showed a displaced distal femur fracture, which was not reviewed until the following day, when hospital imaging confirmed a closed displaced comminuted femur fracture and a hand fracture. The facility’s internal investigation was incomplete and inaccurate, with leadership denying a fall, preparing a single typed statement minimizing the event, and having multiple staff sign it despite later testimony that the statement was false and that staff were told not to discuss the incident.
Surveyors found multiple instances of improper food storage and labeling, including undated and unlabeled opened dairy products, beverages, and prepared foods in the main walk-in cooler and freezer, as well as a serving scoop left resting directly on stored pasta. Additional issues included covered but undated pre-poured juices, milk, and thickened beverages in a reach-in cooler used for tray line, and a nurses' station refrigerator containing a dated bag of a resident’s food from over a week prior and three undated half-sandwiches. In a resident’s personal refrigerator, staff confirmed three undated bags of grapes with visible mold. These conditions did not comply with facility policies requiring cold foods to be stored off the floor, wrapped or covered, labeled, dated, and for resident refrigerators to be monitored daily with unsafe or moldy food discarded.
Surveyors found unsanitary kitchen conditions, including a dirty tray holding clean pitchers, soiled storage carts containing clean dishware and disposables, and multiple trays of open juice in a reach-in refrigerator that were unlabeled and undated. In a walk-in refrigerator, they observed a bag of bologna marked only with a freeze date, lacking a thaw or use-by date, and appearing slimy and discolored. Observation of the high-temp dishwasher showed rinse temperatures below the 180°F minimum required for hot water sanitizing, and review of several months of temperature logs revealed repeated sub-minimum wash and rinse temperatures and numerous missing entries. Facility policies required dishwashing to meet specified temperature standards and all refrigerated foods to be covered, labeled, and dated with a use-by date, but these requirements were not consistently followed.
Surveyors found that the facility did not maintain a safe, clean, and homelike environment as required by its policy. In one shared bedroom, wallpaper was peeling in several areas, including behind each bed, below a window, and near baseboards, and a black substance was present around the base of the toilet. A CNA confirmed these conditions. In addition, three cracked or broken light covers were observed in a hall restroom. These environmental issues affected two residents and had the potential to affect all residents.
Failure to Maintain Self-Closing Doors for Multiple Hazardous Storage Areas
Penalty
Summary
Surveyors identified a deficiency related to hazardous area protection and door requirements under NFPA 101, 2012 Edition. During facility tours, they observed that multiple hazardous storage areas did not have self-closing or automatic-closing doors as required for hazardous areas such as combustible storage and chemical storage. These areas included a closet next to medical records, a beauty salon being used to store cases of chemicals, a supply room in Station #2, and the room leading to the smoking area in Station #3. On a subsequent tour, surveyors observed additional hazardous areas without self-closing doors. The housekeeping room across from therapy and the lobby storage room were both noted to lack self-closing door mechanisms. The facility census at the time was 59 residents, and the surveyors stated that this deficient practice had the potential to affect all residents and staff's ability to assist in an emergency. The Maintenance Director verified these findings at the time they were observed.
Plan Of Correction
K 0321 This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be admissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as its allegation of substantial compliance as of 06/12/2026 K-0321 Doors with Self-Closing Devices Corrective action for resident/s: 1. The closet door next to medical records was lacking a self-closing door on 5/19/2026. Maintenance director to add self-closing device to closet door next to medical records on or before 06/12/2026 in accordance with applicable code. 2. The beauty salon had chemicals stored in it on 5/19/2026. Maintenance director moved chemicals from beauty salon on 05/20/2026 in accordance with applicable code. 3. The supply room on station 2 was lacking a self-closing door on 5/19/2026. Maintenance director to add self-closing door to supply room on station 2 on or before 06/12/2026 in accordance with applicable code. 4. The room to the smoking area on station 3 was lacking a self-closing door on 5/19/2026. Maintenance director to add a self-closing door to the smoking are on station 3 on or before 06/12/2026 in accordance with applicable code. 4. The housekeeping room across from therapy was lacking a self-closing door on 5/19/2026. Maintenance director to add a self-closing door to the housekeeping room across from therapy gym on or before 06/12/2026 in accordance with applicable code. 5. The lobby storage room was lacking a self-closing door on 5/19/2026. Maintenance director to add a self-closing door to the lobby storage room on or before 06/12/2026 in accordance with applicable code. Identification of other residents who may be affected: LNHA and Maintenance director/designee completed a full facility audit for doors with self-closing devices on 05/26/2026. Any corrective action, including, doors identified as needing self-closures will be added on or before 06/09/2026 in accordance with applicable code. Measures for systemic change: LNHA educated Maintenance Director on 05/26/2026 regarding NFPA 101-2012 sections 19.3.2.1 and 19.3.5.9 specifically regarding doors with self-closing devices. How Corrective Action will be monitored Ongoing "Doors with Self-Closing device audit" to be completed weekly x 2 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 06/12/2026
Failure to Conduct Required Quarterly Fire Drills on All Shifts
Penalty
Summary
The facility failed to conduct fire drills in accordance with NFPA 101, 2012 Edition, sections 19.7.1 through 19.7.1.8, specifically by not holding drills every shift each quarter and not varying drill conditions as required. Record review on 06/09/25 at approximately 10:32 A.M. showed there was no fire drill conducted for the first shift during the third quarter. The documented first-shift fire drills occurred on 01/30/26 at 2:42 P.M., 04/30/26 at 1:51 P.M., and 10/31/25 at 10:58 A.M., indicating a missed quarter. Second-shift fire drills were recorded on 02/26/26 at 5:20 P.M., 06/03/25 at 4:35 P.M., 08/29/25 at 3:46 P.M., and 11/25/25 at 5:09 P.M., and third-shift drills on 02/28/26 at 11:47 P.M., 05/30/25 at 12:18 A.M., 07/22/25 at 11:34 P.M., 09/26/25 at 11:40 P.M., and 12/15/25 at 5:17 A.M. The surveyor determined that drills were not conducted under varied conditions and that the required quarterly drill on each shift was not consistently performed. The Maintenance Director confirmed these findings at the time they were identified, and the deficiency had the potential to affect all 59 residents and staff response in an emergency. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency related to facility-wide emergency preparedness practices and documentation of fire drills.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 05/29/2026 K-0712 Fire Drills Corrective action for resident/s: There were no records of a fire drill for the first shift of the third quarter of 2025. First shift fire drill completed on 5/24/2026 by maintenance director/designee with no findings or corrective action necessary. Identification of other residents who may be affected: On 5/26/2026 Maintenance director/designee completed 100% audit of the scheduled fire drills to ensure a drill is scheduled quarterly each shift with no findings or corrective action necessary. Measures for systemic change: LNHA educated Maintenance Director on 05/26/2026 regarding NFPA 101-2012 section 19.7.1.4 through 19.7.1.7. specifically including fire drill frequency requirements. How Corrective Action will be monitored Ongoing "Fire Drill Audit" to be completed weekly x 2 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 05/29/2026
Obstructed Egress Corridors Due to Equipment and Chairs
Penalty
Summary
The facility failed to maintain required clear egress widths in corridors in accordance with NFPA 101, 2012 Edition, sections 19.2.3.4 through 19.2.3.5 and 7.3.2 through 7.3.2.3, creating projections into the egress corridor that exceeded allowable limits. Surveyors observed that on one day in Station #3, a cart with a television and video equipment was plugged into an outlet in the corridor by room 38, and five activity room chairs were placed in the corridor near the secured unit dining room directly in front of a fire extinguisher. On the following day, surveyors again observed chairs in the Station #3 corridor, with four by room 35 and four by the activities room, and the same television cart still in the corridor; the chairs were not secured. The corridor was approximately eight feet wide, and the projections extended approximately 29 inches into the corridor in front of the handrail. These conditions had the potential to affect 28 residents in the facility and the staff’s ability to assist in an emergency, and the Maintenance Director confirmed the observations at the time of discovery. No specific resident medical histories or conditions were described in the report, only that 28 residents were potentially affected and the facility census was 59.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be subsequent remedial measures and should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 05/29/2026 K-0232 Clear path of egress Corrective action for resident/s: 1. On 05/18/2026 station 3 had a cart with a television parked in the corridor by room 38 that exceeded allowable limits. Maintenance director/designee moved the TV cart into the activity room, out to the corridor on 05/18/2026 in accordance with applicable code. 2. On 5/18/2026 station 3 had 5 chairs in the corridor near the dining room directly in front of the fire extinguisher. Maintenance director/designee moved the chairs into the dining room, out of the corridor on 5/18/2026 in accordance with applicable code. 3. On 5/19/2026 station 3 had 4 chairs by the activity room and 4 by room 35. In addition, the TV cart was in the corridor. The maintenance director/designee moved the chairs and TV cart into the dining room, out of the corridor on 5/19/2026 in accordance with applicable code. Identification of other residents who may be affected: Maintenance director/designee completed a 100% facility audit for clear paths of egress on 5/26/26 with no findings or corrective action necessary. Measures for systemic change: Maintenance Director/designee educated staff on 5/26/2026 regarding NFPA 101-2012 section 19.2.3.4 and 19.2.3.5 specifically including maintaining a clear path of egress. How Corrective Action will be monitored Ongoing "Path of Egress Audit" to be completed weekly x 2 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 05/29/2026
Failure to Issue Required SNF ABN When Discontinuing Medicare Part A Services
Penalty
Summary
The deficiency involves the facility’s failure to issue a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) when Medicare Part A services were discontinued for a resident who still had available benefit days. The resident was admitted with a diagnosis of metabolic encephalopathy and had intact cognition per the Minimum Data Set assessment. The facility’s own SNF Beneficiary Notification Review documented that Medicare Part A skilled services began on 02/11/26 and the last covered day was 03/11/26, and that the facility initiated discharge from Medicare Part A services before the resident’s benefit days were exhausted. Despite this, no SNF ABN was provided to the resident or the resident’s representative. During interviews, the Social Services Director stated that the SNF ABN was issued hours prior to the last covered day but, upon reviewing her files, confirmed that no SNF ABN had actually been issued for this resident. She further explained that she believed an SNF ABN was only required if one skilled service remained and that if all skilled services were being discontinued, only the Notice of Medicare Non-Coverage (NOMNC) needed to be issued. The Administrator, however, stated that a resident should always receive both a SNF ABN and a NOMNC when Medicare Part A services are discontinued and benefit days remain. Review of the facility’s written policy dated 03/28/23 showed that the facility was required to issue SNF ABNs for initiation, reduction, or termination of extended care items or services when Medicare payment was not expected, which did not occur in this case.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as its allegation of substantial compliance as of 05/29/2026 F-0582 Corrective action for resident/s: On 5/14/26 Resident #34 was informed of rights and responsibilities related to Advanced Beneficiary Notice and voiced understanding of information for future reference by administrator. Identification of other residents who may be affected: Any resident receiving skilled services from nursing or therapy services. The Administrator audited all residents who were discharged from skilled services in the past 30 days to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary Notice on 5/29/26. No non-compliance was noted. Measures for systemic change: On 5/14/2026 Business Office Manager, Director of Rehab, Minimum Data Set nurse, Director of Nursing and Social Services Director were educated on proper procedure of issuing of Notice Of Medicare Non Coverage and Advanced Beneficiary Notice by administrator. All upcoming discharges from skilled services will be reviewed weekly at Utilization Review meeting to ensure notices will be delivered timely. How Corrective Action will be monitored: Administrator or designee to complete audits of all residents being discharged from skilled services to ensure they were issued a Notice of Non-Coverage and Advanced Beneficiary. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance 5/29/26
Insulin Administration Errors and Failure to Prime Insulin Pens
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5%, with surveyors identifying 3 errors out of 28 medication administration opportunities, resulting in a 10.71% error rate. For one resident with type 2 diabetes mellitus and moderate cognitive impairment, the physician’s order directed Novolog insulin 10 units via subcutaneous pen-injector to be given before meals. During an observed medication pass, the LPN administered 10 units of Novolog insulin without priming the pen and did so after the resident had already consumed approximately 50% of the breakfast meal. The LPN later confirmed she did not prime the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer instructions for the Novolog FlexPen specified that an air shot (priming) must be performed before each injection to ensure proper dosing. Another resident, also diagnosed with type 2 diabetes mellitus and with intact cognition, had orders for insulin glargine 35 units subcutaneously twice daily and insulin lispro 20 units subcutaneously before meals, plus 12 units subcutaneously if blood glucose was between 251 mg/dL and 300 mg/dL. During an observed medication administration, an LPN administered 35 units of insulin glargine and 32 units of insulin lispro without priming the insulin pens and after the resident had consumed approximately 90% of the breakfast meal, despite orders for insulin lispro to be given before meals. The LPN later stated she could not remember if she had primed the pen and acknowledged that the insulin was ordered to be administered prior to meals. Manufacturer information for insulin lispro stated that the pen must be primed before each injection to confirm insulin delivery and remove air, and that failure to prime could result in too much or too little insulin. The DON confirmed the expectation that insulin be administered as ordered, including priming each pen with two units before dialing the prescribed dose, and facility policy required medications, including insulin, to be administered safely, timely, and in accordance with prescriber orders and required time frames.
Plan Of Correction
This Plan of Correction is submitted as required under State and Federal law. This Plan of Correction does not constitute an admission on the part of the Facility that the findings cited are accurate, that the findings constitute a deficiency or that the scope and severity regarding the deficiency cited are correctly applied. Any changes to the Facility's policies and procedures should be inadmissible in any proceeding on that basis. Without admitting or denying the validity or the existence of the alleged noncompliance, the Facility submits this Plan of Correction with the intention that it be inadmissible by any third party in any civil or other action against the facility or any employee, agent, officer, director or shareholder of the Facility. The Facility is utilizing this Plan of Correction as an allegation of substantial compliance as of 5/29/2026. F-0759 Corrective action for resident/s: Residents #21 and #22 were assessed and evaluated by nurse and Director of Nursing 5/14/26. Resident #21 and #22 both denied any adverse effects and none were noted upon assessment by the Director of Nursing on 5/14/2026. Notification made to physician on 5/14/2026. LPN # 2 competency Eval on insulin administration with the Director of Nursing completed 5/14/2026. Identification of other residents who may be affected: Diabetic residents on assignment of LPN #2/station 2 have the potential to be affected and were assessed by the DON/Designee on 5/14/26 and found to be within normal limits. Measures for systemic change: All Nurses were educated by the Director of Nursing on the steps for Insulin administration per competency, diabetes clinical protocol policy, Medication and treatment orders policy, administering medications policy, and Obtaining fingerstick Glucose Level policy On 5/14/2026. How Corrective Action will be monitored: Director of Nursing and Assistant Director of Nursing will complete insulin administration audits on 5 nurses. This audit will be completed weekly x 4 weeks, then monthly x 2 months. Corrective action will be initiated for any noted non-compliance. Audit findings will be reviewed as part of the monthly quality assurance process to determine the need for further monitoring. Date of Compliance: 5/29/2026
Staff-to-resident physical abuse resulting in jaw fracture and tooth loss
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from staff-to-resident physical abuse, resulting in serious injury. A dietary aide entered a secured unit where a cognitively intact resident with a history of behavioral issues, including physical aggression and noncompliance with care and medications, was located. The resident had been tapping or knocking on the window/door of the secured unit, drawing the attention of the dietary aide. Multiple staff, including a CNA and an RN, told the dietary aide not to go onto the secured unit, noting that the resident’s assigned aide could assist and that the resident had been agitated the previous day. Despite these instructions, the dietary aide went onto the secured unit. Witness statements and interviews indicate that upon entering the unit, the aide interacted with the resident, including offering to buy the resident a soda after seeing the resident holding money. According to staff statements and the aide’s own account, the resident then struck the aide in the face. The aide responded by punching the resident in the face. A CNA on the unit reported stepping between the two to attempt to deescalate the situation and then calling for the nurse due to the resident’s aggression. The CNA also reported hearing the aide tell the resident, “I will hit you again,” and then observed that the resident was bleeding. Following the punch, the resident was noted by staff to be bleeding from the nose and mouth. The resident was assessed by nursing and subsequently transported to the hospital. Hospital records documented that the resident sustained an open fracture of the right jaw, with a loose right lateral mandibular incisor and bleeding from the socket at the fracture site. The resident’s remaining 11 teeth were extracted because they could not be restored. A police report documented that staff reported the incident as an assault in which a staff member punched a resident after the resident had punched the staff member. The facility’s policy defined abuse as the willful infliction of injury resulting in physical harm, including physical abuse such as hitting and punching, and the facility substantiated that the dietary aide had physically abused the resident.
Failure to Ensure Safe Mechanical Lift Transfer, Timely Assessment, and Pain Management After Traumatic Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure safe mechanical lift transfers, adequate assessment, timely physician and representative notification, and appropriate pain management for a severely cognitively impaired, non‑ambulatory resident who required a mechanical lift with two‑person assistance for all transfers. The resident had multiple relevant diagnoses, including vascular dementia, osteoarthritis, a right hip prosthesis, chronic kidney disease, and a history of fractures and osteoporosis/osteopenia. On the morning of 04/22/26, during a mechanical lift transfer from bed to wheelchair, multiple CNAs reported that the sling appeared too small, the lift was pulled forcefully from under the bed, and the resident fell feet‑first out of the sling, with staff catching her upper body while both legs hit the floor and one leg bent behind her. A loud popping sound was heard, the resident screamed and cried out in pain, and witnesses observed immediate bruising, swelling, and apparent misalignment of the left knee/leg. Despite this, the nurse who responded did not perform a complete head‑to‑toe or range‑of‑motion assessment focused on the leg, and the incident was not documented as a fall from the lift. Following the incident, nursing staff actions and documentation were incomplete and inconsistent with the resident’s presentation. Progress notes on 04/22/26 documented only a skin tear to the left forearm and a head‑to‑toe assessment with no new areas, and there were no notes describing a fall, leg injury, or significant pain. Multiple CNAs and the resident’s roommate reported that the resident cried out in pain throughout the night and that her left leg appeared swollen, bruised, and deformed, yet nursing notes from the night shift only recorded administrations of acetaminophen without documenting the reason for administration, pain assessment findings, or any musculoskeletal concerns. One RN reported being asked to look at the resident on 04/22/26, noting swelling of the left leg but performing no further assessment. The physician was not notified within one hour of a suspected musculoskeletal injury as required by facility policy, and the resident’s representative was not informed that the resident had fallen from the mechanical lift. On 04/23/26, staff continued to report the resident’s ongoing pain and abnormal leg appearance, but the physician was contacted only about increased yelling and behavior, with a focus on agitation and prior hip/groin pain history rather than a new traumatic event. The DON later documented that a loud popping noise occurred during a Hoyer lift transfer with three staff present and that no abnormalities or signs of pain were noted, and the physician was asked to order bilateral hip and knee X‑rays as a precaution, without documenting a fall. Mobile X‑rays were obtained on 04/23/26, but the results, which showed a displaced distal femur fracture on a limited lateral view, were not reviewed until 04/24/26. Only then was the fracture acknowledged and discussed with the physician and resident representative. Subsequent hospital evaluation identified a closed displaced comminuted supracondylar fracture of the left femur and a distal fifth metacarpal fracture of the left hand. The facility’s internal investigation was incomplete and inaccurate: the DON denied a fall on 04/22/26, prepared a single typed statement describing only a popping sound while the resident was suspended over the bed, and had multiple staff sign it, even though at least two CNAs and an agency DON later reported that the statement was false and that staff felt intimidated and were told not to talk about the incident. The facility also failed to adequately manage the resident’s pain following the injury. Although the MAR shows acetaminophen administrations on 04/22/26 and early 04/23/26, there was no associated documentation of pain scores or clinical rationale in the progress notes for some doses, and staff interviews and the roommate’s account described the resident crying out in pain whenever touched and throughout the night. The physician later stated he was under the impression the fracture was non‑displaced and that, because the resident was bedbound, he did not feel she needed pain medication, and he was unaware of the severity of the femur fracture or the additional hand fracture. Overall, the facility did not follow its own physician communication policy for falls with musculoskeletal deformity or leg pain, did not perform and document thorough assessments at the time of the incident and during the subsequent night, did not promptly review diagnostic imaging, and did not conduct a complete, accurate investigation into the circumstances of the mechanical lift transfer and resulting injuries.
Improper Food Storage and Labeling in Facility and Resident Refrigerators
Penalty
Summary
Surveyors identified a failure to store food in accordance with professional standards and facility policy, creating the potential for foodborne illness for nearly all residents who received food from the kitchen. In the walk-in cooler, they observed multiple items that were opened and partially used without any open dates, including two cartons of heavy whipping cream, bins of individually poured and covered beverages, and a tray of covered fruit cocktail bowls. A large pan of pasta with ground meat was stored with the serving scoop resting directly on the food, covered with plastic wrap and not dated. A cart in the cooler held a 22-quart container of dark liquid with no label or date, and a pink plastic pitcher resting directly on the cart surface, which was coated with a dark unidentified material. A box of bacon was stored directly on the floor. The Director of Dietary Services confirmed the presence of undated, unlabeled, and improperly stored food items in the walk-in cooler. In the walk-in freezer, surveyors found an unsealed and undated bag of frozen chicken breasts and an unsealed and undated bag of pork pizza topping, which the Director of Dietary Services also confirmed. The reach-in cooler used for tray line contained a variety of pre-poured juices, milk, thickened beverages, and tea that were covered but not dated. At a nurses' station refrigerator, surveyors observed a plastic bag of food labeled with a resident’s name and dated more than a week earlier, along with three half-sandwiches wrapped in plastic without dates; the LPN present verified these findings. In a resident’s personal refrigerator, three undated bags of grapes with visible mold were found, and a CNA confirmed the grapes were moldy and undated. Facility policies required cold foods to be stored at least six inches above the floor, wrapped or in covered containers, labeled, and dated, and required resident refrigerators to be monitored daily, with food appropriately labeled and unsafe or moldy food discarded. These practices were not followed, resulting in the cited deficiency under the complaint investigation.
Unsanitary Kitchen Practices and Improper Dishwashing Temperatures
Penalty
Summary
Surveyors identified a deficiency in the facility’s food service operations related to unsanitary kitchen conditions, improper food labeling and dating, and failure to operate the dishwasher according to manufacturer and policy requirements. During an initial kitchen tour, they observed a plastic tray holding clean pitchers with a brown-like substance on it, and three open, three-shelf carts with crumbs and debris on the shelves where clean insulated plate lids and sleeves of disposable bowls, cups, and lids were stored. Multiple trays of juice in a reach-in refrigerator were open, unlabeled, and undated. In the walk-in refrigerator, surveyors found a plastic bag of bologna with only a freeze date and no thaw or use-by date; the bologna appeared slimy and lighter in color. The facility census was 67, with one resident identified as not receiving meals from the kitchen, and the deficiency was noted as having the potential to affect all residents receiving food from the kitchen. Surveyors also observed the high-temperature dishwasher in use and recorded a wash temperature of 168°F and rinse temperatures of 160°F, 176°F, 178°F, 178°F, and 178°F over five cycles, despite the machine label and facility policy requiring a minimum wash temperature of 150°F and a minimum rinse temperature of 180°F for hot water sanitizing. A staff member confirmed the dishwasher had not been running earlier that morning, verified it was a high-temperature machine that should rinse at a minimum of 180°F, and acknowledged the observations regarding the dirty tray, soiled carts, unlabeled juice, and improperly dated bologna. The staff member stated that items in the reach-in refrigerator were normally prepped the night before and asserted that the bologna always had that color before discarding it. Review of the dishwasher temperature logs for January through April 2026 showed repeated failures to meet required wash and rinse temperatures and numerous instances of missing documentation. In January, multiple wash temperatures were below the 150°F minimum, and several meals lacked recorded wash and rinse temperatures. February logs showed at least one sub-minimum wash temperature and many missing wash and rinse entries for various meals. March logs included at least one meal with no documented wash or rinse temperatures. April logs documented several wash temperatures below 150°F and rinse temperatures below 180°F, along with multiple days and meals where wash and/or rinse temperatures were not recorded at all. Facility policies on sanitation, kitchen infection control, and food receiving and storage required dishwashing to meet temperature and sanitation standards and refrigerated foods to be covered, labeled, dated, and used, frozen, or discarded by their use-by date, which was not consistently followed according to the survey findings.
Environmental Maintenance and Cleanliness Deficiencies in Resident Room and Common Restroom
Penalty
Summary
Surveyors identified that the facility failed to maintain a safe, clean, comfortable, and homelike environment as required by its “Homelike Environment” policy. Observation of a shared bedroom for Residents #46 and #56 showed wallpaper peeling from the wall in multiple locations, including behind each resident’s headboard, below the window, and near the baseboards. In the same room’s bathroom, a black substance was observed around the base of the toilet. During an interview conducted concurrently with these observations, CNA #175 confirmed the presence of the peeling wallpaper and the black substance around the toilet base. Further observation with CNA #175 in the C hall restroom revealed that three light covers in that restroom were cracked or broken. The facility’s written policy, revised in February 2021, states that residents are to be provided with a safe, clean, comfortable, and homelike environment. The conditions observed in the residents’ bedroom, bathroom, and the C hall restroom were inconsistent with this policy and affected two identified residents, with the potential to affect all residents in the facility.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
