Majestic Care Of Perrysburg
Inspection history, citations, penalties and survey trends for this long-term care facility in Perrysburg, Ohio.
- Location
- 28546 Starbright Blvd, Perrysburg, Ohio 43551
- CMS Provider Number
- 365624
- Inspections on file
- 32
- Latest survey
- April 24, 2026
- Citations (last 12 mo.)
- 16
Citation history
Health deficiencies cited at Majestic Care Of Perrysburg during CMS and state inspections, most recent first.
Surveyors found that the facility did not carry out or document required Legionella control measures, including routine flushing of infrequently used water outlets and scheduled cleaning or replacement of shower heads, despite having a written water management plan and CDC guidance. In addition, enhanced barrier precautions (EBP) ordered for residents with abdominal wounds, tracheostomies, and diabetic foot ulcers were not followed: an LPN and an RN performed wound and trach care without gowns, without disinfecting bedside tables before placing supplies, and without appropriate hand hygiene between glove changes, and staff assisted a resident with a chronic foot wound in ADLs and transfers without PPE or EBP signage or supplies available, contrary to facility policy and physician orders.
The facility failed to maintain adequately warm water temperatures in the East Hall shower room, resulting in multiple residents with conditions such as CHF, Parkinson’s disease, COPD, anxiety, and diabetes reporting that the shower water was too cold, leading some to refuse showers and instead receive bed baths or wash at the sink. CNAs and an LPN confirmed ongoing resident complaints and described one shower stall as cold and the other as only barely warm. Direct measurements with the Maintenance Director showed shower and sink water temperatures well below the minimum required level, and review of water temperature logs revealed that weekly monitoring was not consistently performed, with several weeks lacking any recorded temperatures.
The facility failed to provide and/or document scheduled bathing and grooming for multiple dependent residents. One hospice resident with severe cognitive impairment and extensive ADL needs had only sporadic bed baths and showers documented, with no evidence of hair washing, nail care, or beard grooming, and was observed with greasy hair, unkempt facial hair, and long jagged nails amid conflicting statements between CNAs and a Hospice CNA about responsibility for care. Another cognitively impaired resident dependent for showering reported only weekly showers despite being scheduled for twice-weekly showers, and records showed several missed showers without refusals documented. Two additional cognitively intact residents requiring substantial assistance with bathing had incomplete shower documentation, with only some scheduled baths recorded and no evidence of refusals, despite staff acknowledging that shower sheets should be completed for all showers, bed baths, or refusals and a policy requiring provision of ADL care including bathing and grooming.
Surveyors identified multiple deficiencies involving resident safety and assessment practices. A resident with cognitive impairment, neurological history, and documented exit-seeking behaviors, who was care planned as an elopement risk with a wander management device, eloped twice from the building and was found outside on facility grounds and later across a street near a high-speed roadway, while the administrator acknowledged staffing was not adequate to maintain the needed level of supervision and 15‑minute checks had been discontinued without added interventions. Another cognitively intact resident, assessed as safe to smoke only with supervision and subject to a policy requiring all smoking materials, including e‑cigarettes, to be stored by the facility, was found to have a vape pen left on his bed on more than one occasion, contrary to facility policy and staff expectations. In a separate case, a resident with multiple comorbidities and high assistance needs who sustained an unwitnessed fall had post-fall neurological assessments documented over two days in which hand grasps and motor function checks were repeatedly omitted, and the administrator confirmed these neuro checks were completed inaccurately.
A resident with hemiplegia, dysphagia, dementia, and an ADL self-care deficit was care-planned to receive partial assistance from one staff member for eating and was dependent on staff for meals. While about 13 residents were in a secured dining area awaiting breakfast, a CNA, from the hallway, loudly referred to the resident as a “feeder” to another CNA in the dining room, in front of other residents. The CNA later confirmed she had used this term and acknowledged it was not dignified or respectful, contrary to the facility’s resident rights policy requiring staff to treat residents with kindness, respect, and dignity.
Surveyors found that the facility failed to develop and implement timely and complete baseline care plans for two newly admitted residents. One resident with multiple chronic conditions and extensive ADL assistance needs had no baseline care plan in place for nearly two weeks after admission, and monitoring for diabetes was not initiated until a comprehensive care plan was developed later. Another cognitively intact resident with multiple medical diagnoses had a baseline care plan that did not address oxygen administration, even though the resident was observed using oxygen via nasal cannula at 4 L/min and used oxygen as needed. Facility policy required the admission nurse to initiate a baseline care plan and required care plans to include objectives to meet medical needs.
A resident with diabetes, peripheral vascular disease, dementia, and a history of diabetic ulcers was care planned for skin integrity risks and had orders for weekly skin observations and heel off-loading. A scheduled weekly skin assessment was not completed, and the next day an LPN documented a new wound on the left great toe and heel but did not record measurements or a detailed description until a week later, when the ulcers were measured and noted to contain significant eschar. Despite orders for heel boots and later heel elevation, surveyors repeatedly observed the resident in bed with feet resting on the mattress, without pressure-relief boots, heel elevation, or a linen tent, and CNAs reported never seeing such devices in use. A later dressing change revealed yellow/green drainage from the toe wound. These omissions in timely assessment, documentation, and implementation of ordered off-loading measures resulted in a deficiency for inadequate diabetic foot care.
A resident with impaired cognition and complex neurological and ventilator-related diagnoses was discharged to a hospital, but the EMR contained no documentation of the discharge, no alert charting, and no change in condition assessment. Although an MDS Discharge Return Anticipated was completed and the facility’s Admission, Discharge, and Transfer Report showed the hospital discharge, progress notes for the relevant period lacked any information about the reason for discharge or the resident’s condition at the time. The interim DON and ADON confirmed the absence of required documentation, despite a facility policy requiring each medical record to accurately represent the resident’s experience and progress.
Staff failed to ensure a call light was within reach for a resident with severe cognitive and physical impairments, despite care plan interventions and facility policy requiring accessibility. The call light was repeatedly found on the floor and out of reach, and CNAs confirmed it was not accessible as required.
A resident with severe cognitive impairment and total dependence on staff was found with unexplained scratches on the left arm. Staff did not document the origin of the injuries, initiate treatment orders, or report the incident to the State Agency as required. The incident was not investigated, and no Self-Reported Incident was filed, resulting in non-compliance with reporting and investigation policies.
A resident with severe cognitive impairment and multiple medical conditions was found with unexplained scratches on the left arm. Although the injury was assessed by an RN and noted in a skin evaluation, there was no documentation in progress notes, no treatment orders, and no investigation into the cause of the injury. The DON confirmed that the incident met the criteria for an injury of unknown origin and should have been investigated according to facility policy, but this was not done.
Two cognitively intact residents did not have comprehensive, resident-specific discharge care plans developed or implemented. One resident's care plan lacked details about their discharge preferences and potential for returning to the community, while another had no discharge planning care plan initiated. Staff confirmed these omissions, which did not align with facility policy requiring individualized, measurable care plans reflecting resident goals and preferences.
The facility did not thoroughly investigate or document falls, nor did it consistently implement immediate and appropriate interventions for three residents at high risk for falls. Multiple falls occurred without root cause analysis, and in some cases, interventions were either missing or duplicated, despite facility policy requiring comprehensive follow-up and documentation.
Two residents with specific dietary preferences, including avoidance of pork and beef due to health and religious reasons, did not have their preferences consistently honored. Nutrition assessments were not completed in a timely manner, and staff failed to accurately document and follow dietary restrictions, resulting in residents receiving meals with items they wished to avoid.
The facility did not ensure that wound care treatments and follow-up appointments were completed as ordered for three residents. Missed wound care treatments were documented for two residents with chronic ulcers, and another resident did not receive scheduled Unna boot changes or attend a wound clinic follow-up. Staff interviews and record reviews confirmed these deficiencies, despite residents not refusing care.
Two residents with significant wounds did not receive pressure ulcer treatments as ordered, with multiple missed wound care interventions documented in the TARs. Despite physician orders and care plans specifying daily and twice-daily wound care, the required treatments were not completed on several occasions, as confirmed by the DON. Facility policy required wound management to promote healing, but these protocols were not followed.
The facility failed to maintain a pest-free environment, with ants observed in multiple residents' rooms and hallways. Pest control services had not been conducted since August 2024, as confirmed by the Regional Director of Maintenance. Staff and residents reported frequent ant sightings, and temporary measures like disinfectant spray were used. The facility's pest control policy required routine monthly visits, which were not followed, resulting in this deficiency.
A facility failed to correctly identify and manage a resident's wound care, leading to improper treatment. The resident, with multiple health conditions, was initially noted to have a pressure ulcer on the left buttock, but a later assessment revealed a laceration on the left posterior thigh. The wound care orders were not entered into the electronic medical record promptly, resulting in missed daily dressing changes. The facility's wound care policy was not adhered to, leading to a deficiency in care.
A resident with multiple health conditions, including multiple sclerosis and vascular dementia, did not receive timely incontinence care, resulting in wet clothing and a saturated brief. The CNA responsible had not attended to the resident for several hours due to other duties, and the facility's policy lacked specific guidelines for care frequency. The DON confirmed that care should be provided every two hours.
A facility failed to clarify physician orders and administer medications as prescribed for a resident with multiple health conditions. The resident did not receive lactulose and ezetimibe until two days after admission, and pregabalin was not administered on the day of admission despite being available. Interviews confirmed the orders should have been clarified upon admission, highlighting non-compliance with facility policies.
Failure to Implement Legionella Controls and Enhanced Barrier Precautions
Penalty
Summary
The deficiency involves the facility’s failure to implement and monitor its Legionella Water Management Plan and to follow its own policies and CDC guidance for Legionella control. The written plan, dated 12/01/25, required flushing hot and cold water for three to five minutes in empty rooms and less frequently used outlets, including soiled utility rooms, medication rooms, shower stalls, private room showers, and eyewash stations, as well as cleaning, disinfecting, or replacing shower heads on a six‑month cycle. Review of facility documentation showed no evidence that these flushing tasks or shower head maintenance were completed. The Maintenance Director stated that flushing of less frequently used outlets was performed and tracked in TELS but acknowledged he was unaware that documented evidence of task completion was required and confirmed that shower heads were not cleaned, disinfected, or replaced every six months as required by the plan. CDC Legionella control guidance reviewed by surveyors recommended maintaining hot water above 140°F and flushing low‑flow piping at least weekly and infrequently used fixtures regularly. The facility also failed to implement enhanced barrier precautions (EBP) for residents with wounds and indwelling devices as required by its own policies and physician orders. One resident with multiple diagnoses including bladder injury, septic shock, ascites, diabetes, and chronic kidney disease had an abdominal wound and a physician order for EBP during wound care. During observed wound care to the abdomen and closed‑suction bulb drain site, an LPN did not don a gown, did not disinfect the bedside table before placing wound care supplies on it, and did not perform hand hygiene between glove changes. The LPN and the Assistant DON confirmed these omissions and acknowledged that a gown should have been worn, the table disinfected, and hand hygiene performed between glove changes. Another resident with chronic respiratory failure, tracheostomy status, and dependence for all care had care plan interventions and physician orders for EBP every shift and tracheostomy care every 12 hours. During observed tracheostomy care, an RN did not perform hand hygiene before entering the room or between glove changes, did not don a gown, and did not disinfect the bedside table before placing sterile tracheostomy supplies on it; the RN confirmed these failures. A third resident with dementia, diabetes, peripheral vascular disease, and a diabetic foot ulcer had ongoing wound treatments to the left toes and heel, but no EBP were in place during observations of routine care and transfers, and CNAs providing ADL assistance wore no PPE. An LPN confirmed the resident had a current wound, that there was no EBP signage or accessible PPE outside the room, and that EBP should have been in place. The ADON later verified that EBP had not been implemented for this resident until the previous day, despite wound treatment orders being in place since late February. Facility policies required EBP, including readily available gowns and gloves, for residents with chronic wounds or indwelling medical devices and specified hand hygiene after glove removal.
Failure to Maintain Adequately Warm Shower Water Temperatures in East Hall
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequately warm shower water temperatures in the East Hall shower room, resulting in residents not receiving safe, comfortable, and homelike bathing conditions. Multiple residents who required staff assistance for showers reported that the shower water was too cold, leading some to avoid showers and instead receive bed baths or wash at the sink. One resident with congestive heart failure, weakness, and parkinsonism stated he rarely used the shower because the water was too cold and instead received bed baths. Another resident with Parkinson’s disease, asthma, and depression reported that the shower water was chilly but bearable and acknowledged refusing showers in the past due to cold water. A resident with congestive heart failure, anxiety, and atrial fibrillation described the East Hall shower room as so cold she felt like she had icicles coming off her body and avoided showers, receiving bed baths instead. A closed record review for a resident with COPD, anxiety, Type II diabetes mellitus, and restless legs showed documentation that the shower water was too cold, leading the resident to wash up at the sink rather than shower. Staff interviews with CNAs and an LPN confirmed that residents complained about cold water in the East Hall shower room and that one shower stall was cold while the other was only barely warm. Direct observation with the Maintenance Director showed shower stall temperatures of 83°F and 88°F after several minutes of running, and the sink reaching only 90°F, all below the stated minimum requirement of 105°F and the facility’s intended range of approximately 109°F to 115°F. Review of water temperature logs revealed that required weekly monitoring for the East Hall shower room was not consistently performed, with no temperatures logged for several weeks and only two recorded readings showing compliant temperatures shortly before the survey. The Maintenance Director verified the low temperatures, acknowledged the lack of recorded monitoring during the specified periods, and confirmed that the water temperatures did not meet the minimum requirement.
Failure to Provide and Document Scheduled Bathing and Grooming for Dependent Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure dependent residents received appropriate bathing, showers, grooming, and fingernail care in accordance with their assessed needs, care plans, and facility policy. One resident with severe cognitive impairment, multiple complex diagnoses, and on Hospice care required substantial to maximal assistance with ADLs and was care planned for showers on specific days with assistance for bathing and grooming. Documentation showed only intermittent bed baths and showers, with no recorded refusals, and no evidence of hair washing, fingernail clipping, or beard grooming. On observation, this resident was noted to have greasy long hair, unkempt facial hair, and long jagged fingernails. CNAs stated Hospice was responsible for showers and hair care, while the Hospice CNA stated facility CNAs were responsible, and confirmed the resident’s unkempt condition. Another resident with severe cognitive impairment, dependence on others for showering and personal hygiene, and multiple medical conditions reported only receiving showers once a week and wanting more frequent showers. Facility shower sheets and nurse aide task checklists showed showers were scheduled twice weekly, but documentation reflected that showers were only completed on some of the scheduled days, with only one documented refusal. The Interim DON confirmed that shower sheets were expected to be completed for each scheduled shower day, regardless of whether the resident accepted a shower, received a bed bath, or refused, and verified there was no evidence that several scheduled showers had been provided. Two additional residents, both cognitively intact and requiring substantial to maximal assistance with bathing, also lacked documented showers according to their schedules. For one resident, who was dependent for mobility and ADLs, shower sheets showed bathing on only three of eight scheduled opportunities, with no documentation of refusals in nursing notes. For the other resident, admitted and discharged within the review period, shower sheets showed no evidence of showers during the initial days after admission, including a scheduled shower day, and staff interviews confirmed that shower sheets should be completed for all showers, bed baths, or refusals. The IDON and other staff confirmed that the facility had no additional documentation to show that these residents were offered or received scheduled bathing, despite a facility policy stating that ADL care and services, including bathing, dressing, grooming, and oral care, would be provided.
Elopement Supervision, Smoking Material Storage, and Post-Fall Neuro Checks Deficiencies
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and accident prevention for residents at risk of elopement, improper storage of smoking materials, and incomplete neurological assessments after a fall. One resident with traumatic subdural hemorrhage, diabetes, alcohol withdrawal history, dysphagia, cognitive communication deficit, slurred speech, anxiety, and unsteadiness on his feet had been assessed as an elopement risk and care planned for exit-seeking behaviors. His care plan and physician orders required a wander management device with daily functional checks, and elopement risk assessments consistently identified him as at risk. Despite this, he experienced an elopement incident in which he was found outside near the employee access door after door alarms were activated, and a subsequent elopement in which he was found on a lawn across a two-lane street and near a four-lane state route. The administrator later stated that staffing was not adequate to provide the level of supervision necessary for this resident and that 15‑minute checks, initiated after the first elopement, were discontinued without additional interventions while he remained an elopement risk. Another deficiency involved a resident who was cognitively intact, used a manual wheelchair with supervision, and required maximal assistance with transfers and ADLs. This resident had a care plan focus area for smoking, with interventions to orient him to smoking policies and procedures, and a smoking assessment indicating he was safe to smoke with supervision. Facility policy defined smoking to include electronic cigarettes and required that smoking supplies be stored by the facility. However, a vape pen was documented as being found in the resident’s bed by an LPN, and on subsequent observation a red vape pen was again seen on the resident’s bed while he was not in the room. Staff, including a CNA, ADON, and LPN, confirmed that the vape pen was not allowed to be stored in the resident’s room and should have been secured with other smoking supplies, and the resident himself acknowledged that all smoking materials, including vape pens, were required to be stored in a locked box maintained by the facility. A further deficiency concerned the facility’s completion of neurological assessments following a fall. A resident with COPD, anxiety, Type II diabetes mellitus, heart disease, and restless legs, who required substantial to maximal assistance for mobility, transfers, toileting, and personal care and did not ambulate due to medical or safety concerns, had an unwitnessed fall documented on the incident log. The neurological assessment flowsheet for the period following this fall showed that hand grasps and motor functions were not completed at multiple required assessment time points over two days, even though other parameters such as level of alertness and pupil response were documented. In an interview with the administrator, concurrent review of the flowsheet confirmed that these neurological assessments were completed inaccurately and should have included hand grasps and motor function at all assessment times.
Failure to Maintain Resident Dignity During Dining Assistance
Penalty
Summary
The deficiency involves a failure to maintain resident respect and dignity in accordance with resident rights and facility policy. Resident #5, who had diagnoses including hemiplegia and hemiparesis following cerebral infarction, dysphagia, and dementia without behavioral disturbance, was admitted on an unspecified date. A comprehensive MDS assessment dated 04/15/26 documented that the resident was rarely or never understood and was dependent on staff for eating. The revised care plan dated 04/01/26 identified an ADL self-care performance deficit and included an intervention for partial assistance of one staff member to eat. On 04/14/26 at 8:22 A.M., surveyors observed approximately 13 residents in the secured unit dining area awaiting breakfast while CNA #110 passed out breakfast trays. As CNA #110 exited the secured unit, she turned back from the hallway and yelled to another CNA in the dining room that Resident #5 was a “feeder,” referring to the resident’s need for assistance with eating. During an interview at 8:35 A.M. the same day, CNA #110 confirmed she had yelled out that the resident was a feeder and acknowledged that referring to the resident in this manner was not dignified or respectful. Review of the facility’s Residents Rights policy, dated 02/20/26, stated that care team members would treat each resident with kindness, respect, and dignity, which was not followed in this instance.
Failure to Develop and Complete Baseline Care Plans for Newly Admitted Residents
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement baseline care plans within the required timeframe and to provide them to the resident’s representative. One resident was admitted with multiple diagnoses including COPD, anxiety, Type II diabetes mellitus, heart disease, and restless legs, and required substantial to maximal assistance with ADLs such as toileting, bathing, dressing, transfers, and mobility. Review of the nursing admission/readmission evaluation showed that this resident needed physical assistance for ambulation, transfers, toileting, and bathing and used a walker and manual wheelchair. However, no baseline care plan was initiated at admission. The MDS Coordinator confirmed that no baseline care plan was in place from admission until nearly two weeks later, with the first care area initiated 13 days after admission and monitoring for diabetes mellitus not started until 14 days after admission. A second resident was admitted with diagnoses including peptic ulcer, schizoaffective disorder, bipolar disorder, rheumatoid arthritis, anxiety disorder, COPD, and lung cancer. Social services documentation indicated this resident was cognitively intact, had adequate vision and hearing, could be understood, and did not display behaviors or refusals of care. A baseline care plan was in place, but it did not address the administration of oxygen. Observation showed the resident wearing an oxygen nasal cannula connected to an oxygen concentrator running at 4 L/min, and the Administrator confirmed there was no care plan developed to include oxygen administration, despite the resident using oxygen as needed. Facility procedures stated that the baseline care plan would be initiated by the nurse conducting the admission assessment, and facility policy required care plans to include objectives to meet residents’ medical needs.
Failure to Provide Timely Assessment and Preventive Care for Diabetic Foot Ulcer
Penalty
Summary
The deficiency involves the facility’s failure to provide timely assessment and preventive interventions for a diabetic foot ulcer in a resident with multiple risk factors. The resident had Type II diabetes mellitus, a history of diabetic ulcers, peripheral vascular disease, dementia, and impaired mobility, and was care planned for potential skin integrity impairment and an existing diabetic foot ulcer. The care plan and physician orders included weekly skin observations on day shift every Wednesday, encouragement and assistance with off-loading heels, turning and repositioning, use of a low air loss mattress, monitoring and documenting skin injuries, and referral to a podiatrist or foot care nurse. A skin risk assessment identified the resident as at risk for skin breakdown due to age and dementia. Despite these identified risks and interventions, the weekly skin observation scheduled for a Wednesday in late February was not completed, and there was no documentation of that required assessment. On the following day, a change in condition evaluation documented that the resident had developed a new skin wound or ulcer to the left great toe and second toe, described as a new onset grade two or higher pressure ulcer/injury or progression of an ulcer despite interventions, with a black scab on the great toe and a scarred heel. A wound/scab was also noted on the left heel. At that time, no wound measurements or detailed description of the toe wound were documented, and the only recorded intervention was an order to apply betadine every shift and obtain bilateral arterial Doppler studies. The DON and ADON later confirmed that no description or measurements of the wound were obtained until a week later, when a skin condition evaluation documented an in-house acquired diabetic foot ulcer on the left great toe measuring 5 cm by 4 cm with undetermined depth and mostly eschar, and a second diabetic foot ulcer on the left heel measuring 1 cm by 1 cm with undetermined depth. Subsequent documentation and observations showed that preventive off-loading interventions were not consistently implemented. Although there were physician orders to encourage off-loading heel boots/protectors every shift and later to elevate/float heels when resting in bed, surveyor observations on multiple occasions found the resident in bed with socks on, feet resting directly on the mattress, without pressure relief boots, heel elevation, or a tent to keep bed linens off the lower extremities. CNAs interviewed confirmed that the resident did not have heel elevation or pressure relief boots in place when in bed and that such boots had not been observed. Later observation of the left great toe dressing revealed it had not been changed since the prior day and showed a moderate amount of yellow/green drainage when removed. The facility’s own wound management policy stated that residents with impaired skin integrity would be recognized and treated timely, with systems in place for early identification and monitoring of new skin impairments, but the documented lapses in weekly skin assessment, initial wound measurement and description, and consistent implementation of off-loading interventions led to the cited deficiency.
Failure to Accurately Document Resident Discharge and Condition in Medical Record
Penalty
Summary
The deficiency involves the facility’s failure to ensure complete and accurate documentation in a resident’s medical record in accordance with its own policy and accepted professional standards. A closed record review for Resident #59, who had diagnoses including traumatic subdural hemorrhage, intracranial abscess and granuloma, and dependence on ventilator status, showed an admission date of 11/21/25 and a discharge date of 02/10/26. The quarterly MDS dated 02/06/26 documented impaired cognition, and a Discharge Return Anticipated MDS was completed on 02/10/26. The facility’s Admission, Discharge, and Transfer Report indicated the resident was discharged to the hospital on that date. However, concurrent review of the progress notes from 02/05/26 through 02/11/26 with the Interim DON and ADON revealed there was no documentation in the EMR regarding the resident’s discharge. During interviews, the Interim DON and ADON, both recently employed at the facility, stated they were unfamiliar with the resident and the circumstances of the discharge. They confirmed there was no alert charting, no change in condition assessment, and no documentation in the medical record explaining the reason for the resident’s discharge, despite the MDS indicating a Discharge Return Anticipated. The ADON stated that a change in condition assessment and alert charting should have been completed if the resident left emergently. In a follow-up interview, the Interim DON reported that the Administrator later explained the resident had a scheduled surgical appointment at the hospital and was discharged from the hospital to another LTC facility, but this information was not reflected in the resident’s medical record. Review of the facility’s “Documentation in the Medical Record” policy, dated 01/02/24, showed the expectation that each medical record present an accurate representation of the resident’s experience and progress through complete and accurate documentation, which was not met in this case.
Failure to Ensure Call Light Accessibility for Dependent Resident
Penalty
Summary
A deficiency was identified when staff failed to ensure that a call light was within reach for a resident with severe cognitive impairment and significant physical limitations, including hemiplegia affecting the non-dominant left side and non-ambulatory status. The resident was dependent on staff for activities of daily living except eating and was at risk for falls, as documented in the care plan. The care plan specifically included an intervention to ensure the call light was within reach and to encourage its use for assistance. During observations and interviews, it was found that the resident's call light was repeatedly out of reach, including being on the floor behind the bed and on the floor while the resident was in bed. The resident reported not having access to the call light most times and stated he could use it if it were accessible. Certified Nursing Assistants confirmed during interviews that the call light was not within reach and acknowledged it should have been. Facility policy required staff to ensure call lights were within reach and secured as needed.
Failure to Report and Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to report an allegation of an injury of unknown origin to the State Agency, affecting one resident with severe cognitive impairment and total dependence on staff for activities of daily living. The resident, who had multiple complex medical conditions including anoxic brain damage and dysphagia, was found to have multiple scratches on the left arm during a skin evaluation. There was no documentation in the medical record or progress notes regarding the origin of the scratches, and no physician orders were made for their treatment. An incident report was opened in error and not completed, and no Self-Reported Incident (SRI) was filed for this event. Interviews with facility staff revealed that the DON did not properly address the incomplete skin evaluation and could not locate documentation explaining the scratches. The RN who assessed the resident's scratches did not initiate treatment orders or complete the required risk documentation, and only notified the family, who were already aware. The DON confirmed that the incident was not investigated to determine the cause of the injury, which met the facility's definition of an injury of unknown origin and should have been reported and investigated according to policy. The facility's failure to report and investigate the injury constituted non-compliance as identified during a complaint investigation.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to investigate an injury of unknown origin for a resident with severe cognitive impairment and multiple complex medical conditions, including anoxic brain damage, gastrostomy and tracheostomy status, anxiety, and dysphagia. The resident was dependent on staff for all activities of daily living and had a care plan addressing skin integrity risks. On a skin evaluation, multiple scratches were noted on the resident's left arm, but the evaluation was marked incomplete and the incident report was opened in error. There was no documentation in the progress notes or physician orders regarding the scratches, and no treatment orders were initiated. Interviews with the DON and an RN revealed that the scratches were assessed, but no investigation was conducted to determine their origin, and the required documentation and reporting procedures were not followed. The facility's policy required immediate reporting and investigation of all injuries of unknown source, but this was not done. The DON confirmed that the incident met the criteria for an injury of unknown origin and acknowledged that it should have been investigated, but there was no supporting documentation or evidence of an investigation.
Failure to Develop and Implement Resident-Specific Discharge Care Plans
Penalty
Summary
The facility failed to ensure that comprehensive, resident-specific care plans were developed and implemented for two residents regarding discharge planning. For one resident with diagnoses including hypertension, congestive heart failure, chronic pain disorder, and major depressive disorder, the care plan included only a general intervention for social services to assist with discharge planning. The care plan did not specify the resident's preferences or potential for future discharge, nor did it document whether the resident's desire to return to the community was determined, despite the resident being cognitively intact. For another cognitively intact resident with diagnoses such as pneumonia, kidney transplant status, end stage renal disease, and anemia, there was no specific care plan initiated to address discharge planning. Staff interviews confirmed that care plans are updated at least quarterly or with significant changes, and that the two residents in question did not have completed, resident-specific discharge care plans. Policy review indicated that care plans should include measurable objectives, timeframes, and reflect the resident's goals and preferences, which was not followed in these cases.
Failure to Investigate and Document Falls with Immediate Interventions
Penalty
Summary
The facility failed to ensure that falls were thoroughly investigated to determine a root cause, were properly documented in the medical record, and that immediate and appropriate interventions were implemented. This deficiency affected three residents who were reviewed for falls. For one resident with severe cognitive impairment and multiple risk factors for falls, there were repeated incidents where the resident was found on the floor in various locations, including the dining room, activity room, and their own room. In several instances, there was no documentation of immediate interventions following the falls, and interventions such as non-skid socks were repeatedly implemented despite already being in place. There was also no evidence of a root cause analysis or thorough investigation for any of the falls during the review period. Another resident with severe cognitive impairment and a history of falls had multiple falls for which there was no nursing documentation or fall follow-up notes completed. The care plan for this resident included numerous interventions for fall prevention, but the medical record lacked documentation for some falls and did not include thorough investigations or root cause analyses for any of the falls that occurred during the review period. A third resident, who was cognitively intact but at high risk for falls due to cervical spine issues and weakness, experienced falls while attempting to transfer or ambulate. Immediate interventions were inconsistently documented, and in at least one instance, there was no documentation of an intervention following a fall. Interviews with facility leadership confirmed the lack of immediate interventions, duplicate interventions, and the absence of thorough investigations or root cause analyses for the falls. Facility policy required immediate interventions, thorough documentation, and root cause analysis for incidents such as falls, but these procedures were not followed.
Failure to Complete Timely Nutrition Assessments and Honor Dietary Preferences
Penalty
Summary
The facility failed to ensure that nutritional assessments were completed in a timely manner to determine dietary preferences and failed to honor food preferences for two residents. For one resident with multiple diagnoses including congestive heart failure, diabetes, and moderate cognitive impairment, the care plan and physician orders did not specify the resident's request to avoid pork and beef, despite documentation and interviews indicating these preferences. Observations confirmed that this resident received beef on his meal tray, and staff verified the presence of beef despite the resident's stated aversion. Another resident, with a history of kidney transplant, end stage renal disease, and diabetes, also reported a preference to avoid pork for religious reasons. Although the dietician was made aware of this preference, the resident continued to receive pork on meal trays and had to return them. Staff interviews revealed that dietary staff did not consistently review meal tickets thoroughly and relied on cheat sheets, which were incomplete regarding certain preferences. The facility's policy required interviews within 72 hours of admission to determine food preferences, but this was not completed for one of the residents involved.
Failure to Complete Wound Care Treatments and Follow-Up Appointments as Ordered
Penalty
Summary
The facility failed to ensure that wound care treatments and follow-up appointments were completed as ordered for three residents. For one resident with a history of atherosclerotic heart disease and an open chest lesion, daily wound care orders were not carried out on multiple specified dates, despite the resident being cognitively intact and not refusing care. Another resident with a non-pressure chronic ulcer of the right heel and midfoot did not receive daily wound care as ordered on several dates, and a change in wound care orders was also not implemented on the day it was prescribed. In both cases, the treatment administration records (TARs) confirmed the missed treatments, and the DON verified these omissions during interviews. A third resident, admitted with cerebral palsy, lymphedema, and cellulitis, had orders for Unna boots to be changed three times weekly, but these were not completed on two scheduled days. Additionally, this resident missed a scheduled wound clinic follow-up appointment, which was not documented in the electronic health record, and the resident was not transported to the appointment. Interviews with facility staff and wound clinic personnel confirmed these lapses. The facility's wound management policy required the promotion of treatment and healing of skin integrity impairments, but the documented failures show that wound care and follow-up were not consistently provided as ordered.
Failure to Complete Ordered Pressure Ulcer Treatments
Penalty
Summary
The facility failed to ensure that pressure ulcer treatments were completed as ordered for two residents with significant medical conditions and wounds. For one resident with a non-pressure chronic ulcer of the right heel and midfoot, medical record review showed multiple missed wound care treatments on specific dates, despite physician orders for daily care involving cleansing, application of collagen, and appropriate dressings. The resident's care plan included interventions for impaired skin integrity, but the treatment administration records (TARs) documented that wound care was not performed on several occasions. Another resident with a history of traumatic brain injury, tracheostomy, and pressure injuries to both feet also did not receive wound care as ordered. Physician orders and TARs indicated missed daily and twice-daily wound care treatments for both the left and right foot on multiple dates. Staff interviews with the DON confirmed that wound care was not completed as required for both residents. Facility policy required the promotion of treatment and healing of skin integrity impairment, but the documented omissions in wound care represented a failure to follow these protocols.
Failure to Maintain Pest-Free Environment
Penalty
Summary
The facility failed to maintain a pest-free environment, specifically regarding an ant infestation affecting multiple residents. Observations revealed ants in the rooms of five residents and in the hallways, with the potential to affect additional residents. The pest control service records indicated that the facility had not received preventative pest control treatments since August 2024, with no services provided in September, October, November, and the first half of December 2024. This lack of pest control services was confirmed by the Regional Director of Maintenance, who acknowledged the absence of services and stated that a request for pest control had been made. Interviews with staff and residents confirmed the presence of ants in various locations within the facility. Environmental Services Staff verified the ants in several residents' rooms and mentioned using disinfectant spray as a temporary measure. Residents reported frequent sightings of ants, particularly in bathrooms, and staff members, including a CNA, RN, and LPN, verified these observations. The facility's pest control policy, dated 2018, required routine monthly visits and additional visits if necessary, but this policy was not adhered to, leading to the deficiency.
Failure to Identify and Manage Wound Care Correctly
Penalty
Summary
The facility failed to correctly identify the type and location of a wound for a resident, leading to improper wound care management. The resident, who had multiple diagnoses including multiple sclerosis and vascular dementia, was noted to have an open area on the left ischium, but later documentation revealed a stage two pressure ulcer on the left buttock. However, a nurse practitioner later identified a laceration on the left proximal posterior thigh, which was not documented in the electronic medical record until several days later. This discrepancy in wound identification and documentation resulted in the resident not receiving the appropriate wound care treatment as per physician orders. The physician orders for the newly identified wound were not entered into the electronic medical record in a timely manner, leading to a failure to perform daily dressing changes as required. The Director of Nursing confirmed that the wound care orders had not been entered and that the daily dressing changes had not been completed. Additionally, there was no documentation that the previously ordered barrier cream was applied to the laceration on the posterior thigh. The facility's policy on wound care, which requires staff to verify physician orders and provide care accordingly, was not followed, resulting in a deficiency in wound care management for the resident.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care for a resident, which was identified during a review of medical records, observations, staff interviews, and policy reviews. The resident, who was admitted with diagnoses including multiple sclerosis, vascular dementia, and hemiplegia, was always incontinent of bladder and frequently incontinent of bowel. The resident was dependent on staff for toileting and personal hygiene. The plan of care indicated that staff should change the resident per protocol, preference, and as needed. On a specific observation, the resident was found with wet pants and a saturated incontinence brief with a strong urine odor, indicating a lack of timely care. The CNA responsible for the resident's care admitted to not providing incontinence care since early morning due to being busy with other tasks. The DON confirmed that incontinence care should be provided every two hours, but the facility's policy lacked specific guidelines for the frequency of incontinence care and checks. This deficiency was part of a complaint investigation.
Failure to Administer Medications Per Physician Orders
Penalty
Summary
The facility failed to timely clarify physician orders and ensure medications were administered per physician orders for a resident with multiple diagnoses, including cirrhosis of the liver and cognitive impairment. Upon admission, the resident had orders for pregabalin, ezetimibe, and lactulose, but the lactulose order lacked a specified frequency. The physician orders were not clarified until two days after admission, resulting in the resident not receiving lactulose and ezetimibe until then. Additionally, pregabalin was not administered on the day of admission and was only given once the following day, despite being available in the contingency medication supply. Interviews with the Director of Nursing and the Regional Clinical Nurse confirmed that the physician orders should have been clarified upon admission, and the resident did not receive the medications as prescribed. The facility's policies on order processing and medication administration required timely clarification and administration of medications, which were not adhered to in this case. This deficiency was investigated under a specific complaint number, indicating non-compliance with the facility's procedures.
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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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