Merit House Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Toledo, Ohio.
- Location
- 4645 Lewis Ave, Toledo, Ohio 43612
- CMS Provider Number
- 365279
- Inspections on file
- 23
- Latest survey
- April 23, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Merit House Llc during CMS and state inspections, most recent first.
An LPN improperly certified 64 MDS assessments as the RN MDS Coordinator over two separate employment periods, affecting 40 residents. The Administrator discovered the issue while reviewing an MDS and, after auditing a large number of assessments, found that the LPN had participated in the MDS process for many residents and had signed as the RN MDS Coordinator on a subset of those assessments, despite qualified RN staff and the DON being available to certify them. The facility could not confirm the prior RN MDS Coordinator’s process for ensuring proper review and certification because that RN was no longer employed.
A CNA who had completed a training program but was not yet listed on the state nurse aide registry was observed providing morning care, including dressing and wheelchair positioning, to a resident. Personnel and state registry checks showed no proof of active certification, and staffing records confirmed the CNA had been scheduled and worked in the CNA role beyond the allowable grace period for non-registered aides. The CNA reported she was working as a CNA and providing resident care, and the Administrator acknowledged she had failed her first registry exam and should not have been working in a CNA capacity without passing the required competency test, contrary to facility policy requiring valid certification for such positions.
A resident with multiple fractures and a care plan goal for adequate pain control had PRN orders for acetaminophen for mild to moderate pain and Roxicodone for severe pain defined as 8–10 on a 1–10 scale. Nursing staff repeatedly administered PRN Roxicodone when the resident’s documented pain scores were below the ordered threshold, including doses given for pain levels of 7 and once for a pain level of 0, instead of using the ordered acetaminophen for lower pain levels. An LPN and an RN confirmed that the narcotic was given outside the prescribed parameters, contrary to the facility’s medication administration policy requiring medications to be given as ordered.
A resident with a right humerus fracture, lumbar fractures, and other comorbidities had a physician-ordered orthopedic follow-up appointment requiring accompaniment by medically trained staff. On the morning of the appointment, the resident was observed dressed, with arm in a sling and appointment papers in hand, waiting in the doorway and later still in the room, reporting that no one came to take him to the visit and that the appointment was missed. Review of records and appointment paperwork confirmed the scheduled follow-up and staff accompaniment requirement, and an RN acknowledged the resident was not transported due to miscommunication with the physician’s office.
A medication cart was found unattended and unlocked in a hallway, and an LPN confirmed it should have been secured when not attended. Facility policy requires medications to be stored in locked compartments, but this was not followed, potentially affecting all residents.
The facility failed to provide opportunities and assistance for voting to three cognitively intact residents, despite their expressed importance of voting. An Activity Coordinator confirmed the lack of assistance, and an external individual with credentials was denied entry to help residents vote. The facility's policy mandates arrangements for residents to exercise their voting rights.
The facility failed to provide a dignified dining experience by serving meals on disposable dishware, affecting 79 residents. Observations and staff interviews confirmed the use of Styrofoam bowls and carryout containers for meals, which contradicted the facility's dignity policy. A resident expressed discomfort with this practice.
The facility did not follow its established menu cycle and failed to maintain a substitution log, affecting 79 residents. Meals served on specific days did not match the planned menu, and staff admitted to creating their own menus due to defrosted meat. The Dietary Manager and Technician confirmed the discrepancies and the absence of a substitution log, violating facility policy.
A facility failed to ensure timely cleaning and disinfection of soiled bedpans, affecting a resident who was frequently incontinent and staff-dependent for toileting. A soiled bedpan with a pink substance was observed uncovered on the bathroom floor, confirmed by an RN. The facility's infection control policy was not followed.
A resident with a suspected deep tissue injury on the right heel did not receive dressing changes as ordered by the physician. Despite documentation indicating compliance, interviews and observations revealed the dressing had not been changed since its initial application. The facility's wound care policy was not adhered to, leading to non-compliance with physician orders.
A resident with COPD and other conditions was receiving oxygen therapy without a physician order since admission. Despite being cognitively intact and having a history of oxygen use at home, the facility failed to secure the necessary order, as confirmed by staff and hospital referral records. This oversight was discovered during a complaint investigation.
A resident with COPD did not receive prescribed medications, Zithromax and prednisone, due to facility staff not utilizing the fully stocked emergency medication box (E-box). The MAR indicated non-administration, and interviews revealed a lack of communication and adherence to facility policy, which required medications to be administered per prescriber orders.
A resident in the facility did not receive several prescribed medications as ordered, despite the medications being available in the facility. The resident, who was independent in most ADLs and had multiple diagnoses, was affected by this deficiency. The facility's policy required medications to be administered as per prescribers' orders, but this was not adhered to, leading to continued non-compliance.
A facility failed to maintain a pest-free environment, leading to a bed bug infestation affecting a resident with mild intellectual disabilities, congestive heart failure, and diabetes mellitus. Staff observed bug bites on the resident's extremities, and an exterminator found dead bed bugs in the resident's room. The room and its contents were treated, and the DON confirmed the resident suffered from bed bug bites.
The facility failed to investigate allegations of verbal abuse involving three cognitively impaired residents who were dependent on staff. Despite reports of a State tested Nurse Aide threatening residents, there was no documentation or evidence of an investigation. The facility policy required immediate reporting and removal of the accused staff member, but the accused continued working until the surveyor's inquiry.
The facility failed to maintain a safe environment, leading to a small outdoor fire near resident rooms. A nurse noticed smoke, and staff found a smoking flowerpot under a chair with a burn hole. Numerous cigarette butts were found in the potting soil, suggesting the fire started from a cigarette. The facility's safety policy emphasized accident prevention, indicating a lapse in adherence.
A resident with a surgically absent right breast requested a prosthetic bra, as documented in physician notes. Despite the facility's awareness, there was no follow-up on the request, leaving the resident without the necessary item to maintain a dignified appearance. The resident expressed feelings of shame, and a social worker confirmed the oversight.
The facility failed to provide a call light within reach for a resident with diabetes and gangrene, who required assistance for transfers. The resident reported not having a working call light for weeks, confirmed by the DON. Additionally, another resident with pulmonary disease and heart failure did not have siderails as ordered by a physician, confirmed by an LPN and the resident's family.
A resident with a history of severe malnutrition and other health issues experienced a significant weight loss of 13.5 pounds, which was not reported to the physician or dietitian as required by the facility's policy. The resident's care plan included interventions for weight changes, but the facility failed to notify the necessary medical personnel in a timely manner.
A resident's restroom sink was found to contain a brown liquid that was not draining, persisting over several days despite being reported by staff. The resident, who is moderately cognitively impaired, reported the issue had been ongoing for four days. Multiple staff members confirmed the condition of the sink, which was eventually resolved.
The facility failed to report an allegation of verbal abuse involving three residents to the state agency in a timely manner. Despite being cognitively impaired and dependent on staff, the residents' medical records lacked documentation of the abuse allegations. Interviews revealed that a STNA reported the threats to management, but the facility did not report the incident to the state agency as required by their policy.
A resident with a surgical incision was admitted without proper orders for incision care, leading to a delay in treatment. The hospital recommended washing the incision twice daily, but the facility did not initiate this care until several days later. The ADON confirmed the oversight in obtaining necessary orders upon admission.
A resident with severe cognitive impairment and multiple health issues did not receive necessary grooming services, resulting in long, dirty nails and facial hair. Despite the facility's policy requiring assistance with ADLs, the resident's grooming needs were neglected, as confirmed by staff observations.
The facility failed to provide timely vision services to two residents. One resident, admitted with dementia and atrial fibrillation, requested eye care but was not seen by a vision provider despite multiple requests. Another resident, with cerebral infarction and congestive heart failure, requested an optometrist visit but was not evaluated until months later. The facility did not adhere to its policy of assisting residents in obtaining needed services.
A resident with severe protein-calorie malnutrition did not consistently receive a prescribed dietary supplement, a magic cup, with meals as ordered by the physician. Despite being cognitively intact and aware of the prescription, the resident reported irregularities in receiving the supplement. Observations and staff interviews confirmed the resident did not receive the supplement with several meals, including breakfast and lunch, as required.
A facility failed to administer medications as per physician orders, resulting in a five percent medication error rate. A resident with multiple diagnoses, including breast cancer and diabetes, did not receive prescribed fluticasone and simethicone. An LPN confirmed the medications were unavailable for administration.
A facility failed to use proper PPE for a COVID-19 positive resident. An STNA was observed exiting the resident's room wearing only a surgical mask, without an N95 respirator or eye protection, as required by the facility's policy. Interviews confirmed the absence of necessary PPE on the isolation cart, indicating non-compliance with infection control protocols.
The facility failed to educate and offer COVID-19 vaccinations to two residents, despite their cognitive ability to understand the information. One resident had no documentation of vaccination education or administration, while another had only received one vaccination with no further offers. Interviews confirmed the lack of adherence to the facility's policy on providing recommended vaccines.
A resident with chronic hepatic failure did not receive prescribed doses of lactulose due to medication unavailability and storage issues. An LPN reported a delay in pharmacy delivery, while the DON later revealed the medication was available but not located by the nurse. The facility's policy on timely medication administration was not followed.
The facility did not complete required performance reviews for two STNAs, affecting their compliance with annual and 90-day evaluations. This oversight was confirmed by an administrator and had the potential to impact all residents in the facility.
Unqualified Staff Certifying MDS Assessments
Penalty
Summary
The deficiency involves the facility’s failure to ensure that MDS assessments were certified by qualified staff, as required. The Administrator discovered that an LPN had certified an MDS assessment as the RN MDS Coordinator when she printed an MDS for a resident. Subsequent review revealed that this same LPN had signed and certified a total of 64 MDS assessments as the RN MDS Coordinator over two separate periods of employment, despite not being qualified to do so. These improperly certified assessments involved 40 residents and occurred between July 2022 and December 2025. The Administrator’s audit of approximately 1,500 MDS assessments showed that the LPN participated in the MDS assessment process for 351 residents and, without an identifiable pattern or rationale, signed as the RN MDS Coordinator on 64 of those assessments. The Administrator stated there was always an RN MDS Coordinator or the DON available to review and certify assessments during the relevant time frames, and she did not know why the LPN certified them. The previous RN MDS Coordinator was no longer employed, so the Administrator could not verify what process that RN had followed to ensure proper review and certification of MDS assessments. Review of records for selected residents confirmed that the original MDS assessments in question had been certified by the LPN as the RN MDS Coordinator.
Uncertified CNA Allowed to Provide Direct Resident Care Beyond Permitted Timeframe
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a nurse aide had obtained proper placement on the state nurse aide registry before working as a CNA. Observation showed that Certified Nursing Assistant (CNA) #101 was providing morning care to a resident, including dressing and positioning the resident in a wheelchair. Review of CNA #101’s personnel file showed a hire date of 08/22/25 and completion of a Nurse Aide Training and Competency Evaluation Program on 06/13/25, but there was no proof of state registry in the file. A check of the State of Ohio State Tested Nursing Assistant website also did not show evidence of registry for this individual. Further review of the staffing schedule confirmed that CNA #101 was scheduled and worked in the role of CNA on 01/27/26 and 01/28/26. During an interview, CNA #101 stated she was employed as a CNA and was caring for residents on the day of observation. In an interview, the Administrator confirmed that CNA #101 had been employed longer than four months since completion of her CNA program, had failed her first registry test, and was scheduled to retake it. The Administrator acknowledged that CNA #101 should not have been working as a CNA providing resident care without having passed the registry examination. The facility’s policy stated that positions requiring certification or licensing must maintain valid credentials, and failure to do so could result in termination and reporting to the licensing board.
Narcotic Pain Medication Administered Outside Ordered Parameters
Penalty
Summary
The deficiency involves the facility’s failure to administer narcotic pain medication according to the physician’s ordered parameters for a resident with multiple fractures and other comorbidities. The resident was admitted with diagnoses including nondisplaced right humerus fracture, lumbar vertebral fractures, morbid obesity, fall, anxiety disorder, and alcohol use. The baseline care plan identified the resident as alert and aware, with goals for physical and occupational therapy and adequate pain control. Physician orders included PRN acetaminophen 500 mg every six hours for mild to moderate pain and PRN Roxicodone (oxycodone HCl) 5 mg every six hours for severe pain, defined as a pain level of 8–10 on a 1–10 scale. Record review showed that staff administered the PRN Roxicodone outside the ordered parameters on multiple occasions. Under the first Roxicodone order, the resident received the narcotic for pain scores of 7 on several dates and once for a documented pain level of 0, even though the order specified use only for severe pain (8–10). After the order was refilled, the resident again received Roxicodone for a pain level of 7, which was below the ordered threshold. In total, there were eight administrations under the first order and one under the second order when the resident’s pain level was below 8. Staff interviews with an LPN and an RN confirmed that the PRN narcotic was given outside the ordered parameters and that acetaminophen, ordered for mild to moderate pain, should have been used when pain levels were below 8. The facility’s medication administration policy required medications to be administered safely, timely, and as prescribed.
Failure to Transport Resident to Scheduled Orthopedic Appointment
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was transported to an outside orthopedic appointment as scheduled. The resident was admitted with multiple significant diagnoses, including a nondisplaced right humerus fracture, lumbar fractures at L1 and L2, morbid obesity, anxiety disorder, alcohol use, and a traumatic subdural hematoma from prior falls. The baseline care plan indicated the resident was alert and aware, non-weight bearing on the affected extremity, and was to receive physical and occupational therapy with the goal of discharge home, with social services coordinating services to achieve discharge goals. Physician orders documented an orthopedic follow-up appointment scheduled for 8:50 A.M. on 01/27/26, with instructions that staff accompaniment was required and that the accompanying staff needed to be medically trained. On the morning of the scheduled appointment, surveyor observation found the resident standing in the doorway with his right arm in a sling, wearing shoes and holding appointment papers, looking up and down the hallway shortly before the appointment time. In an interview, the resident stated he had been admitted about a week earlier, was supposed to have a follow-up with his orthopedic doctor that day, that his arm and sling were bothering him, and that no one had come to get him for the appointment. A later observation the same morning showed the resident still in his room with his arm in a sling, shoes on, and the appointment paperwork on the bedside table; he reported that no one ever came to get him and that he missed the appointment. Review of the appointment paperwork confirmed the scheduled orthopedic follow-up and the requirement for medically trained staff accompaniment. An RN interview verified the resident had not been transported to the appointment and attributed the missed appointment to miscommunication with the doctor’s office.
Unattended and Unlocked Medication Cart
Penalty
Summary
A medication cart was observed unattended and unlocked in the hallway outside a resident room. An LPN confirmed that the cart was left unattended and unlocked, and acknowledged that it should have been locked when not attended by staff. Review of the facility's policy on medication storage indicated that medications are to be stored in locked compartments. This failure to secure the medication cart had the potential to affect all 81 residents in the facility.
Failure to Assist Residents with Voting
Penalty
Summary
The facility failed to ensure that residents were provided opportunities and assistance with voting, affecting three residents who were cognitively intact and expressed the importance of voting to them. Resident #4, diagnosed with Parkinson's disease, Resident #7, with diabetes mellitus, hypertension, and a cerebral vascular accident, and Resident #47, with diabetes mellitus, hypertension, heart failure, and chronic obstructive pulmonary disease, all reported that the facility did not assist or offer opportunities for them to vote in recent elections. Interviews with these residents confirmed their cognitive ability to participate in voting, yet they were not supported in exercising this right. The Activity Coordinator (AC) #500 confirmed that residents were not assisted or offered the opportunity to vote, stating a lack of awareness of the facility's policy regarding voting assistance. Additionally, AC #510 recounted an incident where an individual with credentials from the board of elections was denied entrance by the previous facility Administrator, preventing residents from receiving external voting assistance. The facility's policy, dated October 2019, clearly states that residents have the right to exercise their civil rights, including voting, and arrangements must be made to facilitate this. This deficiency was investigated under Complaint Number OH00161624.
Deficiency in Dignified Dining Experience Due to Disposable Dishware
Penalty
Summary
The facility failed to maintain a dignified dining experience for its residents by serving meals on disposable dishware, which affected 79 out of 81 residents who received meals from the kitchen. Observations on December 26, 2024, revealed that desserts were served in Styrofoam bowls, and dinner meals were served in disposable carryout containers. Interviews with Certified Nursing Assistants (CNAs) confirmed the use of disposable dishware, and one CNA stated that the decision was made to avoid dirtying regular dishes. A resident expressed discomfort with meals being served on disposable dishware instead of regular plates. The facility's policy on dignity, revised in February 2021, emphasizes caring for residents in a manner that promotes their well-being and self-esteem. However, the practice of serving meals on disposable dishware was inconsistent with this policy. The facility identified two residents who were NPO (nothing by mouth) and did not receive meals from the kitchen, but the deficiency primarily affected the other residents who were served meals. This issue was investigated under Complaint Number OH00160314.
Failure to Follow Menu and Maintain Substitution Log
Penalty
Summary
The facility failed to adhere to its established menu cycle and did not maintain a substitution log, affecting 79 of 81 residents who received meals from the kitchen. On 12/26/24, the breakfast served did not match the planned menu, which was supposed to include cereal, scrambled eggs, bacon, wheat toast, and beverages. Instead, residents received french toast, sausage links, and hot cereal. The staff member responsible for the meal was unable to confirm the portion sizes used. Similarly, on 12/31/24, the lunch menu was not followed. The planned meal of maple mustard glazed pork tenderloin and accompanying sides was replaced with spaghetti, green beans, and ice cream. The staff member admitted to creating her own menu due to the need to use defrosted meat. Interviews with the Dietary Manager and Dietary Technician confirmed that the meals served did not align with the planned menu and that the facility did not maintain a substitution log as required by their policy. The facility's policy mandates that all menu changes be recorded and retained according to state regulations. The lack of adherence to the menu and absence of a substitution log were identified as deficiencies during the investigation of Complaint Number OH00160314.
Failure to Timely Clean and Disinfect Soiled Bedpans
Penalty
Summary
The facility failed to ensure timely cleaning and disinfection of soiled bedpans, affecting one resident reviewed for bedpan use. Resident #22, who was admitted with diagnoses including spinal stenosis, congestive heart failure, atrial fibrillation, and hypertension with heart disease, was frequently incontinent and dependent on staff for toileting. Observations on December 26, 2024, revealed a soiled bedpan with a pink substance on the bottom, left uncovered on the bathroom floor of Resident #22. This was confirmed by a registered nurse during an interview. The facility's infection control policy, revised in October 2018, was intended to maintain a safe and sanitary environment to prevent disease transmission, but was not adhered to in this instance.
Failure to Follow Physician Orders for Wound Care
Penalty
Summary
The facility failed to complete dressing changes according to physician orders for a resident with a suspected deep tissue injury on the right heel. The resident, who was cognitively intact and had no unhealed pressure or vascular ulcers upon admission, developed an intact purple area on the right heel. A physician order was obtained to apply skin prep, cover with an ABD pad, and wrap with kerlix twice daily and as needed. However, the dressing change was not completed as ordered, and the dressing was observed to be dated several days prior, indicating it had not been changed. Interviews with the resident and nursing staff confirmed that the dressing had not been changed since the initial application, despite documentation in the Treatment Administration Record indicating otherwise. The wound care RN confirmed the original physician order for twice daily dressing changes and acknowledged the discrepancy in the treatment record. The facility's policy on wound care, which aims to promote healing, was not followed, resulting in non-compliance with the physician's orders.
Failure to Obtain Physician Order for Oxygen Therapy
Penalty
Summary
The facility failed to obtain a physician order for the administration of oxygen therapy for a resident, identified as Resident #30, who was one of three residents reviewed for oxygen therapy. Resident #30 was admitted with diagnoses including status post cardiac arrest, respiratory arrest, chronic obstructive pulmonary disease (COPD), and congestive heart failure. The admission Minimum Data Set (MDS) assessment indicated that the resident was cognitively intact and received oxygen therapy. However, a review of the physician orders for December 2024 revealed no order for oxygen therapy, despite the resident receiving it since admission. An observation on December 30, 2024, confirmed that Resident #30 was wearing oxygen via nasal cannula at two liters per minute. During an interview, the resident stated that she had been on oxygen therapy since her admission and had also used it at home prior to admission. A registered nurse confirmed the absence of a physician order for the oxygen therapy, acknowledging that it was an oversight, as the hospital referral records indicated the need for such an order. The facility's policy on oxygen administration required verification of a physician order, which was not adhered to in this case. The deficiency was identified during a complaint investigation.
Failure to Administer Medications as Ordered
Penalty
Summary
The facility failed to administer medications per physician order for a resident with chronic obstructive pulmonary disease (COPD), emphysema, and anxiety. The resident was ordered Zithromax and prednisone for an acute exacerbation of COPD. However, the Medication Administration Record (MAR) indicated that these medications were not administered as ordered on a specific date. The nursing progress notes revealed that the Zithromax was not given due to awaiting pharmacy, and the prednisone was not administered because the medication was on order. Interviews with facility staff, including an LPN and the Director of Nursing (DON), revealed that the facility had an emergency medication box (E-box) that contained common medications for immediate use. Despite this, the medications were not administered. The pharmacy Processing Manager confirmed that the E-box was fully stocked with the required medications and that no requests for these medications were submitted to the pharmacy during the relevant period. The facility's policy required medications to be administered per prescriber orders, but this was not followed, leading to the deficiency.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure medications were administered as ordered for a resident, affecting one of three residents reviewed for medications. The resident, who had an intact cognitive function and was independent in most activities of daily living, was admitted with diagnoses including cellulitis, diabetes mellitus, ulcerative colitis, and schizophrenia. Upon admission, the resident's medications were reviewed and confirmed with the physician. However, the medication administration record revealed multiple instances where medications were not administered as ordered, including atorvastatin, Seroquel, Fluticasone-Salmeterol, mesalamine, warfarin, doxycycline, and memantine. The nursing progress notes indicated that several medications were not available at the time they were supposed to be administered, despite the Director of Nursing confirming that the medications were in the facility. The facility's policy on administering medications stated that medications should be administered in accordance with prescribers' orders, including any required time frame. This deficiency was investigated under a complaint and represented continued non-compliance from a previous survey.
Failure to Maintain Pest-Free Environment
Penalty
Summary
The facility failed to maintain a pest-free environment, resulting in a bed bug infestation that affected a resident. The resident, who had mild intellectual disabilities, congestive heart failure, and diabetes mellitus, was admitted to the facility and had an intact cognition with a risk for skin impairment. On two separate occasions, staff noted small bug bites on the resident's legs and arms during showers. An exterminator service record indicated that a significant number of dead bed bugs were found in the resident's room, specifically on the mattress. The room and its contents, including the mattress, chair, dresser drawers, armoire, and perimeter baseboards, were treated for bed bugs. The Director of Nursing confirmed the resident suffered from bed bug bites due to the infestation. The facility's policy on preventing and managing bed bug infestations was reviewed, revealing that staff were expected to employ infection control strategies to manage such infestations.
Failure to Investigate and Protect Residents from Verbal Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of verbal abuse and did not protect residents from potential abuse. This deficiency affected three residents who were cognitively impaired and dependent on staff for most activities of daily living. Despite the allegations being reported to management, there was no evidence in the medical records of any investigation or documentation regarding the abuse allegations for these residents. The facility's Self-Reported Incidents (SRIs) also did not contain any reports related to the verbal abuse allegations. Interviews with staff revealed that a State tested Nurse Aide (STNA) had threatened to hit two residents, and this was reported to the Director of Nursing (DON). However, the DON could not provide any investigative documentation, and the facility was unable to produce any evidence of an investigation. The facility policy required immediate reporting and documentation of such incidents, as well as the removal of the accused staff member pending investigation. Despite this, the accused STNA continued to work at the facility until being sent home after the surveyor's inquiry.
Facility Fails to Maintain Safe Environment, Resulting in Outdoor Fire
Penalty
Summary
The facility failed to maintain a safe environment, resulting in a small outdoor fire that had the potential to affect 11 residents with rooms near the incident site. The incident occurred when a nurse noticed smoke outside the 200 Hall lounge exit door. Upon investigation, a small flowerpot under a chair was found smoking, and staff had already attempted to extinguish it with dirt and water. The chair had a burn hole, and there was black soot staining on the wall behind it. Numerous cigarette butts were found in the potting soil, suggesting that the fire may have started when a cigarette was put out in the flower planter. The Director of Maintenance confirmed the burn hole, soot, and cigarette butts during an observation. An LPN also confirmed the fire in the flowerpot and stated that no staff or residents were present in the courtyard at the time. The facility's policy on safety and supervision, last revised in 2017, emphasized making the environment as free from accident hazards as possible, highlighting a lapse in adherence to this policy. This deficiency was investigated under a specific complaint number, indicating noncompliance with safety standards.
Failure to Provide Prosthetic Bra for Resident
Penalty
Summary
The facility failed to ensure that a resident received the necessary services to maintain a dignified appearance, specifically regarding the provision of a prosthetic bra. The resident, who was admitted with multiple diagnoses including chronic obstructive pulmonary disease, chronic kidney disease, heart failure, gout, hypertension, and type II diabetes mellitus, had a moderate cognitive impairment and was dependent on staff for dressing and personal hygiene. The medical record indicated that the resident had a surgically absent right breast and had requested a prosthetic bra, as noted in physician progress notes on multiple occasions. Despite the resident's request and the facility's awareness of the need for a prosthetic bra, there was no evidence in the medical record that the request was followed up on. The resident expressed feelings of shame about going out without an appropriate bra, and an observation confirmed the absence of a prosthetic bra. An interview with a licensed social worker verified that the request had not been addressed, highlighting a failure in the facility's responsibility to honor the resident's right to a dignified existence.
Failure to Provide Call Light and Siderails as Ordered
Penalty
Summary
The facility failed to ensure that a call light was within reach for Resident #128, who was admitted with diagnoses including type two diabetes mellitus, hypothyroidism, depressive disorder, and gangrene of the right leg. The resident, who had intact cognition and required substantial assistance for toileting and transfers, was observed without a call light within reach. The call light was found on the floor, detached from the wall. During an interview, the resident mentioned not having a working call light for a couple of weeks, which was confirmed by the Director of Nursing. Additionally, the facility did not comply with physician orders for Resident #182, who was admitted with chronic destructive pulmonary disease, asthma, and heart failure. The resident, who was cognitively intact and required moderate assistance for bed mobility, had an active physician order for top bilateral siderails to aid in bed mobility and promote independence. However, an observation revealed that the resident's bed did not have any siderails, as confirmed by an Agency Licensed Practical Nurse. The resident's family member also reported that siderails were supposed to be in place since admission, but they were not provided.
Failure to Notify Physician of Significant Weight Loss
Penalty
Summary
The facility failed to notify the physician of a significant weight loss experienced by a resident, which is a deficiency in their care protocol. The resident, who was cognitively intact, had a history of severe protein-calorie malnutrition, nutritional deficiency, heart disease, heart failure, weakness, anxiety, depression, and bipolar disorder. The resident's care plan, revised on August 15, 2024, indicated a risk for decline in nutrition and hydration status due to these diagnoses and weight loss. The plan included interventions such as providing supplements and reporting significant weight changes to the physician. Despite these interventions, the resident experienced a weight loss of 13.5 pounds between August 31, 2024, and September 1, 2024, which was not reported to the physician or dietitian. The facility's policy required that any weight change of five percent or more should be verified and reported immediately. However, an interview with the Director of Nursing and the Assistant Director of Nursing confirmed that there was no evidence of notification to the physician or dietitian about the weight loss until September 18, 2024.
Failure to Maintain a Clean and Homelike Environment
Penalty
Summary
The facility failed to provide a clean, comfortable, and homelike environment for a resident, as evidenced by the condition of the restroom sink in the resident's room. The sink was observed to contain a brown liquid that filled to approximately four inches from the top and was not draining. This condition persisted over several days, as confirmed by multiple observations and interviews with the resident and staff members, including a medication aide and housekeeping aides. The resident, who was moderately cognitively impaired with a BIMS score of eight, reported that the sink had been in this condition for approximately four days. Despite the issue being noticed by a housekeeper the week prior and reported to a nurse, the problem remained unaddressed until it was finally resolved. The resident's medical history includes cerebral infarction, hyperlipidemia, type two diabetes, bipolar disorder, nutritional deficiency, hypertension, seborrheic dermatitis, unspecified intellectual disabilities, personal history of COVID-19, and tinea unguium.
Failure to Timely Report Alleged Verbal Abuse
Penalty
Summary
The facility failed to report an allegation of verbal abuse to the state agency in a timely manner, affecting three residents. Resident #9, who was cognitively impaired and required substantial assistance for daily activities, had no evidence of abuse allegations in their medical record. Similarly, Resident #42, also cognitively impaired and dependent on staff, showed no documentation of abuse allegations. Resident #54, who was cognitively impaired, receiving hospice services, and dependent on staff, also had no record of abuse allegations. Despite these residents' vulnerabilities, the facility did not document or report the alleged verbal abuse. Interviews revealed that a State tested Nurse Aide (STNA) reported that another STNA had threatened to hit Residents #42 and #54, and this was communicated to management. The Director of Nursing (DON) confirmed that an investigation was conducted and documentation was provided to the previous Administrator. However, the current Administrator could not locate any investigative documentation and acknowledged that the allegation should have been reported to the state agency but was not. The facility's Self-Reported Incidents (SRIs) lacked any reports of the verbal abuse allegation, and the facility's policy required immediate reporting of such incidents to the state agency, which was not adhered to in this case.
Failure to Obtain Admission Orders for Surgical Incision Care
Penalty
Summary
The facility failed to ensure that admission orders were obtained for a resident with a surgical incision, which led to a deficiency in providing appropriate care and treatment. Resident #178, who was admitted with a surgical incision on the neck, did not have any orders in place to wash the incision as recommended by the hospital from which they were discharged. The hospital record indicated that the incision should be washed twice daily with soap and water, but this was not initiated until several days after the resident's admission. Upon observation, it was noted that the resident had clear tape covering the incision, and the resident reported that no treatments had been performed on it by the facility. The physician orders for the month did not include any instructions for incision care until an order was finally placed to wash the incision every shift. The Assistant Director of Nursing confirmed that there should have been an order in place upon admission to cleanse the surgical incision, which was not done, resulting in a lapse in care.
Failure to Provide Grooming Services
Penalty
Summary
The facility failed to provide necessary grooming services for a resident, identified as Resident #20, who was unable to perform activities of daily living independently. Resident #20, who was admitted with multiple diagnoses including polyosteoarthritis, acute respiratory failure, and severe cognitive impairment, required substantial or maximal assistance with personal hygiene as per the most recent Minimum Data Set (MDS) assessment. Despite this, observations revealed that the resident had long and dirty nails and multiple long, coarse hairs on her chin, which she expressed dissatisfaction with during an interview. The facility's policy on Activities of Daily Living (ADLs) mandates that residents who cannot independently perform ADLs should receive necessary services to maintain good grooming and personal hygiene. However, the facility did not adhere to this policy for Resident #20, as confirmed by a State tested Nursing Assistant (STNA) who verified the resident's unkempt nails and facial hair. This oversight affected the resident's grooming needs, contrary to the facility's stated policy and the resident's care plan.
Failure to Provide Timely Vision Services
Penalty
Summary
The facility failed to assist two residents in gaining timely access to vision services. Resident #32, who was admitted with diagnoses including dementia and atrial fibrillation, had requested eye care services on 06/13/24. Despite this request, there was no documentation indicating that the resident had seen a vision provider. The resident expressed to staff multiple times the need to see an eye doctor, but was not added to the list for the vision provider's visit on 09/16/24. The facility's policy, which mandates assisting residents in obtaining needed services, was not adhered to in this case. Similarly, Resident #46, who was admitted with multiple diagnoses including cerebral infarction and congestive heart failure, requested to see an optometrist on 03/08/24. Although the optometrist visited the facility on 04/03/24, Resident #46 was not evaluated at that time. The resident, who was cognitively intact, expressed a desire to see an eye doctor but was not provided the opportunity until 09/16/24. The facility's failure to ensure timely access to vision services for these residents constitutes a deficiency in care.
Failure to Administer Dietary Supplements as Ordered
Penalty
Summary
The facility failed to ensure that dietary supplements were administered according to the physician's order for a resident diagnosed with severe protein-calorie malnutrition and other health conditions. The resident, who was cognitively intact, was prescribed a magic cup supplement three times per day with meals. However, the resident reported inconsistencies in receiving the supplement, describing it as a 'throw of the coin' whether they received it with meals. Observations and interviews confirmed the resident did not receive the magic cup with several meals, including breakfast and lunch on multiple occasions. A Licensed Practical Nurse and a State-tested Nurse Aide verified that the resident was supposed to receive the supplement with breakfast, but it was not provided. This deficiency affected the resident's nutritional care plan, which aimed to prevent a decline in their nutrition and hydration status.
Medication Administration Deficiency
Penalty
Summary
The facility failed to ensure medications were administered in accordance with physician orders, resulting in a medication error rate of five percent. During an observation, it was noted that 37 medications were administered, with two errors occurring, affecting one of the two residents reviewed for medication administration. Specifically, Resident #17, who had diagnoses including malignant neoplasm of the breast, type two diabetes mellitus, chronic obstructive pulmonary disease, and chronic kidney disease, was not administered fluticasone propionate and simethicone as ordered by the physician. The Medication Administration Record (MAR) confirmed that these medications were not given on the specified date. An interview with LPN #419 revealed that the medications were unavailable for administration at the time.
Failure to Use Proper PPE for COVID-19 Positive Resident
Penalty
Summary
The facility failed to utilize proper Personal Protective Equipment (PPE) for a resident who tested positive for COVID-19. During an observation, it was noted that a COVID-19 isolation cart was present outside the room of the resident, who had a range of medical conditions including Alzheimer's disease, COPD, and type two diabetes. The door to the resident's room was open, and a State tested Nursing Assistant (STNA) was observed doffing her gown and gloves inside the room and exiting while wearing only a surgical mask. At no point did the STNA wear an N95 respirator or eye protection, which are required for entering the room of a COVID-19 positive resident. Interviews with the STNA and the Director of Nursing (DON) confirmed that N95 masks and face shields were not present on the isolation cart, contrary to the facility's policy. The facility's policy, updated earlier in the year, mandates that staff entering the room of a resident with a suspected or confirmed SARS-CoV-2 infection must use an N95 mask, gown, gloves, and eye protection. The STNA admitted to changing her mask after leaving the room and not using the required PPE, highlighting a lapse in adherence to the infection prevention and control program.
Failure to Educate and Offer COVID-19 Vaccination
Penalty
Summary
The facility failed to ensure that residents were educated on and received the COVID-19 vaccination, affecting two residents out of five reviewed. Resident #32, who was cognitively intact with a BIMS score of 13, had no documentation in their medical record regarding education, administration, or refusal of the COVID-19 vaccination. Similarly, Resident #46, also cognitively intact with a BIMS score of 15, had only received one COVID-19 vaccination in May 2021, with no further documentation of education or offers for additional vaccinations upon admission or thereafter. Interviews with RN #484 confirmed the lack of documentation and education regarding COVID-19 vaccinations for both residents. The facility had received information about the availability of COVID-19 vaccinations but had not yet begun offering them to residents. The facility's policy, revised in February 2024, stated that recommended vaccines should be provided to residents and staff, with information encouraging vaccination shared with families and visitors. However, the facility had not adhered to this policy, as confirmed by the administrator.
Failure to Administer Medications as Prescribed
Penalty
Summary
The facility failed to ensure medications were administered per physician orders for a resident with multiple diagnoses, including chronic hepatic failure. The resident was prescribed lactulose oral solution to be administered three times a day. However, the Medication Administration Record (MAR) indicated that the resident did not receive two doses on one day and one dose on the following day. The medication was reportedly unavailable on these occasions, as noted in the administration records. Interviews with staff revealed discrepancies in the availability of the medication. An LPN stated that the medication was not available upon the resident's arrival due to a delay in pharmacy delivery. However, the Director of Nursing later indicated that the medication was indeed available but was not found by the nurse because it was stored in a side drawer of the medication cart. The facility's policy on administering medications, which mandates timely and prescribed administration, was not adhered to in this instance.
Failure to Conduct Timely Performance Reviews for STNAs
Penalty
Summary
The facility failed to conduct performance reviews for every nurse aide at least once every 12 months, affecting two State tested Nursing Assistants (STNAs) out of four reviewed. Specifically, STNA #402, hired on 08/24/23, did not have a 90-day or annual employee evaluation in her file. Similarly, STNA #475, hired on 03/28/24, lacked a 90-day employee evaluation in her file. This deficiency was confirmed during an interview with Administrator #2, who verified the absence of the required evaluations for both STNAs. This oversight had the potential to impact all residents residing in the facility, which had a census of 85.
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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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