Mt Airy Gardens Rehabilitation And Nursing Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Cincinnati, Ohio.
- Location
- 2250 Banning Road, Cincinnati, Ohio 45239
- CMS Provider Number
- 365293
- Inspections on file
- 41
- Latest survey
- September 8, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Mt Airy Gardens Rehabilitation And Nursing Center during CMS and state inspections, most recent first.
Surveyors identified unsanitary conditions in the kitchen, including sticky substances on the floor, chipped and peeling flooring, brown debris under and along the walls, and standing water in uncovered pipes near the dishwasher. These findings were confirmed by the Administrator and affected all but three residents who did not receive food from the kitchen.
The facility did not ensure the kitchen was free of pests, as multiple gnats were observed around the dishwasher and trash cans. Both the Administrator and a Dietary Aide confirmed the ongoing issue, which had persisted for several weeks, in violation of the facility's pest control policy. This affected all residents except for three who did not receive food from the kitchen.
The facility failed to serve appropriate portion sizes, affecting all 77 residents. A dietary staff member used a green-handled scoop for macaroni and cheese, providing only 2 and 2/3 ounces instead of the required 4 ounces. The Dietary Director confirmed the error, leading to a deficiency in portion control.
The facility failed to properly store and handle food, risking foodborne illness for all 77 residents. Observations revealed opened and undated food items not refrigerated, milk and cheese stored on the floor, expired sanitizer test strips, and unsanitary food preparation practices. Numerous unlabeled and improperly stored food items were found in nourishment rooms, violating facility policies.
The facility failed to cover catheter bags for two residents, compromising their dignity and privacy. One resident with severe cognitive impairment had a visible catheter bag, while another with a nephrostomy tube had an uncovered leg bag. Both instances were confirmed by nursing staff, violating the facility's catheter care policy.
A facility failed to provide a safe and homelike environment, as observed in a resident's room and the Heritage nursing unit's shower room. A resident's room had missing cove base, an unsecured sink, and exposed drywall, while the shower room had peeling drywall. These issues were confirmed by staff, and the facility's policy on Resident Rights was not upheld.
The facility failed to accurately complete MDS assessments for three residents, leading to deficiencies in documenting their care needs. A resident was discharged before a comprehensive MDS was completed, another's assessments did not reflect a fall or hospice admission, and a third's assessment missed documenting a hand contracture. These inaccuracies were confirmed by staff interviews and observations.
A facility failed to update the PASARR for a resident admitted to hospice care, despite completing a significant change MDS assessment. The resident had multiple diagnoses, including hemiplegia and schizophrenia. The Social Services Director confirmed the oversight, acknowledging that the PASARR should have been updated upon hospice admission.
A facility failed to update a resident's care plan to reflect the discontinuation of a g-tube, despite the resident being on a regular diet and able to eat independently. The care plan inaccurately included interventions for tube feeding, which were no longer applicable. Staff interviews confirmed the care plan was not updated to reflect the resident's current dietary status.
A facility failed to ensure timely suture removal for a resident with a history of traumatic brain injury and cognitive impairment. The resident sustained a laceration to the right eyebrow after a fall, and the hospital discharge summary lacked orders for suture removal. Observations and staff interviews confirmed that the sutures remained in place beyond the typical removal period, with no order for their removal, indicating a lapse in wound management protocol.
The facility failed to provide necessary care for residents with impaired mobility and contractures. A resident with peripheral vascular disease did not receive a prescribed hand orthotic, another with a shoulder injury was not encouraged to use a sling, and a third with hemiplegia had an undocumented hand contracture. Staff were unaware or unable to locate necessary equipment, leading to inadequate care.
A resident on hospice care with moderate protein-calorie malnutrition was found without fluids available at the bedside on multiple occasions. Despite being on a mechanically altered diet with regular liquids, the resident did not have a water pitcher or cup in her room. Staff interviews revealed the absence was due to the resident's behavior of throwing the pitcher or taking it to other rooms. The DON confirmed fluids should have been available, and the NP stated there was no medical reason to withhold water. The facility did not provide a hydration policy when requested.
The facility failed to monitor adverse effects of psychoactive medications for three residents. One resident on Seroquel did not receive required AIMS assessments quarterly. Another resident on Invega Sustenna had no AIMS assessments conducted. A third resident on Depakote and Rexulti had no Depakote levels monitored and lacked quarterly AIMS assessments. These oversights were confirmed by facility staff.
A resident with complex medical conditions did not receive a Lidocaine patch as ordered, which was found undated and unsupervised on the bedside table. The LPN confirmed the patch was not applied, and the facility lacked a medication administration policy.
A facility failed to collaborate with a hospice agency to develop a comprehensive care plan for a resident with dementia and malnutrition. The hospice plan included nursing and aide visits, but lacked coordination with facility staff. Interviews confirmed unsuccessful attempts to engage the hospice agency in care planning, and the facility's care plan did not reflect hospice services.
A facility failed to provide full visual privacy in a resident's room, affecting a resident with severe cognitive impairment and multiple diagnoses. The room's window curtains allowed visibility from the parking lot, were damaged, and lacked a privacy curtain despite having tracking in place. The Housekeeping Director confirmed these issues, which violated the facility's policy on resident rights to personal privacy.
The facility failed to maintain a safe, clean, and comfortable environment for residents, as observed in multiple rooms. A resident with severe cognitive impairment lived in a room with potentially moldy drywall, while other rooms had issues like torn curtains, peeling wallpaper, and unsanitary bathrooms. These deficiencies were confirmed by staff and the Administrator.
A resident with a complex medical history was discharged from the hospital with new medication orders, which were not transcribed or administered upon their return to the LTC facility. The oversight was discovered when the resident was readmitted to the hospital with health complications. The error occurred because the discharge orders were misplaced, and the responsible LPN did not verify the physician orders, leading to a significant medication error.
The facility failed to prevent a high-risk resident from eloping and did not provide adequate supervision for residents who smoked. A resident left the facility unsupervised and was found walking in a busy street. Additionally, several residents were observed smoking in non-designated areas without staff supervision, contrary to the facility's policy.
The facility failed to maintain elevators in good working order and did not provide appropriate containers for cigarette disposal. Observations revealed numerous cigarette butts around the entrance, and residents were seen smoking and disposing of butts improperly. One elevator was out of order, and the other frequently malfunctioned, confirmed by staff, residents, and the Ombudsman. The facility lacked a policy for elevator maintenance.
A resident with dementia and cognitive impairments eloped from the facility and was found on a main road by a housekeeper. The nursing staff was unaware of the elopement, and the resident's representative was not notified until two days later, contrary to the facility's policy.
The facility failed to ensure that an interdisciplinary team was present during care conference meetings for four residents with varying cognitive impairments and multiple diagnoses. Care conferences were attended only by the SSD and, in some cases, an additional nurse, contrary to the facility's policy requiring full interdisciplinary team participation.
Unsanitary Kitchen Conditions Identified During Survey
Penalty
Summary
Surveyors observed that the facility failed to maintain a clean and sanitary kitchen, as required for food procurement and service. During an inspection, a sticky substance was found on the floor at the kitchen entrance, and the floor by the walls was chipped and peeling. There was a brown substance on the floor under the dishwasher and along the kitchen walls, as well as brown debris in two black rubber mats. Additionally, an uncovered pipe with standing water and a rag was noted near the dishwasher, and a second pipe nearby contained standing brown water. These unsanitary conditions were confirmed by the Administrator during a concurrent interview. The deficiency affected all residents except for three who did not receive food from the kitchen, with a facility census of 91.
Failure to Maintain Pest-Free Kitchen Environment
Penalty
Summary
The facility failed to maintain a kitchen environment free of pests, as required by its pest control program policy. During an observation of the kitchen, multiple gnats were seen around the dishwasher and trash cans. Both the Administrator and a Dietary Aide confirmed the presence of gnats in these areas, with the Dietary Aide stating that the issue had persisted for several weeks. The facility's pest control policy indicated an obligation to eradicate and contain common household pests, but the ongoing presence of gnats demonstrated non-compliance with this policy. This deficiency affected all residents except for three who did not receive food from the kitchen.
Inadequate Portion Control in Meal Service
Penalty
Summary
The facility failed to ensure appropriate portion sizes were served to residents, which had the potential to affect all 77 residents in the facility. During an observation, a dietary staff member was seen using a green-handled scoop to serve macaroni and cheese, which was not the correct size according to the facility's portion control chart. The dietary spreadsheet specified a 4-ounce serving for macaroni and cheese, which required a dark gray-handled scoop. However, the green-handled scoop used provided only 2 and 2/3 ounces. The Dietary Director confirmed the incorrect scoop was used, leading to the deficiency in portion control.
Deficiencies in Food Storage and Handling Practices
Penalty
Summary
The facility failed to store and handle food in a manner that prevents the potential spread of foodborne illness, affecting all 77 residents. Observations in the kitchen revealed several issues, including a jar of grape jelly and a jug of barbeque sauce that were opened, partially used, and not dated, which should have been refrigerated according to manufacturer labels. Additionally, milk cartons and a box of cheese were stored directly on the floor in the walk-in cooler and freezer, respectively. The use of expired sanitizer test strips for the dishwasher was also noted, compromising the sanitation process. Further observations in the food preparation area showed unsanitary practices, such as draining green beans against the inside of a sink, which was not considered sanitary. In the nourishment rooms on both the first and second floors, numerous food items were found unlabeled, undated, and improperly stored, including a jar of applesauce with mold, opened bottles of chocolate syrup and coffee creamer, and various sandwiches and beverages. These items were not in compliance with the facility's policy, which requires all foods to be labeled, dated, and stored properly to prevent contamination. Interviews with staff, including the Dietary Director, Dietary Aid, and Licensed Practical Nurse, confirmed the deficiencies in food storage and handling practices. The facility's policies on food storage and personal food brought in from outside sources were not adhered to, as evidenced by the numerous unlabeled and improperly stored food items. The facility's failure to follow these policies posed a risk of foodborne illness to all residents.
Failure to Cover Catheter Bags
Penalty
Summary
The facility failed to ensure that catheter bags were covered, affecting two residents. Resident #235, who was admitted with diagnoses including metabolic encephalopathy, diabetes mellitus type two, and chronic kidney disease, was observed with a full catheter bag visible from the hallway, which was not covered with a dignity bag. This observation was confirmed by a registered nurse, who acknowledged that catheter bags should be covered. The resident had severe cognitive impairment and was dependent on staff assistance for activities of daily living. Similarly, Resident #236, who was admitted with diagnoses including complications of an incontinent external stoma of the urinary tract, chronic kidney disease, and cerebral infarction, was observed with a nephrostomy tube and a leg bag pinned to the outside of his pajama pants. The leg bag contained visible urine and was not covered with a dignity bag, contrary to the resident's plan of care, which required the nephrostomy bag to be covered at all times. This was confirmed by a licensed practical nurse. The facility's policy on catheter care, dated 2024, stated that privacy bags should be available and catheter drainage bags should be covered at all times to maintain resident dignity and privacy.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for its residents, as evidenced by the conditions observed in Resident #59's room and the Heritage nursing unit's shower room. Resident #59, who was cognitively intact and required supervision with activities of daily living, expressed dissatisfaction with the physical state of his room. Observations revealed a missing section of cove base by the bathroom door, an unsecured sink, a wide gap without grout between the countertop and backsplash, exposed drywall needing repair, and an extra cable wire on the floor. Resident #59 could not recall if he had reported these issues, but the Housekeeping Director confirmed the concerns. Additionally, the shower room on the Heritage nursing unit was found to have a ceiling with damaged drywall that was peeling and required repair or replacement and painting. This condition was confirmed by the Housekeeping Director and a Registered Nurse, who noted that two residents on the unit had the ability to use the shower room. The facility's policy on Resident Rights emphasizes the right to a safe, clean, comfortable, and homelike environment, which was not upheld in these instances.
Inaccurate MDS Assessments for Residents
Penalty
Summary
The facility failed to ensure accurate completion of Minimum Data Set (MDS) assessments for three residents, leading to deficiencies in the documentation of their care needs and conditions. Resident #77 was admitted with multiple diagnoses, including atherosclerosis and diabetes mellitus, and was discharged before the comprehensive MDS assessment was completed. The assessment was inaccurately dated after the resident's discharge, and the Minimum Data Coordinator confirmed the need to deactivate the incorrect submission. Resident #8, who had dementia and was admitted to hospice, had MDS assessments that failed to reflect a fall and the initiation of hospice services, as confirmed by the reviewing nurse. Resident #51, diagnosed with cerebral infarction and other conditions, had an MDS assessment that did not document contractures or limitations in range of motion, despite observations of a contracted left hand and the presence of a hand splint. The Rehab Director was unaware of the contracture, and the nurse confirmed the inaccuracy of the MDS assessment. These deficiencies highlight the facility's failure to maintain accurate and timely assessments, impacting the quality of care provided to the residents.
Failure to Update PASARR for Hospice Admission
Penalty
Summary
The facility failed to complete a significant change Preadmission Screening and Resident Review (PASARR) for a resident following their admission to hospice care. The resident, who was admitted with diagnoses including hemiplegia, hemiparesis following cerebral infarction, hypertension, congestive heart failure, unspecified dementia, and schizophrenia, had a physician's order for hospice admission dated 07/18/24. Although the facility completed a significant change Minimum Data Set (MDS) assessment due to the hospice admission, they did not update the PASARR as required. This oversight was confirmed during an interview with the Social Services Director, who acknowledged that the PASARR should have been updated on the date of the hospice admission.
Failure to Update Resident Care Plan
Penalty
Summary
The facility failed to update the care plan for a resident, which did not accurately reflect the resident's current health care status. The resident, who had a history of schizophrenia, subdural hemorrhage, traumatic brain injury, and a gastrostomy (g-tube), was admitted with orders to flush the g-tube every shift. However, the care plan continued to include interventions related to tube feeding, despite the resident not using the g-tube for nutritional support. The care plan included various interventions for tube feeding, such as monitoring tube placement and patency, which were no longer applicable. The deficiency was identified when a nurse practitioner noted that the g-tube was no longer in use and recommended its discontinuation. Despite this, the care plan was not updated to reflect the resident's ability to consume meals orally and the absence of g-tube use. Interviews with facility staff confirmed that the care plan was inaccurate and not updated to reflect the resident's current dietary status, as the resident was on a regular diet and able to eat independently.
Failure to Ensure Timely Suture Removal
Penalty
Summary
The facility failed to ensure timely suture removal for Resident #73, who was admitted with a history of physical injury, traumatic brain injury, and altered mental status. The resident, who was cognitively impaired, sustained a two-centimeter laceration to the right eyebrow after falling from a stretcher in the emergency room. The hospital discharge summary did not include orders for suture removal, and the physician's orders only instructed monitoring of the sutures twice daily without specifying removal. Observations and interviews revealed that the sutures remained in place beyond the typical removal period of seven to ten days. The Licensed Practical Nurse confirmed the absence of an order for suture removal, and the Assistant Director of Nursing acknowledged that the Wound Nurse Practitioner was not following the resident for the sutured wound. This oversight resulted in the resident having sutures in place without a plan for their removal, highlighting a lapse in the facility's care protocol for wound management.
Failure to Provide ROM and Contracture Care
Penalty
Summary
The facility failed to provide appropriate care and services for residents with impaired mobility and contractures, affecting three residents. Resident #9, who had diagnoses including peripheral vascular disease and schizophrenia, was ordered to wear a left-hand orthotic to maintain joint integrity. However, observations revealed the resident was not wearing the brace, and staff confirmed they had never applied it nor could they locate it. The resident indicated a willingness to wear the splint, but it was not provided as ordered. Resident #72, with a history of traumatic brain injury and shoulder injury, was supposed to wear a sling for his right arm and shoulder. Despite orders to encourage sling use, observations showed the resident was not wearing it, and staff were unable to find the sling. Interviews with staff confirmed the resident had not been seen wearing the sling, and it was not present in his room, indicating a failure to follow the care plan. Resident #51, diagnosed with cerebral infarction and hemiplegia, was found to have a contracted left hand, which was not documented in the care plan or MDS assessment. A splint was found in the resident's belongings, but staff were unaware of the contracture, and the MDS assessment was inaccurate. This oversight highlights a lack of proper assessment and documentation for the resident's condition, leading to inadequate care.
Failure to Provide Fluids at Bedside for Resident
Penalty
Summary
The facility failed to ensure that a resident had fluids available at the bedside, which is essential for maintaining hydration. The resident, who was on hospice care with a diagnosis of moderate protein-calorie malnutrition, was observed on multiple occasions without any fluids available in her room. Despite being on a mechanically altered diet with regular liquids, the resident did not have a water pitcher or cup at her bedside during observations on two separate days. Interviews with staff revealed that the resident had a history of throwing the water pitcher at staff or taking it to other residents' rooms, which led to the absence of fluids in her room. The Director of Nursing confirmed that the resident should have had fluids available, and the Administrator was unaware of the situation. The Nurse Practitioner stated there was no medical reason for the resident not to have water at the bedside, and no laboratory tests were conducted regarding hydration due to hospice services. The facility did not provide a policy related to hydration when requested during the survey, indicating a lack of documentation or adherence to hydration protocols.
Failure to Monitor Adverse Effects of Psychoactive Medications
Penalty
Summary
The facility failed to ensure timely monitoring of adverse side effects of psychoactive medications for three residents. Resident #08, diagnosed with dementia and psychotic disorders, was prescribed Seroquel. However, the required Abnormal Involuntary Movement Scale (AIMS) assessments were not completed quarterly as mandated, with the last assessment recorded in June 2024. The MDS Coordinator confirmed the oversight, acknowledging that the assessments were not conducted during the specified periods in 2025. Resident #72, with diagnoses including schizophrenia and traumatic brain injury, was prescribed Invega Sustenna. The facility's records showed no evidence of AIMS assessments being conducted, which was confirmed by the Director of Nursing. The resident's care plan required AIMS assessments every six months, but this was not adhered to, indicating a lapse in monitoring for potential adverse effects of the medication. Resident #06, with multiple diagnoses including dementia and mood disorder, was on Depakote and Rexulti. The facility failed to monitor Depakote levels as ordered, with no records of such tests being conducted since the medication was prescribed in January 2022. Additionally, the last AIMS assessment was conducted in June 2024, contrary to the policy requiring quarterly assessments. The Director of Nursing and a Nurse Practitioner confirmed the lack of monitoring, highlighting a significant oversight in the resident's medication management.
Medication Storage and Administration Deficiency
Penalty
Summary
The facility failed to ensure medications were stored and administered in accordance with professional standards, affecting a resident who was admitted with multiple complex medical conditions, including acute respiratory failure, diabetes, schizophrenia, and opioid dependence. The resident had a physician's order for a Lidocaine patch to be applied topically for pain management. However, during an observation, it was noted that the patch was left on the resident's bedside table, undated and with the protective backing still attached, indicating it was not applied as ordered. The resident confirmed that the nurse did not apply the patch the previous evening as required. The LPN and ADON present during the observation verified that the patch was not applied and should not have been left unsupervised in the resident's room. Additionally, the facility was unable to provide a policy related to medication administration upon request, further highlighting the deficiency in medication management and storage practices.
Lack of Collaboration with Hospice Agency in Care Planning
Penalty
Summary
The facility failed to collaborate effectively with a hospice agency to develop a comprehensive plan of care for a resident receiving hospice services. The resident, who was admitted with diagnoses including dementia with behavioral disturbances and psychotic disorders, had an advanced directive for do not resuscitate comfort care and was on hospice for moderate protein-calorie malnutrition. The facility's plan of care included dietary interventions and monitoring for swallowing difficulties, but there was no evidence of collaboration with the hospice agency to integrate their services into the care plan. The hospice plan of care outlined services such as skilled nursing visits, aide visits, and the provision of equipment, but did not indicate any coordination with the facility staff. Interviews with facility staff, including a CNA, the Administrator, the Social Service Director, and the MDS Coordinator, confirmed the lack of collaboration and communication with the hospice agency. The facility had attempted to contact the hospice agency for scheduling information and to involve them in care planning, but these efforts were unsuccessful. The hospice staff did not participate in a recent care conference, and the facility's plan of care did not include details of the hospice services being provided. Additionally, the facility was unable to provide a policy related to the development of the plan of care upon request during the survey.
Failure to Ensure Visual Privacy in Resident's Room
Penalty
Summary
The facility failed to ensure full visual privacy in the resident bedrooms, affecting one of the four residents reviewed for physical environment. The resident in question, admitted with diagnoses including Alzheimer's dementia, psychotic disorder with delusions, and depressive disorder, was observed to have severe cognitive impairment and was dependent on staff assistance for activities of daily living. During an observation, it was noted that the resident's room window overlooked the facility parking area, and the window curtains were made of a material that allowed observation from the parking lot into the room. Additionally, the curtains were ripped and torn, and there was no privacy curtain in place despite the presence of privacy curtain tracking. An interview with the Housekeeping Director confirmed these findings, and a review of the facility's Resident Rights policy indicated that residents have a right to personal privacy in their living accommodations.
Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to provide a safe, clean, and comfortable environment for its residents, as evidenced by multiple observations and interviews. Resident #8608, who had severe cognitive impairment and was frequently incontinent, was living in a room with exposed drywall that was black in color, potentially indicating mold. This issue was reported by the resident's family, but it remained unaddressed for approximately two weeks. Additionally, other residents' rooms were found to have various issues, such as torn privacy curtains, peeling wallpaper, missing ceiling tiles, and unsanitary bathroom conditions. During the initial tour, several deficiencies were noted in the rooms of other residents. These included a torn privacy curtain in the room of two residents, peeling wallpaper and a missing ceiling tile in an unoccupied room, and a toilet bowl covered in brown material resembling feces in another room. Furthermore, a large brown ring stain was observed on the bathroom ceiling tile in one room, and peeling wallpaper was noted in the bathroom of another room. These observations were confirmed by a State tested Nursing Assistant and the facility's Administrator, indicating a widespread issue with maintaining a safe and clean environment for residents.
Failure to Administer Medications Post-Hospital Discharge
Penalty
Summary
The facility failed to ensure that a resident's medications were ordered and administered following a hospital discharge, resulting in a significant medication error. The resident, who had a history of myocardial infarction, transient ischemic attacks, HIV, and cerebrovascular disease, was discharged from the hospital with new medication orders for Ticagrelor, ferrous sulfate, and metoprolol. Upon returning to the facility, these medications were not listed on the Medication Administration Record (MAR) and were never ordered, leading to a lapse in the resident's prescribed treatment. The deficiency was discovered when the resident was readmitted to the hospital with symptoms of shortness of breath and abnormal vital signs. A subsequent review of the resident's records revealed that the medications ordered upon hospital discharge were not transcribed into the facility's system. Interviews with staff indicated that the discharge orders were misplaced among other paperwork, and the error was not identified until the hospital contacted the facility to reconcile the resident's medications. The Director of Nursing confirmed that the responsible LPN failed to check and implement the physician orders upon the resident's readmission, which led to the medication error. The Medical Director was not informed of the error due to being on vacation at the time. The facility's policy on administering medications requires adherence to physician orders, which was not followed in this case, resulting in non-compliance with the standard of care.
Failure to Prevent Elopement and Ensure Supervised Smoking
Penalty
Summary
The facility failed to ensure adequate supervision to prevent a high-risk resident from eloping. Resident #26, who had been assessed as being at high risk for elopement, left the facility unsupervised and was found by an off-duty employee approximately 0.1 miles from the facility, walking in the middle of a busy street. The facility did not have a care plan or interventions in place to prevent the elopement, and staff were unaware of the resident's absence until notified by the off-duty employee. The facility did not document the elopement in the medical record or complete an investigation into the incident, as they did not consider it an elopement. Additionally, the facility failed to provide adequate supervision for residents who smoked, allowing them to smoke in non-designated areas without staff supervision. Residents #32, #33, #40, and #68 were observed smoking less than 10 feet from the facility entrance, under a 'No Smoking' sign, and without appropriate receptacles for cigarette butts. The facility's policy required residents who needed supervision to always have a staff member present while smoking and to smoke only in designated areas. However, these residents were left unsupervised, and the facility did not adhere to its smoking policy. The facility's deficiencies in supervision and policy adherence placed residents at risk for potential harm. Resident #26's elopement and the unsupervised smoking incidents highlight the facility's failure to implement and follow appropriate care plans and safety measures for high-risk residents and those requiring supervision while smoking.
Removal Plan
- Certified Nurse Practitioner (CNP) #91 assessed Resident #26 with no negative findings.
- The DON completed the Secured Unit Screening and Resident #26 was moved to the secured unit.
- DOO #01 educated the DON and Administrator on the definition of elopement.
- The Administrator and DON completed elopement in-services to all staff in-person, by telephone, and by text notification. Education included whom to notify and how to identify if an elopement had occurred. Agency staff will be provided with a copy of the education, and it will be in the assignment binder that the agency staff report to for each shift.
- The Administrator began investigating Resident #26's elopement. It was discovered that Resident #26 met qualifications for placement on the secured unit when Resident #26 was assessed to be at a high risk of elopement, but the resident was not moved to the unit. Root cause analysis indicates the system failure was an Elopement Risk Assessment was completed with no follow up action.
- The DON and designee completed audits of all 88 residents for Elopement Risk with no negative findings. No additional residents were impacted by the Elopement Risk Assessments. All 16 high-risk residents were appropriately located on the secured unit. All high-risk residents had care plans reviewed to ensure elopement risk was included. Care plans were revised to reflect changes for Residents #04, #13, #14, #21, and #26.
- The Administrator provided verbal education to the DON, and two unit managers [Registered Nurse (RN) #345 and Licensed Practical Nurse (LPN) #165] on identifying high elopement risk residents and the appropriate placement of exit-seeking individuals onto the secured unit as applicable.
- Minimum Data Set (MDS) Nurse #340 initiated a care plan for Resident #26. The care plan included that Resident #26 was an elopement risk/wanderer with an intervention of placement on a secured unit. Other interventions included identifying the pattern of wandering: divert as needed and intervene as appropriate.
- The facility held an ad hoc Quality Assurance Performance Improvement (QAPI) meeting with Medical Director #90, the Administrator, DOO #01, DOO #02, and the DON. The long-term care Ombudsman was also notified of the Immediate Jeopardy situation involving Resident #26.
- The DON or designee completed education to the nursing staff regarding Elopement Risk assessments and their completion/accuracy to ensure all nursing staff are knowledgeable.
- The Administrator or designee will complete weekly audits for four weeks for elopement risk assessments for all admissions, readmissions, and any resident with a change in condition.
Elevator Malfunctions and Improper Cigarette Disposal
Penalty
Summary
The facility failed to ensure the elevators were maintained in good working order and failed to ensure cigarette butts were disposed of in appropriate containers. Observations over several days revealed numerous cigarette butts lying on the ground in front of the facility entrance doors, in the mulch, and in the rocks located beside the entrance doors. Residents were observed smoking within ten feet of the entrance doors and disposing of cigarette butts on the ground due to the absence of appropriate receptacles. The Director of Nursing (DON) confirmed the area was not a designated smoking area and that residents continued to smoke and dispose of cigarette butts improperly despite a 'No Smoking' sign being present. The facility's smoking policy, revised in January 2024, stated that smoking was only permitted in designated areas with appropriate containers, which was not adhered to in this case. Additionally, the facility had issues with elevator maintenance. One of the two elevators was out of order, and the other frequently malfunctioned, failing to open its doors on the second floor and returning to the first floor without allowing passengers to disembark. Interviews with staff, residents, and the Ombudsman confirmed the frequent malfunctioning of the elevators. The DON and the Administrator acknowledged the ongoing issues despite multiple repair attempts. The facility did not have a policy pertaining to elevator maintenance, and concerns about the elevators were documented in the Resident Council Meeting minutes from April 2024.
Failure to Timely Notify Resident's Representative of Elopement
Penalty
Summary
The facility failed to timely notify the resident's representative of a resident's elopement from the facility. This deficiency affected Resident #26, who had diagnoses including dementia, altered mental status, cognitive communication deficits, and high blood pressure. On 04/20/24, Resident #26 was found by a housekeeper ambulating on the main road in front of the facility with his wheeled walker, approximately 0.1 miles away, and in the middle of the road with vehicles swerving around him. The housekeeper alerted the nursing staff, who were unaware that Resident #26 had left the floor. The resident was then brought back to the facility by an unknown staff member and escorted to the second floor. However, there was no documentation or recollection of the events in the nursing notes for that day. The facility's policy required the Nurse Supervisor/Charge Nurse to notify the resident's family or representative when the resident is involved in any accident or incident. Despite this, the resident's representative was not informed of the elopement until two days later, on 04/22/24, when the Social Services Director called the resident's niece to discuss future placement on the secure unit. The Director of Nursing confirmed that the facility should have notified the resident's representative immediately following the elopement, verifying the lapse in timely notification.
Failure to Ensure Interdisciplinary Team Participation in Care Conferences
Penalty
Summary
The facility failed to ensure that an interdisciplinary team was present during care conference meetings for four residents. Resident #5, who had severe cognitive impairments and multiple diagnoses including seizures and dementia, had a care conference attended only by the Social Services Director (SSD) and the MDS Nurse. Similarly, Resident #7, with severe cognitive impairments and diagnoses such as hypertension and dementia, had a care conference attended only by the SSD and an unidentifiable Licensed Practical Nurse (LPN), with no documentation indicating if the resident representative was invited. Both instances were verified by SSD #200 during an interview, confirming that the interdisciplinary team was not fully present as required by facility policy. Resident #26, who had moderate cognitive impairments and diagnoses including cerebrovascular disease and anemia, had a care conference attended solely by the SSD. Resident #67, with minimal cognitive impairments and multiple diagnoses such as metabolic encephalopathy and atrial fibrillation, also had a care conference attended only by the SSD. These deficiencies were confirmed through interviews with SSD #200, who acknowledged that the care conferences did not include all members of the interdisciplinary team as mandated by the facility's policy. The facility's policy, revised in December 2008, clearly states that care plans should be developed by the entire interdisciplinary team based on each resident's comprehensive assessment.
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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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