O'neill Healthcare Bay Village
Inspection history, citations, penalties and survey trends for this long-term care facility in Bay Village, Ohio.
- Location
- 605 Bradley Rd, Bay Village, Ohio 44140
- CMS Provider Number
- 365264
- Inspections on file
- 27
- Latest survey
- January 21, 2026
- Citations (last 12 mo.)
- 23
Citation history
Health deficiencies cited at O'neill Healthcare Bay Village during CMS and state inspections, most recent first.
Surveyors found that the facility did not ensure meals were palatable, visually appealing, or served at appetizing temperatures. A family member reported ongoing concerns about food quality and temperature, and multiple residents stated that their food was cold, overcooked, hard, unappetizing, or had declined in quality, with one resident needing to ask CNAs to reheat meals. Observation of a test breakfast tray with the Dietary Manager showed an extremely hard biscuit, bland and lukewarm sausage gravy, and thick, unseasoned oatmeal without typical enhancers, contrary to the facility’s policy that meals be promptly distributed to maintain adequate temperature and appearance.
Surveyors found that the facility failed to maintain a clean, safe, and well-maintained environment, with multiple rooms showing loose or damaged flooring under beds, dislodged baseboard covers with exposed heating elements, broken or cracked walls and windowsills, and holes or peeling drywall near beds. Some residents’ bedding was stained or damaged, with one room having a strong urine odor, and another bed cover showing a brown stain. Environmental cleanliness issues included dirty air conditioner filters, a wall unit vent with only a thin cover, dead bugs in overhead hallway light fixtures, and a dented, discolored, and sticky hallway air filter unit. One resident reported that loose floor planking under the bed was related to how she is positioned in bed.
Surveyors found that two residents were exposed to cold drafts in their rooms due to a window leak and a gap above an AC unit, resulting in discomfort. One resident used a rolled towel at the base of a closed window next to the bed to block cold air, while another resident’s room had a visible gap above the AC unit where cold air entered. Both residents reported feeling cold and uncomfortable, and the Director of Ancillary Services confirmed these environmental issues during rounds.
A high-risk resident with multiple comorbidities and a low Braden score was admitted without pressure ulcers but later sustained an unwitnessed fall resulting in a coccyx skin tear and right buttock bruising. The wound was not comprehensively measured or assessed at the time of injury, and although general skin integrity interventions were care planned, no problem or interventions specific to the new coccyx/right buttock wound were added. Days later, a CNP evaluated the area and classified it as an unstageable pressure ulcer with 100% slough, and new wound treatments and an air mattress were ordered. The care plan, however, was not revised to include the pressure ulcer, its specific treatment, or the added pressure-relieving interventions, contrary to facility policy requiring care plan modification and ongoing wound assessment for residents who develop pressure ulcers.
A resident with COPD, chronic atrial fibrillation, lumbago with bilateral sciatica, and moderate cognitive impairment had a care plan and MD order requiring all transfers to be done with a Hoyer lift and specified sling with 2-person assist. The resident later reported to family and a police officer that an aide picked her up under the arms and placed her in a wheelchair, causing back pain, with no mention of a mechanical lift. One CNA stated she and another CNA twice transferred the resident between bed and chair without using a gait belt or knowing the resident required a Hoyer lift, while the assisting CNA claimed a Hoyer was used and accused the family of lying. The Administrator confirmed the facility determined the CNAs had body-lifted the resident instead of using the ordered Hoyer lift, constituting a failure to follow the resident’s transfer requirements.
A resident with Parkinson’s disease, muscle weakness, and intact cognition had physician-ordered podiatry appointments but repeatedly missed them because transportation was not properly arranged. Although the resident had Ohio managed Medicaid coverage that allowed multiple round-trip visits and required transport scheduling in advance, the insurer reported no transports were ever set up. The resident stated he missed two appointments due to the facility’s failure to arrange transportation, outside office staff reported multiple no-shows without cancellation or rescheduling, and an NP was not informed of any missed visits. An RN unit manager indicated transport confirmations were sent by text to the resident’s phone, while the resident reported his phone had been broken for two years, and the RN confirmed the resident was not transported to at least one scheduled appointment due to transportation issues.
A resident with multiple comorbidities, cognitive impairment, a stage II pressure ulcer, MASD, and an MDRO-infected right foot wound was care planned for Enhanced Barrier Precautions (EBP). During observed wound care to the right fifth toe, an LPN entered the room marked for EBP without a gown, removed a soiled dressing, then cleansed the wound and applied calcium alginate using the same pair of gloves before changing gloves only to place the foam dressing. In interview, the LPN acknowledged both the EBP requirement for gown and gloves and that gloves should have been changed after removing the old dressing, which was inconsistent with the facility’s wound care policy requiring hand hygiene and new gloves between dressing removal and wound care.
A resident with a history of stroke and other conditions did not receive prescribed wound care for a skin tear on the left hand. Despite physician orders for daily treatment, the wound was left open and untreated, as confirmed by observations and family interviews. An LPN admitted to not being aware of the wound care orders.
A resident with severe cognitive impairment and multiple medical conditions did not receive adequate nutritional and hydration care in a facility. The resident required a mechanically altered diet and staff assistance for feeding, but the facility failed to consistently document meal intake and did not have a clear plan for feeding assistance. This led to the resident being hospitalized for dehydration and high sodium levels, highlighting deficiencies in the facility's care practices.
The facility failed to ensure call lights were within reach for three residents, including one with a femur fracture and dementia, another with multiple sclerosis and vision impairment, and a third with dementia and mobility issues. Observations revealed call lights were out of reach, confirmed by staff, despite facility policy requiring accessibility.
A facility failed to timely report an abuse allegation involving a resident who was cognitively intact and had multiple medical conditions. The resident's granddaughter reported that a male CNA refused bathroom assistance and took away the resident's call light, TV remote, and cell phone. The incident was reported to the DON but not fully communicated to the Administrator until several days later, violating the facility's policy on timely reporting of abuse allegations.
The facility failed to provide fortified pudding to several residents during lunch, as required by physician orders or dietitian recommendations. These residents, who had specific dietary needs due to various medical conditions, did not receive the fortified pudding because the facility ran out halfway through meal service. This resulted in non-compliance with the dietary interventions outlined for these residents.
The facility did not provide pureed foods at a smooth consistency for safe swallowing for three residents on prescribed pureed diets. Observations and taste tests revealed that the pureed peas were lumpy and contained pea shell pieces, which was confirmed by a Speech Therapist. This was contrary to the facility's guidelines that required pureed foods to hold their shape on a spoon and have a smooth texture.
The facility failed to honor dietary needs for three residents, including allergies to chocolate and wheat, and a preference for almond milk. Errors were identified during a tray line observation, affecting the potential dietary safety of 110 residents.
Failure to Provide Palatable, Appealing Meals at Appropriate Temperatures
Penalty
Summary
The facility failed to ensure that food and drink were palatable, visually appealing, and served at safe and appetizing temperatures for multiple residents. A family member of one resident reported multiple concerns about food quality and temperature. Several residents reported that the food was always cold, had declined in quality, or was gross. One resident stated they frequently had to ask CNAs to reheat their food, and that the CNAs did so reluctantly. During the annual survey’s resident council portion, numerous residents reported that the food was overcooked, hard, and did not taste good. Direct observation of a test tray for a breakfast meal with the Dietary Manager showed biscuits with sausage gravy, oatmeal, and orange juice that did not meet the facility’s own standards for meal service and distribution. The biscuit was extremely hard and required significant force with a spoon to cut. The sausage gravy was bland, lacked seasoning, and was only lukewarm at 145 degrees. The oatmeal had a thick paste-like texture and was served without milk, brown sugar, or other flavor enhancers. The Dietary Manager confirmed these findings at the time of observation. Review of the facility’s undated meal service and distribution policy showed that residents’ meals were supposed to be distributed promptly to maintain adequate temperature and appearance, which was not achieved in these instances.
Failure to Maintain Clean, Safe, and Well-Maintained Environment
Penalty
Summary
Surveyors identified a deficiency in maintaining a clean, safe, and sanitary environment based on observations during environmental rounds and resident and staff interviews. Multiple resident rooms had physical plant issues, including loose flooring or floorboards under bed legs or footers, dislodged floor baseboard covers with exposed heating elements, broken or damaged walls and windowsills, and an indented hole on a bathroom door. Specific examples included loose flooring under beds in several rooms, a broken windowsill ledge with dislodged triangular pieces and an 18-inch wall crack extending toward the floor, semi-plastered wall holes behind beds, peeling paint and drywall near beds, and exposed drywall in another room. One resident reported that the floor planking had been loose under her bed due to the way she is positioned in bed. Additional environmental concerns involved unclean or stained items and equipment. One resident’s bottom bed sheet had a small hole and two small yellow stains, and there was a strong urine odor in the room without visible urine. Another resident’s bed cover had a brown stain. An air conditioner filter in one room had visible dirt and debris, and a wall unit air conditioner vent had only a thin cover that was cold to the touch. Dead bugs were observed in overhead hallway lighting lids throughout the building. An air filter unit in the hallway had a dent, visible yellow/light brown discoloration on its exterior, and was sticky to the touch. These conditions were verified at the time of discovery by the Director of Ancillary Services and were associated with multiple complaint investigations.
Failure to Maintain Comfortable Room Temperatures Due to Drafty Windows and AC Gaps
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment when two residents experienced cold air infiltration in their rooms. For one resident, surveyors observed a rolled towel placed at the base of the closed window next to the bed, with cold air felt coming through the window; the resident reported that cold air entered through the window, caused discomfort, and that the towel was placed there for that reason. For another resident, surveyors observed a gap above the air conditioner unit below the window, with cold air felt through the gap; this resident stated he was cold in his room and was uncomfortable. During environmental rounds, the Director of Ancillary Services confirmed these findings. This deficiency represents non-compliance investigated under Complaint Numbers 2642470, 1266873 (OH00165876), and 1266871 (OH00165428).
Failure to Assess and Care Plan Newly Developed Coccyx/Buttock Wound
Penalty
Summary
The deficiency involves the facility’s failure to comprehensively assess a newly identified skin alteration on a resident’s sacral/buttock area and to timely revise the resident’s care plan for pressure ulcer prevention and treatment. The resident was admitted with multiple medical diagnoses, including senile degeneration of the brain, emphysema, heart block, obstructive and reflux uropathy, hyperlipidemia, heart failure, and atrial fibrillation. On admission, the resident had no pressure areas but did have scattered bruising, abrasions, scabs, and a surgical incision. A Braden Scale assessment completed on the day of admission showed a score of 12, indicating high risk for skin breakdown, with findings of very limited sensory perception, very moist skin, chairfast status, very limited mobility, probably inadequate nutrition, and a potential problem with friction and shear. A nutrition assessment documented that the diet was adequate and that the resident was at risk for skin breakdown but had no identified pressure ulcers. An MDS assessment confirmed no pressure ulcers and total dependence on staff for ADLs, with an indwelling urinary catheter and bowel incontinence. On a later date, the resident sustained an unwitnessed fall. An LPN found the resident on the floor sitting on his bottom, and the resident reported pain in that area. The LPN documented an injury on the coccyx described as a skin tear and redness, and the facility’s fall report listed a bruise to the coccyx, a bruise to the right cheek, and a skin tear to the coccyx. Weekly wound documentation for the right buttock and coccyx on the date of the fall recorded bruising measuring 4.5 cm by 2.6 cm with a wound bed described as 100% purple, and a skin tear to the coccyx without measurements or further description of the periwound area. There was no evidence in the medical record that the skin tear was fully measured and assessed or that a specific treatment was implemented immediately following the fall. A care plan initiated that same day addressed the resident’s potential for alteration in skin integrity with general preventive interventions such as turning and repositioning, heel offloading, pressure-reducing surfaces, and incontinence care, but it did not include a problem or interventions specific to the right buttock bruise and coccyx skin tear sustained from the fall. Subsequently, a treatment order for the right buttock/coccyx area was entered the day after the fall to cleanse with normal saline, pat dry, and apply Triad cream every shift and as needed for a skin tear related to the fall. Several days later, the wound team CNP evaluated the right buttock wound and classified it as a pressure ulcer with 100% yellow, soft slough and moderate serous drainage, measuring 4.5 cm by 2.5 cm with depth unable to be determined. Weekly wound documentation on that date described the wound as an unstageable pressure ulcer with intact periwound skin, and the treatment was changed to Medihoney, calcium alginate, and a dressing. An air mattress was also ordered at that time. Despite the reclassification of the wound as an unstageable pressure ulcer and the addition of new pressure-relieving interventions, the resident’s care plan was not updated to include the identified pressure ulcer, the new wound treatment, or the air mattress. Interviews with the DON, Regional Director of Clinical Services, MDS coordinator, and CNP confirmed that the initial skin tear and bruising were not comprehensively assessed and that the care plan was not revised to reflect the development and treatment of the pressure ulcer, contrary to the facility’s pressure ulcer prevention and treatment policy, which requires care plan modification to reflect changes in condition and weekly wound evaluation and discussion by the IDT. The facility’s policy on Pressure Ulcer Prevention and Treatment Protocol states that residents with a Braden score of 12 or less are considered high risk for pressure ulcer development and that residents who develop a pressure ulcer must have appropriate nutritional evaluation, wound care interventions per protocol or MD orders, referrals as needed, and care plan modifications to reflect changes in condition. The policy also requires daily monitoring of periwound skin, weekly wound measurements, and weekly IDT discussion of wound status, with adjustments to treatment as needed. In this case, the resident, who was identified as high risk on admission, developed a wound to the coccyx/right buttock area following a fall that was initially documented as a bruise and skin tear but not fully measured or assessed, and the care plan was not updated when the wound was later classified as an unstageable pressure ulcer and new interventions were ordered. These omissions constitute the failure to provide appropriate pressure ulcer care and to prevent new ulcers from developing as cited in the deficiency.
Failure to Follow Hoyer Lift Transfer Requirements for a Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was transferred in accordance with physician orders and the resident’s care plan, which required use of a Hoyer mechanical lift with a medium purple sling and assistance of two staff for all transfers. The resident had multiple diagnoses, including COPD, lumbago with sciatica on both sides, and chronic atrial fibrillation, and had a care plan intervention in place specifying mechanical lift transfers. A physician order also directed that a Hoyer lift be used for all transfers on all shifts. The resident’s MDS reflected moderate cognitive impairment. The incident came to light when the resident’s daughter reported that the resident complained of back pain after being gotten out of bed the previous evening and expressed concern that the pain was related to how staff had transferred the resident. The daughter contacted the local police department, and an officer subsequently interviewed the resident. The resident reported that an aide, described as a black female in her late 20s, picked her up under both armpits and placed her in a wheelchair, and that she experienced pain during the move from bed to chair. This description did not include the use of a Hoyer mechanical lift as required by the care plan and physician order. During the facility’s investigation, one CNA stated in a witness statement that she had cared for the resident on the relevant day shift and had transferred the resident twice, from bed to chair and later from chair back to bed, with assistance from another CNA. She acknowledged having a gait belt but not using it and stated she did not know the resident required a Hoyer lift, and that the resident appeared comfortable and voiced no concerns at the time. The assisting CNA, in a later telephone interview, claimed that a Hoyer lift had been used and alleged the family was lying. The Administrator, however, confirmed that the facility determined the two CNAs had not used a Hoyer mechanical lift and had instead body-lifted the resident from bed to chair and back, contrary to the resident’s care plan and physician orders.
Failure to Arrange Transportation for Outside Podiatry Appointments
Penalty
Summary
The deficiency involves the facility’s failure to ensure transportation was adequately arranged for an insured resident’s outside podiatry appointments. The resident was admitted with Parkinson’s disease, muscle weakness, and a cognitive communication deficit, but the admission MDS showed intact cognition. Physician orders documented podiatry appointments on 12/04/25 at 11:15 A.M. and 01/08/26 at 2:15 P.M., and the resident was covered by an Ohio managed Medicaid plan that, per facility transportation guidelines, required transportation to be scheduled at least two days in advance and allowed up to 30 round trips per year. Despite these provisions, the insurance transportation representative reported that no transportation had been set up for any past or future appointments for this resident. The resident reported missing two appointments because the facility did not set up transportation in a timely manner. Outside office staff stated the resident was a no-show to multiple appointments due to transportation issues and that facility staff did not call to cancel or reschedule. The NP reported she was not notified of any missed appointments and confirmed transportation was a problem. The RN unit manager stated that confirmation for transport had been sent to the resident’s phone, but the resident reported his phone had been broken for two years and he could not receive texts. The RN unit manager confirmed the resident was not transported to the 01/08/26 appointment due to transportation issues. Facility transportation guidelines also indicated that routine or unrelated appointments should be canceled or rescheduled during a skilled stay, and that certain Medicare transports without secondary insurance would be billed to the resident at booking, but there was no evidence these guidelines were effectively implemented to ensure the resident’s ordered podiatry appointments were supported with appropriate transportation.
Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to implement appropriate infection prevention and control measures during wound care for one resident on Enhanced Barrier Precautions (EBP). The resident was admitted with multiple diagnoses including hemiplegia, hemiparesis, type II diabetes, dysphagia, cerebral infarction (stroke), depression, anxiety, right knee contracture, hypertension, and heart failure. A quarterly MDS documented that the resident was cognitively impaired, dependent on staff for hygiene and transfers, and had a stage II pressure ulcer and moisture associated skin damage. The care plan indicated the resident required EBP due to a multidrug resistant organism (MDRO) infection in a right foot wound, and physician orders directed cleansing the right fifth toe with normal saline, patting dry, applying calcium alginate, and covering with a foam dressing. During an observation of wound care, an LPN gathered supplies and entered the resident’s room, which had signage indicating EBP and the requirement for staff to wear gloves and a gown when providing wound care to any skin opening requiring a dressing. The LPN did not don a gown, washed her hands, put on gloves, and removed the old dressing from the right fifth toe. Using the same gloves that had been used to remove the soiled dressing, she then cleansed the wound and applied calcium alginate before changing gloves to apply the foam dressing. In a subsequent interview, the LPN confirmed she did not change gloves after removing the dressing and before cleansing the wound, and acknowledged that the resident required EBP and that she was required to wear gloves and a gown while providing wound care. Review of the facility’s wound care policy showed it required handwashing, glove use to remove the dressing, handwashing again, and then new gloves to complete the dressing change. This deficiency was investigated under Complaint Numbers 2703441 and 2642470.
Failure to Provide Wound Care as Ordered
Penalty
Summary
The facility failed to provide appropriate wound care for a resident, identified as Resident #109, according to the physician's orders. Resident #109, who has a medical history including stroke, diabetes mellitus, kidney disease, anxiety, post-traumatic stress disorder, and cognitive impairment, experienced a fall and was transferred for evaluation. Following the fall, a physician's order was issued on 02/25/25 for the treatment of a skin tear on the resident's left hand. The order specified that the wound should be cleansed with normal saline, patted dry, treated with triple antibiotic ointment, covered with a non-adherent dressing, and wrapped with gauze once daily until healed. However, observations and interviews revealed that the prescribed wound care was not performed. On 02/26/25, the resident was observed with an open laceration on the left hand, covered only by steri-strips, some of which were peeling, and a moderate amount of dried blood was noted. Interviews with the resident's wife and son confirmed that no dressing was applied on 02/25/25 after the resident returned from the emergency department, nor was there a dressing in place the following morning. An LPN, who was responsible for the resident's care on 02/25/25, admitted to not performing the wound care, stating she was unaware of the wound orders. This deficiency was investigated under Complaint Number OH00161145.
Failure to Provide Adequate Nutritional and Hydration Care
Penalty
Summary
The facility failed to provide adequate nutritional and hydration care for a resident, identified as Resident #108, who was dependent on staff for feeding assistance. The resident had multiple medical conditions, including encephalopathy, dysphagia, and Alzheimer's disease, and required a mechanically altered diet with honey thickened liquids. Despite these needs, the facility did not consistently document the resident's meal intake on several occasions, and there was no clear plan addressing the extent of feeding assistance required. Resident #108 was admitted with a weight of 130.6 pounds and had a nutritional assessment indicating a need for 1800 calories and 1800 milliliters of fluid daily. However, the resident's meal intake records showed significant gaps, with no documentation on several days and instances of meal refusal. The resident was eventually admitted to the emergency department with dehydration and high blood sodium levels, conditions that had led to multiple hospitalizations in the past. Interviews with facility staff, including a registered dietician and the administrator, confirmed that the care plan did not adequately address the resident's feeding assistance needs. The facility's policies on activities of daily living and weight recording were not effectively implemented, contributing to the resident's nutritional and hydration deficiencies. This deficiency was investigated under two complaint numbers, indicating ongoing issues with the facility's care practices.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to ensure that residents had their call lights within reach while unattended in their rooms, affecting three residents. Resident #39, who had a history of falls and was at high risk for falls due to a femur fracture, weakness, and dementia, was observed lying in bed with the call light on the opposite side of the room, out of reach. Despite being alert and responsive, the resident was unable to access the call light due to the bed's position against the wall. This was confirmed by an LPN who noted that the call light could reach the resident if stretched across the room. Resident #36, diagnosed with multiple sclerosis, paraplegia, and vision impairment, was also affected. The resident was observed sitting in a tilt chair with the call light connected to the bed and out of reach. Despite requiring assistance for mobility and being at high risk for falls, the resident confirmed the inability to reach the call light. A CNA verified the situation, acknowledging that the resident used the call light for assistance when it was accessible. Similarly, Resident #43, who had dementia and was at high risk for falls, was found in a wheelchair with the call light located behind the bed and out of reach. The resident, who required assistance for mobility and was dependent on staff for transfers, confirmed the inability to reach the call light. A CNA corroborated this, noting that the resident could normally use the call light but was unable to do so due to its placement. The facility's policy required call lights to be within reach, but this was not adhered to, as confirmed by the Administrator and DON.
Failure to Timely Report Allegation of Abuse
Penalty
Summary
The facility failed to timely report an allegation of abuse involving a resident, which was identified during a review of records, interviews, and the facility's self-reported incident (SRI). The incident involved a resident who was cognitively intact and had multiple medical conditions, including metabolic encephalopathy and cirrhosis of the liver. The resident's granddaughter reported that a male CNA refused to assist the resident to the bathroom, took away her call light, TV remote, and personal cell phone, and instructed her not to call anyone. This incident was initially reported to the DON on November 30th, but the SRI was not initiated until December 4th, indicating a delay in reporting. The facility's policy requires that all alleged violations involving abuse, neglect, or mistreatment be reported immediately, or within two hours if they involve abuse or result in serious bodily injury. However, the facility did not adhere to this policy, as the Administrator was not informed of the full extent of the allegations until December 4th. The investigation into the allegations was completed on December 11th and was found to be unsubstantiated. This deficiency was identified under Complaint Number OH00160465, highlighting non-compliance with timely reporting requirements.
Failure to Provide Fortified Pudding as Ordered
Penalty
Summary
The facility failed to provide fortified pudding to five residents during lunch, as required by physician orders or dietitian recommendations. These residents were identified as being at risk for altered nutrition or hydration due to various medical conditions, including dementia, diabetes mellitus, chronic obstructive pulmonary disease, depression, anxiety disorder, malignant neoplasm, chronic kidney disease, and dysphagia. The deficiency was observed when the facility ran out of fortified pudding halfway through the meal service, affecting residents who were supposed to receive it as part of their dietary interventions. The affected residents had specific dietary needs documented in their care plans and physician orders, which included fortified pudding to help maintain weight, support wound care, or prevent weight loss. Despite these documented needs, the facility's failure to provide the fortified pudding as ordered resulted in non-compliance with the dietary interventions outlined for these residents. The deficiency was noted during an observation of the tray line, where it was confirmed that the fortified pudding was unavailable for the residents in question.
Failure to Provide Smooth Pureed Foods for Residents
Penalty
Summary
The facility failed to provide pureed foods at a smooth consistency for safe swallowing for three residents who were prescribed pureed diets. During an observation of the tray line, it was noted that the pureed peas appeared lumpy, and a taste test confirmed the presence of pea shell pieces, indicating the food was not smooth in consistency. This was verified by a Speech Therapist who confirmed the inconsistency of the pureed food. The facility's guidelines stated that pureed foods should hold their shape on a spoon and have a smooth texture, which was not adhered to in this instance.
Failure to Honor Resident Dietary Needs
Penalty
Summary
The facility failed to honor food allergies and preferences for three residents, which was identified during an observation of the tray line. Resident #43, who has a diagnosis of hemiplegia, anxiety disorder, and depression, was noted to have a chocolate allergy. Despite this, their lunch tray included chocolate chip cookies, which were only replaced with fruit after the error was pointed out. Similarly, Resident #111, diagnosed with dementia, osteoarthritis, and atherosclerotic heart disease, was allergic to wheat but also received chocolate chip cookies on their tray. This mistake was corrected only after it was brought to the attention of the dietary aide. Additionally, Resident #69, who has quadriplegia, chronic obstructive pulmonary disease, anxiety disorder, and major depressive disorder, was supposed to receive almond milk as part of their dietary plan to address nutritional risks. However, the dietary aide confirmed that almond milk was not available for this resident. These deficiencies were noted to have the potential to affect 110 out of 111 residents who received meals from the facility kitchen, indicating a systemic issue in the dietary service's ability to accommodate resident-specific dietary needs.
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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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