Rolling Hills Rehab And Care Ctr
Inspection history, citations, penalties and survey trends for this long-term care facility in Bridgeport, Ohio.
- Location
- 68222 Commercial Drive, Bridgeport, Ohio 43912
- CMS Provider Number
- 365559
- Inspections on file
- 34
- Latest survey
- April 13, 2026
- Citations (last 12 mo.)
- 18 (1 serious)
Citation history
Health deficiencies cited at Rolling Hills Rehab And Care Ctr during CMS and state inspections, most recent first.
A resident with a history of CVA, depression, anxiety, and moderate cognitive impairment, whose care plan included emotional support and reassurance, was involved in an incident where an RN reacted to the resident’s loud swearing and use of religious profanity by stating she was consecrated to the Lord and then spraying holy water twice in the resident’s direction from a spritzer bottle the RN carried. The resident had not agreed to this, was visibly bothered, and later reported to an LPN that someone had sprayed her in the face with something. The RN admitted to the LPN that she sprayed holy water at the resident because of the resident’s use of the Lord’s name in vain, and the resident became very agitated and confrontational afterward, leading to a finding of staff-to-resident physical abuse and inappropriate treatment.
A resident with a history of substance use, recent toe amputations, bilateral lower extremity impairment, a PICC line for IV antibiotics, and intact cognition signed a consent for a substance use safety program that included restrictions on LOA and required supervision, but the program was never implemented and no additional supervision was added. Despite staff awareness that the resident was focused on retrieving a motorized wheelchair and likely to leave, the resident accessed the LOA book, signed out without verbally notifying staff, and left with a friend to get the chair. Facility leadership had previously told the resident he could get the chair if he found a way, and when staff learned he was riding the wheelchair back several miles, they did not arrange transportation, instead considering him on LOA because he was alert and oriented. The resident traveled through the community, including stops at private homes, businesses, and a tavern, before returning later that evening, and the deficiency was cited for failure to keep the environment as free of accident hazards as possible and to provide adequate supervision to prevent accidents.
A resident with a history of bipolar disorder, alcohol abuse, and other psychoactive substance abuse was admitted after hospitalization for osteomyelitis and toe amputations, with a PICC line and a signed consent for a Substance Use Disorder/Stepping Stones program that specified safety measures, restricted LOAs, and counseling. The care plan required participation in Stepping Stones activities and adherence to its protocol, but the facility had no functioning program, no counselor, no weekly check-ins, and no documented Stepping Stones services. Staff acknowledged that only a consent form existed, while the resident repeatedly left the facility unsupervised, including signing himself out using the LOA book without clear staff control and later leaving after an appointment and being found at a store with alcohol. The resident stated he knew he was not allowed to leave and confirmed he had not received any substance abuse program services, demonstrating the facility’s failure to provide the behavioral health care and safety interventions it had identified and agreed to deliver.
The facility failed to maintain continuous licensed nurse coverage and adequate CNA staffing, resulting in periods when no nurse was present in the building and routine delays in care. On one afternoon, all nurses left the building, leaving dozens of residents without access to a nurse while they requested medications and IV care. Multiple CNAs, LPNs, and residents reported chronic understaffing, especially on nights, with only one CNA per hall and two nurses and two CNAs for nearly 70 residents, causing late medications, delayed incontinence care, missed showers, prolonged call-light response times, and residents remaining in bed or on the toilet for extended periods. Residents also described inadequate supervision, including confused residents wandering into rooms, and a resident with a PICC line reported walking the halls with IV tubing hanging from her arm without finding a nurse. The admission agreement promised 24-hour nursing care and assistance with ADLs, but the facility assessment did not specify needed licensed nurse numbers or detailed recruitment and contingency plans, despite acknowledged staffing chaos and high-acuity residents requiring intensive supervision and assistance.
The facility failed to maintain required RN coverage for at least eight consecutive hours daily and did not have a full-time DON actively working on site. Staff time records showed days with no documented continuous RN presence, despite the facility’s own assessment requiring a full-time DON, ADON, wound care nurse, and MDS nurse. CNAs and other staff reported there was no nursing management (DON, ADON, MDS, or wound care nurse) in the building, no one to report concerns to, and poor communication, including new admissions arriving without notice. Human resources confirmed the prior DON left before completing a notice period, the ADON resigned immediately, and key nursing positions remained vacant, while an LPN and other staff stated that RNs were listed on schedules and PPD sheets but often were not physically present.
A resident with abdominal and peritoneal abscesses and a PICC line had a physician order for daily Cubicin (daptomycin) IV at a specific morning time, along with orders for shift-by-shift monitoring of the PICC for leakage and infection. The care plan did not include goals or interventions for the resident’s IV antibiotic therapy or PICC maintenance and observation. On one day, the Cubicin dose scheduled for the morning was not administered until six hours later by an LPN, who reported being the only nurse giving medications to nearly 70 residents. The Regional Director of Clinical Operations confirmed the late administration, and the facility’s medication therapy policy required appropriate medication use and quality assurance review of medication-related issues.
A resident with dementia, severe cognitive impairment, and a documented high risk for elopement, who used a wheelchair and required moderate assistance for mobility, was care planned as an elopement risk with interventions such as diversion, monitoring of wandering patterns, 1:1 supervision during exit-seeking, and supervised off-unit activities. Despite these measures on paper, the resident was able to leave the building unnoticed and was later seen by another resident sitting on a parking stop in the parking lot in the rain, with the wheelchair still inside. Staff, including CNAs and the administrator, confirmed they only became aware the resident had exited after being alerted by another resident, demonstrating a failure to implement adequate supervision and elopement-prevention interventions consistent with the facility’s own wandering and missing-resident policy.
A resident with Alzheimer’s disease and HTN, dependent on staff for eating and ordered a mechanical soft diet, was not provided food in the required mechanically altered form. Staff interviews indicated that kitchen staff were serving regular food or food cut into large pieces instead of properly prepared mechanical soft meals. During observation, the resident’s meal ticket correctly showed a mechanical soft diet, but the tray contained a hamburger cut into large pieces on a full-size bun, which staff acknowledged was not appropriate or safe for a mechanical soft diet.
The facility did not complete a comprehensive facility-wide assessment to determine necessary resources for competent resident care during day-to-day operations and emergencies. The assessment lacked information on the resident population, including the number of residents, facility capacity, and care needs related to behavioral health, cognitive disabilities, and overall acuity. It also failed to address direct care staff such as RNs, LPNs, and CNAs, and did not document the total number of staff needed to ensure sufficient qualified personnel to meet residents’ assessed needs. Leadership confirmed that the assessment was missing required elements, and this issue was identified incidentally during a complaint investigation.
Surveyors found persistent sewer odors from a shower room extending into hallways and the nurse's station, stained and dirty carpets, mold behind wallpaper, improperly installed and missing carpet tiles, and unclean conditions in multiple areas. Staff and residents confirmed the odors and uncleanliness, with one resident's room exhibiting a strong urine odor and visible black substance in the toilet. These issues affected all 51 residents in the facility.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
The facility did not manage its operations in a way that ensured effective and efficient use of its resources, as identified by surveyors.
The facility did not maintain an effective pest control program, resulting in a significant presence of flies and gnats throughout the building. Staff, residents, and families reported and observed pests in resident rooms and common areas, with some attributing the issue to musty odors, damp conditions, and lack of window screens. The infestation led to discomfort for residents and staff, with families bringing in bug spray and fly swatters due to the ongoing problem.
A resident with multiple medical conditions and intact cognition was not transported to a scheduled medical appointment after the facility became aware that transportation was unavailable. No documentation showed attempts to arrange alternative transportation, and the resident was not informed of the cancellation, leading to confusion and frustration. The facility's admission agreement included transportation as a provided service.
A resident with multiple chronic conditions and dependent on hemodialysis had a care plan that inaccurately listed the dialysis center location, despite the resident having changed facilities. Interviews with staff and the resident confirmed the care plan was not updated to reflect the new dialysis site, resulting in inaccurate documentation.
Peeling wallpaper and visible mold-like areas were found in the Social Services Director's office, which was used regularly and visited by residents. The issue was reported to both the Administrator and Regional DM, but the office was not promptly vacated or remediated, resulting in a failure to maintain a safe and sanitary environment.
The facility did not consistently notify resident representatives of changes in condition or new treatment orders for three residents, despite facility policy and resident preferences. In several cases, new medication orders or significant changes in condition were not communicated to the designated emergency contacts or powers of attorney, even when residents had cognitive impairments or had requested such notifications. Documentation confirming that representatives were informed was lacking, and staff interviews confirmed the notifications did not occur as required.
Two residents at risk for falls did not receive required fall prevention interventions as outlined in their care plans. One resident's garbage can was not kept within reach as specified, and another resident's visual reminder to call for assistance was not transferred to her new room. Both lapses were confirmed by staff and observed during the survey, indicating non-compliance with established fall prevention policies.
A resident with severe cognitive impairment and multiple comorbidities was scheduled for neurosurgery but continued to receive daily aspirin due to the facility's failure to implement and document preoperative orders. The absence of instructions to hold aspirin was only discovered at the hospital, leading to the cancellation and rescheduling of the procedure. Staff interviews confirmed that required medication management and documentation processes were not followed.
A resident avoided using a shared shower room due to a persistent foul odor and visible stains, opting for another shower area. Staff and administration confirmed the presence of the odor and stain, with reports indicating the problem had been ongoing for about a month and worsened after several showers were used in the room.
The facility's governing body failed to engage in the oversight of the QAPI program, affecting all 50 residents. No QAPI meetings were held since before the last annual survey, and the Medical Director was unaware of the program's absence. The governing body did not review QAPI information or attend QA meetings, despite being responsible for these actions.
The facility did not inform residents or their representatives about their right to communicate with local, state, or federal officials before or within thirty days of signing an arbitration agreement. The arbitration agreement lacked this information, and staff interviews confirmed the absence of such guidance. The facility also did not have a policy and procedure for arbitration agreements.
The facility's arbitration agreement did not allow for a mutually agreeable arbitrator and venue, affecting all residents. The agreement specified arbitration by the American Arbitrators Association or another association chosen solely by the facility, with the venue near the facility's business. Interviews revealed residents or representatives were not given a choice, and no policy on arbitration agreements existed.
The facility failed to implement a comprehensive QAPI program, affecting all 50 residents. Multiple citations were noted in areas such as nursing services and quality of care. The Administrator could not provide evidence of quarterly meetings or monitoring of corrective actions. The facility's QAPI policy goals were not met.
The facility failed to hold required quarterly QAPI meetings with necessary members, impacting all residents. Despite multiple complaint surveys and citations, the QAPI committee did not meet since the last annual survey. The Medical Director confirmed no meetings occurred since his hire, and the facility's policy for monthly meetings was not followed.
A resident with diabetes and other conditions did not receive privacy during medication administration. An RN left the door open and did not close the curtain, exposing the resident to the hallway while administering a Lovenox injection and applying a Lidocaine patch. The RN confirmed the privacy lapse, which violated the facility's policy on maintaining resident dignity.
The facility failed to provide timely transfer notices to residents and/or their representatives when residents were transferred to the hospital. This affected two residents, one with multiple diagnoses including diabetes and heart failure, and another with acute kidney failure and heart disease. The facility's policy requires written notice in urgent medical situations, but this was not followed. The absence of transfer notices was confirmed by the DON and attributed to the unexpected departure of the responsible staff.
The facility failed to provide bed hold notices to two residents following hospital transfers, as required by policy. One resident with multiple health issues was transferred without receiving a notice, confirmed by the DON. Another resident, privately paying and with severe health conditions, was also transferred without a notice due to the unexpected departure of the responsible staff member.
A facility failed to obtain psychiatric progress notes for a resident, resulting in a missed diagnosis of schizoaffective disorder. The resident's medical record and care plan were not updated, and medication orders were inaccurately transcribed, leading to the resident receiving extra doses of Abilify. The DON confirmed these deficiencies, highlighting a lack of follow-up with the psychiatrist's office and errors in medication transcription.
A resident with severe cognitive impairment and other health issues experienced a delay in UTI treatment due to a transcription error in the facility's Medication Administration Record (MAR). Despite complaints of pain and an order for a urinalysis and culture, the test was not conducted until several days later, delaying antibiotic therapy. The facility's policy lacked a process for transcribing physician orders, contributing to the oversight.
The facility failed to monitor weights and administer nutritional supplements as ordered for three residents. A resident experienced significant weight gain without a reweigh, another had only one weight check despite needing weekly monitoring, and a third did not receive a prescribed supplement for months due to a transcription error. These oversights were confirmed by staff, including the DON and RD.
The facility failed to properly store nebulizer masks for two residents, affecting their respiratory care. A resident with COPD had an uncovered nebulizer mask, contrary to facility policy. Another resident's oxygen flow rate was set higher than prescribed, and the humidification bottle was empty, as confirmed by staff, indicating a lapse in following safe oxygen administration procedures.
A resident with a history of chronic conditions did not receive prescribed Anbesol gel for tooth pain due to a communication lapse among staff. Despite the physician's order, the medication was not available in the facility pharmacy, and the resident was given Tylenol instead. The issue was identified when the resident reported the lack of medication, and staff interviews confirmed the oversight.
A facility failed to ensure a physician addressed pharmacy recommendations for a resident on valproic acid, affecting medication monitoring. Despite recommendations in August, September, and October, the physician did not respond, and the last valproic acid level was checked in June. Interviews confirmed the oversight, impacting one of five residents reviewed for unnecessary medications.
A resident experienced a delay in receiving dental care despite ongoing dental pain, due to miscommunication among staff and a rescheduled appointment. The resident's care plan included interventions for dental issues, but the first dental exam since admission revealed significant dental problems requiring extraction.
A facility failed to ensure that a qualified dietitian conducted quarterly nutritional assessments, instead relying on a Certified Dietary Manager (CDM) without a bachelor's degree in nutrition. This affected a resident with complex medical conditions, including acute kidney failure and diabetes, who required a therapeutic diet. The CDM used a calculator to assess nutritional needs, contrary to the facility's contract and Ohio Medical Board guidelines, which require licensed dietitians for such evaluations.
A resident reported missing money to the previous administration, but the facility failed to report the misappropriation to the state agency in a timely manner. Despite an initial interview with the resident, no follow-up or resolution occurred, violating the facility's policy.
A resident reported missing money to the previous administration, but no investigation was conducted, and the money was not returned. The facility's policy requires timely investigation of such allegations, which was not followed. The deficiency was identified under Complaint Number OH00159928.
A facility failed to ensure competent tracheostomy care for a resident with a history of larynx cancer and tracheostomy. An STNA, unaware of her limitations, provided care without proper training or sterile technique, using a solution from the resident's bathroom. The facility's policy requiring aseptic technique and a spare tracheostomy tube at the bedside was not followed. The STNA resigned after the incident but was later re-hired.
The facility failed to maintain proper infection control practices for COVID-19, affecting all residents. Several residents under droplet precautions lacked isolation signage, PPE carts, and waste receptacles. Staff reused N95 masks and did not follow PPE protocols, indicating a significant lapse in infection control measures.
A resident admitted with multiple fractures and wounds did not receive timely skin assessments or wound treatments as ordered due to delays over a weekend and holiday. Facility staff confirmed the delay in entering hospital discharge orders and administering treatments, leading to a deficiency investigation.
The facility failed to provide a proper discharge notice and appeal rights to a resident transferred to a behavioral health unit. The resident was not allowed to return after being cleared for discharge, and there was no documented evidence that the discharge notice was provided or included appeal rights.
A facility failed to readmit a resident after hospitalization, despite the resident's desire to return and the facility's policy allowing it. The resident, who had multiple diagnoses and required continued care, was refused readmission and was instead directed to her grandmother's home, which was not equipped to provide the necessary support.
The facility failed to protect two residents from physical abuse by an STNA. One resident with multiple diagnoses reported being hit and verbally abused during incontinence care, while another resident with vascular dementia and other conditions reported being hit in the testicles. The facility's investigation could not substantiate the allegations due to lack of witnesses and physical evidence.
Staff-to-Resident Abuse Involving Spraying Holy Water Without Consent
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from staff-to-resident physical abuse when an RN attempted to spray holy water on the resident without consent. The resident had been admitted with diagnoses including hemiplegia, hemiparesis, aphasia following cerebral infarction, major depressive disorder, anxiety disorder, and a need for assistance with personal care. The resident’s care plan addressed depression with interventions such as reassurance, diversional activities, decreased stimuli, and allowing the resident to vent feelings, and also addressed emotional issues related to a prior CVA. A quarterly MDS assessment documented moderate cognitive impairment and no physical or verbal behaviors. The incident occurred when the resident was conversing with another resident, during which they were swearing, using curse words, and laughing. According to the RN’s own statement, the two residents were swearing loudly and using an explicit word alongside the name of Jesus. The RN reported that she reminded them to be quieter because it was late. When the resident began to “insult the Lord,” the RN told the resident that this hurt her because she was consecrated to the Lord and then stated she had holy water that might help the resident be nicer. The RN had a spritzer bottle of holy water on her person that she used on herself and then spritzed it twice in the direction of the resident from about six feet away. The resident did not agree to this action and was visibly bothered by it. The resident subsequently reported to an LPN that someone had sprayed her in the face with something. The LPN then approached the RN at the nurse’s station, and the RN admitted she had sprayed the resident with holy water due to the resident using the Lord’s name in vain. The RN further reported that the resident became very agitated, red-faced, pointing, swearing, and continued to threaten the RN’s safety after the spraying. The facility determined that the RN did not provide appropriate behavioral intervention and that the conduct constituted inappropriate treatment and physical abuse related to the imposition of religious beliefs and spraying holy water toward the resident without consent.
Failure to Supervise Resident Who Left on LOA With PICC Line and Recent Toe Amputations
Penalty
Summary
The deficiency involves the facility’s failure to implement appropriate supervision and safety interventions to prevent a resident from leaving the facility unsupervised and engaging in unsafe behaviors, despite known substance use history and medical vulnerabilities. The resident had been admitted following a hospitalization for bilateral lower extremity pain, osteomyelitis of two toes, and subsequent toe amputations, and was discharged from the hospital with a PICC line for IV antibiotics. Hospital records showed the resident had tested positive for amphetamines and cannabinoids prior to admission. On admission, the resident signed a Substance Use Disorder Program (Stepping Stones) consent that outlined safety measures including supervised visits, restricted visitation hours, random searches, and no LOA without collaboration with the counselor, IDT, and physician. The resident’s elopement assessment rated him as low risk, and his care plan documented a substance abuse disorder with an intervention that he would follow the Stepping Stones protocol. The resident’s admission assessments documented intact cognition with a BIMS score of 15, bilateral lower extremity impairment, use of a wheelchair or scooter, and a surgical wound on the right foot. Despite the Stepping Stones consent and the documented plan that the resident would follow the program protocol, the facility did not actually implement the program because there was no counselor available, and no additional supervision or interventions were added based on his needs. The Regional Director of Clinical Services confirmed that although the resident signed the consent and the care plan referenced following the Stepping Stones protocol, he was never actually placed on the program. The Admission Director stated she had informed the resident he was not allowed to leave without supervision, but also reported that the Administrator told the resident that if he could find a way to get his motorized wheelchair, he could do so. Staff interviews showed that multiple staff were aware the resident was focused on obtaining his power chair and was likely to leave, but there was confusion about his LOA status and no clear restriction or supervision was enforced. On the day of the incident, the resident signed himself out in the LOA book without verbally notifying staff and left the facility in a friend’s car to retrieve his motorized wheelchair. CNA staff knew he planned to leave to get his wheelchair but were unsure of the time and believed he did not have privileges to leave; the LPN on duty believed the resident was going to leave that day and later realized the resident had signed out by accessing the LOA book himself. The facility investigation documented that the police contacted the facility about someone having escaped, and staff reported the resident was on LOA and safe. The Admission Director communicated with the resident by cell phone while he was away and reported to the Administrator that he would be riding his wheelchair back, but the Administrator declined to have staff pick him up. The resident then traveled approximately five miles back to the facility in his motorized wheelchair, wearing regular clothes with a hospital gown, stopping at private and public locations, including a tavern, to charge the chair. Staff, including the ADON and LPN, were aware he was riding back unsupervised, and the physician later stated he would have preferred the resident sign out AMA if leaving without supervision due to the PICC line. The resident ultimately returned to the facility that evening, where he was assessed, but the deficiency centers on the facility’s failure to maintain an environment as free of accident hazards as possible and to provide adequate supervision and safety interventions to prevent the unsupervised departure and unsafe behaviors. Observation of the resident after the incident showed he had a PICC line in place, a surgical boot on his right foot, slightly unsteady gait, and a large motorized wheelchair in his room. The resident reported that he knew he was not supposed to leave unsupervised based on prior conversations with administration but chose to leave to obtain his chair. He stated he informed the facility while away and asked to be picked up, but was told they would not pick him up, requiring him to ride and at times push his wheelchair back, stopping multiple times to charge it. Staff interviews corroborated that the resident’s picture appeared on social media while he was out, that staff saw him in the community wearing a hospital gown over his clothing, and that the facility considered him to have signed out LOA because he had a BIMS of 15 and was alert and oriented. The Administrator later stated that because the Stepping Stones program was no longer offered, the resident did not have restrictions in place, despite the signed consent and care plan references. This sequence of events, combined with the lack of implemented safety measures and supervision, formed the basis of the cited deficiency under F689 for failure to ensure the environment was as free of accident hazards as possible and that the resident received adequate supervision to prevent accidents.
Plan Of Correction
Preparation and submission of this plan of correction does not constitute an admission or agreement by the provider of the truths of the facts alleged or correctness of the conclusions set forth on the statement of deficiencies. This plan of correction is prepared and submitted solely because of the requirements under the state and federal law. This plan of correction will serve as the Facility's allegation of substantial compliance and completion with an allegation of compliance date of 4/28/2026. Resident #2 no longer resides in the facility. On 4/23/2026 the Director of nursing/designee identified and interviewed all like residents with a BIMS 13 and higher to address any needs expressed of belongings needed outside of facility. No one identified any needs outside of facility. Director of Nursing/designee will educate all staff that if the any resident has any needs outside of the facility to fill out a concern form and give concern form to Social Service or Administrator to be addressed. This will be completed by 4/28/2026. Director of Nursing/designee will educate all staff to include LOAs, and will be completed by 4/28/2026. Residents requiring supervision for LOAs were reviewed on 4/23/2026 by Director of Nursing to ensure they are receiving appropriate supervision when needed. To ensure the deficient does not recur the Director of Nursing/designee will audit any new admissions for assistance with outside needs x 4 Weeks then continue compliance with daily room checks done by all department managers daily Monday thru Friday.
Failure to Implement Substance Use Disorder Program and Safety Measures for Resident on Stepping Stones Consent
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary behavioral health care and services for a resident with a known substance use disorder, in accordance with the resident’s assessment, hospital history, and the facility’s own Substance Use Disorder/Stepping Stones program consent and care plan. Prior to admission, the resident signed a Substance Use Disorder Program consent that outlined specific safety measures and monitoring, including supervised visits, restricted visitation hours, random room and package searches, random drug screens, and no LOA without collaboration among the counselor, IDT, and physician. Hospital discharge paperwork documented that the resident had tested positive for amphetamines and cannabinoids and was discharged with a PICC line for IV antibiotics after toe amputations. The resident’s admission MDS showed intact cognition (BIMS 15), and the care plan identified a substance abuse disorder with interventions requiring participation in Stepping Stones activities and adherence to the Stepping Stones protocol. Despite these documented needs and the signed consent, the facility did not actually provide the Stepping Stones program or its associated behavioral health services. There was no documented evidence that the resident received Stepping Stones activities, homework, counseling sessions, or follow-up with a counselor. Multiple staff, including the Admission Director, Regional Director of Clinical Services, and Social Service Director, acknowledged that the facility did not have a functioning substance abuse program, had no counselor, and that no one was doing weekly check-ins on residents who were supposedly in the program. The Regional Director of Clinical Services confirmed there were no policies, procedures, or admission information for the Stepping Stones program other than the consent form, and the physician reported he was only made aware that the facility did not have a substance abuse program after the resident’s admission. The lack of implemented behavioral health interventions and safety measures contributed to repeated unsupervised departures from the facility by the resident, who had a history of substance use and was admitted under a program that was not actually in place. On one occasion, the resident signed himself out for an LOA, obtained access to the LOA book without clear staff oversight, and left in a friend’s car to retrieve his power wheelchair, traveling through the community and stopping at various locations before returning later that night. Staff interviews revealed confusion about whether the resident had privileges to leave, uncertainty about his destination, and acknowledgment that he was supposed to have limited LOA access under the Stepping Stones program. On another occasion, after a medical appointment, the resident left the facility without notifying staff, was later found at a grocery store with alcohol, and was observed back at the facility smelling of alcohol and upset. The resident himself confirmed he had been admitted on a substance abuse program, knew he was not allowed to leave, and had not received any services related to the program, demonstrating the facility’s failure to deliver the behavioral health care and safety interventions it had identified and consented to provide.
Plan Of Correction
Resident #2 no longer resides at the facility. On 4/23/2026 Director of nursing /designee reviewed program policy and contract to discover any like residents, no qualifying residents for the program as of 4/23/2026. On 4/17/2026 new counselor/therapist started to be available to provide services. As of 4/23/2026 there are currently no residents on the program. To ensure the deficit practice does not recur the Administrator/designee will assess new referrals/admission to the facility if they meet criteria to participate in the substance use disorder program. Regional Director of Operations will educate facility program director and facility administrator on substance use disorder program. This will be completed by 4/27/2026. On 4/23/2026 Administrator/designee will educate all staff on program guidelines and contract. Audits will be completed weekly by the Administrator/designee with any residents on the program to ensure program is being compliant if not compliant, physician notified. Administrator/designee will add any new candidates to the audit upon admission x 4 weeks.
Failure to Maintain Continuous Licensed Nurse Coverage and Adequate Staffing
Penalty
Summary
The deficiency involves the facility’s failure to provide sufficient licensed nursing staff on all shifts and adequate CNA staffing to meet resident needs, including a period when no nurse was present in the building. On one afternoon, two nurses left the facility, resulting in a gap of approximately 40 minutes to 1.5 hours with no licensed nurse on site while about 65–70 residents remained in the building. During this time, residents requested medications and nursing interventions, including removal of IV tubing from a PICC line, but no nurse was available to respond. A resident with diagnoses including peritoneal abscess, anemia, and a history of substance abuse reported that medications were often late and that on the day she left against medical advice, she walked the halls with IV antibiotic tubing hanging from her arm and could not find any nurse in the facility. Multiple CNAs and nurses reported that staffing was routinely insufficient across shifts, especially on nights, with only one CNA on each side of the building and two nurses and two CNAs for nearly 70 residents. Staff described being unable to complete timely incontinence care, showers, toileting, feeding assistance, and medication and treatment administration. They reported residents being found soaked in incontinence products at shift change, residents remaining in bed most or all day due to lack of staff to get them up, and residents waiting extended periods for call lights to be answered, sometimes 30 minutes or longer. Staff also reported that medications were consistently late, often documented as being “in the red,” and that nurses and CNAs frequently had to stay hours past their shifts due to call-offs and high workload. Residents and a resident representative corroborated that there were not enough staff to supervise and assist residents. Residents reported long waits for call lights to be answered, delays in receiving water and other basic assistance, and instances of being left on the toilet for prolonged periods while waiting for staff to return. Some residents described other residents wandering into their rooms without staff intervention, and one resident reported that she had to redirect confused residents herself. Another resident reported not receiving migraine medication after notifying a nurse leader and activating the call light twice more, with no staff response. Residents also noted that staff appeared frustrated and that staff turnover was high. Review of the facility’s admission agreement showed that the facility agreed to provide 24-hour nursing care and assistance or supervision with activities of daily living, including toileting, bathing, feeding, and ambulation. The facility assessment stated that its purpose was to determine necessary resources to care for residents during routine operations and emergencies and to inform staffing decisions, including day, evening, and night shifts, recruitment and retention, and contingency planning for staffing shortages. However, the assessment only identified the need for a full-time DON, ADON, MDS nurse, and part-time wound care nurse and did not specify how many licensed nurses were needed for the resident population or provide details on recruitment or contingency plans. This lack of detailed staffing planning, combined with ongoing staff departures and reliance on minimal staffing, contributed to repeated instances where resident care and supervision needs were not met. Human resources staff acknowledged difficulty filling night shift schedules for both nurses and CNAs and described recent initiation of agency use to fill open shifts. A newly hired LPN reported being scheduled to work independently on a unit during what was supposed to be an orientation day, without prior training on that unit. Staff interviews consistently described high-acuity residents, including geriatric psychiatric residents with behavioral issues, residents with frequent falls, and residents requiring 1:1 supervision or two-person mechanical lift transfers, being cared for with staffing levels that staff considered inadequate. The facility’s failure to ensure continuous licensed nurse coverage and adequate direct care staffing on all shifts, as well as its incomplete facility assessment regarding licensed nurse staffing and contingency planning, led to delays and omissions in resident care and supervision for the entire resident population.
Failure to Maintain Required RN Coverage and Full-Time DON
Penalty
Summary
The facility failed to provide the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week, and failed to employ and have an actively working full-time Director of Nursing (DON). Review of staff clock-in times and resident records showed no documentation of an RN being in the building for eight consecutive hours on 02/21/26 or 03/08/26. The facility assessment dated 01/30/26 stated the facility must have a full-time DON, full-time Assistant DON (ADON), full-time wound care nurse, and full-time MDS nurse, but these positions were not filled or actively working in the facility during the survey period. Multiple staff interviews confirmed the absence of key nursing leadership and RN coverage. CNAs reported there was no DON, ADON, MDS nurse, or wound care nurse in the facility and that there was no nursing management available to report issues or concerns to. Human resources staff stated the previous DON gave a 30‑day notice but stopped working before the end of the notice period, and the ADON resigned effective immediately, leaving those positions vacant; positions for MDS nurse, wound care nurse, and ADON remained open. An LPN reported the facility was short on RN hours, that RNs were scheduled but often did not show up or quit, and that the situation worsened without a DON or ADON in the building. Other staff confirmed the facility was not meeting required RN hours, that RN names were placed on schedules and PPD sheets without the individuals being physically present, and that no corporate nurses came in to fill in for the DON or ADON.
Late IV Antibiotic Administration and Missing Care Plan for PICC Therapy
Penalty
Summary
The deficiency involves the facility’s failure to administer an IV antibiotic according to the physician’s order and to incorporate the resident’s IV therapy into the care plan. A resident admitted with diagnoses including abscess of the spleen, chronic viral hepatitis C, and peritoneal abscess had a physician’s order for Cubicin (daptomycin) 350 mg IV once daily at 9:30 a.m. for an abdominal abscess, with an active order through 03/24/26. The resident also had a left arm PICC/midline with orders to monitor for leaking and signs and symptoms of infection every shift. Record review showed that the resident’s care plan contained no documentation, goals, or interventions related to the IV medication therapy for the active infection, nor for the maintenance, use, or observation of the PICC line. Review of the medication administration record revealed that the Cubicin dose scheduled for 9:30 a.m. on 02/27/26 was not administered until 3:20 p.m., six hours late, by an LPN. In interview, the LPN stated that on that date she was the only nurse administering medications to nearly 70 residents and that medications, including this resident’s Cubicin, were given late. The Regional Director of Clinical Operations confirmed that the IV antibiotic was documented as administered six hours after the scheduled time. Facility policy on medication therapy stated that each resident’s medication regimen shall include only those medications necessary to treat existing conditions and that medication-related issues shall be reviewed as part of quality assurance activities. This situation was cited as a deficiency under the referenced master complaint number.
Failure to Prevent Elopement of High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and interventions to prevent an identified elopement-risk resident from leaving the building unsupervised. The resident had diagnoses including dementia, type 2 diabetes, hypertension, anxiety, major depressive disorder, and neurocognitive disorder with Lewy bodies. A Significant Change MDS showed a BIMS score of 03, indicating severe cognitive impairment. The resident used a wheelchair and required moderate assistance for transfers and mobility. An elopement assessment completed earlier in the year scored the resident as high risk for elopement, and the care plan identified the resident as an elopement risk/wanderer with a history of attempts to leave the facility unattended and impaired safety awareness. The care plan for this resident included goals to maintain safety and interventions such as distracting the resident from wandering with diversions and structured activities, identifying patterns of wandering and diverting as needed, initiating 1:1 supervision if the resident exhibited exit-seeking or verbalized wanting to leave, monitoring for fatigue and weight loss, providing activities of interest to deter wandering, and providing supervision for off-unit activities. Despite these identified risks and planned interventions, on the day of the incident the resident was able to leave the building without staff awareness. The resident’s wheelchair remained inside the facility, and staff later reported they were unsure how the resident had the strength to open the doors and ambulate outside, as they had rarely seen the resident walk and knew the resident required assistance for mobility. The event came to light when another resident, while watching TV, noticed a man sitting on a parking stop in the parking lot in the rain and realized it was a resident. This resident activated the call light and informed a CNA that there was a resident outside. Staff then observed the elopement-risk resident sitting outside in the rain in the parking lot and assisted him back into the building. Multiple CNAs and the administrator confirmed that staff only became aware the resident had left the building after being alerted by another resident. The facility’s written policy on unsafe wandering and elopement stated that staff will identify residents at risk, assess for risk factors, care plan for elopement risk with safety interventions such as monitoring plans and devices, and treat a missing resident as a facility-wide emergency with initiation of an elopement/missing resident procedure; however, the resident was able to exit and remain outside unsupervised until discovered by another resident.
Failure to Provide Ordered Mechanical Soft Diet
Penalty
Summary
The deficiency involves the facility’s failure to provide food in a mechanically altered form as ordered for a resident who required a mechanical soft diet. The resident was admitted with diagnoses including Alzheimer’s disease and hypertension, and a quarterly MDS assessment documented that she was dependent on staff for eating and required a mechanically altered diet. An undated facility list of residents needing mechanically altered diets also identified her as requiring a mechanical soft diet. Despite these documented needs, staff interviews revealed that the kitchen was cutting food into large pieces rather than preparing it in an appropriate mechanical soft form. A CNA reported that mechanical soft food should be small, but the kitchen was only cutting food into large pieces, and another CNA stated that kitchen staff were providing regular food to residents who required a mechanical soft diet, including this resident. During an observation of the resident’s supper tray, the meal ticket correctly indicated a mechanical soft diet, but the tray contained a hamburger cut into large pieces and placed on a full-size bun. The CNA present at the time of observation confirmed that this was not appropriate for a mechanical soft diet and stated that the hamburger in large pieces on the tray would not be safe for the resident to consume. This noncompliance was investigated under a specific complaint number and affected one of three residents reviewed for appropriate diets, with 13 residents in the facility identified as requiring mechanically altered diets.
Incomplete Facility-Wide Assessment of Resident and Staffing Needs
Penalty
Summary
The facility failed to complete a comprehensive facility-wide assessment to determine the resources necessary to care for residents competently during routine operations and emergencies. Review of the facility assessment dated 01/30/26, completed by the administrator, showed it did not address the resident population, including the number of residents, the facility’s capacity, or the care required based on behavioral health needs, cognitive disabilities, and overall acuity. Further review showed the assessment did not address direct care staff such as RNs, LPNs, and CNAs, and did not document the overall number of facility staff needed to ensure a sufficient number of qualified staff to meet each resident’s needs as identified through assessments and care plans. During an interview, the regional director of clinical operations and the administrator confirmed that the facility assessment was not completed with all required elements. This deficiency was identified as an incidental finding during the course of a complaint investigation, and the facility census at the time was 65 residents.
Environmental Deficiencies: Odors, Mold, and Unclean Conditions
Penalty
Summary
Surveyors identified multiple environmental deficiencies throughout the facility, including persistent sewer odors originating from the South Unit shower room, which extended into the 100 and 200 hallways and nurse's station. The carpet behind the nurse's station was observed to be stained and dirty, and the wallpaper near the vending machine was pulled away, revealing mold spots behind it. In the vending room, carpet tiles were improperly installed, loose, and missing under the snack vending machine. The North Unit shower room had missing and broken tiles on the floors and walls, missing corner strips, a brown/black substance on the walls, partially missing skid strips, and dirty floors. These conditions were confirmed by multiple staff members, including the Maintenance Director, who noted that some issues had not yet been addressed due to recent hiring and ongoing repairs. Interviews with staff and residents confirmed the ongoing presence of sewer odors, particularly in the South Unit shower room and adjacent hallways. One resident reported the odor lingering down the hallway near their room. Additional observations included a resident room with a strong urine odor, a black substance inside the toilet bowl, and flooring in the bathroom that was coming up and stained. These findings were corroborated by several staff members present during the observations. The facility census at the time was 51 residents, all of whom had the potential to be affected by these environmental deficiencies.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Administer Facility Resources Effectively
Penalty
Summary
The facility failed to administer its operations in a manner that enabled it to use its resources effectively and efficiently. This deficiency was identified based on observations and findings by surveyors, indicating that the facility did not meet the required standards for resource management. Specific actions or inactions leading to this deficiency are not detailed in the report provided.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to implement an effective pest management program, resulting in a widespread issue with flies and gnats throughout the building. Multiple staff members, including CNAs and LPNs, reported that flies and gnats were prevalent in resident rooms and common areas, with some attributing the problem to musty odors, damp carpeting, and lack of daily housekeeping. Observations confirmed the presence of flies and gnats in various locations, including the nurses' station, vending machine room, and crash cart room. Staff and residents reported being bitten, and families brought in bug spray and fly swatters due to the severity of the infestation. Some staff noted the absence of window screens as a possible entry point for pests. Residents were directly affected, with reports of flies swarming around individuals, particularly those requiring topical creams, and flies landing on personal belongings. The issue was noted to be persistent and worsening, with both staff and family members expressing concern over the lack of resolution. The deficiency was observed to have the potential to impact all 52 residents in the facility, as pests were present in both private and communal spaces.
Failure to Provide and Communicate Transportation for Medical Appointment
Penalty
Summary
The facility failed to ensure that a resident was provided transportation to a scheduled medical appointment, despite being aware that transportation was unavailable. The resident, who had diagnoses including type 2 diabetes, vascular dementia, anemia, hypertension, and nicotine dependence, was cognitively intact with a BIMS score of 13. Documentation showed that as of 07/18/25, the facility knew transportation was not available, but there was no evidence that alternative arrangements were attempted so the resident could attend the appointment. On the day of the appointment, the resident prepared and waited at the front of the building for transport, but the van did not arrive. After inquiring with staff, the resident was informed that the appointment was cancelled due to the van being broken, but he had not been notified beforehand. The resident expressed confusion and frustration about not being kept informed, despite having requested updates. The dermatology office confirmed the appointment was scheduled and cancelled on the same day. The facility's admission agreement indicated that transportation services were among the physician-ordered services available to residents.
Failure to Update Care Plan for Dialysis Location
Penalty
Summary
The facility failed to maintain an accurate and up-to-date care plan for a resident with multiple complex medical conditions, including respiratory failure, type 2 diabetes, COPD, GERD, osteoarthritis, anemia, atherosclerotic heart disease, insomnia, schizophrenia, hypercholesterolemia, overactive bladder, borderline personality disorder, hypothyroidism, pyoderma, hypertension, anxiety, major depressive disorder, chronic kidney disease, kidney failure, and who was dependent on renal dialysis. The resident was cognitively intact and had a physician's order for hemodialysis every Monday, Wednesday, and Friday. The care plan, completed on 04/11/25, indicated that the resident received dialysis at a specific center in St. Clairsville and included interventions such as encouraging attendance at scheduled dialysis appointments, monitoring vital signs, and assessing the AV fistula site. However, interviews with staff at the St. Clairsville dialysis center revealed that the resident no longer received dialysis at their facility and had not done so for some time. Further interviews confirmed that the resident was actually receiving dialysis at a different center in Bridgeport. The resident also confirmed this information. Despite this change, the care plan had not been updated to reflect the new dialysis location, resulting in inaccurate documentation. The facility's policy requires the care plan to be individualized and based on the resident's comprehensive assessment, developed by an interdisciplinary team, but this was not followed in this instance.
Failure to Maintain Sanitary Office Environment Due to Peeling Wallpaper and Suspected Mold
Penalty
Summary
A section of peeling wallpaper approximately 12 inches long was observed near the baseboard of the back wall in the Social Services Director's (SSD) office. When the wallpaper was pulled back, black areas resembling mold were visible on the drywall. The Director of Maintenance (DM) was aware of the peeling wallpaper but was not aware of the mold-like areas beneath it. During the survey, residents were seen stopping at the SSD office and speaking with the SSD, who kept her office door open. The SSD reported that she had notified the Administrator about the peeling wallpaper and her concerns regarding air quality in her office. She was offered the option to move to another office but did not relocate, as she did not receive confirmation that the air quality in the alternative office would be tested. The SSD also informed the Regional Director of Maintenance about her concerns. The Regional DM later acknowledged that he should have insisted on the SSD relocating so repairs could be made, but the SSD declined to move due to the amount of items in her office and her impending departure from the position.
Plan Of Correction
This plan of correction ("POC") has been prepared at the request of the Ohio Department of Health, and not because this facility agrees with and/or admits to any of the allegations contained within the notice of deficiency issued by the Department. This POC does not constitute an admission that any of the citations are legally and/or factually correct, to include the scope and severity associated thereto. For the avoidance of doubt, this facility asserts that it was in substantial compliance with all data tags cited by the Department before, during, and after the dates referenced in the notice of deficiency and the dates on which the Department conducted the survey. This POC does not establish any standard of care, contract, obligation, and/or position beyond those of a reasonably prudent nursing home, and this facility reserves the right to raise all possible contentions and defenses in any administrative, civil or criminal action or proceeding. Rolling Hills Rehabilitation and Care Center will continue to ensure employees have a clean and comfortable environment. This plan of correction serves as Rolling Hills Rehabilitation and Care Center's allegation of substantial compliance. Staff member #84 stated she had no adverse effects as a result of this deficiency, she currently does not have any signs/symptoms related to potential mold exposure. The areas of suspected mold were contained and undisturbed. Staff member #84 was immediately moved to a clean and comfortable environment on 06/05/2025 with assistance from facility maintenance and other members of the management team using proper PPE and disinfected all items that were possibly exposed using fungicide. An air quality test was performed on 06/05/2025 with no negative findings. On 06/05/2025 the office was sealed off, locked, and placed under construction. On 06/06/2025 the areas of concern were treated twice with mold armor. On 06/12/2025 another air quality test was performed with no negative findings, and the office was reopened and used for operation as of 06/16/2025. The facility followed all CDC recommendations for all potential mold remediation. A whole facility baseline audit was completed to ensure a clean and comfortable environment by the facility Administrator on 06/12/2025. There were no negative findings identified through this audit. All residents located on the unit in proximity to the social services office were assessed along with a review of their EHR by the Director of Nursing on 06/12/2025 to ensure there was no negative impact, with no negative findings. The Director of Nursing reviewed the infection control log on 06/13/2025 for signs/symptoms of respiratory concerns in the last 30 days related to potential mold exposure, with no negative findings. Interviews were initiated on 06/06/2025 and completed on 06/13/2025 with all interview-able residents by the facility Administrator and designee, to ensure no current concerns with potential mold. There were no negative findings identified. An audit of the grievance/concern log was completed over the past 90 days with no concerns from family, visitors, or staff of suspected mold in the facility. We have not received any reports by staff and/or visitors of adverse effects as a result of this deficient practice. Verbal education on the facility's best practice for reporting environmental concerns was completed on 06/10/2025 for all facility staff by the facility Administrator. A facility walkthrough will be completed weekly for four weeks by the facility administrator/designee, starting on or by the week of 06/13/2025. Results will be brought to the Quality Assurance Committee for further review and recommendations. Facility administrator will be responsible for overall compliance with this plan.
Failure to Notify Resident Representatives of Changes in Condition and Treatment
Penalty
Summary
The facility failed to ensure that resident representatives were notified when there were changes in residents' treatments or medications, as required by policy. In the case of one resident with anoxic brain damage, epilepsy, and other conditions, there were four documented occasions over five months where new orders or changes in condition occurred, but there was no evidence that the resident's designated representative, her sister, was notified. Although the resident was cognitively intact and able to communicate, she had expressed her desire for her sister to be informed of any changes, a preference that was not consistently honored or documented by the facility. Another resident with unspecified dementia and moderately impaired cognition had changes in condition and new orders issued on multiple occasions. The resident's son was listed as the primary emergency contact, but there was no documented evidence that he was notified of significant changes, including the discovery of a blood clot and new medication orders. While the resident's daughter was informed in one instance, the primary contact was not, and the facility's staff could not provide documentation to show that proper notification occurred as required. A third resident, diagnosed with Parkinson's disease, congestive heart failure, and moderate cognitive impairment, also experienced several changes in condition and new orders without evidence that his durable power of attorney for healthcare, his son, was notified. Despite the resident being made aware of the changes, the facility's policy and the resident's records indicated that the son should have been informed due to the resident's cognitive status and the son's legal authority. The DON confirmed that the notifications were not documented as required, and no additional evidence was provided to show that the representative had been informed.
Failure to Implement Fall Prevention Interventions for At-Risk Residents
Penalty
Summary
The facility failed to implement fall prevention interventions as outlined in the care plans for two residents identified as being at risk for falls. For one resident with diagnoses including anoxic brain damage, epilepsy, and major depressive disorder, the care plan required that her garbage can be kept within reach to prevent her from attempting to get up unassisted. Observation revealed that the garbage can was placed out of her reach, and both the resident and the Director of Nursing confirmed that this intervention was not being followed, despite its inclusion in the care plan. Another resident, with diagnoses such as adult failure to thrive, dizziness, hypertension, unspecified dementia, and difficulty walking, had a care plan intervention requiring a visual reminder in her room to call for assistance. Observation found that after the resident was moved to a new room, the visual reminder was not transferred with her. An LPN confirmed that the intervention was not in place in the new room and was unaware of the requirement, even though the sign had been present in the resident's previous room. The facility's policy on managing falls requires staff to implement resident-centered fall prevention plans based on individual risk factors. In both cases, the specific interventions designed to mitigate fall risk were not carried out as documented in the residents' care plans, resulting in non-compliance with the facility's own policies and procedures for fall prevention.
Failure to Implement and Document Preoperative Orders Resulting in Cancelled Surgery
Penalty
Summary
A deficiency occurred when the facility failed to implement and document preoperative orders for a resident scheduled for a craniotomy. The resident, who had severe cognitive impairment and multiple diagnoses including aftercare following nervous system surgery, diabetes, major depression, hypertension, and hyperlipidemia, was on a daily aspirin regimen as a blood thinner. Despite being scheduled for neurosurgery, there were no preoperative orders in the medical record to hold aspirin or provide other specific instructions prior to the procedure. The resident continued to receive aspirin up to the day before surgery. The lack of preoperative instructions was discovered when the resident arrived at the hospital for surgery, and the neurosurgery department identified that aspirin had not been held, placing the resident at high risk for bleeding. As a result, the surgery was cancelled and had to be rescheduled. Interviews with facility staff revealed that the nurse responsible for entering preoperative orders did not document or implement any instructions regarding medication management, nor did they seek clarification from the surgeon when such orders were missing. Facility policy required that changes in care plans and significant events be accurately documented in the resident's medical record. However, the process for receiving, documenting, and acting on preoperative orders was not followed. The Director of Nursing confirmed that the failure to hold aspirin and the absence of preoperative documentation directly led to the cancellation of the resident's surgery.
Failure to Maintain Clean and Comfortable Shower Room Environment
Penalty
Summary
The facility failed to maintain a clean and comfortable environment in a shared shower room used by residents on the 100 and 200 units. One resident reported avoiding the shower room on her unit due to a persistent bad odor and visible stains on the floor, opting instead to use a different shower room. Direct observation confirmed a musty, sewage-like odor and a gray-brown stain on the floor near the shower stall. Both a housekeeper and the facility administrator acknowledged the presence of the odor and stain, with the administrator noting a perceived improvement due to a lack of recent complaints. A CNA reported that the odor issue began about a month prior, temporarily improved, but recurred after multiple showers were given in the room.
Lack of Governing Body Engagement in QAPI Program
Penalty
Summary
The facility failed to ensure the governing body was actively engaged and involved in the oversight of the Quality Assurance Performance Improvement (QAPI) program, affecting all 50 residents. The facility had not conducted any QAPI meetings since before their last annual survey, which was completed on 11/17/22. This lack of engagement was confirmed through interviews with the facility's Administrator and the Medical Director, who both acknowledged the absence of QAPI meetings and the lack of a functioning QAPI program. The Medical Director was not informed about the absence of the QAPI program since his hiring, and the Administrator admitted to the lack of evidence for any QAPI meetings since the last annual survey. The governing body was responsible for reviewing QAPI information quarterly and ensuring compliance with the QA committee, but there was no evidence of their involvement or attendance at any QA meetings since the last annual survey. The facility's policies outlined the governing board's responsibility for the management and operation of the facility, including the establishment and implementation of a QAPI program. However, the governing body failed to fulfill these responsibilities, as confirmed by the President of Clinical Operations, who verified the absence of a QAPI program and the governing body's lack of attendance at QA meetings.
Failure to Inform Residents of Rights Regarding Arbitration Agreements
Penalty
Summary
The facility failed to ensure that residents or their representatives were informed about their right to communicate with local, state, or federal officials before signing an arbitration agreement or within thirty days of signing it. This deficiency affected all residents in the facility, which had a census of 50. The facility's arbitration agreement did not include information about the right to communicate with officials, and interviews with the Administrator and Admission Staff #502 confirmed that this guidance was not provided to residents or their representatives. Additionally, the facility lacked a policy and procedure regarding arbitration agreements.
Arbitration Agreement Lacks Mutual Agreement
Penalty
Summary
The facility failed to ensure their arbitration agreement allowed for a mutually agreeable arbitrator and venue, potentially affecting all residents. The arbitration agreement specified that disputes would be resolved by binding arbitration administered by the American Arbitrators Association, or another reasonable arbitration association chosen solely by the facility if the former did not enforce pre-dispute arbitration agreements. The agreement also stated that the venue for arbitration would be near the facility's principal place of business. Interviews with the Administrator and Admission Staff revealed that the agreement did not provide residents or their representatives with a choice of arbitrator or venue, and there was no policy or procedure regarding arbitration agreements in place at the facility.
Failure to Implement Comprehensive QAPI Program
Penalty
Summary
The facility failed to establish a comprehensive Quality Assurance and Performance Improvement (QAPI) program that effectively evaluated areas in need of improvement and monitored the effectiveness of corrective actions. This deficiency affected all 50 residents in the facility. The facility's survey history revealed multiple citations in areas such as nursing services, quality of care, admission discharge and transfer, freedom from abuse neglect and exploitation, and food and nutrition services. Despite submitting plans of corrections, there was no evidence that these were reviewed or further interventions were implemented by the QAPI committee. An interview with the facility's Administrator revealed that there was no documentation of a comprehensive QAPI program being implemented since the last annual survey. The Administrator could not provide evidence of quarterly meetings or that the committee had thoroughly evaluated and identified areas needing improvement. Additionally, there was no documentation showing that prior deficient practices were being monitored to ensure the plan of correction was implemented and sustained. The facility's undated QAPI policy outlined the goals and responsibilities of the QAPI Committee, but there was no evidence these were being met.
Failure to Conduct Required QAPI Meetings
Penalty
Summary
The facility failed to hold quarterly Quality Assurance and Performance Improvement (QAPI) meetings with the required members, affecting all 50 residents. The QAPI committee did not meet since before the last annual survey, which was completed on 11/17/22. The facility's survey history showed multiple complaint surveys resulting in citations across various care areas, with plans of correction indicating findings would be reported to QAPI for review. However, the facility's QAPI attendance logs confirmed the absence of meetings, and the Medical Director, who was aware of the need for quarterly meetings, confirmed that no QAPI meetings had been held since his hire. The facility's policy required a QAPI committee to meet monthly, with a specific composition including the Administrator, DON, Medical Director, and other representatives. Despite this, the facility did not adhere to its policy, as evidenced by the Administrator's admission of the lack of meetings and the Medical Director's acknowledgment of the absence of a QAPI program. The failure to conduct these meetings meant the facility was not actively monitoring or addressing the care and services provided, as intended by the QAPI program.
Failure to Maintain Resident Privacy During Medication Administration
Penalty
Summary
The facility failed to maintain privacy during the administration of medication to a resident, which was observed by surveyors. Resident #160, who has a medical history including diabetes mellitus, acute respiratory failure, and asthma, was affected by this deficiency. The resident had physician orders for Lovenox injections and a Lidocaine patch for pain management. During the medication administration, the registered nurse (RN) did not ensure the resident's privacy, leaving the door open and the curtain unclosed, which allowed the resident to be visible from the hallway. The RN administered the Lovenox injection and applied the Lidocaine patch without providing adequate privacy, exposing the resident's abdomen and rib cage. This was confirmed during an interview with the RN, who acknowledged the failure to maintain privacy. The facility's policy on Quality of Life and Dignity, which mandates the protection of resident privacy during personal care and treatment procedures, was not adhered to in this instance.
Failure to Provide Transfer Notices to Residents
Penalty
Summary
The facility failed to provide timely transfer notices to residents and/or their representatives when residents were transferred to the hospital. This deficiency affected two residents out of three reviewed for hospitalization and discharge. Resident #55, who had multiple diagnoses including diabetes mellitus, chronic kidney disease, and heart failure, was transferred to the hospital but did not receive a transfer/discharge form. The Director of Nursing confirmed that no written notice was given to the resident or their representative at the time of transfer. Similarly, Resident #45, who had a complex medical history including acute kidney failure and heart disease, was transferred to the hospital following an episode of unresponsiveness. The facility's records showed no evidence of a transfer notice being provided for this hospitalization. The facility's policy requires a written notice to be given as soon as practicable in urgent medical situations, but this was not adhered to in these cases. The Administrator acknowledged the absence of the transfer notice, attributing it to the unexpected departure of the staff responsible for completing the forms.
Failure to Provide Bed Hold Notices After Hospital Transfers
Penalty
Summary
The facility failed to provide bed hold notices to residents or their representatives following hospital transfers, affecting two residents. Resident #55, who had multiple diagnoses including diabetes mellitus and heart failure, was transferred to the hospital but did not receive a bed hold notice. The Director of Nursing confirmed the absence of such documentation, which was required by the facility's policy. Similarly, Resident #45, who was privately paying for their stay and had conditions such as acute kidney failure and heart disease, was transferred to the hospital due to an episode of unresponsiveness and sepsis. The facility did not provide a bed hold notice for this resident either. The Administrator acknowledged the oversight, attributing it to the unexpected departure of the staff member responsible for completing the form. The facility's policy required written information to be given to residents or their representatives prior to transfers.
Failure to Obtain Psychiatric Notes and Transcribe Medication Orders
Penalty
Summary
The facility failed to ensure that psychiatric progress notes were obtained from an outside provider for a resident, leading to a lack of awareness of a new diagnosis of schizoaffective disorder. The resident, who was admitted with diagnoses including encephalopathy, PTSD, unspecified psychosis, major depressive disorder, and anxiety disorder, did not have the new diagnosis added to their medical record or care plan. The facility did not follow up with the psychiatrist's office to receive chart notes from the resident's visits, resulting in the omission of the schizoaffective disorder diagnosis from the resident's records. Additionally, the facility failed to accurately transcribe changes to the resident's psychiatric medications. An order was written to continue Abilify and start Olanzapine, but the facility's records showed discrepancies in the medication administration. The resident received 12 extra doses of Abilify due to inaccurate transcription of the physician's order. The Director of Nursing confirmed these issues, acknowledging that the facility did not obtain the necessary chart notes and failed to accurately transcribe medication orders.
Delayed UTI Treatment Due to Transcription Error
Penalty
Summary
The facility failed to obtain a physician-ordered urinalysis (UA) and culture and sensitivity (C&S) for a resident, which delayed antibiotic treatment for a urinary tract infection (UTI). The resident, who had severe cognitive impairment, unspecified dementia, end-stage renal disease, and muscle wasting and atrophy, complained of pain upon urination and abdominal pain. Despite an order being placed on 10/25/24 for a UA C&S due to these symptoms, the test was not conducted until 10/30/24. The delay was due to an error in transcribing the order to the Medication Administration Record (MAR), which was not caught until 10/29/24. The Director of Nursing (DON) confirmed that the transcription error led to a delay in obtaining the necessary laboratory tests, which subsequently delayed the initiation of antibiotic therapy. The culture results, completed on 11/03/24, indicated the presence of Escherichia coli (E-coli), confirming the UTI. The facility's policy on Medication and Treatment Orders, dated July 2016, did not include a process for transcribing physician orders to the MAR, contributing to the oversight.
Deficiencies in Weight Monitoring and Nutritional Supplement Administration
Penalty
Summary
The facility failed to ensure proper weight monitoring and nutritional supplement administration for three residents, leading to deficiencies in their care. Resident #25 experienced an 18-pound weight increase over a short period, which was not reweighed as per the facility's protocol. Despite the resident's concern about her weight gain, the staff, including the LPNs and the DON, acknowledged the oversight in not reweighing the resident, attributing it to a missed observation by both the DON and the dietitian. Resident #158, who was admitted with a requirement for weekly weight checks, only had his weight recorded once upon admission. This oversight was confirmed by the Administrator and the RD, who stated that the facility's policy required weekly weight checks for new admissions. The resident's family expressed concern about potential weight loss, highlighting the importance of regular monitoring, which was not adhered to in this case. Resident #16, diagnosed with Alzheimer's Disease and other conditions, did not receive the ordered Pro-Stat supplement for nearly three months due to a transcription error. Additionally, the facility failed to obtain weekly weights as ordered, which was confirmed by the DON. The RD was unaware of both the lack of weekly weight checks and the missed supplement administration, indicating a lapse in communication and adherence to care plans for this resident.
Improper Respiratory Care and Oxygen Administration
Penalty
Summary
The facility failed to ensure proper storage of nebulizer masks for two residents, affecting their respiratory care. Resident #47, diagnosed with COPD and emphysema, had a nebulizer mask that was consistently observed to be uncovered and improperly stored on multiple occasions. Despite the facility's policy requiring nebulizer equipment to be rinsed, disinfected, and stored in a labeled plastic bag, the mask was left exposed, as confirmed by both the resident and staff interviews. This oversight was noted over several days, indicating a lapse in adherence to the facility's respiratory care protocols. Additionally, the facility did not adhere to physician orders regarding oxygen administration for Resident #25, who also had COPD among other health issues. The resident's oxygen flow rate was set higher than prescribed, and the oxygen humidification bottle was found empty, contrary to the facility's policy that mandates regular checks to ensure proper oxygen flow and humidification. This was confirmed by an LPN and the Director of Nursing, highlighting a failure to follow established procedures for safe oxygen administration.
Failure to Administer Prescribed Pain Medication
Penalty
Summary
The facility failed to provide a resident with the prescribed Anbesol Maximum Strength Mouth/Throat Gel for tooth pain, as ordered by the physician. The resident, who had a history of type two diabetes mellitus, chronic obstructive pulmonary disease, dysphagia, and muscle weakness, was admitted with a care plan that included managing oral health problems and administering medications as ordered. Despite the physician's order for the Anbesol gel dated several months prior, the medication was not administered to the resident, as confirmed by the Medication Administration Record and interviews with the resident and staff. The deficiency was attributed to a lack of communication among the facility staff regarding the need to obtain the medication from an external source, as it was not available in the facility pharmacy. The resident reported asking for the medication multiple times and was instead given Tylenol occasionally for pain relief. Interviews with the LPN and the Laundry and Housekeeping Manager, who was responsible for obtaining over-the-counter medications, revealed that the medication was not ordered or picked up until several months later, resulting in a delay in the resident's pain management.
Failure to Address Pharmacy Recommendations for Medication Monitoring
Penalty
Summary
The facility failed to ensure that a pharmacy recommendation for laboratory monitoring was addressed by the physician for a resident with multiple diagnoses, including epilepsy and seizure disorder. The resident was prescribed valproic acid, a medication used for seizures, and the pharmacist recommended monitoring the valproic acid and ammonia levels in August, September, and October 2024. However, the physician did not address or sign these recommendations, and the last valproic acid level was obtained in June 2024. Interviews with the Director of Nursing and the pharmacist confirmed that the physician did not respond to the pharmacy recommendations. The pharmacist stated that his usual procedure would be to contact the physician after a second recommendation was issued. The deficiency affected one of the five residents reviewed for unnecessary medications, highlighting a lapse in the facility's process for ensuring appropriate medication monitoring and physician response to pharmacy recommendations.
Failure to Provide Timely Dental Services
Penalty
Summary
The facility failed to ensure timely dental services for a resident experiencing dental pain, affecting one out of two residents reviewed for dental services. The resident, who had been admitted with diagnoses including type two diabetes mellitus, chronic obstructive pulmonary disease, dysphagia, and muscle weakness, reported experiencing dental pain several months prior but only recently saw a dentist. The resident's care plan indicated a potential for oral/dental health problems, with goals to be free of infection, pain, or bleeding, and interventions to coordinate dental care. Despite these plans, the resident's first dental examination since admission occurred months later, revealing broken teeth and a cavity requiring extraction. The delay in dental care was attributed to miscommunication among facility staff. The Social Work Director was unaware of the resident's dental pain and stated that if informed, she would have ensured a timely dental visit. A scheduled dental appointment in July was postponed to November due to insufficient residents needing dental services at that time. The facility's policy stated that residents would receive dental services as needed, but this was not adhered to, resulting in the resident not receiving prompt dental care.
Unqualified Staff Conducting Nutritional Assessments
Penalty
Summary
The facility failed to ensure that the nutritional staff member responsible for completing quarterly reviews was qualified to assess the nutritional status of residents. This deficiency was identified through a review of records, staff interviews, and the Ohio Dietetics website, which revealed that a Certified Dietary Manager (CDM), who is a non-licensed professional without a bachelor's degree in nutrition, was conducting these assessments. The CDM was responsible for all quarterly nutritional reviews, while a Registered Dietitian, Licensed Dietitian (RDLD) handled annual, new or readmission, and significant change assessments. The CDM confirmed that she used a calculator to determine if there had been a significant change in residents' nutritional needs and whether their dietary intakes were meeting those needs. The deficiency specifically affected one resident, who had multiple complex medical conditions, including acute kidney failure, COPD, morbid obesity, type two diabetes mellitus, heart failure, a history of malignant neoplasm of the large intestine, and major depressive disorder. The resident was cognitively intact, required assistance with eating, and was on a therapeutic diet. The facility's contract with the consulting dietetics company stipulated that a nutritionist/dietitian with a minimum of a bachelor's degree in nutrition or dietetics and relevant experience should be provided, yet the CDM did not meet these qualifications. The Ohio Medical Board's guidelines state that unlicensed personnel can collect and record nutritional data but cannot evaluate or interpret it, which is considered the practice of dietetics.
Failure to Report Misappropriation of Resident Property
Penalty
Summary
The facility failed to report an allegation of misappropriation of resident property to the state agency in a timely manner, affecting one resident. The incident involved a resident who reported approximately one hundred and thirty-two dollars missing, which he had reported to the previous administration three months prior. Despite the resident's report, no follow-up was conducted, and the money was not returned. The resident, who had intact cognition and no hallucinations or delusions, had informed the previous administration about the missing money, but the issue was not resolved. Interviews with staff revealed that the resident had reported the missing money to the previous Business Office Manager, who then informed the administration during a morning meeting. The Social Work Director and the previous Administrator conducted an initial interview with the resident, who stated that the money was kept between his phone and phone case. The resident's girlfriend was mentioned as the source of the money. However, after the initial interview, no further investigation or reporting to the state agency was conducted by the previous Administrator, as required by the facility's policy. The current Administrator confirmed that the previous Administrator did not report the allegation, which was a violation of the facility's policy to report such incidents within twenty-four hours.
Failure to Investigate Misappropriation of Resident Property
Penalty
Summary
The facility failed to investigate an allegation of misappropriation of resident property, specifically affecting one resident. The incident involved a resident who reported that approximately one hundred and thirty-two dollars was taken from him. The resident had informed the previous administration about the missing money three months prior, but no follow-up was conducted, and the money was not returned. The resident had intact cognition and had not experienced hallucinations or delusions during the review period. The facility's self-reported incidents revealed no filing with the state agency regarding this allegation. Interviews with the Social Work Director and the current Administrator confirmed that the previous Administrator and Business Office Manager were aware of the allegation. However, there was no documentation or evidence of an investigation being conducted. The facility's policy on Abuse, Neglect, Exploitation, and Misappropriation of Resident Property mandates that all allegations be investigated within five working days, which was not adhered to in this case. The deficiency was investigated under Complaint Number OH00159928.
Incompetent Tracheostomy Care by Untrained Staff
Penalty
Summary
The facility failed to ensure that only competent staff provided tracheostomy care to residents, specifically affecting one resident with a tracheostomy. The resident had a history of malignant neoplasm of the larynx and an acquired absence of the larynx, requiring a tracheostomy tube. Upon the resident's arrival, his son demonstrated tracheostomy care to the staff. However, a State tested Nursing Assistant (STNA) later provided tracheostomy care without proper training or sterile technique, using a solution found in the resident's bathroom and a scrubber to clean the tracheostomy tube. The STNA was unaware that she was not permitted to perform tracheostomy care and was only educated on this restriction after the incident. The facility's policy required aseptic technique and the availability of a replacement tracheostomy tube at the bedside, which was not adhered to in this case. The STNA used clean gloves instead of sterile gloves and did not follow the aseptic procedure. Additionally, there was no spare tracheostomy tube available at the resident's bedside, contrary to the facility's policy. The STNA resigned after the incident but was later re-hired. The deficiency was identified during a complaint investigation, and there were no residents with a tracheostomy during the onsite survey.
Inadequate Infection Control Practices for COVID-19
Penalty
Summary
The facility failed to maintain proper infection control practices to prevent the spread of COVID-19, affecting all 54 residents. Resident #14, diagnosed with COVID-19, was not properly isolated as there was no signage, PPE cart, or waste receptacle in place. Staff confirmed the absence of necessary isolation measures, which were required for droplet precautions. Similarly, Resident #31, also under strict droplet precautions, lacked isolation signage, a PPE cart, and waste receptacles, as verified by a registered nurse. Resident #47, who tested positive for COVID-19, was not adequately isolated. The room lacked proper signage, and the PPE cart was missing essential items like masks and gowns. Additionally, Resident #29, requiring enhanced barrier precautions due to a colostomy, was not provided with appropriate PPE during care. An STNA was observed providing care with only gloves, contrary to the requirement for a gown during high-contact activities. Interviews with staff revealed a shortage of N95 masks and gowns, with staff reusing N95 masks throughout the day, even after entering COVID-19 isolation rooms. The facility's policies required full PPE for COVID-positive residents and changing N95 masks after exiting such rooms. However, these protocols were not followed, indicating a significant lapse in infection control measures.
Delayed Skin Assessment and Treatment Administration
Penalty
Summary
The facility failed to complete an admission skin assessment and administer post-trauma skin treatments as ordered for a resident admitted with multiple fractures and wounds following a motorcycle accident. The resident was admitted with hospital discharge orders for specific wound care treatments, including triad, mesalt rope, and hydrofera blue dressings, which were not implemented until several days after admission. The medical records showed no evidence of a completed admission skin assessment or timely administration of the prescribed treatments until days later. Interviews with the resident and facility staff confirmed that the wound treatments were delayed due to a weekend and a holiday. The Director of Nursing and a Licensed Practical Nurse acknowledged that the hospital discharge orders were not entered, and treatments were not administered until several days after admission. Additionally, the Wound Nurse Practitioner did not document the necessary measurements or enter new orders promptly. This deficiency was investigated under a specific complaint number.
Failure to Provide Proper Discharge Notice and Appeal Rights
Penalty
Summary
The facility failed to ensure all requirements were met in issuing a discharge notice to Resident #51. The resident, who had diagnoses including morbid obesity, bipolar disorder, borderline personality disorder, muscle wasting and atrophy, and hypertension, was transferred to an in-patient behavioral health unit for evaluation and treatment of suicidal ideations. The facility refused to allow the resident to return after being cleared for discharge from the psychiatric facility. The Minimum Data Set (MDS) 3.0 discharge assessment indicated an unplanned discharge to a short-term general hospital with no return anticipated. However, there was no documented evidence that the discharge notice was provided to the resident or included information about appeal rights. Email communications between the Ombudsman Program Director and the facility's Corporate RN and Administrator revealed that the discharge notice was allegedly sent on the day of the transfer, but there was no documentation to support this. A second discharge letter was issued almost 30 days later, lacking essential details such as the proposed discharge location and appeal rights. The Director of Nursing (DON) confirmed that the resident's medical record did not include updates following her discharge. The Ombudsman was working with the resident to request an appeal of the discharge, but as of the post-survey revisit, a hearing had not been held.
Failure to Readmit Resident After Hospitalization
Penalty
Summary
The facility failed to ensure a resident was permitted to return to the facility following a hospitalization. Resident #51, who had diagnoses including morbid obesity, bipolar disorder, and borderline personality disorder, was admitted to the facility and later hospitalized due to suicidal ideations. Despite the resident's desire to return to the facility and the Ombudsman's intervention, the facility refused to readmit her, citing discharge plans to her grandmother's home and the need for a bariatric bed. The facility's policy indicated that residents may return after hospitalization, but this was not followed in this case. The resident had been living at the facility for approximately six months and had participated in care conferences where discharge planning was discussed. Initially, the plan was for the resident to return to her grandmother's home with the assistance of the Home Choice program. However, there were no additional progress notes or finalized plans for this discharge. When the resident was hospitalized for psychiatric reasons, the facility decided not to readmit her, despite her belongings still being at the facility and her expressed desire to return. Interviews with the Ombudsman, the Director of Nursing, the Administrator, and the hospital discharge coordinator confirmed that the facility refused to allow the resident to return. The hospital discharge coordinator and the resident both indicated that the facility had boxed up the resident's belongings and insisted on her discharge to her grandmother's home, despite the resident's need for continued care and her grandmother's inability to provide the necessary support. This refusal to readmit the resident was against the facility's policy and the resident's rights.
Failure to Protect Residents from Physical Abuse
Penalty
Summary
The facility failed to ensure residents were free from staff physical abuse, affecting two residents. Resident #56, who has diagnoses including Asperger syndrome, bipolar disorder, anxiety disorder, and Wernicke's encephalopathy, reported that a State tested Nursing Assistant (STNA) physically abused her during incontinence care. The resident described being hit on the back multiple times and verbally abused. A subsequent assessment revealed light blue markings on her left shoulder. The STNA involved was suspended pending investigation but was later reinstated due to lack of substantiating evidence. The resident's mother suggested that her daughter's sensory processing disorder might have influenced her perception of the incident. However, the facility's investigation could not substantiate the allegations due to the absence of witnesses and additional evidence. Resident #38, who has vascular dementia, hemiplegia, hemiparesis, and type two diabetes mellitus, also reported physical abuse by the same STNA. The resident claimed that the STNA was rough during care and hit him in the testicles. Despite the resident's cognitive intactness, the facility's investigation found no visible injuries and no witnesses to the incident. The STNA denied the allegations and subsequently resigned. The facility interviewed all involved parties and conducted abuse training for all staff members. The Director of Nursing (DON) reported that both residents required full assistance with care and transfers and did not usually attend activities, minimizing their contact with each other. The facility's investigation into both incidents revealed no history of false allegations from either resident. Despite the serious nature of the allegations, the facility was unable to substantiate the claims due to the lack of witnesses and physical evidence. The facility's policy on abuse, neglect, exploitation, and misappropriation of resident property defines abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish. The STNA involved had received abuse training upon hire and resigned her position following the allegations.
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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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